Pharmacological therapy of cardiac arrhythmias


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Pharmacological therapy of cardiac arrhythmias

  1. 1. ‫) قالوا سبحانك ل‬ ‫علم لنا إل ما‬ ‫علمتنا إنك أنت‬ ‫العليم الحكيم(‬
  2. 2. P harmacological T herapy of Cardiac Arrhythmias By: Mahmoud Shah Professor of Cardiology Zagazig University
  3. 3. Vaughan Williams ClassificationClass I: * block fast Na channels * can block K channels IA: * V max (phase 0 AP) * prolong AP duration * include: quinidine, procainamide, disopyramide * intermediate onset and offset in blocking Na channels (< 5 seconds)
  4. 4. IB * Doesn’t decrease V max * Shorten AP duration * Mexiletine, Phenytoin, Lidocaine * Rapid onset and ofset (<500 msec) Ic * Decrease V max * Slow conduction * Prolong refractoriness minimally * Flecanide, propafenone , moricizine,ajmaline * Slow onset and ofset (10-20 sec)
  5. 5. Class II *Block B receptors *propranolol, timolol, metoprololClass III *block k channels *prolong repolarization *Sotalol, Amoidarone, bretylium, drondarone, dofetilide, ibutilide, azimilideClass IV *block slow ca Channel * Verapamil ,Diltiazim
  6. 6. Unclassified drugs1 – Adenosine activates K channels (IK ach.,IK Ade)2 – Ivabradine If current blocker3 – digoxin
  7. 7. Recommendations for acute management of hemodynamically stable and regular tachycardia ECG Recommendation Class Level of evidenceNarrow QRS-complex tachycardia Vagal manoeuvres I B (SVT) Adenosine I A Verapamil, diltiazem I A Beta-blockers lIb C Amiodarone lIb C Digoxin lIb C Wide QRS-complex tachycardia See above I B • SVT and BBB Flecainide I B • Pre-excited Ibutilide I B • VT/AF + Procainamide I C DC cardioversion• Wide QRS-complex tachycardia Procainamide I B of Sotalol I B unknown origin Amiodarone I B Udocaine IIb B Adenosine IIb C Beta-blockers III C Verapamil III B DC cardioversion I B Wide QRS-complex tachycardia of Amiodarone I B unknown origin in patients with Lidorainp I B poor LV function DC cardioversion
  8. 8. Specificarrhythmias
  9. 9. 1- InapproprIate SInuS tachycardIa (ISt)* Persistent high HR unrelated to level ofphysical , emotional, pathological orpharmacological stress* 90% Female* Asymptomatic to totally incapacitatedTreatment* Symptomatic driven* Catheter ablation – 66% of SAN modification* Postural Orthostatic tachycardia syndrome(POTs) excluded before ablation.
  10. 10. Recommendation for treatment of IST Treatment Recommendation Class Level of evidence Medical Beta-blockers I C Verapamil, diltiazem II a C Interventional Catheter ablation – II b C sinus node modification/elimination
  11. 11. 2. atrIoventrIcular nodalrecIprocatIng tachycardIa (avnrt) * Typical form slow – fast 85-90% RP<PR * Atypical form fast – slow 10-15% RP>PR * Standard treatment B blocker Ca blocker Adenosine * Alternative ttt Ablation Tolerance of symptoms Tachycardia frequency Patient inclination relative to chronic drug therapy vs ablation The patient must accept risk (<1% Av block) P. pacemaker
  12. 12. ECG pattern of typical AVNRT A: during AVNRT and B: after cardioversion Note the pseudo r’ in V1 andpseudo S in II, III and a VF which are pathognomonic of typical AVNRT
  13. 13. Recommendations for long-term treatment of patients with recurrent AVNRT Clinical Intervention Class Level presentation of evide nce Poorly tolerated Catheter ablation I B AVNRT with Verapamil, IIa C haemodynamic diltiazem, beta- intolerance blockers, sotalol, amiodarone Flecainide, IIa C propafenone I Recurrent Catheter ablation I B symptomatic Verapamil I B AVNRT Diltiazem, beta- I C blockers Digoxin IIb C Recurrent AVNRT Flecainide, IIa B unresponsive to propafenone, beta-blockade or sotalol calcium-channel blocker and Amiodarone IIb C patient not desiring RF ablation
