Antidysrhythmic Drugs

Conditions Causing
Dysrhythmias
CAD HTN
MI DM
Cardiac Surgery Smoking
Valvular disease
Hypoxia
Caffeine
Electrolyte imbalance
Cold medicines
Acid/Base imbalance Irregular can also
Hypovolemia occur with normal
External forces heart
 Antidysrhythmics
Dysrhythmia
Any deviation from the
normal rhythm of the
heart
Anti-dysrhythmic
Drugs used for the
treatment and
prevention of
disturbances in cardiac
rhythm
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 Cardiac Action Potential
Brief change in voltage (membrane potential)
across the cell membrane of heart cells.
Caused by the movement of charged atoms
(called ions) between the inside and outside
of the cell, through proteins called ion
channels.
5 phases: 0-4
Heart Beat Night Club
 Vaughan Williams Classification
System commonly used to classify
antidysrhythmic drugs
Based on the electrophysiologic effect of
particular drugs on the action potential
 MOA: Classes of Anti-
dysrhythmic
I
Affect Na channels to increase AP
Some Block
II Potassium Channels
Beta-blockers; block beta- Sodium Channel
adrenergic receptors & Blockers
catecholamines (NE, Epi &
dopamine) Beta-blockers
III Potassium Channel
Affect K channels Blockers
IV
Calcium Channel
Affect Ca channels
V
Blockers
Others
 Vaughan Williams Classification
Class IA
Moderate block Na channel w/decrease Action
Potential
DOUBLE QUARTER POUNDER WITH CHEESE
DISOPYRAMIDE, QUINIDINE,
PROCAINAMIDE
 Vaughan Williams Classification
Class 1B
Mild block Na channels, decrease AP
LETTUCE, MAYO, PICKLES
LIDOCAINE, MEXILETINE, PHENYTOIN
 Vaughan Williams Classification
Class 1c
Marked block Na channels & No change in
action potential
Have BB effects (Propafenone)
Bradycardia, decrease cardiac inotropy
MORE FRIES PLEASE
MORICIZINE
FLECAINIDE
PROPAFENONE
 Vaughan Classification System
Class II: Beta-Blockers CARDIOPROTECTIVE
-blockers: atenolol, esmolol,
metoprolol, propranolol, nadolol, Uses
sotalol, acetabolol
Block beta-adrenergic receptors
Supraventricular &
Block catecholamines: Norepi,Epi, ventricular dysrhythmias
Dopamine Beneficial post-MI
Decrease myocardial need for O2
Can decrease ischemia Anti-anginal & anti-
Slows HR & contractility, delay AV hypertensive uses
conduction
Slows phase 4 depolarization which
can decrease automaticity of heart
 Vaughan
Class III Class IV
Block K channels Calcium Channel
AMIODARONE, Blockers
DRONEDARONE, DILTIAZEM,
SOTALOL, VERAPAMIL
IBUTELIDE, Other
DOFETILIDE DIGOXIN
ADENOSINE
 Toxicity and Management
Main toxic effect of antidyrhythmics involve
Heart, circulation and CNS
No specific antidotes
No specific antidote available
Maintain circulation and Airway
 Interactions
Amiodarone and Warfarin: Monitor INR
closely; INR increases by 50%
Amiodarone, disopyramide, quinidine: GF
inhibits metabolism of drug
Amiodarone: Digoxin, diltiazem, verapamil,
beta-blockers, azole antifungals: Prolonged
QT interval
 Vaughan Williams Classification:
Indications

Class Ia: quinidine, procainamide,

disopyramide
Used for atrial fibrillation, premature atrial
contractions, premature ventricular contractions,
ventricular tachycardia, Wolff-Parkinson-White
syndrome
 Drug Profie
Procainamide
Chemically related to local anesthetic
procaine
Significant AE: Ventricular dysrhythmias &
blood disorders: SLE-like [LUPUS] syndrome,
GI: n/v/d, fever, leukopenia, maculopapular
rash, flushing and minimal TORSADES de
Pointe [PROLONGED QT INTERVAL]
Route: PO, IM/IV
 Drug Profile
Quinidine
AE:
Blocks HERG channel = Long QT > Torsades de
pointe
Cardiac asystole, ventricular ectopi beats,
cinchonism: tinnitus, loss of hearing, slight
blurring of vision & GI upset
Contra: Thrombocytopenia purpura from
previous Rx, Torsades de Pointe
Route: PO
 Vaughan Williams Classification:
Indications

Class Ib: Lidocaine, mexilitine, phenytoin,

[tocainide]
Used for ventricular tachyarrhythmias only

Premature ventricular contractions,

ventricular tachycardia, ventricular
fibrillation
 Drug Profile
Lidocaine
Prototypical 1b
Effective for ventricular dysrhythmias
Route: IV only due to extensive first-pass effect if
taken orally
Renal dose [50%] in liver disease & renal
impairment
AE: CNS: twitching, convulsions and confusions,
respiratory depression or arrest; CV: hypotension,
bradycardia and dysrhythmias
 Vaughan Williams
Classification:Indications

Class Ic: flecainide, propafenone , moricine

Used for severe ventricular dysrhythmias
May be used in atrial fibrillation/flutter, Wolff-
Parkinson-White syndrome, supraventricular
tachycardia dysrhythmias
 Drug Profile
Flecainide
FDA: treatment is limited to documented life-
threatening ventricular dysrhythmias
Used Afib
Action: Negative inotropic effect; depresses
left ventricular function
Can possibly increase ventricular arhythmias
Route: PO only
 Drug Profile Class II
Atenolol-Cardio- Esmolol
selective properties Ultra-shorting BB
Used to treat HTN Treat acute SVT or
and angina dysrhythmias that
Route: PO originate above
ventricles
Metoprolol
Route: IV only
Cardio-selective
Given after MI to reduce risk Commonly used in
of sudden cardiac death anesthesia
Used for HTN and angina
Route: PO, Parenteral
 Indications
Class III: amiodarone, sotalol,* ibutilide,
Used for dysrhythmias that are difficult to treat
Life-threatening ventricular tachycardia or fibrillation, atrial
fibrillation or flutterresistant to other drugs
Sustained ventricular tachycardia

