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Medical University of Sofia, Faculty of Medicine
Department of Pharmacology and Toxicology
ANTIARRHYTHMIC DRUGS (Summary)
Assoc. Prof. Ivan Lambev
www.medpharm-sofia.eu BASIC ELECTROPHYSIOLOGY Myocardial cells maintain transmembrane ion gradients by movement of the Na+, Ca2+ and K+ through membrane channels. The resting potential of a cardiac cell is – 85 mV compared to the extracellular environment. Depolarization is initiated by a rapid influx of Na+ (phase 0). Rapid repolarization Plateau
Depolarization Final repolarization
Resting potential Spontaneous
depolarization In the AV node depolarization is due to the slower influx of calcium ions. This results in slower conduction of the impulse through the AV node than in other parts of the heart. During the period between phase 0 and the end of phase 2, the cell is refractory to the further depolarization (absolute refractory period) since the sodium channels are inactivated. During phase 3, a sufficiently large stimulus can open enough sodium channels to over- come the potassium efflux. This is the relative refractory period. Rapid repolarization
Plateau
Depolarization
Absolute Final repolarization
refractory period Relative refractory period Threshold potential Spontaneous depolarization
Resting membrane potential The cardiac action potential MECHANISMS OF ARRHYTHMOGENESIS
Arrhythmias can arise as the result of
abnormal impulse generation or abnormal impulse conduction. The main mechanisms:
•RE-ENTRY (the most frequently): if an
impulse arrives at an area of tissue when it is refractory to the stimulus, this impulse will be conducted by an alternative route. If the impulse again reaches the “blocked” tissue distally when it has had sufficient time to recover, the same impulse will be conducted retrogradely (re-entry). This retrograde conduction is slow, because to initiate a circuit of electrical acti- vity, the healthy tissue has to be given time to repolarize. Such a mechanism can initiate a selfperpetuating “loop” of electrical activity which acts as a pacemaker. The re-entry circuit can be localized within small a area of the myocardium or it can exist as a large circuit, for example between the atria and ventricles. •AUTOMATICITY Subsidiary (or ectopic) pacemakers may
Spontaneous depolarization develop when a site in the myocardium develops a more rapid phase 4 depolarization Threshold potential than the SA node, e.g. as a result of ischaemia. ANTIARRHYTHMIC DRUGS (AAD) I. AAD used in tachyarrhythmias
The Vaughan William’s
Classification of AAD is based on their effects on the cardiac action potential (AP). Class I (membrane stabilizers) These AAD slow the rate of raise of phase 0 of AP by inhibiting fast sodium channels. The class is subdivided according to the effects of drugs on the duration of AP. Indications: SV and ventricular arrhythmias.
IA IB IC Increase Decrease No effect on the duration of AP the duration the duration IA IB IC
Disopyramide Lidocaine Propafenone
Procainamide Mexiletine Flecainide Ajmaline Phenytoin - weak negative inotropic effect Quinidine ADRs: Bradycardia, AV block, (–) inotropic effect, disturbances of GIT, rashes Cinchona succirubra Rauwolfia serpentina •Quinidine •Ajmaline •Chinine •Reserpine Treatment: Lidocaine, Ajmaline Ventricular fibrillation, fibrillation characterized by irregular undulations without clear ventricular complexes. Treatment: Lidocaine or electrical defibrillation Ventricular flutter Class II (-adrenoceptor antagonists)
Reduce the rate
of spontaneous depo- larization of sinus and AV nodal tissue by indirect blockade ( cAMP) of calcium channels. Indications: SV and Pindolol, Propranolol ventricular arrhythmias. Atenolol, Esmolol Esmolol (short action)
Atrial flutter with a 4:1 conduction ratio.
Class III These AAD prolong the duration of the AP and increase the abso- Amiodarone (p.o.; i.v. inf.) t1/2 20–100 days ADRs: bradycardia, lute refractory period. hypo/hyper thyreoidism, This is the result of corneal micro-deposits under reduced influx of K+ pupil, neuritis n. opticus, pulmonary fibrosis. into the cell. Dronedarone (contains no iodine Ind: SV and ventri- but has hepatotoxic effect) cular arrhythmias. Sotalol, Bretylium Class IV (calcium channel antagonists) Mainly Verapamil (22% oral availability) and Diltiazem (i.v.) from calcium antagonists have specific action on the SA and AV nodes. They decrease the duration of AP. ADRs: headache, edema, Ind: SV arrhythmias. bradycardia, AV block Atrial fibrillation Other drugs used in tachyarrhythmias Adenosine inhibits AV conduction. The duration of effect is less than 60 s. •used as an i.v. bolus in SV tachycardia with narrow QRS complex. •ADRs: bradycardia, AV block.
Digoxin reduces conduction
through the AV node and is useful in the control of atrial flutter and atrial fibrillation. II. AAD used in bradyarrhythmias Atropine is given by bolus i.v. inj. in sinus brady-
Atropa belladonna L. cardia and AV block. It blocks M2-receptors and increases conduction through the AV node. Isoprenaline is used in AV block Pacemaker III. AAD used in Digitalis arrhythmia Phenytoin Digitalis purpurea
Digitalis lanata Potassium (foxglove) chloride Magnesium aspartate •Digoxin- specific FAB (Fragment AntiBody): Digibind® (38 mg connect 0,5 mg Digitoxin Digoxin) Digoxin PROARRHYTHMIC ACTIVITY OF AAD All AAD have the potential to precipitate serious arrhythmias, particularly ventri- cular tachycardia or fibrillation. Mainly the AAD from class IA prolong the Q–T interval which predisposes to the development of a polymorphic ventricular tachycardia known as “torsades de pointes”. Torsades de Pointes Polymorphic ventricular tachycardia with a twisting axis on the ECG Torsades de Pointes: Treatment Treat hypokalemia if it is the precipitating factor and administer magnesium sulfate in a dose of 2–4 g i.v. initially. Magnesium is usually very effective, even in the patient with a normal magnesium level. If this fails, repeat the initial dose, but because of the danger of hypermagnesemia (depression of neuromuscular function) the patient requires close monitoring. Other therapies include overdrive pacing and isoprenaline infusion. Most (75–82%) torsade de pointes rhythms are started by a pause. Pacing at rates up to 140 bpm may prevent the ventricular pauses that allow torsade de pointes to originate. The patient with torsade who is in extremis should be treated with electrical cardioversion or defibrillation . See: http://emedicine.medscape.com/article/760667-treatment
Get Cardiology-An Integrated Approach (Human Organ Systems) (Dec 29, 2017)_(007179154X)_(McGraw-Hill) 1st Edition Elmoselhi PDF ebook with Full Chapters Now
Get Cardiology-An Integrated Approach (Human Organ Systems) (Dec 29, 2017)_(007179154X)_(McGraw-Hill) 1st Edition Elmoselhi PDF ebook with Full Chapters Now
