1. Antiarrhythmic Drugs Munir Gharaibeh MD, PhD, MHPE Faculty of Medicine, The University of Jordan The University of Jordan October 2014

2. Types of Cardiac Arrhythmias Abnormalities of Impulse Formation: Rate disturbances. Triggered automaticity. Abnormalities of Impulse Conduction: Blocks.Reentry.

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4. Ion Permeability Changes Potential Changes Ion Permeability Changes Potential Changes Genes and Proteins 9/7/20154 Munir Gharaibeh MD, PhD, MHPE

5. Causes of Cardiac Arrhythmias Cardiac Causes: Ischemic heart disease. Inflammation. Inflammation. Trauma e.g. heart surgery. Congestive heart failure. Hypotension. Hypotension. 9/7/20155 Munir Gharaibeh MD, PhD, MHPE

6. Causes of Cardiac Arrhythmias Non Cardiac Causes: Electrolyte imbalance. Acid-Base imbalance. Hypoxia. Drugs: Digitalis, Anesthetics, Tricyclic, Diuretics,Bronchodilators. G.I. reflexes. Neural reflexes. 9/7/20156 Munir Gharaibeh MD, PhD, MHPE

7. Na+ channels cycling through different conformational states during the cardiac action potential 9/7/20157 Munir Gharaibeh MD, PhD, MHPE

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10. Normal Circuitry 9/7/201510 Munir Gharaibeh MD, PhD, MHPE

11. Re-entry Rhythm 9/7/201511 Munir Gharaibeh MD, PhD, MHPE

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14. Pre-requisites for Reentry (Circus Movement) Anatomic or physiologic obstacle. Unidirectional block. Conduction time around the circuit must be longer than the effective refractory period. 9/7/201514 Munir Gharaibeh MD, PhD, MHPE

15. Molecular and Genetic Basis of some Cardiac Arrhythmias 9/7/201515 Munir Gharaibeh MD, PhD, MHPE

16. ECG of some Arrhythmias 9/7/201516 Munir Gharaibeh MD, PhD, MHPE

17. Torsade de Pointes Polymorphic Ventricular Tachycardia LQT, syncope, and sudden death. Causes: Familial long QT interval Drug - Induced (drugs which prolong APD) Mechanisms: Increased inward current (GF), or Decreased outward (LF) current during the plateau. Genetic Studies: 300 different mutations in at least 8 ion channel genes. 9/7/201517 Munir Gharaibeh MD, PhD, MHPE

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19. Torsade de Pointes Risk Factors: Bradycardia.Hypokalemia. Triggered upstrokes. Drugs which  APD. Treatment:K+  Triggered upstrokes (  Blockers or Mg++)  APD (Pacemaker or isoproterenol). www.sads.org 9/7/201519 Munir Gharaibeh MD, PhD, MHPE

20. Other Congenital Arrhythmias Short QT Syndrome: –GF mutations in three potassium channel genes(KCNH2, KCNQ1, and KCNJ2). Chatecholaminergic Polymorphic Ventricular Tachycardia (CPVT): –Stress or emotion-induced syncope. –Caused by mutations in sarcoplasmic proteins that control calcium. 9/7/201520 Munir Gharaibeh MD, PhD, MHPE

21. Other Congenital Arrhythmias Sick Sinus Syndrome: –Mutations in HCN4 and SCN5A Brugada Syndrome: –Ventricular fibrillation, persistent ST elevation, and BBB. –Linked to LF mutations in SCN5A Familial Atrial Fibrillation: –Linked to GF mutation in the potassium channel gene, KCNQ1. 9/7/201521 Munir Gharaibeh MD, PhD, MHPE

22. Nonpharmacologic Therapy Surgery. Radiofrequency Catheter Ablation. Implantable Cardioverter- Defibrillator (ICD). 9/7/201522 Munir Gharaibeh MD, PhD, MHPE

