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2. P harmacological
T herapy of
Cardiac
Arrhythmias
By: Mahmoud Shah
Professor of
Cardiology
Zagazig University

3. Vaughan Williams Classification
Class I: * block fast Na channels
* can block K channels
IA: * V max (phase 0 AP)
* prolong AP duration
* include: quinidine, procainamide,
disopyramide
* intermediate onset and offset in blocking
Na
channels (< 5 seconds)

4. IB * Doesn’t decrease V max
* Shorten AP duration
* Mexiletine, Phenytoin, Lidocaine
* Rapid onset and ofset (<500 msec)
Ic * Decrease V max
* Slow conduction
* Prolong refractoriness minimally
* Flecanide, propafenone , moricizine,
ajmaline
* Slow onset and ofset (10-20 sec)

5. Class II *Block B receptors
*propranolol, timolol,
metoprolol
Class III *block k channels
*prolong repolarization
*Sotalol, Amoidarone,
bretylium, drondarone,
dofetilide, ibutilide, azimilide
Class IV *block slow ca Channel
* Verapamil ,Diltiazim

6. Unclassified drugs
1 – Adenosine activates K channels (IK ach.,IK Ade)
2 – Ivabradine If current blocker
3 – digoxin

7. Recommendations for acute management of
hemodynamically stable and regular tachycardia
ECG Recommendation Class Level of evidence
Narrow QRS-complex tachycardia Vagal manoeuvres I B
(SVT) Adenosine I A
Verapamil, diltiazem I A
Beta-blockers lIb C
Amiodarone lIb C
Digoxin lIb C
Wide QRS-complex tachycardia See above I B
• SVT and BBB Flecainide I B
• Pre-excited Ibutilide I B
• VT/AF + Procainamide I C
DC cardioversion
• Wide QRS-complex tachycardia Procainamide I B
of Sotalol I B
unknown origin Amiodarone I B
Udocaine IIb B
Adenosine IIb C
Beta-blockers III C
Verapamil III B
DC cardioversion I B
Wide QRS-complex tachycardia of Amiodarone I B
unknown origin in patients with Lidorainp I B
poor LV function DC cardioversion

8. Specific
arrhythmias

9. 1- InapproprIate SInuS
tachycardIa
(ISt)
* Persistent high HR unrelated to level of
physical , emotional, pathological or
pharmacological stress
* 90% Female
* Asymptomatic to totally incapacitated
Treatment
* Symptomatic driven
* Catheter ablation – 66% of SAN modification
* Postural Orthostatic tachycardia syndrome
(POTs) excluded before ablation.

10. Recommendation for treatment of
IST
Treatment Recommendation Class Level of
evidence
Medical Beta-blockers I C
Verapamil, diltiazem II a C
Interventional Catheter ablation – II b C
sinus node
modification/elimination

11. 2. atrIoventrIcular nodal
recIprocatIng tachycardIa
(avnrt)
* Typical form slow – fast
85-90%
RP<PR
* Atypical form fast – slow
10-15%
RP>PR
* Standard treatment B blocker
Ca blocker
Adenosine
* Alternative ttt Ablation
Tolerance of symptoms
Tachycardia frequency
Patient inclination relative to chronic
drug therapy vs ablation
The patient must accept risk (<1% Av
block) P. pacemaker

12. ECG pattern of typical AVNRT
A: during AVNRT and B: after cardioversion Note the pseudo r’ in V1 and
pseudo S in II, III and a VF which are pathognomonic of typical AVNRT

13. Recommendations for long-term treatment of
patients with recurrent AVNRT
Clinical Intervention Class Level
presentation of
evide
nce
Poorly tolerated Catheter ablation I B
AVNRT with
Verapamil, IIa C
haemodynamic
diltiazem, beta-
intolerance
blockers, sotalol,
amiodarone
Flecainide, IIa C
propafenone
I Recurrent Catheter ablation I B
symptomatic
Verapamil I B
AVNRT
Diltiazem, beta- I C
blockers
Digoxin IIb C
Recurrent AVNRT Flecainide, IIa B
unresponsive to propafenone,
beta-blockade or sotalol
calcium-channel
blocker and Amiodarone IIb C
patient not
desiring RF
ablation

