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Digital PharmD

Informatics in Pharmacy

Choosing Antiarrhythmics

August 12, 2018 By Dr. G, PharmD

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  • In heart failure: only amiodarone and dofetilide
  • Wolfe Parkinson White: procainamide or ibutilide
  • Hypothyroid: non-DHP, avoid beta blockers
  • Pregnancy: digoxin, non-DHP, no warfarin or heparin
  • Do not use fenoldopam in patients with stroke, dopamine agonist can cause cerebral vasodilation and reduced blood flow to the brain
  • 1a agents cause Torsades, usually avoid in structural heart disease
  • 1b agents have little atrial affinity
  • Sotolol: 50/50 sodium and potassium blockade, Torsades, especially in renal disease
  • amio: TSH, pulmonary, liver, eyes, get baseline chest x-ray
Class Name VTach Vfib Afib Other Mech AE
1a disopyramide X X
  • block of both open Na & K
  • decrease membrane response
  • increases action potential duration
  • prolong both the QRS and QT
  • widens QRS
procainamide X X
  • widen QRS
  • agranulocytosis
  • drug-induced lupus
quinidine X X malaria
aflutter
  • QT prolongation
1b lidocaine X X
  • weak block of open & inactivated Na channels
  • slightly decreases action potential duration
  • little effect on the QRS
  • hypotension and seizure at high dose
mexiletine X
  • agranulocytosis
  • blurry vision
tocainide X
  • agranulocytosis
  • bone marrow supression
  • leukemia
1c flecainide X convert (rare) PSVT and
PAF
  • Strong block of open Na channels.
  • no change to action potential duration
  • large effect to prolong the QRS
  • hypokalemia
  • hypomagnesemia
  • worsen HFi
  • increase QRS
propafenone X PSVT and
PAF
  • increase QRS
  • neutropenia
  • agranulocytosis
II esmolol X X aflutter, ST,
HTN
  • Beta blockade
III amiodarone X X convert aflutter
PSVT
  • blocks K channels
  • prolongs action potential duration
  • decrease K
  • decrease Mg
  • QT prolongation
  • liver toxicity
  • thyroid toxicity
  • neuropathy
  • blue syndrome
dofetilide convert aflutter
  • increase QT
  • decrease HR
  • decrease K
ibutilide convert aflutter
  • increase QT
  • decrease HR
sotalol X X aflutter
  • increase QT
  • decrease HR
  • decrease K
IV diltiazem X aflutter
  • not in WPW
  • blocks Calcium channel
  • bradycardia
  • HB
  • worsens HF
  • sick sinus syndrome
verapmil X
Misc digoxin X aflutter
can be used in HF
  • increases vagal tone
  • narrow therapeutic index
  • decrease heart rate
  • HB
  • renal failure
  • hypokalemia
adenosine PSVT in pregnancy
  • adenosine receptor agonist
  • increases potassium and shortens AP
  • bronchospasm
  • when administered, there is a brief pause of asystole on the monitor
dronedarone X aflutter
  • blocks sodium channels
  • beta-blockade
  • blacks calcium channels
  • Class I, II, III, IV effects
  • prolongs action potential duration
  • worsens hearts failure
  • worsens liver disease
  • bradycardia
  • heart block
  • QT prolongation

This site has a great rundown on the mechanism and actions and how these agents shift the action potential. You probably don’t need to know all that for the BCPS. Just know how to pick an agent for a specific patient population.

Filed Under: Cardiology, Guideline Materials and Tips

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