Pharmacological Treatment of Arrhytmia
Pharmacological Treatment of Arrhytmia
Pharmacological Treatment of Arrhytmia
Pharmacologic
Arrhythmias
management of
tachycardia
Peter M Kistler BACKGROUND
Cardiac arrhythmias may present with palpitations, chest pain, shortness of breath, dizziness and syncope. Diagnosis may
MBBS, PhD, FRACP,
is a cardiologist and be complicated by an inability to document the arrhythmia particularly when symptoms are infrequent and short lived.
electrophysiologist,
OBJECTIVE
Department of Cardiology,
The Alfred Hospital, and This article aims to provide an overview of the pharmacological management of supraventricular tachycardia including
Department of Clinical atrial flutter and haemodynamically stable ventricular tachycardia. Management of atrial fibrillation is discussed in a
Electrophysiology Research, companion article in this issue.
The Baker Heart Research
Institute, Melbourne, Victoria. DISCUSSION
[email protected] Antiarrhythmic medications are effective in reducing symptoms, however, side effects are frequent. Fortunately
Manoj N Obeyesekere nonpharmacological strategies such as catheter ablation have evolved which offer long term cure in the majority of
MBBS, MRCP, is a cardiology patients. However, despite technological advances, pharmacotherapy retains an important place in the therapeutic
advance trainee, Department of approach to cardiac arrhythmias in many patients. It is important to remember that pharmacological management should
Cardiology, The Alfred Hospital, also address any underlying cardiac disease process.
and Department of Clinical
Electrophysiology Research,
The Baker Heart Research
Institute, Melbourne, Victoria.
Arrhythmias may be responsible for worsening paroxysmal AT) and macro re-entrant (atrial flutter). The
heart failure, stroke, myocardial infarction or sudden most common sustained arrhythmia: atrial fibrillation (AF)
death. They may be primary or occur secondary to is the subject of a separate review.
underlying cardiac, pulmonary or endocrine disease. Ventricular arrhythmias also include ectopic beats
It is important to remember that pharmacological and tachycardia. Further management of ventricular
management is not confined to modulation of the tachycardia (VT) requires assessment of underlying
cardiac ion channel but should also address any cardiac function. This is important in determining the risk
underlying cardiac disease process. of sudden cardiac death and the need for an implantable
cardioverter defibrillator (ICD).
An understanding of the underlying mechanism and
categorisation according to cardiac chamber assists
Supraventricular tachycardia
the therapeutic approach to cardiac arrhythmias. Atrial Acute management
arrhythmias include:
• ectopy Management depends on the accurate diagnosis of a
• supraventricular tachycardia (SVT) due to narrow complex tachycardia (QRS width <120 ms) typically
– atrioventricular (AV) nodal re-entry tachycardia (AVNRT) without discernible P waves. Broad complex tachycardia
– AV re-entrant tachycardia (AVRT), or (QRS width >120 ms) should be managed as VT unless
– atrial tachycardia (AT) (Figure 1a–d). there is strong evidence to support alternate diagnoses.
Atrial tachycardia is further divided according to If the patient is hemodynamically compromised, electrical
electrophysiological mechanism into focal (previously cardioversion should be considered.
500 Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007
If the patient is stable, carotid sinus massage or
Valsalva manoeuvre may be useful in producing transient A B
AV block and terminating tachycardia. However this Atrium Atrium
manoeuvre will be ineffective for arrhythmia circuits that
Fast pathway
do not include the AV node.
The most effective approach in terminating SVT is the Slow pathway
AV AV
node node
administration of adenosine �(Figure 2a)����������������
. Adenosine has
a half life of 10 seconds and requires cardiac monitoring
during intravenous (IV) administration. Monitoring is not Accessory
pathway
only important in terminating arrhythmias safely, but (retrograde
provides diagnostic information regarding arrhythmia conduction)
Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007 501
THEME Pharmacologic management of tachycardia
A Atrial ectopy
Reassurance and lifestyle modification (eg. coffee and
alcohol intake, smoking) are usually all that are required
for symptomatic patients. If symptoms remain distressing
despite these measures, beta blockers or verapamil are
effective.
Atrial flutter
B If prevention of atrial flutter is required following reversion
then antiarrhythmics or electrophysiological study and
ablation can be undertaken. Flecainide may have a
long term efficacy of 50% in maintaining SR.5 Because
flecainide can slow the flutter rate, AV nodal blocking
agents need to be used with flecainide to prevent 1:1
conduction. For maintenance of SR, sotalol or amiodarone
can also be used.
Figure 2. AV nodal block with adenosine terminating AVNRT (A) and revealing underlying atrial AV node blocking agents alone in the long term can be
flutter (B) used to affectively rate control patients with atrial flutter.
Although the risk of thromboembolism is less compared to
Table 1. Response of narrow complex tachycardia to vagal manoeuvres or adenosine AF, long term anticoagulation (INR 2–3) recommendations
are the same for atrial flutter and are presented in the
No change Consider inadequate dose/poor technique
'Management of atrial fibrillation' article in this issue.