14. AVNRT with Catheter ablation I B
infrequent or
single episode in
patients who
desire complete
control of
arrhythmia
Documented Verapamil,diltiaze I C
PSVT with only m, beta-blockers,
dual AV-nodal flecainide*,
pathways or propafenone
single echo beats
demonstrated
during
electrophysiologi Catheter ablation I B
cal study and no ++
other identified
cause of
arrhythmia
Infrequent, well- No therapy I C
tolerated AVNRT
Vagal I B
manoeuvres
«Pill-in-the- I B
pocket»
Verapamil,diltiaze I B
m, beta-blockers
Catheter ablation I B

15. 3- Focal and nonparoxymal
junctIonal tachycardIa
A - focal junctional tachycardia
* Automatic ectopic tachycardia
* Junctional ectopic tachycardia
* Originate from AVN or His bundle
* ECG: - HR: 110-250 bpm
- Narrow QRS or BBB pattern with AV
dissociation
* Rare arrhythmia
* In young adult
* may produce CHF
* Drug therapy ----- Variable success
* Ablative therapy 5-10%risk A-V block

16. Surface ECG recording from leads V1, II, and V5 in a
patient with focal junctional tachycardia. The upper panel shows
sinus rhythm. The lower panel shows tachycardia onset with the
characteristic finding of isorhythmic AV dissociation (arrows).
The large arrow signifies continuous recording. AV indicates
atrioventricular.

17. B – Nonparoxysmal junctional tachycardia
(NJT)
* Benign arrhythmia
* HR 70-120 bpm
* due to abnormal automaticity
or triggered activity
* due to digitalis toxicity , post
cardiac surgery , hypokalemia ,
myocardial ischemia
* Treatment directed toward the
underlying condition

18. Recommendation for treatment of focal and
nonparoxymal junctional tachycardia
Clinical Recommendation Class Level of evidence
presentation
Focal junctional Beta-blockers IIa C
tachycardia
Flecainide IIa C
Propafenone IIa C
Sotalol IIa C
Amiodarone IIa C
Catheter ablation IIa C
Nonparoxysmal Reverse digitalis I C
junctional toxicity
tachycardia
Correct I C
hypokalemia
Treat myocardial I C
ischaemia
Beta-blockers, IIa C
calcium-channel
blockers

19. 4. a-v recIprocatIng re-
entry tachycardIa (avrt)
* Extranodal AP
* Only retrograde conduction
concealed AP
* Antegrade conduction manifest AP
* WPW Syndrome Preexcitation
+ Tachycardia

20. Forms * orthodromic AVRT
* antidromic AVRT
* pre-excited tachycardia in AT or A.Fl with
bystander AP
* Pre-excited AF
* PJRT ( permanent form of JRT)
- Slowly conducting concealed
posteroseptal AP
- Incessant , long RP tachycardia with
negative pin II ,III ,avf
- rare syndrome

21. Orthodromic atrioventricular reentrant tachycardia. This
patient has Wolff-Parkinson-White syndrome

22. Wolff-Parkinson-White pattern. Note the short PR
interval and slurred upstroke (delta wave) to the
QRS complexes

23. Acute treatment of pre-excited tachycardias
* AVN blocking agents not effective
* Adenosine may produce AF with rapid
ventricular rate
* Anti-arrhythmic drugs preventing rapid
conduction through AP
- Flecanide
effective even
- Procainamide may not
- Ibutilide convert the
atrial rhythm.
- Amiodarone

24. Long-term therapy of pre-excited tachycardias
* Catheter ablation the preferred with 95% success
option
* Antiarrhythmic drugs Another therapeutic option
for
- Infrequent episodes
- Well-tolerated episodes
* Some patients with infrequent episodes Single
dose (pill-in pocket approach)
* Only at the onset of tachycardia episode
- Patient without pre-excitation
- Uncommon and hemodynamically tolerated
tachycardia.