23. Mechanism of Action of Antiarrhythmic Drugs Readily bind to activated channels or inactivated channels, but bind poorly to rested channels. i.e.: Use –Dependent or State-Dependent. Channels in normal cells will rapidly lose the drug from the receptors during the resting portion of the cycle. Channels in normal cells will rapidly lose the drug from the receptors during the resting portion of the cycle. This selectivity is lost with increasing doses, leading to drug-induced arrhythmias. Also, these drugs may become” Proarrhythmic or Arrhythmogenic” during fast heart rates, acidosis, hyperkalemia, or ischemia. 9/7/201523 Munir Gharaibeh MD, PhD, MHPE

24. ways to reduce the rate of spontaneous discharge 9/7/201524 Munir Gharaibeh MD, PhD, MHPE

25. Possible Effects of the Drugs on Action Potential 9/7/201525 Munir Gharaibeh MD, PhD, MHPE

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29. Class 1A Drugs Quinidine: Prototype, Antimalarial. Cinchona tree  Antipyretic. Inhibits  and muscarinic receptors. Slows upstroke, conduction, and prolongs APD and QRS duration. 9/7/201529 Munir Gharaibeh MD, PhD, MHPE

30. Quinidine Use restricted to patients with normal hearts( no failure, no ischemia), but have atrial or ventricular arrhythmias. Occasionally used in acute severe malaria. 9/7/201530 Munir Gharaibeh MD, PhD, MHPE

31. Quinidine Side Effects: Nausea (18%), Diarrhea (33%). Headache, Dizziness, and tinnitus= Cinchonism Headache, Dizziness, and tinnitus= Cinchonism Hypersensitivity, fever, rash, angioedema. Thrombocytopenia. Excessive prolongation of QT interval, slowed conduction and sudden death (TdP). Hypotension.  Serum Digoxin levels.  Warfarin effects. Sudden death. 9/7/201531 Munir Gharaibeh MD, PhD, MHPE

32. Class 1A Drugs Procainamide: Oral, but has short t½. L.E. (30% of patients Tx over 6 moths) Acetylated  NAPA (Class III) action Disopyramide More anticholinergic effects but less diarrhea than quinidine 9/7/201532 Munir Gharaibeh MD, PhD, MHPE

33. Class 1B Drugs Lidocaine: High affinity to bind with activated and inactivated Na+ channels with rapid kinetics. High affinity to bind with activated and inactivated Na+ channels with rapid kinetics. Acts selectively on ischemic tissue to promote conduction & block reentry. Acts selectively on ischemic tissue to promote conduction & block reentry. More effective with  K+. Not effective in atrial arrhythmias. 9/7/201533 Munir Gharaibeh MD, PhD, MHPE

34. Class 1B Drugs Lidocaine:Kinetics: Well absorbed, but ineffective orally, due to first pass effect. Well distributed, including the brain. Side Effects: Least cardiotoxic of the class, except for hypotension with high doses due to depression of the myocardium. Least cardiotoxic of the class, except for hypotension with high doses due to depression of the myocardium. CNS: parasthesia, tremor, nausea, slurred speech, and convulsions. CNS: parasthesia, tremor, nausea, slurred speech, and convulsions. Was routinely given to all MI patients to prevent ventricular arrhythmias. Was routinely given to all MI patients to prevent ventricular arrhythmias. 9/7/201534 Munir Gharaibeh MD, PhD, MHPE

35. Class 1B Drugs Tocainide: Oral analog of lidocaine. CNS, GI and blood dyscrasia. Mexiletine: Oral analog of lidocaine. Neurologic side effects. Neurologic side effects.Phenytoin: Digitalis induced arrhythmias. Epilepsy. Epilepsy. Congenital heart surgery. Congenital prolonged QT interval. 9/7/201535 Munir Gharaibeh MD, PhD, MHPE

36. Class 1C Drugs Flecainide: Potent blocker of Na + and K+ channels. Potent blocker of Na + and K+ channels. Negative inotropic effect. Proarrhythmic  ventricular. Effective in supra ventricular tachycardia with normal hearts. Side Effects:Ventricular arrhythmias, CNS, and sudden death. 9/7/201536 Munir Gharaibeh MD, PhD, MHPE

