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Class II: Action: -blocker, slows AV conduction Note: Other -blockers may also have antiarrhythmic effects but are not yet approved for this indication in the United States Indications: Supraventricular tachycardia; may prevent ventricular fibrillation Esmolol 500 mcg/kg over 1 2 min; maintain at 25 200 mcg/ kg/min 1 5 mg at 1 mg/min Other -blockers may be used concomitantly 40 320 mg in 1 4 doses daily (depending on preparation) 50 200 mg daily Not established Hepatic LVF, bronchospasm
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LVF, bradycardia, AV block, bronchospasm LVF, bradycardia, AV block
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Class III: Action: Prolong action potential Indications: Amiodarone: refractory ventricular tachycardia, supraventricular tachycardia, prevention of ventricular tachycardia, atrial fibrillation, ventricular fibrillation; dofetilide: atrial fibrillation and flutter; sotalol: ventricular tachycardia, atrial fibrillation; bretylium: ventricular fibrillation, ventricular tachycardia; ibutilide: conversion of atrial fibrillation and flutter Amiodarone 150 300 mg infused rapidly, followed by 1-mg/ min infusion for 6 h (360 mg) and then 05 mg/min 800 1600 mg/d for 7 21 days; maintain at 100 400 mg/d (higher doses may be needed) 1 5 mg/mL Hepatic Pulmonary fibrosis, hypothyroidism, hyperthyroidism, corneal and skin deposits, hepatitis, Dig, neurotoxicity, GI (continued )
CMDT 2008
Table 10 8 Antiarrhythmic drugs (continued)
Agent Sotalol Intravenous Dosage Oral Dosage 80 160 mg every 12 h (higher doses may be used for life-threatening arrhythmias) Therapeutic Plasma Level Route of Elimination Renal (dosing interval should be extended if creatinine clearance is < 60 mL/min) Renal (dose must be reduced with renal dysfunction) Hepatic and renal Side Effects Early incidence of torsades de pointes, LVF, bradycardia, fatigue (and other side effects associated with -blockers) Torsades de pointes in 3%; interaction with cytochrome P-450 inhibitors Torsades de pointes in up to 5% of patients within 3 h after administration; patients must be monitored with defibrillator nearby
Dofetilide
500 mg twice daily
Ibutilide
1 mg over 10 min, followed by a second infusion of 05 1 mg over 10 min
Class IV: Action: Slow calcium channel blockers Indications: Supraventricular tachycardia Verapamil 10 20 mg over 2 20 min; maintain at 5 mg/kg/min 80 120 mg every 6 8 h; 240 360 mg once daily with sustained-release preparation 180 360 mg daily in 1 3 doses depending on preparation (oral forms not approved for arrhythmias) 01 015 mg/mL Hepatic LVF, constipation, Dig, hypotension
Diltiazem
025 mg/kg over 2 min; second 035-mg/kg bolus after 15 min if response is inadequate; infusion rate, 5 15 mg/h 6 mg rapidly followed by 12 mg after 1 2 min if needed; use half these doses if administered via central line 05 mg over 20 min followed by increment of 025 or 0125 mg to 1 15 mg over 24 h
Hepatic metabolism, renal excretion
Hypotension, LVF
Miscellaneous: Indications: Supraventricular tachycardia Adenosine Adenosine receptor stimulation, metabolized in blood Transient flushing, dyspnea, chest pain, AV block, sinus bradycardia; effect by theophylline, by dipyridamole AV block, arrhythmias, GI, visual changes
Digoxin
1 15 mg over 24 36 h in 3 or 4 doses; maintenance, 0125 05 mg/d
07 2 mg/mL
Renal
AV, atrioventricular; CNS, central nervous system; Dig, elevation of serum digoxin level; GI, gastrointestinal (nausea, vomiting, diarrhea); LVF, reduced left ventricular function; NAPA, N-acetylprocainamide; SLE, systemic lupus erythematosus; VT, ventricular tachycardia
calcium channel blockers, such as diltiazem and verapamil, or -blockers are typically used first For patients with heart failure, digoxin can be effective as initial treatment Patients who do not respond to agents that increase refractoriness of the AV node may be treated with antiarrhythmics The class Ic agents (flecainide, propafenone) can be used in patients without underlying structural heart disease In patients with evidence of structural heart disease, class III agents, such as sotalol or amiodarone, are probably
a better choice because of the lower incidence of ventricular proarrhythmia during long-term therapy
Blomstrom-Lundqvist C et al; European Society of Cardiology Committee, NASPE-Heart Rhythm Society ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias executive summary A report of the American College of Cardiology/American Heart Association task force on practice guidelines and the European Society of Cardiology committee for practice guidelines (writing com-
Heart Disease
mittee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society J Am Coll Cardiol 2003 Oct 15;42(8):1493 531 [PMID: 14563598] Chauhan VS et al Supraventricular tachycardia Med Clin North Am 2001 Mar;85(2):193 223 [PMID: 11233946] Hebbar AK et al Management of common arrhythmias: Part I Supraventricular arrhythmias Am Fam Physician 2002 Jun 15;65(12):2479 86 [PMID: 12086237]
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