25. Recommendations for long-term therapy of AP-mediated
arrhythmias

26. 5 Focal atrial
tachycardia (Fat)
* Atrial rate: 100-250 bpm (rarely 300)
* progressive increase in atrial rate with
tachycardia onset (warm-up) and/or
* progressive decrease before
termination of tachycadia suggests automatic
mechanism
* 10 % have multiple foci
* Focal AT may be incessant tachycardia
inducing CM

27. Focal atrial tachycardia showing a long RP interval relationship.
The P wave in AT usually occurs in the latter part of the
tachycardia cycle (arrows) but can appear earlier, depending on
the rate and status of AV-nodal conduction. AT indicates atrial
tachycardia; AV, atrioventricular

28. Treatment
* Rate control - B- blocker
- Ca blocker
- Digoxin
* Or suppression of arrhythmias focus
Class Ia - Flcamide
- Propafenone
* IV adenosine, B blocker or Ca blocker
acute termination (unusual) or rate control
* Adenosine terminate FAT in significant number
of patients.
* chronic control: AV blocking agents
* ablation: 80- 90% for RA focus and 70-80% in
LA focus

29. Recommendations for treatment of focal atrial
tachycardia

30. 6) multiFocal
atrial
tachycardia
* correction of underlying abnormalities:
- pulmonary disease
- metabolic
- electrolyte disorders
* CCB
* No role for DCC, AADs or ablation

31. • Multifocal atrial tachycardia. Note the
different P-wave morphologies and irregularly
irregular ventricular response

32. 7) atrial Flutter
* isthmus-dependent: more frequent
*Non-isthmus-dependent:less frequent

33. • Atrial flutter. The patient's heart rate is approximately
135 bpm with 2:1 conduction. Note the sawtooth pattern
formed by the flutter waves.

34. ttt Hemodynamically destabilizing
shock, ongoing ischemia): DCC
(HF,
Hemodynamically stable: rate control by
AVN blocking drugs
class Ic: may cause paradoxical increase in
ventricular rate.
AVN blocking drugs and amiodarone are
NOT effective for cardioversion
IV ibutilide is the most effective agent for
acute drug termination of A Fl (38-76%)
Class III (especially dofetilide): effective
chronic therapy (73%)
Chronic therapy: NOT required after sinus
rhythm is restored if AFl occurs as part of
acute disease process

35. Recommendations for acute management of atrial
flutter

36. Recommendations for long-term
management of atrial flutter

37. Management of atrial flutter
depending on hemodynamic stability

38. Recommendations for treatment strategies for SVT
during pregnancy

39. Recommendations for treatment of
SVTs in adults with congenital
heart disease

40. Response of narrow
complex tachycardias
to adenosine

41. Acute management of patients with
hemodynamically stable and regular
tachycardia

42. 8. atrial
Fibrillation (aF)
Objectives of management:
* Rate control
* Rhythm control
* Prevention of thromboembolism
Patterns of AF:
Newly discovered AF
Recurrent paroxysmal AF
Recurrent paroxysmal AF
Permanent AF

43. • Atrial fibrillation. The patient's ventricular rate
varies from 130-168 bpm. Rhythm is
irregularly irregular. P waves are not
discernible

44. Pharmacological management of patients with newly
discovered AF

45. Pharmacological management of
patients with recurrent paroxysmal
AF

46. Pharmacological management of
patients with recurrent persistent or
permanent AF

47. Antiarrhythmic drug therapy to maintain sinus rhythm in
patients with recurrent paroxysmal or persistent atrial
fibrillation

48. Recommendations for Pharmacological Cardioversion of Atrial
Fibrillation of Less Than or Equal to 7 Days’ Duration

49. Recommendations for Pharmacological
Cardioversion of Atrial Fibrillation of More
Than 7 Days’ Duration

50. Recommended Doses of Drugs Proven
Effective for Pharmacological Cardioversion
of Atrial Fibrillation

51. Pharmacological Treatment Before Cardioversion
in Patients With Persistent Atrial Fibrillation:
Effects of Various
Antiarrhythmic Drugs on Acute and Subacute
Outcome of Transthoracic Direct Current Shock

