Page 264 - Basic _ Clinical Pharmacology ( PDFDrive )

250 SECTION III Cardiovascular-Renal Drugs

Relevant structural heart disease No or minimal heart disease including
ESC: Heart failure, CAD, valvular heart disease, LVH hypertension without LVH
ACCF/AHA/HRS: heart failure, CAD, valvular heart disease, LVH ESC: Includes LVH with preserved LV function
CCS only considers heart failure or LVEF < 35% CCS: Including CAD, LVH, and HFpEF

Heart failure Coronary artery Hypertension Paroxysmal Persistent
disease with LVH AF AF

Dronedarone Dronedarone ESC: Ablation possible Dronedarone
Sotalol Amiodarone as first-line therapy Flecainide
US: Only Amiodarone Propafenone
Sotalol
Catheter
ablation for AF

Amiodarone Catheter Amiodarone
Dofetilide ablation for AF
CCS: Sotalol when LVEF > 35%

FIGURE 14–11 Selection of rhythm control therapies depends on presence and nature of any underlying heart disease. Patients
may be divided into two broad categories: those with and those without underlying heart disease. Patient with heart failure, left ventricular
ejection fraction (LVEF) less than 35%, coronary artery disease (CAD), valvular heart disease, and left ventricular hypertrophy (LVH) fall into the
first category. The second category includes patients with mild LVH and with heart failure but a preserved ejection fraction (HFpEF). The
recommendations are based on the guidelines of the American College of Cardiology Foundation (ACCF), the American Heart Association
(AHA), the Heart Rhythm Society (HRS), and the Canadian Cardiology Society (CCS). AF, atrial fibrillation; ESC, European Society of Cardiology;
LV, left ventricle.

SUMMARY Antiarrhythmic Drugs

Mechanism Pharmacokinetics, Toxicities,
Subclass, Drug of Action Effects Clinical Applications Interactions
CLASS 1A
• Procainamide I Na (primary) and I Kr Slows conduction velocity and Most atrial and ventricular Oral, IV, IM • eliminated by hepatic
(secondary) blockade pacemaker rate • prolongs action arrhythmias • drug of second metabolism to N-acetylprocainamide
potential duration and dissociates choice for most sustained (NAPA; see text) and renal elimination
from I Na channel with intermediate ventricular arrhythmias • NAPA implicated in torsades de pointes
kinetics • direct depressant effects associated with acute in patients with renal failure • Toxicity:
on sinoatrial (SA) and atrioventricular myocardial infarction Hypotension • long-term therapy
(AV) nodes produces reversible lupus-related
symptoms
• Quinidine: Similar to procainamide but more toxic (cinchonism, torsades); rarely used in arrhythmias; see Chapter 52 for malaria
• Disopyramide: Similar to procainamide but significant antimuscarinic effects; may precipitate heart failure; not commonly used
CLASS 1B
• Lidocaine Sodium channel (I Na ) Blocks activated and inactivated Terminates ventricular IV • first-pass hepatic metabolism
blockade channels with fast kinetics • does tachycardias and prevents • reduce dose in patients with heart
not prolong and may shorten action ventricular fibrillation after failure or liver disease • Toxicity:
potential cardioversion Neurologic symptoms
• Mexiletine: Orally active congener of lidocaine; used in ventricular arrhythmias, chronic pain syndromes
(continued)