*Sotalol also exhibits Class II properties

 Drug to Know:
Amiodarone
Indication: Life-threatening
ventricular arrhythmias , part of
ACLS protocol
Action: Prolongs action potential,
slows sinus rate, prolongs QT
interval, suppresses arrhythmias
Side Effects: Dizziness, fatigue,
pulmonary fibrosis, CHF,
TORSADES, bradycardia,
hypotension, hypo or
hyperthyroidism, nausea, vomiting,
constipation, anorexia, corneal
microdeposits, photosensitivity
 Amiodarone
Long-half life-25-60 days
Significant drug-drug interaction
Warfarin and digoxin
Digoxin levels: increase by 50%
Warfarin: INR increases by 50%
Recommend decrease dose of these
meds by 50% in patients already taking
these meds when amiodarone is started
 Amiodarone
Nursing Assessment
Monitor ECG continuously during IV therapy
Monitor for QT prolongation
Assess for signs of pulmonary toxicity
Assess for signs of thyroid dysfunction
Monitor BP for hypotension
Regular ophthalmic exams for oral route
Monitor for neurotoxicity
 Indications

Class IV: verapamil,

diltiazem
Calcium channel blockers
Inhibit slow-channel (calcium-
dependent) pathways
Used for paroxysmal
supraventricular
tachycardia; rate control for
atrial fibrillation and flutter
HTN, afib or aflutter
[Diltiazem]
 Unclassified Anti-dysrhythmic
Digoxin
Adenosine (Adenocard)****** Cardiac monitoring
Slows conduction through the AV Emergency equipment
node
Used to convert paroxysmal
available at bedside
supraventricular tachycardia to PUSH drug RAPIDLY
sinus rhythm
over 1-2 seconds
Very short half-lifeless than 10
seconds Monitor BP every 15-
Only administered as fast IV push 30 minutes after
May cause asystole for a few
seconds
Monitor for changes
ROUTE: FAST IVP in rhythm
Other adverse effects minimal
 Atropine for Bradydysrhythmias
Blocks action of vagus nerve on heart
One of lead drugs along with Epi during cardiac arrest
Treats symptomatic bradycardia, sometimes
asystole
Often given preoperatively to dry up respiratory
secretion
Intended responses-increased HR and CO
SE: DRY MOUTH, blurred vision, tachycardia,
urinary hesistancy or retention [Anticholingeric
drug]
AE: rare
 Magnesium Sulfate for Torsades
*TORSADES DE POINTE-
Ventricular dysrhythmia:
Low magnesium levels
Need to monitor Mg levels
Given IV to prevent
ventricular dysrhythmia after
a patient has been
defibrillated [given shock] to
get back into a normal rhythm
Intended responses
Decrease Hear muscle
excitability, no more Torsades
SE: DIARRHEA
AE: rare: Complete heart
block, Respiratory arrest
Interventions
Check before and after:
Mg levels
NEED cardiac
monitoring
Teach about dietary
sources of magnesium*
Pregnancy and
breastfeeding-SAFE
during pregnancy: infant
may have decreased
reflexes for 24 hours
after birth
 Adrenergic Agonists/Vasopressors/Positiove
Inotropic as AntidysrhymthmiCS
Dobutamine
INCREASES mycardial force and cardiac output
Dopamine
INCREAESES BP, CO, and renal blood flow
Epinephrine
CARDIAC stimulation in cardia arrest
One of the lead drugs along w/Atropine
*Norepinephrine bitartrate [LEVOPHED OR THE
LEAVE EM DEAD DRUG
Stimulates heart in cardiac arrest and vasoconstricts
and increases BP in hypotension and shock
 SE:
Dysrhythmias
Angina, Restlessness, Urinary urgency or
incontinence
Interventions
Vital sign, urine output, EKG monitoring
Cardiac monitor
Need to MONITOR patient closely-Look at
name-esp. the LEAVE EM DEAD DRUG

Adrenergic Agonists/Vasopressors/Positiove
Inotropic as AntidysrhymthmiCS
 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
Assess for conditions that may be contraindications
for use of specific drugs
Assess for potential drug interactions
Instruct patients regarding dosing schedules and
adverse effects to report to physician
 Nursing Implications

Instruct patients regarding dosing schedules

and adverse effects to report to physician
During therapy, monitor cardiac rhythm, heart
rate, BP, general well-being, skin color,
temperature, heart and lung sounds
Assess plasma drug levels as indicated
Monitor for toxic effects
 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
 Nursing Implications
For class I drugs, monitor ECG for QT
intervals prolonged more than 50%
IV infusions should be administered with
an IV pump
Solutions of lidocaine that contain
epinephrine should not be given IVthey are
to be used ONLY as local anesthetics
 Nursing Implications
Ensure that the patient knows to notify health
care provider of any worsening of
dysrhythmia or toxic effects
Shortness of breath Chest pain
Edema GI distress
Dizziness Blurred vision
Syncope
 Nursing Implications

Patients taking -blockers, digoxin, and other

drugs 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
 Nursing Implications
Monitor for therapeutic response
Decreased BP in hypertensive patients
Decreased edema
Decreased fatigue
Regular pulse rate
Pulse rate without major irregularities
Improved regularity of rhythm
Improved cardiac output