52. Typical Doses of Drugs Used to Maintain
Sinus Rhythm in Patients With
Atrial Fibrillation

53. Intravenous Pharmacological
Agents for Heart Rate Control in
Patients With Atrial Fibrillation

54. Orally Administered Pharmacological
Agents for Heart Rate Control in
Patients With Atrial Fibrillation

55. Recommendations for management of AF:
I. Pharhacological rate control during AF:
Class I:
1. Rate control for patients with persistent or permanent AF
(LOE: B)
2. With no pre-excitation: IV BB or CCB to slow acute settings
without hypotension or HF (LOE: B)
3. IV digoxin or amiodarone in AF with HF (LOE: B)
4. digoxin effective to control HR at rest (LOE: C)

56. Class IIa:
1. digoxin + BB or CCB for control of HR at
rest and during exercise (LOE: B)
2. Ablation of AVN or AP to control HR
when drugs are insufficient or with side
effects (LOE: B)
3. IV amiodarone when other measures are
unsuccessful or contraindicated (LOE:
C)
4. IV procainamide or ibutilide when DCC
is not necessary in Af+AP (LOE: C)

57. Class IIb:
1. oral amiodarone when HR can’t
be controlled using BB, CCB or
digoxin alone or in combination
(LOE: C)
2. IV procainamide, disopyramide,
ibutilide, or amiodarone
forhemodynamically stable
patients with AF + AP (LOE: B)
3. When HR can’t be controlled by
drugs or tachycardia-mediated
myopathy is suspected : Ablation
of AVN (LOE: C)

58. Class III: 1. digitalis is not used as the sole agent to
control HR in patients with paroxysmal
AF (LOE: B)
2. Ablation of AVN: is not attempted
without prior trial of medication to
control rate (LOE: C)
3. HF+AF: IV CCB exacerbate AF so NOT
recommended (LOE: C)
4. IV digitalis or CCB in AF+AP increase
ventricular rate so not recommended
(LOE: C)

59. Pharmacological Cardioversion of
AF:
Class I:
Flecainide, dofetilide, propafenone or
Ibutilide (LOE: A)
Class IIa :
1. IV amiodarone (LOE: A)
2. single oral dose of propafenone or flecainide
(pill in the pocket) may terminete persistent AF
(LOE: C)
3. amiodarone in paroxysmal or persistent AF
when rapid restoration of sinus rhythm is not
necessary (LOE: C)

60. Class IIb:
Quinidine or procainamide considered for
AF cardioversion but not well established
(LOE: C)

61. CLASS III:
1. Digoxin and sotalol are not
recommended for pharmacologic
carioversion of AF (LOE: A)
2. quinidine , procainamide, dofetilide not
started out of hospital for cardioversion of
AF (LOE: B)

62. Maintenance of sinus rhythm:
Class I:
before starting AADs treat precipitating or reversible
causes of AF
Class II:
1. lone AF without structural heart disease
propafenone or flecainide in outpatients with
paroxysmal AF who are in SR (LOE: B)
2. Sotalol in patients with SR with little or no heart
disease prone to paroxysmal AF (LOE: C)
3. Amiodarone (LOE: C)

63. Class III
1. Antiarrhythmic therapy not
recommended in patient with AF
who have risk factors for
proarrhythmia (LOE:A)
2. Pharmacological therapy not
recommended in patients with
advanced SAN disease or AVN
dysfunction unless have
functioning pacemaker (LOE:C)

64. Postoperative AF
Class I
1- Oral B blocker prevent
postoperative AF for patients
undergoing cardiac surgery
(LOE:A)
2- AVN blocking agents for rate
control in patients who develop
postoperative AF (LOE:B)

65. Class II a
1- Preoperative amoidarone
decrease incidence postoperative AF
(LOE:A)
2- Ibutilide or DC conversion of
postoperative AF (LOE:B)
3- Antiarrhythmic medications
maintain SR in recurrent or refractory
AF (LOE:B)
Class II b
prophylactic satalol for patient at
risk of developing AF after cardiac
surgery (LOE:B)

66. Post AMI AF
Class I
1- DC cardioversion haemodynamic
compromise (LOE:C)
2- IV amiodarone slow ventricular
rate response to AF (LOE:C)
3- IV blocker or Ca blocker slow
ventricular rate response to AF who
do not have LV dysfunction,
bronchospasm or A-V block (LOE:C)

67. Class II a
1- IV digitalis in AMI + LV
dysfunction (LOE:C)
Class III
2- Class Ic antiarrhythmic drugs
are not recommended in AMI + AF
(LOE:C)