Sudden reversion to SR* Atrioventricular re-entry tachycardia
Atrioventricular nodal re-entry tachycardia AVNRT/AVRT
Atrial tachycardia (rarely reverts)
In patients with burdensome symptoms who do not
Atrioventricular block Atrial flutter
wish to undergo catheter ablation, first line treatment
Atrial tachycardia
is AV nodal blocking agents (except in patients with
Gradual slowing and acceleration Atrial tachycardia
pre-excitation). Atrioventricular nodal blocking agents
Sinus tachycardia
in combination can also be used. A randomised trial
comparing verapamil, digoxin and propanolol failed to
* Tachycardia which terminates with a nonconducted P wave is most likely due to
reveal a superior agent over another.6
AVNRT or AVRT
Class I or class III antiarrhythmic drugs should not
502 Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007
Pharmacologic management of tachycardia THEME
Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007 503
THEME Pharmacologic management of tachycardia
Conclusion
Amiodarone
Sotalol*^ Antiarrhythmic drugs play an important role in the
Flecainide# acute management of arrhythmias. Patients with
Procainamide# recurrent symptoms or single episodes associated
DCR† with haemodynamic compromise should be referred
to an arrhythmia specialist for consideration of long
Figure 3. Acutely managing SVT term therapy. This may include catheter ablation,
† DC cardioversion remains an alternative at any point in the
treatment regimen, as a last resort, or if hemodynamiclly
pharmacological management or device based therapy.
compromised
# Not to be used in patients with LV dysfunction Conflict of interest: none declared.
* Reduce dose in renal impairment
^ Caution should be used in patients with LV dysfunction Acknowledgment
Dr Kistler is the recipient of the Neil Hamilton Fairley Fellowship
achieved by echo, nuclear gated blood pool scan or from the National Health and Medical Research Council of Australia
left ventriculography. If LV function is compromised and National Heart Foundation.
then further assessment of underlying aetiologies
References
(eg. ischaemic heart disease, cardiomyopathy, valvular 1. Di Marco JP, Miles W, Akhtar M, et al. Adenosine for paroxysmal
disease) should be investigated. Ventricular tachycardia supraventricular tachycardia: dose ranging and comparison with
may also occur in the structurally normal heart and be verapamil: assessment in placebo controlled multicentre trials. Ann
associated with a good prognosis. Int Med 1990;113:104–10.
2. Garrat C, Antoniou A, Ward D, et al. Misuse of verapamil in pre-
In patients with ventricular arrhythmias and a left
excited atrial fibrillation. Lancet 1989;1:367–9.
ventricular ejection fraction <40%, an ICD is associated 3. Wren C. Incessant tachycardias. Eur Heart J 1998;19(Suppl E):
with improved survival and should be considered. E32–59.
The device offers antitachycardia pacing in addition to 4. Delacretaz E. Supraventricular tachycardia. N Engl J Med
electrical cardioversion to revert arrhythmias. 2006;354:1039–51.
Beta blockers have been shown to prolong survival 5. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/
ESC guidelines for the management of patients with supraventricular
and prevent ventricular arrhythmias in patients with and
arrhythmias. J Am Coll Cardiol 2005;42:1493–531.
without heart failure and should be used as first line 6. Winniford MD, Fulton KL, Hillis LD. Long term therapy of paroxysmal
agents.13 Amiodarone may be added if arrhythmias break supraventricular tachycardia: a randomised double blinded comparison
through on beta blockers. Amiodarone is associated with of digoxin, propanolol and verapamil. Am J Cardiol 1984;54:1138–9.
504 Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007
Pharmacologic management of tachycardia THEME
7. Wellens HJ, Brugada P, Abdollah H. Effects of amiodarone in 14. Cleland JG, Ghosh J, Feemantle N, et al. Clinical trials update and
paroxysmal supraventricular tachycardia with or without Wolff- cumulative meta-analysis from the American college of Cardiologists:
Parkinson-White syndrome. Am Heart J 1983;106:876–80. WATCH, SCD-HeFT, DINAMIT, CASINO, INSPIRE, STRATUS-US, RIO-
8. Kunze KP, Schluter M, Kuck KH. Sotalol in patients with Wolff- Lipids and cardiac resynchronisation therapy in heart failure. Eur J
Parkinson-White Syndrome. Circulation 1987;75:1050–7. Heart Fail 2004;6:501–8.
9. Dagress N, Clague JR, Lottkamp H, et al. Impact of radio fre- 15. Kuhlkamp V, Mewis C, Mermi J, et al. Suppression of sustained
quency catheter ablation of accessory pathways on the frequency of ventricular tachyarrhythmias: a comparison with d, l sotalol with no
atrial fibrillation during long term follow-up; high recurrence rate of antiarrhythmic drug treatment. J Am Coll Cardiol 1999;33;46–52.
atrial fibrillation in patients older than 50 years of age. Eur Heart J 16. Connolly SJ, Dorian P, Roberts RS, et al. comparison of beta-blockers,
2001;22:423–7. amiodarone plus beta-blockers, or sotalol for prevention of shocks
10. Alboni P, Tomasi C, Menozzi C, et al. Efficacy and safety of out of from implantable cardioverter defibrillators: the OPTIC study. JAMA
hospital self administered single dose oral drug treatment in the 2006;295:165–71.
management of infrequent well tolerated paroxysmal supraventricu-
lar tachycardia. J Am Coll Cardiol 2001;37:548–53.
11. Kistler PM, Sanders P, Hussin A, et al. Focal atrial tachycardia arising
from the mitral annulus, electrocardiographic and electrophysiologic
characterisation. J Am Coll Cardiol 2003;41:2212–9.
12. Nasir N, Taylor A, Doyle TK, et al. Evaluation of intravenous lidocaine
for the termination of sustained monomorphic ventricular tachycardia
in patients with coronary artery disease with or without healed myo-
cardial infarction. Am J Card 1994;74:1183–6.
13. Reiter MJ, Reiffel JA. Importance of beta blockade in the therapy of
CORRESPONDENCE email: [email protected]
serious ventricular arrhythmias. Am J Card 1998;82:9I–19I.
Reprinted from Australian Family Physician Vol. 36, No. 7, July 2007 505