2Drug List Class 1 Sodium Channel Blockers Class 2 Beta-blockers Potassium Channel blockersClass 4Calcium Channel BlockersOthers1aProcainamideQuinidineMetoprololPropranololAmiodoroneIbutilideDofetilideSotalolVerapamilDiltiazemAdenosineMagnesiumDigoxin1bLidocaineMexiletinePhenytoin1cFlecainideMore drugs have been mentioned in other slides
3Physiology ReviewTo function efficiently, heart needs to contract sequentially (atria, then ventricles) and in synchronyRelaxation must occur between contractionsCoordination of heartbeat is a result of pacemaker activity of the SA node and transfer of impulses through AV node and the purkinje system
4Arrhythmia A condition where there is a disturbance in Pacemaker impulse formationImpulse conductionCombination of the twoResults in change of heart rate or contraction of heart muscle in a way that is insufficient to maintain normal cardiac outputTo understand how antiarrhythmic drugs work, need to understand electrophysiology of normal contraction of heart
5Ventricular Arrhythmia Ventricular arrhythmias are common in most people and are usually not a problem but…VA’s are most common cause of sudden deathMajority of sudden death occurs in people with neither a previously known heart disease nor history of VA’sMedications which decrease incidence of VA’s do not decrease (and may increase) the risk of sudden death treatment may be worse then the disease!
6Electrophysiology - resting potential A transmembrane electrical gradient (potential) is maintained, with the interior of the cell negative with respect to outside the cellCaused by unequal distribution of ions inside vs. outside cellNa+ higher outside than inside cellCa+ much higher “ “ “ “K+ higher inside cell than outsideMaintenance by ion selective channels, active pumps and exchangers
7ECG (EKG) showing wave segments Contraction of ventriclesECG (EKG) showing wave segmentsRepolarization of ventriclesContraction of atria
8Cardiac Action Potential Divided into five phases (0,1,2,3,4)Phase 4 - resting phase (resting membrane potential)Phase cardiac cells remain in until stimulatedAssociated with diastole portion of heart cycleAddition of current into cardiac muscle (stimulation) causesPhase 0 – opening of fast Na channels and rapid depolarizationDrives Na+ into cell (inward current), changing membrane potentialTransient outward current due to movement of Cl- and K+Phase 1 – initial rapid repolarizationClosure of the fast Na+ channelsPhase 0 and 1 together correspond to the R and S waves of the ECG
9Cardiac Action Potential Phase 2 - plateau phasesustained by the balance between the inward movement of Ca+ and outward movement of K +Has a long duration compared to other nerve and muscle tissueNormally blocks any premature stimulator signals (other muscle tissue can accept additional stimulation and increase contractility in a summation effect)Corresponds to ST segment of the ECG.Phase 3 – repolarizationK+ channels remain open,Allows K+ to build up outside the cell, causing the cell to repolarizeK + channels finally close when membrane potential reaches certain levelCorresponds to T wave on the ECG
10Differences between nonpacemaker and pacemaker cell action potentials Pacemaker Cells - Slow, continuous depolarization during restContinuously moves potential towards threshold for a new action potential (called a phase 4 depolarization)
11Mechanisms of Cardiac Arrhythmias Result from disorders of impulse formation, conduction, or bothCauses of arrhythmiasCardiac ischemiaExcessive discharge or sensitivity to autonomic transmittersExposure to toxic substancesUnknown etiology(1) Disturbances in impulse formation, (2) Disturbances in impulse conduction, or (3) Both. Factors can precipitate or exacerbate arrhythmias: Ischemia, hypoxia, acidosis or alkalosis, electrolyte abnormalities, excessive catecholamine exposure, autonomic influences, drug toxicity (eg, digitalis or antiarrhythmic drugs), overstretching of cardiac fibers, and the presence of scarred or otherwise diseased tissue
