Antidysrhythmic Agents

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics
Dysrhythmia
Any deviation from the normal rhythm of the heart

Antidysrhythmics
Drugs used for the treatment and prevention of disturbances in cardiac rhythm

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Cardiac Cell
Inside the cardiac cell, there exists a net negative charge relative to the outside of the cell.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Resting Membrane Potential: RMP

This difference in the electronegative charge.
Results from an uneven distribution of ions (sodium, potassium, calcium) across the cell membrane. An energy-requiring pump is needed to maintain this uneven distribution of ions. Sodium-potassium ATPase pump
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Instructors may wish to insert: EIC Image # 61: Heart and Conduction System
EIC Image # 63: Resting Membrane Potential of a Cardiac Cell
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Action Potential
A change in the distribution of ions causes cardiac cells to become excited.
The movement of ions across the cardiac cells membrane results in the propagation of an electrical impulse. This electrical impulse leads to contraction of the myocardial muscle.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Action Potential
Four Phases
The SA node and the Purkinje cells each have separate action potentials.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Instructors may wish to insert: EIC Image # 64: Action Potentials: Phases (SA Node)
EIC Image # 65: Action Potentials: Purkinje Fiber EIC Image # 66: Action Potentials: Intervals
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

System commonly used to classify antidysrhythmic drugs

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class 1
Class Ia Class Ib Class Ic

Class II Class III

Class IV
Other
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class I
Membrane-stabilizing agents Fast sodium channel blockers Divided into Ia, Ib, and Ic agents, according to effects

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class I
moricizine
General Class I agent Has characteristics of all three subclasses Used for symptomatic ventricular and lifethreatening dysrhythmias

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class Ia quinidine, procainamide, disopyramide
Block sodium channels
Delay repolarization Increase the APD Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, ventricular tachycardia, Wolff-Parkinson-White syndrome
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class Ib
tocainide, mexiletine, phenytoin, lidocaine
Block sodium channels Accelerate repolarization Decrease the APD

Used for ventricular dysrhythmias only (premature ventricular contractions, ventricular tachycardia, ventricular fibrillation)
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Vaughan Williams Classification

Class Ic
encainide, flecainide, propafenone
Block sodium channels (more pronounced effect) Little effect on APD or repolarization Used for severe ventricular dysrhythmias

May be used in atrial fibrillation/flutter

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class II
Beta blockers: atenolol, esmolol, petaprolol, propranolol
Reduce or block sympathetic nervous system stimulation, thus reducing transmission of impulses in the hearts conduction system Depress phase 4 depolarization
General myocardial depressants for both supraventricular and ventricular dysrhythmias
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Vaughan Williams Classification

Class III
amiodarone, bretylium, sotalol, ibutilide
Increase APD Prolong repolarization in phase 3 Used for dysrhythmias that are difficult to treat

Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutterresistant to other drugs

Sustained ventricular tachycardia
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Class IV
verapamil, diltiazem
Calcium channel blockers Depress phase 4 depolarization Used for paroxysmal supraventricular tachycardia; rate control for atrial fibrillation and flutter

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Vaughan Williams Classification

Other Antidysrhythmics
digoxin, adenosine
Have properties of several classes and are not placed into one particular class

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics
Digoxin
Cardiac glycoside
Inhibits the sodium-potassium ATPase pump Positive inotropeimproves the strength of cardiac contraction Allows more calcium to be available for contraction Used for CHF and atrial dysrhythmias

Monitor potassium levels, drug levels, and for toxicity

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics
adenosine (Adenocard)
Slows conduction through the AV node Used to convert paroxysmal supraventricular tachycardia to sinus rhythm Very short half-life Only administered as fast IV push May cause asystole for a few seconds Other side effects minimal
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Antidysrhythmics: Side Effects

ALL antidysrhythmics can cause dysrhythmias!!
Hypersensitivity reactions
Nausea Vomiting Diarrhea Dizziness Blurred vision Headache
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Antidysrhythmics: Nursing Implications

Obtain a thorough drug and medical history.
Measure baseline BP, P, I & O, and cardiac rhythm.

Measure serum potassium levels before initiating therapy.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

Assess for conditions that may be contraindications for use of specific agents.
Assess for potential drug interactions.

Instruct patients regarding dosing schedules and side effects to report to physician.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

During therapy, monitor cardiac rhythm, heart rate, BP, general well-being, skin color, temperature, heart and breath sounds.
Assess plasma drug levels as indicated. Monitor for toxic effects.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

Instruct patients to take medications as scheduled and not to skip doses or double up for missed doses.
Patients who miss a dose should contact their physician for instructions if a dose is missed. Instruct patients not to crush or chew any oral sustained-release preparations.
Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

For class I agents, monitor ECG for QT intervals prolonged more than 50%.
IV infusions should be administered with an IV pump.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

Patients taking propranolol, digoxin, and other agents should be taught how to take their own radial pulse for 1 full minute, and to notify their physician if the pulse is less than 60 beats/minute before taking the next dose of medication.

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.

Antidysrhythmics: Nursing Implications

Monitor for therapeutic response:
Decreased BP in hypertensive patients Decreased edema Regular pulse rate or Pulse rate without major irregularities, or Improved regularity of rhythm

Copyright 2002, 1998, Elsevier Science (USA). All rights reserved.