  14. 14. AVNRT with Catheter ablation I B infrequent orsingle episode in patients whodesire complete control of arrhythmia Documented Verapamil,diltiaze I C PSVT with only m, beta-blockers, dual AV-nodal flecainide*, pathways or propafenonesingle echo beats demonstrated duringelectrophysiologi Catheter ablation I Bcal study and no ++ other identified cause of arrhythmiaInfrequent, well- No therapy I Ctolerated AVNRT Vagal I B manoeuvres «Pill-in-the- I B pocket» Verapamil,diltiaze I B m, beta-blockers Catheter ablation I B
  15. 15. 3- Focal and nonparoxymal junctIonal tachycardIaA - focal junctional tachycardia * Automatic ectopic tachycardia * Junctional ectopic tachycardia * Originate from AVN or His bundle * ECG: - HR: 110-250 bpm - Narrow QRS or BBB pattern with AV dissociation * Rare arrhythmia * In young adult * may produce CHF * Drug therapy ----- Variable success * Ablative therapy 5-10%risk A-V block
  16. 16. Surface ECG recording from leads V1, II, and V5 in apatient with focal junctional tachycardia. The upper panel showssinus rhythm. The lower panel shows tachycardia onset with thecharacteristic finding of isorhythmic AV dissociation (arrows).The large arrow signifies continuous recording. AV indicatesatrioventricular.
  17. 17. B – Nonparoxysmal junctional tachycardia (NJT) * Benign arrhythmia * HR 70-120 bpm * due to abnormal automaticity or triggered activity * due to digitalis toxicity , post cardiac surgery , hypokalemia , myocardial ischemia * Treatment directed toward the underlying condition
  18. 18. Recommendation for treatment of focal and nonparoxymal junctional tachycardia Clinical Recommendation Class Level of evidence presentation Focal junctional Beta-blockers IIa C tachycardia Flecainide IIa C Propafenone IIa C Sotalol IIa C Amiodarone IIa C Catheter ablation IIa C Nonparoxysmal Reverse digitalis I C junctional toxicity tachycardia Correct I C hypokalemia Treat myocardial I C ischaemia Beta-blockers, IIa C calcium-channel blockers
  19. 19. 4. a-v recIprocatIng re-entry tachycardIa (avrt) * Extranodal AP * Only retrograde conduction concealed AP * Antegrade conduction manifest AP * WPW Syndrome Preexcitation + Tachycardia
  20. 20. Forms * orthodromic AVRT * antidromic AVRT * pre-excited tachycardia in AT or A.Fl with bystander AP * Pre-excited AF * PJRT ( permanent form of JRT) - Slowly conducting concealed posteroseptal AP - Incessant , long RP tachycardia with negative pin II ,III ,avf - rare syndrome
  21. 21. Orthodromic atrioventricular reentrant tachycardia. This patient has Wolff-Parkinson-White syndrome
  22. 22. Wolff-Parkinson-White pattern. Note the short PR interval and slurred upstroke (delta wave) to the QRS complexes
  23. 23. Acute treatment of pre-excited tachycardias * AVN blocking agents not effective * Adenosine may produce AF with rapid ventricular rate * Anti-arrhythmic drugs preventing rapid conduction through AP - Flecanide effective even - Procainamide may not - Ibutilide convert the atrial rhythm. - Amiodarone
  24. 24. Long-term therapy of pre-excited tachycardias * Catheter ablation the preferred with 95% success option * Antiarrhythmic drugs Another therapeutic option for - Infrequent episodes - Well-tolerated episodes * Some patients with infrequent episodes Single dose (pill-in pocket approach) * Only at the onset of tachycardia episode - Patient without pre-excitation - Uncommon and hemodynamically tolerated tachycardia.
