This document discusses the treatment of various cardiac arrhythmias. It begins by describing common drug classes used to treat arrhythmias and then discusses the treatment of specific arrhythmias including supraventricular arrhythmias like atrial fibrillation and flutter, AV nodal reentrant tachycardia, preexcitation syndrome, AV block, PVCs, ventricular tachycardia, and ventricular fibrillation. For each arrhythmia, it outlines recommended treatment approaches including drugs, cardioversion, ablation, and pacemaker implantation. It provides pricing information for various antiarrhythmic drugs available in Iran.

2. Treatment of cardiac Arrhythmias
For Reform Students
By M. H. Farjoo M.D , Ph.D
Shahid Beheshti University of Medical Sciences

3. Treatment of Cardiac Arrhythmias
 Drug Classes
 Supraventricular Arrhythmias
 Atrial Flutter
 Atrial Fibrillation
 AV Nodal Reentrant Tachycardia
 Preexcitation Syndrome (WPW)
 AV Block
 PVC
 Ventricular Tachycardia
 Ventricular Flutter & Fibrillation & arrest

4. Drug Classes

10. Supraventricular Arrhythmias
 Atrial fibrillation and atrial flutter are common
supraventricular tachycardias.
 Premature atrial complexes (PAC), sinus arrhythmia,
sinus tachycardia, and sinus bradycardia usually do
NOT require drug therapy.
 In symptomatic patients with PAC, treatment with a
beta blocker or a CCB can be attempted.

12. Atrial Flutter
 Cardioversion (synchronous, 50 J) is the treatment of
choice.
 Catheter ablation is preferred for stable patients who
do not require immediate cardioversion.
 Procainamide or amiodarone can be given.

14. Amiodarone 150 mg / 3 ml
Price of each ampule: 3,500 Toman

17. Atrial Fibrillation (AF or AFib)
 AF is the most prevalent arrhythmia and 33% of
arrhythmia-related hospitalizations are for AF.
 AF treatment is based upon:
 Rate control or rhythm control
 Prevention of Thromboembolism
 Pharmacologic rhythm-control and rate-control
strategies result in similar outcomes.

18. Atrial Fibrillation (AF or AFib)
 In the absence of preexcitation, a beta blocker or
nondihydropyridine CCB is used for AF.
 IV digoxin or amiodarone is used in AF with heart
failure and without accessory pathway.
 Digoxin is effective after oral administration to
control the heart rate at rest (NOT in exercise).

19. Diltiazem tab 60 mg
Price of each pack (100 tablets): 13,000 Toman

20. Diltiazem 120 mg
Price of each pack: 17,000 Toman

21. Diltiazem 2%
Price of each pack: 6,500 Toman

22. Verapamil tablet 40 mg
Price of each pack: 7,000 Toman

23. Verapamil ampule 5 mg / 2 ml
Price of each ampule: 3,500 Toman

24. Digoxin tablet 0.25 mg
Price of each package (50 tablets) 8,000 Toman

25. Digoxin ampule 0.25 mg/ml
Price of each package (10 ampule) ??? Toman

26. Digoxin antibody vial 40 mg/4 ml
Price of each package (1 vial) 12,300,000 Toman!!

27. Atrial Fibrillation (AF or AFib)
 For antithrombotic therapy aspirin, or warfarin, or
Dabigatran is used.
 The risk factors for thromboembolism are: age ≥75
years, hypertension, heart failure, EF ≤35%, and
diabetes.
 If none of these risk factors is present, aspirin is used .
 If only one risk factor is present, either aspirin or an
anticoagulant is used, and the choice is individualized.
 If more than one risk factor is present, anticoagulant is
used.

28. Atrial Fibrillation (AF or AFib)
 For post MI AF: cardioversion for patients with
severe hemodynamic instability.
 For AF in pregnancy: Digoxin, a beta blocker, or a
nondihydropyridine CCB, or cardioversion (if the
patient is unstable).
 Antithrombotic therapy is indicated throughout
pregnancy and depends on the stage of pregnancy.