68. Management of AF + WPW syndrome
Class I
1- catheter ablation (LOE:B)
2- Immediate DC shock in haemodynamic
instability
(LOE:B)
3- IV procainamide or Ibutilide restore AF
to SRC if haemodynamically stable + wide
QRS (LOE:C)
Class IIa
IV Flecanide or direct DC very rapid Vent.
Rate (LOE:B)

69. Class IIb
1- IV quinidine, procainamide, disopyramide
or amiodarone , ibutilide if
haemodynamically stable (LOE:B)
Class III
1- IV digitalis or Ca blocker ___ not
recommended (LOE:B)

70. Hyperthyroidism and AF
Class I
1- B blocker (LOE:B)
2- Ca blocker (when B
blockers can not be used)
(LOE:B)

71. Management of AF during prgnancy:
Class I
1- Digoxin, B blocker, Ca blocker
(LOE:C)
2- DC shock if Haemodynamically
unstable (LOE:C)
Class IIb
1- Quinidine or procainamide if
pharmacological cardioversion in
haemodynamically stable (LOE:C)

72. Management of AF + HCM
Class IIa
1- Disopyramide + B blocker or
Ca blocker or amiodarone ___
prevent recurrence of AF
(LOE:C)

73. Management of AF + pulmonary
disease
Class I
1- Diltiazime or Verapamil (LOE:C) if stable
2- DC shock (LOE:C) if unstable
Class II
1- Theophylline and B agonist not
recommended in pulmonary disease +AF
(LOE:C)
2- B blocker , Satolol , Propafenone,
Adenosine not recommended (LOE:C)

74. Management of
Ventricular
arrhythmias

75. 1- Sustained
monomorphic VT
Class I
DC shock (LOE:C)
Class IIa
• 1- IV procainamide or ajmaline (LOE:B)
• 2- IV amiodarone (LOE:C)
Class IIb
• 1- IV Lidocaine if Stable with AMI or acute
Ischemia (LOE:C)
• Class III
• 1- Ca blocker Not used to terminate wide
QRS – complete VT of unknown origin (LOE:C)

76. monomorphic VT

77. 2. Repetitive monomorphic VT
Class IIa
1- IV amiodarone , B blocker and
procainamide , Sotalol or ajmaline in CHD
or idiopathic VT (LOE:C)

78. 3. Polymorphic
VT
ClassI
1- DC Shock if Haemodynamically compromised
(LOE:B)
2- IV B blocker if especially in ischemia (LOE:B)
3- IV amoidarone if in absence of abnormal
repolarization related to congenital or acquired QT
syndrome
(LOE:C)
ClassIIb
1- IV Lidocaine especially in AMI or Ischemia
(LOE:C)

79. 4. Torsades de pointes
Class I
1- Withdrawal of offending drugs
and correction of electrolyte
abnormalities (LOE:A)
2- Acute and long-term pacing if
TdP due to heart block and
symptomatic bradycardia (LOE:A)

80. Class II a
1- IV magnesium __ Long QT + TDP ( Mg
not effective in normal QT) (LOE:B)
2- Acute and long term pacing __
Recurrent pause-dependent TDP
(LOE:B)
3- B blocker + Pacing__TDP + sinus
bradycardia (LOE:C)
4- IV Isopproterenol __ Temporary in
recurrent pause-dependent TDP + no
congenital LQTs (LOE:B)
Class IIb
1- 1<repletion to 405-5 MM/L (LOE:B)
2- IV Lidocaine or oral mexiletine __ in
LQT3 + TDP (LOE:C)

81. 5. Incessant VT
Class I
1- Revascularization +B blocker followed by
IV procainamide or IV Amoidarone ____
Recurrent or incessent polymorphic due to
myocardial ischemia (LOE:C)
Class IIA
1- Amoidarone or Procainamide followed by
VT ablation (LOE:B)

82. Class IIb
1- IV amoidarone and IV B blockers
separately or combined ___ VT
storm (LOE:C)
2- Overdrive pacing or general
anesthesia (LOE:C)
3- Spinal cord modulation (LOE:C)

83. THANK
YOU