37. Class 1C Drugs Propafenone: Blocks Na+ channels but also has some Beta blocking and Ca++ blocking activity. Blocks Na+ channels but also has some Beta blocking and Ca++ blocking activity. No effect on QT interval. Used for supraventricular arrhythmias. Used for supraventricular arrhythmias. Side effects: metallic taste, constipation, and arrhythmias. Side effects: metallic taste, constipation, and arrhythmias. 9/7/201537 Munir Gharaibeh MD, PhD, MHPE

38. Class II Drugs Propranolol: Besides beta blocking, membrane stabilization, and intrinsic sympathmimetic activities, has effective antiarrhythmic activity Very effective, well tolerated, and documented to reduce mortality after acute myocardial infarction by reducing arrhythmias. 9/7/201538 Munir Gharaibeh MD, PhD, MHPE

39. Class II Drugs Esmolol: Short acting, used in intraoperative and acute arrhythmias β1 selective No membrane stabilization effect. Acebutolol: Short acting, used in intraoperative and acute arrhythmias. β1-selective. Also has direct membrane stabilizing. 9/7/201539 Munir Gharaibeh MD, PhD, MHPE

40. Class III Drugs Amiodarone: Blocks K+ channels and markedly prolongs APD. Class I actions. Blocks  and  Receptors. Ca++ blocking actions. Reserved for life-threatening atrial and ventricular arrhythmias. Reserved for life-threatening atrial and ventricular arrhythmias. Only slows heart rate and AV conduction. Only slows heart rate and AV conduction. Low incidence of TdP despite significant QT prolongation. Low incidence of TdP despite significant QT prolongation. Peripheral vasodilator (only with IV). Peripheral vasodilator (only with IV). 9/7/201540 Munir Gharaibeh MD, PhD, MHPE

41. Class III Drugs Amiodarone: Given IV (Loading dose 10gm) and orally. Slow kinetics (t½ 25-110 days), metabolized by CYP3A4 enzymes. Toxicity: mainly extracardiac and dose related. Lung fibrosis (1%). Lung fibrosis (1%). CNS. CNS. Thyroid( hypo and hyper). Thyroid( hypo and hyper). GI and liver. GI and liver. Corneal deposits, Corneal deposits, Skin (photodermatitis and discoloration). Skin (photodermatitis and discoloration).  Digoxin & Anticoagulants. Interactions: affected by CYP3A4 activity and can inhibit other enzymes. Interactions: affected by CYP3A4 activity and can inhibit other enzymes. 9/7/201541 Munir Gharaibeh MD, PhD, MHPE

42. Class III Drugs Sotalol: Beta blocker and Class III actions. Atrial and ventricular arrhythmias. Bradycardia, HF, Prolongation of QT. Bretylium Tosylate: Originally an antihypertensive, but tolerance develops. Originally an antihypertensive, but tolerance develops. Releases NE, then  Release / Reuptake Rarely used except in the prevention of ventricular fibrillation after cardiversion and lidocaine. Hypotension, Parotid swelling. Ibutilide.Dofetilide. 9/7/201542 Munir Gharaibeh MD, PhD, MHPE

43. Class IV Drugs (Ca++ Channel Blockers) VerapamilDiltiazem Block activated and inactivated L-type Ca++ channels. Effects more marked in tissues that fire frequently, less completely polarized at rest and those dependant on Ca++ (SA node and AV node). Paroxysmal Supraventricular Tachycardia. Vasodilators and have negative inotropic effects. Can cause severe AV block in diseased hearts. Safe: Constipation, gastric discomfort, vertigo, headache, nervousness, pruritis.  Digoxin levels. 9/7/201543 Munir Gharaibeh MD, PhD, MHPE