12Types of arrhythmias Tachyarrythmias Bradyarrhythmia Atrial: A fibrillation, Aectopics, Atrial tachycardiaNodal: Supraventricular TachycardiaSinus Tachycardiaventricular: Ventricular Tachycardia , ventricular ectopics,Ventricular fibrillation or flutter
13Brady arrhythmia:Heart rate is less than 60 except in (athletes)Heart blockSinus brady -cardia
14Antiarrhythmic drugsBiggest problem – antiarrhythmics can cause arrhythmia!Example: Treatment of a non-life threatening tachycardia may cause fatal ventricular arrhythmiaMust be vigilant in determining dosing, blood levels, and in follow-up when prescribing antiarrhythmics
15Classification of Antiarrhythmic Drugs Class I: Sodium channel blockers (membrane-stabilizing agents) 1 a: Block Na+ channel and prolong action potential 1 b: Block Na+ channel and shorten action potential 1 c: Block Na + channel with no effect on action potential Class II: β- blockers Class III: Potassium channel blockers (main effect is to prolong the action potential) Class IV: Slow (L-type) calcium channel blockersClass I -membrane- stabilising agents (sodium channel blockers) ( a ) Block Na + channel and prolong action potential Quinidine , disopyramide , procainamide ( b ) Block Na + channel and shorten action potential Lidocaine , mexiletine ( c ) Block Na + channel with no effect on action potential Flecanide , propafenone Class II - β- adrenoceptor antagonists ( β- blockers) Atenolol , bisoprolol , metoprolol , I- sotalol Class III -drugs whose main effect is to prolong the action potential Amiodarone , d- sotalol Class IV -slow calcium channel blockers Verapamil , diltiazem
16Class 1a DrugsThey are the oldest group of antiarrhythmic drugs and are still widely used.ProcainamideBlocks sodium channels, slows the upstroke of the action potential, slows conduction, prolongs the QRS duration of the ECG.The drug also prolongs the action potential duration by nonspecific blockade of potassium channels.Procainamide has direct depressant actions on sinoatrial and atrioventricular nodes
17ProcainamideExtracardiac Effects Procainamide has ganglion-blocking properties. This action reduces peripheral vascular resistance and can cause hypotension, particularly with intravenous use. Pharmacokinetics: Absorbed well orally. Metabolized in liver ,portion of the drug can be acetylated to NAPA which has little class 3 activity it is excreted by kidney . Toxicity : QT interval prolongation, and induction of torsade de pointes arrhythmia and syncope. New arrhythmias can be precipitated. Lupus erythmatosus, Pleuritis , pericarditis, or parenchymal pulmonary disease. Nausea and diarrhea (in about 10% of cases), rash, fever, hepatitis (< 5%) Therapeutic Use : Therapeutic Use Atrial and ventricular arrhythmiasSlide 11:Extracardiac Effects Procainamide has ganglion-blocking properties. This action reduces peripheral vascular resistance and can cause hypotension, particularly with intravenous use.Pharmacokinetics:Pharmacokinetics Absorbed well orally Metabolised in liver and excreted by kidney N-acetylprocainamide (class 3 ) Torsade de pointes .Toxicity :Toxicity Cardiotoxic Excessive action potential prolongation, QT interval prolongation, and induction of torsade de pointes arrhythmia and syncope. New arrhythmias can be precipitated. Lupus erythematosus Pleuritis , pericarditis, or parenchymal pulmonary disease. Renal lupus is rarely induced by procainamide Nausea and diarrhea (in about 10% of cases), rash, fever, hepatitis (< 5%), and agranulocytosis (approximately 0.2%).Therapeutic Use :Therapeutic Use Atrial and ventricular arrhythmias
18Quinidine Similar to procainamide. Also blocks K+ channels. Adverse effectsAnticholinergic (i.e. anti-muscarinic), blocks α receptors.Diarrhea , nauseaA syndrome of headache, dizziness, and tinnitus (cinchonism) is observed at toxic drug concentrations.Excessive QT interval prolongation and induction of torsade de pointes arrhythmia. Toxic concentrations of quinidine also produce excessive sodium channel blockade with slowed conduction throughout the heart.Not very commonly used these days and largely replaced by calcium antagonists in clinical practice