  25. 25. Recommendations for long-term therapy of AP-mediated arrhythmias
  26. 26. 5 Focal atrialtachycardia (Fat) * Atrial rate: 100-250 bpm (rarely 300) * progressive increase in atrial rate with tachycardia onset (warm-up) and/or * progressive decrease before termination of tachycadia suggests automatic mechanism * 10 % have multiple foci * Focal AT may be incessant tachycardiainducing CM
  27. 27. Focal atrial tachycardia showing a long RP interval relationship.The P wave in AT usually occurs in the latter part of thetachycardia cycle (arrows) but can appear earlier, depending onthe rate and status of AV-nodal conduction. AT indicates atrialtachycardia; AV, atrioventricular
  28. 28. Treatment* Rate control - B- blocker - Ca blocker - Digoxin* Or suppression of arrhythmias focus Class Ia - Flcamide - Propafenone* IV adenosine, B blocker or Ca blocker acute termination (unusual) or rate control* Adenosine terminate FAT in significant numberof patients.* chronic control: AV blocking agents* ablation: 80- 90% for RA focus and 70-80% inLA focus
  29. 29. Recommendations for treatment of focal atrial tachycardia
  30. 30. 6) multiFocal atrial tachycardia* correction of underlying abnormalities: - pulmonary disease - metabolic - electrolyte disorders* CCB* No role for DCC, AADs or ablation
  31. 31. • Multifocal atrial tachycardia. Note the different P-wave morphologies and irregularly irregular ventricular response
  32. 32. 7) atrial Flutter * isthmus-dependent: more frequent *Non-isthmus-dependent:less frequent
  33. 33. • Atrial flutter. The patients heart rate is approximately 135 bpm with 2:1 conduction. Note the sawtooth pattern formed by the flutter waves.
  34. 34. ttt Hemodynamically destabilizing shock, ongoing ischemia): DCC (HF, Hemodynamically stable: rate control by AVN blocking drugs class Ic: may cause paradoxical increase in ventricular rate. AVN blocking drugs and amiodarone are NOT effective for cardioversion IV ibutilide is the most effective agent for acute drug termination of A Fl (38-76%) Class III (especially dofetilide): effective chronic therapy (73%) Chronic therapy: NOT required after sinus rhythm is restored if AFl occurs as part of acute disease process
  35. 35. Recommendations for acute management of atrial flutter
  36. 36. Recommendations for long-term management of atrial flutter
  37. 37. Management of atrial flutterdepending on hemodynamic stability
  38. 38. Recommendations for treatment strategies for SVT during pregnancy
  39. 39. Recommendations for treatment of SVTs in adults with congenital heart disease
  40. 40. Response of narrowcomplex tachycardias to adenosine
  41. 41. Acute management of patients withhemodynamically stable and regular tachycardia
  42. 42. 8. atrial Fibrillation (aF)Objectives of management: * Rate control * Rhythm control * Prevention of thromboembolismPatterns of AF: Newly discovered AF Recurrent paroxysmal AF Recurrent paroxysmal AF Permanent AF
  43. 43. • Atrial fibrillation. The patients ventricular rate varies from 130-168 bpm. Rhythm is irregularly irregular. P waves are not discernible
  44. 44. Pharmacological management of patients with newly discovered AF
  45. 45. Pharmacological management ofpatients with recurrent paroxysmal AF
  46. 46. Pharmacological management ofpatients with recurrent persistent or permanent AF
  47. 47. Antiarrhythmic drug therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation
  48. 48. Recommendations for Pharmacological Cardioversion of Atrial Fibrillation of Less Than or Equal to 7 Days’ Duration
  49. 49. Recommendations for PharmacologicalCardioversion of Atrial Fibrillation of More Than 7 Days’ Duration
  50. 50. Recommended Doses of Drugs ProvenEffective for Pharmacological Cardioversion of Atrial Fibrillation
