Atrial

Arrhythmia

Vivian Phyo, PharmD

PGY-2 Internal Medicine
Learning Objectives
1. Compare the electrical activities of
atrial fibrillation and atrial flutter
2. Recognize symptoms and
complications associated with
atrial arrhythmia
3. Identify the four main classes of
antiarrhythmic medications
4. Summarize the general mechanism
of action, clinical indication, and
adverse effects of each
antiarrhythmic agent

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Background
 Classifications
Atrial Fibrillation (AF)

Atrial Flutter (A flutter)

Atrial Arrhythmia
AV Re-Entrant Tachycardia
(AVRT)
AV Nodal Re-Entrant
Tachycardia (AVNRT)

Sinus Tachycardia

Atrial Tachycardia

Heart Block
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Barton AK, et al. Prescriber. 2020;31(3):11-17
AF vs A flutter

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American Heart Association. What are the Symptoms of Atrial Fibrillation? Updated Mar 27, 2023. Accessed Oct 16, 2023
Symptoms
• General • Fluttering or
weakness “thumping” in the 2x heart-related deaths
chest 5x fold risk of stroke!
• Exercise
intolerance • Chest pain/
pressure

Fatigue Palpitation

• + Anxiety • Lightheadedness
• Diaphoresis

Shortness
Dizziness
of Breath 6
American Heart Association. What are the Symptoms of Atrial Fibrillation? Updated Mar 27, 2023. Accessed Oct 16, 2023
 Anti-
arrhythmics
Overview
Cardiac Action Potential

8
King GS, et al. Antiarrhythmic Medications. [Updated Feb 19, 2023]. In: StatPearls [Internet]. Accessed Oct 16, 2023.
Class 1:
Na+ Channel Blocker
Class Ia Class Ib Class Ic
Quinidine Procainamide Lidocaine Mexiletine Flecainide Propafenone
Class - Moderate degree of blockage - Mild degree of blockage - Strong degree of blockage
overview - AF, A flutter, supraventricular and - Ventricular arrhythmias only, - Contraindicated in structural or
ventricular tachyarrhythmias especially post-myocardial ischemic heart disease (e.g., HFrEF,
- QTc prolongation infarction MI)
Clinical - Brugada syndrome - Wolff- - Long QT - Supraventricular tachycardia
place - short QT syndrome Parkinson-White syndrome - AF/A flutter: “Pill-in-the-pocket”
on BB or CCB
Adverse - anticholinergic - Lupus-like - CNS toxicity - CNS toxicity - Blurry vision - Nausea/
effects (moderate) syndrome - hypotension - GI toxicity - Dizziness vomiting
- cinchonism - QTc shortening

Clinical 200 mg of sulfate (IR) = - IV only - Oral only

pearls 267 mg of gluconate - Therapeutic: - Therapeutic:
(ER) 1.5-5 mcg/mL 0.5-2 mcg/mL

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Class 2:
Beta Blocker
Atenolol* Bisoprolol Carvedilol Esmolol Labetalol Metoprolol Propranolol
MOA Blocks beta-adrenoreceptors, prevent the action of catecholamines in the heart
Indirectly prevents calcium entry into myocardial cells
- negative inotropic and chronotopic effects
Cardioselectivity Yes Yes No - α1 Yes No – α1 Yes No - β2
Clinical place - First-line antiarrhythmic
Adverse effects - Risk of bronchoconstriction (especially non-cardioselective agents)
- Higher degree of AV block (i.e., Mobitz II and 3rd degree)
- Fatigue
- Sleep disturbance (less risk with hydrophilic agent*)
- Sexual dysfunction and erectile dysfunction
Clinical pearl First-line reversal: glucagon

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 Class 3:
K+ Channel Blocker
Amiodarone Dronedarone Sotalol Dofetilide Ibutilide
Class Primarily blocks phase 3 repolarization K+ channels
MOA - slow repolarization by slowing conduction increasing action potential and refractory period duration and
- seen as a prolonged QT interval on the ECG (major monitoring parameter)
Unique - Have class 1, 2, and 4 effects, and α-blocking - Have class 2 effect
MOA activity - Have class 3 effect
(> 160 mg/day)
Clinical Atrial and ventricular Atrial arrhythmia Atrial and ventricular Atrial arrhythmia
place arrhythmia arrhythmia
- Preferred in structural Contraindicated in Contraindicated in HF - Safe use in structural - Pharmacological
heart disease permanent AF or heart disease cardioversion ONLY
- Pharmacological symptomatic HF - Pharmacological
cardioversion cardioversion
Adverse See image See image (except Bradycardia, dizziness Headache Nausea, headache,
effects thyroid dysfunction) renal failure
Clinical Half-life: 40-55 days Half-life: 13-19 hours - Initiation requires hospitalization for > 3 days for cardiac IV only
pearls (QD dosing) (BID dosing) monitoring
- Renally eliminated 11
Amiodarone
Side-effects

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Class 4:
Ca2+ Channel Blocker
(Non-dihydropyridine)
Diltiazem Verapamil*
MOA Prevents influx of calcium during depolarization
- Decrease conduction through the AV node and overall cardiac contractility
Clinical place - Ventricular rate control in acute and chronic AF and atrial flutter
- Hemodynamically stable SVT
- Alternative to beta-blockers (caution in concomitant use)
Adverse effects - Flushing and headache
- Dizziness
- Bradycardia
- *Constipation, rash, nausea
Clinical pearl *Greater selectivity to cardiac tissue

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 AFFIRM
A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation
Purpose To compare rate vs rhythm control approach long-term in patients with nonvalvular AF
Design Multicenter, parallel-group RCT
Rate-control (n=2027): β-blocker, CCBs, digoxin
Rhythm-control (n=2033): anti-arrhythmic (majority: amiodarone)
Mean duration of follow-up: 3.5 years
Inclusion Age > 65 with AF that was likely to be recurrent and have other risk factors for stroke
Outcome
Subgroup analysis
Rhythm-control strategy was associated with higher
risk of death than the rate-control strategy among:
- older patients
- patients with CAD
- patients without HF

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Guide

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 THANK
YOU
Vivian Phyo
PGY-2 Internal Medicine
Pharmacy Resident

2/1/20XX PRESENTATION TITLE 16