19Class 1b DrugsLidocaine Block Na + channel and shorten action potential duration. Lidocaine has a low incidence of toxicity. A high degree of effectiveness in arrhythmias associated with acute myocardial infarction. It is used only by the intravenous route. Cardiac Effects Lidocaine blocks activated and inactivated sodium channels with rapid kinetics it shorten the period of repolarization (phase 3) thereby the period of action potential ,it has no effect in refractory period . Adverse effects: Lidocaine is one of the least cardiotoxic of the currently used sodium channel blockers .it shows little impaiment to left ventricular function and no negative iontropic effect,Paresthesias, nausea of central origin, lightheadedness, hearing disturbances. In preexisting heart failure, lidocaine may cause hypotensionLidocaine (Subgroup 1B) :Lidocaine (Subgroup 1B) 1B: Block Na + channel and shorten action potential Lidocaine has a low incidence of toxicity A high degree of effectiveness in arrhythmias associated with acute myocardial infarction. It is used only by the intravenous route.Slide 19:Cardiac Effects Lidocaine blocks activated and inactivated sodium channels with rapid kinetics Toxicity Lidocaine is one of the least cardiotoxic of the currently used sodium channel blockers Paresthesias, tremor, nausea of central origin, lightheadedness, hearing disturbances, slurred speech, and convulsions. preexisting heart failure, lidocaine may cause hypotensionPharmacokinetics:Pharmacokinetics Extensive first-pass hepatic metabolism Lidocaine must be given parenterally Lidocaine has a half-life of 1–2 hours. Heart failure , liver failure Therapeutic Use: Lidocaine is the agent of choice for termination of ventricular tachycardia and prevention of ventricular fibrillation after cardioversion in the setting of acute ischemia
20Class 1b Drugs Pharmacokinetics: Extensive first-pass hepatic metabolism Lidocaine must be given parenterally ,Lidocaine has a half-life of 1–2 hours.Therapeutic Use: Lidocaine is the agent of choice for termination of ventricular tachycardia and prevention of ventricular fibrillation after cardioversion in the setting of acute ischemia (Myocardial infarction)
21Mexiletine (1b)Mexiletine is given orally. Its electrophysiologic and antiarrhythmic actions are similar to those of lidocaine.Therapeutic use: Treatment of ventricular arrhythmias associated with pervious MI. Pain due to diabetic neuropathy and nerve injury.Adverse effects: Tremor , blurred vision, and lethargy. Nausea
22Tocainde (1b) Similar to Mexilitine and Lidocaine It is used for treatment of ventricular tachy- arrhythmiasCan lead to plumonary fibrosis
23Phenytoin (1b)It is an other agent in this category and is usually used to treat ventricular arrhythmias caused by cardiac glycosides
24Class 1c DrugsFlecainide Blocks Na+ channel with no effect on action potential. Flecainide is a potent blocker of sodium and potassium channels. (Note that although it does block certain potassium channels, it does not prolong the action potential or the QT interval). It has no antimuscarinic effects, it prolong the effective refractory period. It suppress the upstroke of phase 0 in purkinji fibers and all myocardial tissues It shows depression of conduction in all cardiac cells Automaticity is reduced by an increase in threshold potential It has prominent effect even in normal heart Recent data have cast serious doubt about safety of this class
25Class 1c DrugsPharmacokinetics: Flecainide is well absorbed and has a half-life of approximately 20 hours. Elimination is both by hepatic metabolism and by the kidneyTherapeutic Uses: Premature ventricular contractions. Atrial fibrillation (AF), Wolf Parkinson White (WPW) syndromeToxicity: Arrhythmia, can aggravate congestive heart failure because it has a negative ionotropic effect
26Class 1c Drugs Propafenone This drug is similar to Flecainide, slows conduction in all cardiac cells and is considered broad spectrum anti-arrhythmic agent.