  51. 51. Pharmacological Treatment Before Cardioversion in Patients With Persistent Atrial Fibrillation: Effects of Various Antiarrhythmic Drugs on Acute and Subacute Outcome of Transthoracic Direct Current Shock
  52. 52. Typical Doses of Drugs Used to Maintain Sinus Rhythm in Patients With Atrial Fibrillation
  53. 53. Intravenous PharmacologicalAgents for Heart Rate Control inPatients With Atrial Fibrillation
  54. 54. Orally Administered Pharmacological Agents for Heart Rate Control in Patients With Atrial Fibrillation
  55. 55. Recommendations for management of AF:I. Pharhacological rate control during AF: Class I: 1. Rate control for patients with persistent or permanent AF (LOE: B) 2. With no pre-excitation: IV BB or CCB to slow acute settings without hypotension or HF (LOE: B) 3. IV digoxin or amiodarone in AF with HF (LOE: B) 4. digoxin effective to control HR at rest (LOE: C)
  56. 56. Class IIa: 1. digoxin + BB or CCB for control of HR at rest and during exercise (LOE: B) 2. Ablation of AVN or AP to control HR when drugs are insufficient or with side effects (LOE: B) 3. IV amiodarone when other measures are unsuccessful or contraindicated (LOE: C) 4. IV procainamide or ibutilide when DCC is not necessary in Af+AP (LOE: C)
  57. 57. Class IIb: 1. oral amiodarone when HR can’t be controlled using BB, CCB or digoxin alone or in combination (LOE: C) 2. IV procainamide, disopyramide, ibutilide, or amiodarone forhemodynamically stable patients with AF + AP (LOE: B) 3. When HR can’t be controlled by drugs or tachycardia-mediated myopathy is suspected : Ablation of AVN (LOE: C)
  58. 58. Class III: 1. digitalis is not used as the sole agent to control HR in patients with paroxysmal AF (LOE: B) 2. Ablation of AVN: is not attempted without prior trial of medication to control rate (LOE: C) 3. HF+AF: IV CCB exacerbate AF so NOT recommended (LOE: C) 4. IV digitalis or CCB in AF+AP increase ventricular rate so not recommended (LOE: C)
  59. 59. Pharmacological Cardioversion of AF: Class I: Flecainide, dofetilide, propafenone or Ibutilide (LOE: A) Class IIa :1. IV amiodarone (LOE: A)2. single oral dose of propafenone or flecainide (pill in the pocket) may terminete persistent AF (LOE: C)3. amiodarone in paroxysmal or persistent AF when rapid restoration of sinus rhythm is not necessary (LOE: C)
  60. 60. Class IIb: Quinidine or procainamide considered forAF cardioversion but not well established(LOE: C)
  61. 61. CLASS III:1. Digoxin and sotalol are not recommended for pharmacologic carioversion of AF (LOE: A)2. quinidine , procainamide, dofetilide not started out of hospital for cardioversion of AF (LOE: B)
  62. 62. Maintenance of sinus rhythm: Class I: before starting AADs treat precipitating or reversible causes of AF Class II: 1. lone AF without structural heart disease propafenone or flecainide in outpatients with paroxysmal AF who are in SR (LOE: B) 2. Sotalol in patients with SR with little or no heart disease prone to paroxysmal AF (LOE: C) 3. Amiodarone (LOE: C)
  63. 63. Class III1. Antiarrhythmic therapy not recommended in patient with AF who have risk factors for proarrhythmia (LOE:A)2. Pharmacological therapy not recommended in patients with advanced SAN disease or AVN dysfunction unless have functioning pacemaker (LOE:C)
  64. 64. Postoperative AFClass I 1- Oral B blocker preventpostoperative AF for patientsundergoing cardiac surgery(LOE:A) 2- AVN blocking agents for ratecontrol in patients who developpostoperative AF (LOE:B)
  65. 65. Class II a 1- Preoperative amoidaronedecrease incidence postoperative AF(LOE:A)2- Ibutilide or DC conversion ofpostoperative AF (LOE:B)3- Antiarrhythmic medicationsmaintain SR in recurrent or refractoryAF (LOE:B)Class II b prophylactic satalol for patient atrisk of developing AF after cardiacsurgery (LOE:B)
