Choice of Antiarrhythmics

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Chapter: Essential pharmacology : Antiarrhythmic Drugs

Asymptomatic arrhythmias and those which do not jeopardize haemodynamics, e.g. most AES and occasional VES, first degree AV block, bundle branch block, etc. in an otherwise normal heart, do not require antiarrhythmic treatment.


CHOICE OF ANTIARRHYTHMICS

 

Asymptomatic arrhythmias and those which do not jeopardize haemodynamics, e.g. most AES and occasional VES, first degree AV block, bundle branch block, etc. in an otherwise normal heart, do not require antiarrhythmic treatment. Chronic prophylactic therapy with class I and class IV antiarrhythmics does not appear to afford survival benefit, except in few selected cases. On the other hand, vigorous therapy is indicated when:

 

·      Arrhythmia is life-threatening, e.g. sustained VT, torsades de pointes, VF.

·      Arrhythmia is causing hypotension, breathlessness or cardiac failure.

·      Palpitation is marked, e.g. in PSVT, sustained VT, AF, torsades de pointes.

·  When simple arrhythmia may lead to more serious ones, e.g. after MI (warning arrhythmias).

 

In the above situations antiarrhythmics are mostly needed for short periods. The choice of an antiarrhythmic in a patient depends on:

 

·      ECG diagnosis

·      Possible mechanism underlying the arrhythmia

·      Mechanism of action and range of antiarrhythmic activity of the drug Pharmacokinetic profile of the drug

·      Haemodynamic effects of the drug

 

The aim is to improve cardiovascular function either by restoring sinus rhythm, or by controlling ventricular rate, or by conversion to a more desirable pattern of electrical and mechanical activity.

 

Despite extensive investigation, choice of an antiarrhythmic is still largely empirical. Current guidelines are summarised in Table 38.2.

 


 


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