27Class 2 Drugs. Beta Blockers PROPRANOLOL: Suppress adrenergically mediated ectopic activity. Drugs have antiarrhythmic properties by virtue of their β -receptor–blocking action and direct membrane effects Some of these drugs have selectivity for cardiac β 1 receptors e.g. metoprolol, Some have intrinsic sympathomimetic activity e.g. pindolol. Some have marked direct membrane effects, and some prolong the cardiac action potential These agents can prevent recurrent infarction and sudden death in patients recovering from acute myocardial infarction.
28Class 2 Drugs. Beta Blockers Therapeutic Uses: Sinus tachycardia, Atrial/ nodal extrasystole. Pheochromacytoma. Arryhthmia due to halothane /digitalis. WPW syndrome Esmolol is a short-acting β blocker used primarily as an antiarrhythmic drug for intraoperative and other acute arrhythmias Sotalol is a nonselective β -blocking drug that prolongs the action potential.
29Class 3 Antiarrhythmic Drugs Amiodarone Amiodarone markedly prolongs the action potential duration (and the QT interval on the ECG) Amiodarone also significantly blocks inactivated sodium channels.Amiodarone also has weak anti-adrenergic and calcium channel blocking actionsExtracardiac Effects Amiodarone causes peripheral vasodilation.
30PharmacokineticsIncompletely and slowly absorbed orally. It undergoes hepatic metabolism, and the major metabolite, desethylamiodarone, is bioactive. The elimination half-life is complex. The drug accumulates in many tissues, including the heart (10–50 times more so than in plasma), lung, liver, and skin, and is concentrated in tearsTherapeutic Use: Recurrent ventricular tachycardia, atrial fibrillation.Rapid termination of supraventricular tachycardia (SVT), ventricular tachycardia (VT) and WPW syndromeWorks on both supraventricular and ventricular arrhythmias.
31Amiodarone adverse effects Fatal pulmonary fibrosisAbnormal liver function tests and hepatitisPhotodermatitis and a gray-blue skin discoloration in sun-exposed areas (smurf skin)Corneal micro-deposits and discolorationOptic neuritis: Halos develop in the peripheral visual fields, may progress to blindnessHypothyroidism or hyperthyroidismBradycardia and heart blockIbutilide Dofetilide Sotalol Vernakalant Dronedarone
32Class 4 Antiarrhythmic Drugs Calcium Channel-Blocking Drugs Verapamil:Cardiac Effects. Verapamil blocks both activated and inactivated L-type calcium channels.AV nodal conduction time and effective refractory period are prolonged.Slows the SA node by its direct actionExtracardiac Effects. Peripheral vasodilation (Less than nifedipine)Pharmacokinetics: Absorbed orally. It is extensively metabolized by the liverTherapeutic Use. Supraventricular tachycardia. Atrial fibrillation and flutter
33Miscellaneous Antiarrhythmic Agents These include digitalis, adenosine, and magnesiumAdenosineMechanism of Action:Adenosine is a nucleoside that occurs naturally throughout the body. Its half-life in the blood is less than 10 seconds. Activation of acetylcholine sensitive K + channels and inhibition of calcium current.Atrioventricular nodal conduction and the atrioventricular nodal refractory period. It is drug of choice (DOC) for conversion of paroxysmal supraventricular tachycardia to sinus rhythm. High efficacy (90–95%) and very short duration of action.Adverse effects: Flushing, shortness of breath or chest burning, high-grade atrioventricular block. Atrial fibrillation may occur. Headache, hypotension, nausea, and paresthesias
34Magnesium Mechanism of action is not known. USES: Digitalis -induced arrhythmias.Torsade de pointes even if serum magnesium is normal.
35PacemakersSurgical implantation of electrical leads attached to a pulse generatorOver 175,000 implanted per yearLeads are inserted via subclavian vein and advanced to the right side of the heartTwo leads used, one for right atrium, other for right ventriclePulse generator containing microcircuitry and battery are attached to leads and placed into a “pocket” under the skin near the claviclePulse generator sends signal down leads in programmed sequence to contract atria, then ventriclesPulse generator can sense electrical activity generated by the heart and only deliver electrical impulses when needed.Pacemakers can only speed up a heart experiencing bradycardia, they cannot alter a condition of tachycardia