  66. 66. Post AMI AFClass I 1- DC cardioversion haemodynamiccompromise (LOE:C) 2- IV amiodarone slow ventricularrate response to AF (LOE:C) 3- IV blocker or Ca blocker slowventricular rate response to AF whodo not have LV dysfunction,bronchospasm or A-V block (LOE:C)
  67. 67. Class II a 1- IV digitalis in AMI + LVdysfunction (LOE:C) Class III 2- Class Ic antiarrhythmic drugsare not recommended in AMI + AF(LOE:C)
  68. 68. Management of AF + WPW syndrome Class I 1- catheter ablation (LOE:B) 2- Immediate DC shock in haemodynamic instability (LOE:B) 3- IV procainamide or Ibutilide restore AF to SRC if haemodynamically stable + wide QRS (LOE:C) Class IIa IV Flecanide or direct DC very rapid Vent. Rate (LOE:B)
  69. 69. Class IIb 1- IV quinidine, procainamide, disopyramideor amiodarone , ibutilide ifhaemodynamically stable (LOE:B)Class III 1- IV digitalis or Ca blocker ___ notrecommended (LOE:B)
  70. 70. Hyperthyroidism and AFClass I1- B blocker (LOE:B) 2- Ca blocker (when Bblockers can not be used)(LOE:B)
  71. 71. Management of AF during prgnancy: Class I 1- Digoxin, B blocker, Ca blocker (LOE:C) 2- DC shock if Haemodynamically unstable (LOE:C) Class IIb 1- Quinidine or procainamide if pharmacological cardioversion in haemodynamically stable (LOE:C)
  72. 72. Management of AF + HCM Class IIa 1- Disopyramide + B blocker orCa blocker or amiodarone ___prevent recurrence of AF(LOE:C)
  73. 73. Management of AF + pulmonary diseaseClass I1- Diltiazime or Verapamil (LOE:C) if stable2- DC shock (LOE:C) if unstableClass II 1- Theophylline and B agonist not recommended in pulmonary disease +AF (LOE:C) 2- B blocker , Satolol , Propafenone, Adenosine not recommended (LOE:C)
  74. 74. Management of Ventricular arrhythmias
  75. 75. 1- Sustainedmonomorphic VT Class I DC shock (LOE:C) Class IIa • 1- IV procainamide or ajmaline (LOE:B) • 2- IV amiodarone (LOE:C) Class IIb • 1- IV Lidocaine if Stable with AMI or acute Ischemia (LOE:C) • Class III • 1- Ca blocker Not used to terminate wide QRS – complete VT of unknown origin (LOE:C)
  76. 76. monomorphic VT
  77. 77. 2. Repetitive monomorphic VT Class IIa 1- IV amiodarone , B blocker and procainamide , Sotalol or ajmaline in CHD or idiopathic VT (LOE:C)
  78. 78. 3. Polymorphic VT ClassI 1- DC Shock if Haemodynamically compromised (LOE:B) 2- IV B blocker if especially in ischemia (LOE:B) 3- IV amoidarone if in absence of abnormal repolarization related to congenital or acquired QT syndrome (LOE:C) ClassIIb 1- IV Lidocaine especially in AMI or Ischemia (LOE:C)
  79. 79. 4. Torsades de pointes Class I 1- Withdrawal of offending drugs and correction of electrolyte abnormalities (LOE:A) 2- Acute and long-term pacing if TdP due to heart block and symptomatic bradycardia (LOE:A)
  80. 80. Class II a1- IV magnesium __ Long QT + TDP ( Mg not effective in normal QT) (LOE:B) 2- Acute and long term pacing __ Recurrent pause-dependent TDP (LOE:B) 3- B blocker + Pacing__TDP + sinus bradycardia (LOE:C) 4- IV Isopproterenol __ Temporary in recurrent pause-dependent TDP + no congenital LQTs (LOE:B)Class IIb1- 1<repletion to 405-5 MM/L (LOE:B) 2- IV Lidocaine or oral mexiletine __ in LQT3 + TDP (LOE:C)
  81. 81. 5. Incessant VTClass I1- Revascularization +B blocker followed by IV procainamide or IV Amoidarone ____ Recurrent or incessent polymorphic due to myocardial ischemia (LOE:C)Class IIA1- Amoidarone or Procainamide followed by VT ablation (LOE:B)
  82. 82. Class IIb1- IV amoidarone and IV B blockers separately or combined ___ VT storm (LOE:C) 2- Overdrive pacing or general anesthesia (LOE:C)3- Spinal cord modulation (LOE:C)
  83. 83. THANK YOU