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7/28/2019 anti aritmia-ijo-a.ppt
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Depart. Of Pharmacology & Therapy
Medical Faculty Padjadjaran University
Dr. Rovina Ruslami SpPD
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Antiarrhythmia 2 goals :
Arrhythmia :
asymptomatic life threatening
Termination of an ongoing Arrhythmia
Prevention of a recurrence
Control arrythmia
Proarrhythmic effect
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Cardiac cycle : automaticity rhythmic AP
SA node AV node HIS-purkinje
system
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0
2
0 mV
-85 mV
3
1
4
eff refractory period
Action Potential
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Mechanisms of Cardiac Arrhythmia
1. Enhanced automaticity / abnormal automaticity
2. Triggered automaticity
3. Block
4. Reentry
Tools
ECG
DC-cardioversion
ICDs (Implantable cardioverter defiblillators)
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Mechanisms of AAD actions :
suppressing the initiating mechanism
slow automaticity
altering the reentrant circuit
1. phase 4 slope2. threshold
3. max. diastolic potential
4. AP duration
-blockersblock of Na+, Ca++
adenosine
block of K+
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Normal Undirectional block
altering the reentrant circuit
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Principles in the clinical use of AADs
Identify & remove precipitating factors
Establish the goals of treatment
- some arrhythmias shouldnt be treated
- symptoms due to arrhythmia
- choosing among therapeutic approach
Minimize risks
- proarrhythmic effect
- monitoring of plasma concentration
- patient-specific contra indication
The electrophisiology of the heart as a moving target
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IA Na+ channel blocker
IB Na+ channel blocker
IC Na+ channel blocker
II -adrenoceptor blocker
III K+ channel blocker
IV Ca++ channel blocker
Classification of AADs :
class mechanism comment
slow phase 0 depol
shorten phase 3 repol
markedly slow phase 0 depol
suppress phase 4 depol
prolongs phase 3 repol
shorten action potential
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Class I AADs
Na channel blocker slow phase 0 depol
excitability
conductivity
Use-dependence tachycardiaClass IA: bind to Na channel in intermediate speed
quinidine, procainamide, disopyramide
Class IB: bind rapidly to Na channellidocaine, mexiletine, tocainide
Class IC: bind slowly to Na channel
flecainide, propafenone
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QUINIDINE
inhibits arrhythmia caused by hyperautomaticityPrevent reentry arrhythmia
Indications :
Wide variety of arrhythmia
A, AV, V - arrhythmia
Maintain SR after DCFK : p.o
Adverse effects : exacerbate arrhythmia--- blockproarrhythmic effect
CI : heart block, liver disease
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PROCAINAMIDE
Analog of local anesthetic
Indications :
VT that non responsive to lidocaine
FK : p.o liver kidney
Adverse effects :inotropic negative, hypotensiondrug induced SLE (long-term therapy)
Intoxication : asystole, CNS depression
quinidine like effect
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LIDOCAINE
Inhibits arrhythmia caused by abnormal automaticity
Indications :
Arrhythmia related to myocardial ischaemia
FK : iv excretion : liver
Adverse effects :inotropic negative (-); CNS effects, tremorproarrhythmic effects
CI : block, bradycardia
rapidly bind to Na channel
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-blocker slow phase 4 depol
Class II AADs
automaticity
AV conduction
Arrhythmia due to :- sympathetic activity
- AF, SVT
- post AMI prevent suddent death
Inotropic (-) CI for HF
HR & contractility
Propranolol, metoprolol, esmolol, carvedilol
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K channel blockers prolong phase 3
Class III AADs
AP duration
eff. Refractory period
sotalol, bretylium, amiodarone
SOTALOL
-blocker that has antiarrhythmia class III activity
Indications : sustained VT, long-term : mortality
Proarrhythmic effect torsade de pointes
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iv excretion : kidney
BRETYLIUM
Indications : life threatening VT , recurrent VF
FK :
AMIODARONE
Indications : severe refractory SVT, VT
Class I, II, III & IV action mainly class III
FK : p.o, EMG case :iv (bolus drip)
clinical effect is achieved in 6 weeks (po)
Adverse effects :
vary toxicity effect, withdrawl effect
liver toxicity, hyper-hypothyroidsm, muscle weaknessCI : block, bradycardia
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Ca channel blocker shorten AP
Class IV AADs
AV conduction
Inotropic (-) CI for HF
HR & PR interval
Verapamil, diltiazem
Vasodilatoranti hypertension, anti anginal
Indication : tachy-arryhthmia: SVT, VT
FK : p.o, iv ( !! hypotension) liver
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refractory period, conductivity, automaticity
Shorten refractory period; AP; conductivityIndications : controll ventr respons to AF
FK : p.o; iv
Adverse effects : intoxication : VES VT / VF
Indications : acute SVT
FK : iv, short d.o.a
Adverse effects : flushing, hypotension, chest pain
ADENOSIN
DIGOXIN
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