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K.7 Pharmacology of Anti-Arrhytmic Drugs
K.7 Pharmacology of Anti-Arrhytmic Drugs
K.7 Pharmacology of Anti-Arrhytmic Drugs
anti-arrhytmic drugs
• Irregular rhythm
• Abnormal Rate
• Conduction abnormality
What causes an arrhythmia?
• Changes in automaticity of the PM
• Ectopic foci causing abnormal APs
• Reentry tachycardias
• Block of conduction pathways
• Abnormal conduction pathways (WPW)
• Electrolyte disturbances and DRUGS
• Hypoxic/Ischaemic tissue can undergo
spontaneous depolarisation and become an
ectopic pacemaker
Normal heartbeat and atrial arrhythmia
AV septum
Definition of arrhythmia
• Cardiac arrhythmia is an abnormality of the
heart rhythm
• Bradycardia – heart rate slow (<60 beats/min)
• Tachycardia – heart rate fast (>100 beats/min)
Spontaneous
depolarisation
Cardiac Action Potential
• Divided into five phases (0,1,2,3,4)
– Phase 4 - resting phase (resting membrane potential)
• Phase cardiac cells remain in until stimulated
• Associated with diastole portion of heart cycle
• Phase 3 – repolarization
– K+ channels remain open,
– Allows K+ to build up outside the cell, causing the cell to repolarize
– K + channels finally close when membrane potential reaches certain level
– Corresponds to T wave on the ECG
Contraction of
ECG (EKG) ventricles
showing
wave segments
Repolarization of
Contraction
ventricles
of atria
Cardiac Na+ channels
Therapeutic overview
• Na+ channel blockade
• β-adrenergic receptor blockade
• Prolong repolarization
• Ca2+ channel blockade
• Adenosine
• Digitalis glycosides
Vaughan-Williams Classification
Class Mechanism Example
ECG : P – R interval
Memanjang
QRS Comp
Q – T interval → torsade de pointes.
Farmakokinetik:
- diserap per-oral komplit
- 80 % berikatan dengan plasma protein
Kontra – Indikasi
A.V Block
C.H.F
Hipotensi
Hati – hati :
pemberian digitalis
hiperkalemia
miastenia gravis == why ?
Prokainamid :
- efek hampir = kinidin dengan perbedaan
- sumber
- antimuskarinik <<
- asetilasi dilever ada yang fast ada yang
rapid acetylator.
- menimbulkan lupus (80% akan mendapat
titer anti nuklear yang tinggi 30%
lupus )., dose-related, biasanya pada yang
slow acetylator.
- dosis besar : agranulositosis.
Classification of antiarrhythmics
(based on mechanisms of action)
– Subclass IB
• Weak Phase 0 depression
• Shortened depolarization
• Decreased action potential duration
• Includes
– Lidocane (also acts as local anesthetic) – blocks
Na+ channels mostly in ventricular cells, also
good for digitalis-associated arrhythmias
– Mexiletine - oral lidocaine derivative, similar
activity
– Phenytoin – anticonvulsant that also works as
antiarrhythmic similar to lidocane
Lignocaine (Lidocaine)
• Class Ib (blocks Na+ channels, reduces AP duration)
• Ventricular arrhythmias (acute Rx)
• IV infusion only (2 hour half life, high first pass
metabolism)
• Hepatic metabolism (inhibited by cimetidine,
propranolol)
• SE mainly CNS - drowsiness, disorientation,
convulsions, hypotension
Classification of antiarrhythmics
(based on mechanisms of action)
– Subclass IC
• Strong Phase 0 depression
• No effect of depolarization
• No effect on action potential duration
• Includes
– Flecainide (initially developed as a local anesthetic)
» Slows conduction in all parts of heart,
» Also inhibits abnormal automaticity
– Propafenone
» Also slows conduction
» Weak β – blocker
» Also some Ca2+ channel blockade
Flecainide
• Class Ic (block Na+ channels, no change to AP)
• Slows conduction in all cardiac cells
• Acute Rx /prophylaxis
• Supraventricular tachycardias
• Paroxysmal atrial fibrillation
• Ventricular tachycardias
• Oral/IV
• Long acting (T1/2 14 hours)
• Hepatic metabolism, urinary elimination
Flecainide
• CAST (Cardiac Arrhythmia Suppression Trial)
1989 – increased mortality post MI (VF
arrest)
• Side-effects:
= cardiac failure,= ventricular-
arrhythmias,blurred vision, abdominal
discomfort, nausea, paraesthesia, dizzyness,
tremor, metallic taste
Classification of antiarrhythmics
(based on mechanisms of action)
• Class II – β–adrenergic blockers
– Based on two major actions
1) blockade of myocardial β–adrenergic receptors
2) Direct membrane-stabilizing effects related to Na+ channel
blockade
– Includes
• Propranolol
– causes both myocardial β–adrenergic blockade and
membrane-stabilizing effects
– Slows SA node and ectopic pacemaking
– Can block arrhythmias induced by exercise or apprehension
– Other β–adrenergic blockers have similar therapeutic effect
• Metoprolol Nadolol Atenolol
Acebutolol Pindolo Stalol
• Timolol Esmolol
Classification of antiarrhythmics
(based on mechanisms of action)
– Includes
• Verapamil – blocks Na+ channels in addition to
Ca2+; also slows SA node in tachycardia
• Diltiazem
Verapamil
• Class IV (calcium channel blocker)
• Prolongs conduction and refractoriness in AV node,
slows rate of conduction of SA node
• Used IV/oral
• SUPRAVENTRICULAR NOT VENTRICULAR
ARRHYTHMIAS (cardiovascular collapse)
• Do not use IV verapamil with ß- blocker (heart
block)
• T1/2 6-8 hours
Verapamil- adverse effects
• Heart failure
• Constipation
• Bradycardia
• Nausea
Adenosine
• Purine nucleoside
• Acts on A1 adenosine receptors
• Opens Ach sensitive K channels
• Inhibits Ca in current – Suppresses Ca dependent AP
(Nodal)
• Increases K out current – Hyperpolarisation
• Inhibits AVN > SAN
• Increases AVN refractory period
ADENOSINE
• Interrupts re-entry and aberrant pathways through AVN
– Diagnosis and Treament
• Drug for narrow complex PSVT
• SVT reliant on AV node pathway
• NOT atrial flutter or fibrillation or VT
• Contraindications:
• VT – Hypotension and deterioration
• High degree AV block
• Poison or drug induced tachycardia
• Bronchospasm but short DOA
ADENOSINE
• Carotid massage and vagal maneuvers first
• Rapid IV push 6mg – 12 mg – 12 mg
• Flush with 20ml N/S
• Record rhythm strip
• FLUSHING
• CHEST PAIN
• ASYSTOLE/BRADY
• VENTRICULAR ECTOPY
Adenosine- adverse effects
• Feeling of impending doom!
• Flushing, dyspnoea, chest pain, transient
arrhythmias
• Contraindicated in asthma, heart block
Digoxin
• Not in Vaughan Williams class