29. Warfarin tab
Available forms in Iran

30. Dabigatran capsule 75 mg

31. Dabigatran capsule 110 mg

32. Dabigatran capsule 150 mg

33. Rivaroxaban tablet 10 mg
Price of each package (30 tablets) 98,400 Toman

34. Rivaroxaban tablet 15 mg
Price of each package (30 tablets) 105,000 Toman

35. Rivaroxaban tablet 20 mg
price of each package (30 tablets) 120,000 Toman

36. AV Nodal Reentrant Tachycardia (AVNRT)
 For some patients, rest may be all that is required to
abort the attack.
 These vagal maneuvers serve as the first line of
therapy:
 Carotid sinus massage
 Valsalva maneuvers
 Müller maneuvers
 Gagging
 Occasionally exposure of the face to ice water

37. AV Nodal Reentrant Tachycardia (AVNRT)
 If vagal maneuvers fail, adenosine is the drug of choice
and terminates (within 1 minute) the tachycardia in 90%
of cases.
 If adenosine fails, verapamil, or diltiazem terminates
reentry in about 2 minutes in 90% of cases.

38. Adenosine 6 mg /2 ml
Price of each pack: 23,000 Toman

39. Adenosine 6 mg /2 ml
Price of each Vial: 23,000 Toman

41. Preexcitation Syndrome (WPW)
 Asymptomatic patients with intermittent complexes are
only observed.
 Two therapeutic options exist, catheter ablation and
pharmacologic therapy.
 For acute episodes, treatment is similar to AVNRT.
 After vagal maneuvers, adenosine followed by IV
verapamil or diltiazem is the treatment of choice.
 AF can occur after adenosine, so a cardioverter-
defibrillator should be immediately available if necessary.

45. AV Block
 For short-term therapy, vagolytic agents such as
atropine are useful for patients who have AV nodal
disturbances.
 Isoproterenol can be used to treat heart block at any
site.
 Isoproterenol should NOT be used in patients with
acute MI.
 For symptomatic AV block or high-grade AV block,
pacemaker placement is the treatment of choice.

46. Atropine ampule 0.5 mg/ml
Price of each package (10
ampules) 13,700 Toman

49. PVC
 In most patients, PVCs do not need to be treated.
 Reassurance that they are benign in those without
structural heart disease is often sufficient.
 In hospitalized patients, IV lidocaine is the treatment
of choice but is rarely indicated.
 Intravenous magnesium may be useful.

50. Lidocaine

51. Lidocaine 2%
Price of each unit : 1,800 Toman

52. Magnesium Sulfate 20% & 50% / 50 ml
Price of each Vial : 5,300 Toman

53. Magnesium Sulfate 50%
Price of each ampule : 3,000 Toman

55. Ventricular Tachycardia (VT)
 VT that does not cause hemodynamic
decompensation is treated by IV amiodarone, or
procainamide.
 If the arrhythmia does not respond to medical
therapy, cardioversion (10 – 50 J) is used.
 When a defibrillator is not available, striking the
patient’s chest can infrequently terminate the VT.

59. Ventricular Flutter and Fibrillation
 Immediate nonsynchronized DC electrical shock
using 200 to 400 J is mandatory therapy for:
 ventricular Fibrillation (VF)
 ventricular flutter
 pulseless VT.

61. Thank you
Any question?

62. Osborn wave in Hypothermia

63. A 76-year-old woman with a history of dementia and coronary
heart disease was brought to the emergency department after
she had been found lying outdoors for an undetermined
period; her core body temperature was 26°C (78.8°F) at
presentation.
An electrocardiogram showed prominent Osborn waves, also
known as J waves (Panel A, arrows), along with prolonged
QRS duration and corrected QT interval.
Hypothermia induces an increase in the activity of the cardiac
transient outward potassium current, which is more prominent
in the epicardium than in the endocardium. This
heterogeneous distribution of potassium current results in J
waves that are typically observed in the inferior and lateral
precordial leads, as seen in this patient.
After the patient was rewarmed for 12 hours, the J waves
disappeared, and the QT interval and QRS duration
normalized
Osborn wave in Hypothermia

64. Frog sign
“Frog Sign” in Atrioventricular
Nodal Reentrant Tachycardia

65. Frog sign
“Frog Sign” in Atrioventricular
Nodal Reentrant Tachycardia

66. Frog sign
“Frog Sign” in Atrioventricular
Nodal Reentrant Tachycardia

67. An 83-year-old man with frequent palpitations.
Examination of the neck revealed rapid and regular pulsations
with bulging of the internal jugular veins.
ECG showed a regular, narrow-complex tachycardia, with
narrow P waves deforming the terminal QRS complex.
On the application of pressure to the carotid sinus, sinus rhythm
was restored.
The arrhythmia is an AV nodal reentrant tachycardia.
In its typical form, anterograde conduction occurs over the slow
pathway to the ventricle, while near-simultaneous atrial
activation occurs over the fast pathway of the AV node.
These events lead to the parallel contraction of the atria and
ventricles against closed atrioventricular valves, causing a reflux
of blood into the neck veins (frog sign).
Frog sign