arrhythmia management


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arrhythmia management

  1. 1. Management of Arrhythmias Abhishek reddy KMC Manipal
  2. 2. Agents classified according to •Mode of action •Site Anti arrhythmic drugs
  3. 3. • Acts principally by suppressing excitability and slowing down conduction in atrial or ventricular muscle. • Blocks Na+ channels • Contraindicated in patients w/ heart failure as they depress myocardial function. Class 1 drugs
  4. 4. Class 1a drugs: • Prolongs cardiac action potential • ↑ tissue refractory period • Uses: atrial and ventricular arrhythmias • E.g. Disopyramide: • Causes anticholinergic side effects- urinary retention, ppts glaucoma. • Depresses myocardial function n hence avoided in cardiac failure • E.g. Quinidine: • Rarely used as it increases mortality n causes GI upset.
  5. 5. Class 1b drugs:  They shorten the AP and tissue refractory period  Acts on ventricles so used in Ventricular tachycardia and ventricular fibrillation.  E.g. Lidocaine, Mexiletine
  6. 6. Class 1c  Affects slope of AP w/o altering duration or refractory period.  Uses: prophylaxis of AF, SVA, VA.  Contraindicated in patients w/ previous MI- leads to pro- arrhythmias  E.g. Flecainide  Effective- AF  Given w/ AV node blocking drugs- β blockers to prevent pro-arrhythmias  E.g. Propafenone
  7. 7. Class 2 drugs  Group comprises of β blockers  These drugs diminish Phase 4 depolarization, thus depresheart rate and contractility. sing automaticity, prolonging AV conduction, and decreasing  These reduce the rate of SA node depolarization and causes a relative block in AV node.  Uses: Rate control in Atrial Flutter, AF, SVA, VT  Reduces myocardial excitability and risk of arrhythmic death in patients w/ CHD & heart failure.
  8. 8.  Cardio selective β blockers:  Acts on myocardial β1 receptors  E.g. Atenolol, Bisoprolol, Metoprolol  Non selective β blockers:  Acts on β1 & β2 receptors  Β2 blockade- bronchospasm and peripheral vasoconstriction  E.g. Propranolol, Nadolol, Carvedilol  Sotalol:  Causes torsade de pointes
  9. 9. Class 3 drugs o Acts by prolonging plateau phase of AP. o Hence lengthens refractory period o Effective- atrial & ventricular tachyarrhythmia o Causes QT prolongation and predisposes to torsade de pointes and VT o E.g. Amiodarone o Principal drug o Also has class 1, 2, 4 activity o Most effective drug- paroxysmal AF o Uses: to prevent recurrent episodes of VT o Side effects: photosensitivity, skin discoloration, thyroid dysfunction, nausea, vomiting etc
  10. 10. Class 4 drugs  Blocks the slow calcium channels( important for impulse generation and conduction in atrial and nodal tissues  Acts at the AV node  E.g. Verapamil, Diltiazem
  11. 11. Other anti- arrhythmic drugs  Atropine Sulphate (0.6 mg i.v., repeated if necessary- maximum of 3 mgs)  ↑ sinus rate and SA, AV conduction  Best choice- severe bradycardia or hypotension due to vagal over activity.  Side effects: dry mouth, thirst, blurred vision, atrial and ventricular extra systoles.
  12. 12. Adenosine:  Given i.v. bolus, initially 3mg over 2 sec. If no response after 1-2 mins, 6mg should be given; and if needed after 1-2 mins, max dose 12mg may be given.  Uses: terminate SVT when AV node is part of re-entry circuit or in Atrial Flutter with 2:1 AV block or broad complex tachycardia.  Side effects: flushing, dyspnea, chest pain  Contraindications: Asthma
  13. 13. Digoxin  Slows conduction and prolongs refractory period in AV node.  Controls ventricular rate in AF & SVT of AV node.  Shortens refractory period and enhances conduction and excitability in other parts of the heart.  Side effects: GI disturbances, xanthopsia, arrhythmias
  14. 14. Therapeutic Procedures • External defibrillation and cardio version • Catheter ablation • Temporary pacemakers • Permanent pacemakers • Implantable cardiac defibrillators(ICDs) • CRT (cardiac resynchronization therapy
  15. 15. External defibrillation
  16. 16. cardio version
  17. 17. Catheter ablation
  18. 18. Flouroscopic image showing catheter
  19. 19. pacemakerImplantable cardiac defibrillators(ICDs)
  20. 20. pacemaker ICDs
  21. 21. CRT (cardiac resynchronization therapy)