Antiarrhythmic

Agents

Overview
What is an arrhythmia?
Types and causes of arrhythmias
Management of arrhythmias
Classes of antiarrhythmic agents
Drugs used to prevent arrhythmias
Amiodarone
Lidocaine

Summary

What is an Arrhythmia?
An irregular rate or rhythm of the heart beat
Arrhythmias are caused by problems with the
hearts electrical conduction system
Abnormal or extra signals
Electrical signals may be blocked or slowed
Electrical signals may travel in new or
different pathways

There are many different types of

arrhythmias that range in severity

Types of Arrhythmias
Atrial
Fibrillation
Most common: type of
arrhythmia
Involves fast and irregular
contraction of the atria
Instead of the hearts
electrical signal
originating at the SA
node, the signal travels
through a disorganized
pathway throughout the

Types of Arrhythmias
Atrial
Flutter:
Heart beat is very rapid, but regular
Organized circuit around the right atrium causes
rapid atrial contraction (250-350 bpm)

Ventricular
Fibrillation:
An erratic, disorganized firing of impulses from the
ventricles
Heart rhythm is irregular
The ventricles are unable to contract or pump
blood to the body

Types of Arrhythmias
Ventricular
Tachycardia:

A rapid, regular heart rhythm that orientates

from the ventricles
Electrical impulses circulate in an endless loop
The rapid rate prevents the heart from filling
adequately with blood and less blood is
pumped through the body
Ventricles can beat up to 120-300 bpm and
are no longer coordinated with the atria

Types of Arrhythmias
Normal
Rhythm
Tachycardia

Ventricular
Fibrillation

Principles of Human Physiology. Germann and

Stanfield. Benjamin Cummings

Causes of Arrhythmias
Heart attack, heart failure
Abnormal levels of potassium
Alcohol, caffeine, stimulants
Beta-blockers
Cigarette smoking
Drugs that mimic the activity of the nervous
system
Medications used for depression

Management of
Arrhythmias
Include both nonpharmacologic and
pharmacologic therapies
Non-pharmacologic Therapy
Primarily for VF and VT that
may cause cardiac arrest
(considered shockable
rhythms)
Defibrillation is the only
way to return a heart to its
normal rhythm- regulates
electrical impulses

http://en.wikipedia.org/wiki/File:D
efibrillation_Electrode_Position.jpg

Management of
Arrhythmias

Pharmacologic Therapies
Sympathomimetics

Epinephrine (Causes vasoconstriction, increases blood flow

to brain during cardiac arrest)

Vasopressin
Also known as antidiuretic hormone
Same effects as epinephrine

Thrombolytics
Antiarrhythmic agents
Can help prevent VT and VF that may lead to cardiac arrest
5 classes according to Vaughn-Williams classification
system

Classes of Antiarrhythmic
Agents
CLASS I: Sodium Channel Blockers
These drugs bind to and block the fast sodium
channels that are responsible for the rapid
depolarization phase of the cardiac action
potentials
Increased duration of the cardiac action potential
Subdivided into 3 sub-classes:
IC>IA>IB
Used to manage atrial fibrillation, atrial flutter,
and ventricular tachycardia
Examples: Quinidine, Lidocaine, Propafenone

Classes of Antiarrhythmic
Agents
CLASS II: Beta Blocking Agents
Blocks sympathetic activity through the beta
adrenoceptor
Increases refractory period of atrial and AV
tissue to slow contraction
Examples: Propranolol, Metroprolol, Atenolol

Classes of Antiarrhythmic
Agents
CLASS III: Potassium Channel Blockers
Bind and block K+ channels responsible for
repolarization of the cell after an action potential
Prevents re-entrant arrhythmias by
lengthening the refractory period
Re-entrant rhythm is less likely to occur with
tissue that is still in the refractory phase
(suppresses tachyarrhythmias)
Examples: Amiodarone, Ibutilide, Sotalol (also
a B-blocker)

CLASS IV: Calcium Channel Blockers (CCBs)

Bind to L-type Ca2+ channels on vascular smooth
muscle, cardiac myocytes, nodal tissue to regulate Ca 2+
influx
Decrease the firing rate of pacemaker cells in the heart
and decrease conduction velocity prolonging repolarization
Help to block re-entry mechanisms at the AV node
(preventing supraventricular tachycardia)
Examples: Dihydropyridines, Verapamil, Diltiazem

Classes of Antiarrhythmic
Agents
CLASS V: Unknown Mechanisms
Suspected mechanism is via direct
nodal inhibition
Used to treat supraventricular
arrhythmias, especially during heart
failure and atrial fibrillation
Examples: Digoxin, Adenosine,
Magnesium Sulfate

Amiodarone
Class III antiarrhythmic (K+ channel blocker), with effects
from other classes
Indication: Ventricular arrhythmias
Good absorption (lipophilic), long elimination phase
Side effects: pulmonary fibrosis, hepatic/thyroid toxicity

http://e-pid.pharmacists.ca

Lidocaine
Class IB antiarrhythmic (Na+
channel blocker)
Indication: Ventricular
tachycardia
IV preferred (unpredictable firstpass metabolism when
administered orally)

http://static.enotes.com/images/n
ursing/genh_03_img0251.jpg

Systemic lidocaine
administration- reduces
incidence of premature action
potentials originating in cardiac
muscle

Summary
An arrhythmia is an irregular rate or rhythm of the heart
beat caused by problems with the hearts electrical
conduction system
The four types of arrhythmias are: ventricular
defibrillation, ventricular tachycardia, atrial flutter, atrial
defibrillation
There are four classes of antiarrhythmic agents:
Class
Class
Class
Class
Class

I (A,B,C) Sodium channel blockers

II Beta blocking agents
III Potassium channel Blockers
IV Calcium channel blockers
V Unknown mechanisms

The two main drugs used to treat arrhythmias are

Lidocaine (Class IB) and Amiodarone (Class III)

References
Campbell, T. J. & Williams, K. M. (1998). Therapeutic drug monitoring: Antiarryhthmic drugs.
Br J Clin Pharmacol, 46: 307- 319.
Cardiovascular Pharmacology Concepts (2009) Antiarrhythmic Classes. [online] Available at:
www.cvpharmacology.com [Accessed: October 2012].
DiPiro, J., Talbert, R. L., Yee, G., Matzke, G., Wells, B., & Posey, L. M. Pharmacotherapy, A
Pathophysiologic Approach. 8e. McGraw-Hill Medical, 2011. Print.
Goodacre, S. & Irons, R. (2002). ABC of clinical electrocardiography: Atrial arrhythmias. Brit
Med J 324: 590-594.
Stanfield, C. L, & Germann, W. J. Principles of Human Physiology. 3. London, England:
Benjamin Cummings, 2007. Print.
Todd, D. W. (2003). A review of the class III antiarrhythmic agents and their uses and
implications for patient management. J oral maxil surg 61: 928-931
Tung, R., Boyle, N,G., & Shivkumar, K. (2010). Catheter ablation of ventricular tachycardia.
Circulation 122: 389-391.