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45. Properties of Several Recognized Voltage-Activated Calcium Channels. TypeChannel Name Where FoundProperties of the Calcium Current Blocked By LCa V 1.1– Ca V 1.3 Cardiac, skeletal, smooth muscle, neurons (Ca V 1.4 is found in retina), endocrine cells, bone Long, large, high threshold Verapamil, DHPs, Cd 2+, -aga- IIIA TCa V 3.1– Ca V 3.3 Heart, neuronsShort, small, low threshold sFTX, flunarizine, Ni 2+, mibefradil 1 NCa V 2.2 Neurons, sperm 2 Short, high threshold Ziconotide, 3 g abapentin, 4 -CTX- GVIA, -aga- IIIA, Cd 2+ P/QCa V 2.1 NeuronsLong, high threshold -CTX- MVIIC, - aga-IVA RCa V 2.3 Neurons, sperm 2 PacemakingSNX-482, - aga-IIIA 9/7/201545 Munir Gharaibeh MD, PhD, MHPE

46. Back F I G U R E 2. 4. E x a m p l e s o f p o t e n ti a l c o n v e r g i n g a n d i n t e r a c ti n g si g n a li n g p a t h w a y s f o r 5 - h y d r o x y t r y p t a m i n e - r e c e p t o r s u b t y p e s. T h is fi g u r e il l u s t r a t e s o n l y a f e w o f t h e n e a rl y u n li m it e d p o s si b il it i e s, d e p e n d i n g o n t h e c e ll p h e n o t y p e. A ls o li s t e d a r e a d d it i o n a l e ff e c t o r s a c ti v a t e d b y o n e o r a n o t h e r o f t h e s e r e c e p t o r s w it h p a t h w a y s o f a c ti v a ti o n t h a t h a v e n o t y e t b e e n d e t e r m i n e d. 9/7/201546 Munir Gharaibeh MD, PhD, MHPE

47. Miscellaneous Drugs Digoxin: Old fashioned agent for atrial arrhythmias. Direct Actions. Direct Actions. Vagotonic Effects.  AV refractoriness. 9/7/201547 Munir Gharaibeh MD, PhD, MHPE

48. Miscellaneous Drugs Magnesium: Works on Na+/K+ ATPase, Na+ channels, certain K+ channels and Ca++ channels. Effective IV in refractory digitalis- induced ventricular arrhythmias only in hypomagnesemic patients. Also, in TdP patients even if serum Mg++ is normal. Potassium salts: For digitalis- induced arrhythmias with hypokalemia. Depress ectopic pacemakers and slow conduction. 9/7/201548 Munir Gharaibeh MD, PhD, MHPE

49. Miscellaneous Drugs Adenosine: Naturally occurring nucleoside. Naturally occurring nucleoside. Activates inward rectifier K+ current and inhibits Ca++ current. Activates inward rectifier K+ current and inhibits Ca++ current. Very short acting (t 1/2 10 seconds). Very short acting (t 1/2 10 seconds).  Phase 4 depolarization in SA node.  Phase 4 depolarization in SA node.  AV conduction.  AV conduction. No effect on ventricles. No effect on ventricles. 9/7/201549 Munir Gharaibeh MD, PhD, MHPE

50. Miscellaneous Drugs Adenosine: 90-95% effective in supraventricular tachycardia. Less effective in the presence of adenosine receptor blockers, e.g. theophylline and caffeine. Less effective in the presence of adenosine receptor blockers, e.g. theophylline and caffeine. Can cause very short –lived flushing (20%), chest tightness, AV block, headache, hypotension, nausea, and parasthesia. Can cause very short –lived flushing (20%), chest tightness, AV block, headache, hypotension, nausea, and parasthesia. 9/7/201550 Munir Gharaibeh MD, PhD, MHPE

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52. Afterdepolarizations (Triggered Automaticity) Require a normal action potential for their initiation. Early Afterdepolarizations (EAD): –Interrupt phase 3. –Exacerbated at low heart rates. –Contribute to development of long QT-related arrhythmias. Delayed Afterdepolarizations (DAD): –Occur with increased intracellular calcium. –Exacerbated by fast heart rates. –Responsible for arrhythmias of digitalis, catecholamines, and ischemia. 9/7/201552 Munir Gharaibeh MD, PhD, MHPE

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