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MINISTRY OF HEALTH OF UZBEKISTAN
CENTRE FOR MEDICAL EDUCATION
Tashkent Medical Academy
Department of Clinical Pharmacology
Subject CLINICAL PHARMACOLOGY
Topic: "Pharmacological Approaches to rational prescribing of drugs for treatment of the
syndrome ARRHYTHMIA"
Educational-methodical development
(For teachers, students)
6. The content of lessons
6.1. Theoretical part
- Classification of antiarrhythmic drugs
- Select the most effective and safe drug or combination of drugs depending on the
severity of arrhythmias, the patient's age and comorbidity
- Select the most effective and safe drug, depending on the goals of treatment (mild
paroxysms of arrhythmias, prolonged therapy)
- Side effects of antihypertensive drugs and measures to help
In the treatment of arrhythmias is very important impact on the underlying disease (use
of hyperthyroidism tireostaticheskim, commissurotomy in mitral stenosis, Antianginal
agent in myocardial ischemia) and the elimination of provoking factors (alcohol, use of
strong tea, coffee, heavy physical exertion). When an arrhythmia due to the progression
of heart failure need adequate therapy vasodilator, diuretics, cardiac glycosides.
Fibrillation, which develops during hypotension, may be eliminated with an increase in
blood pressure, for example, the introduction of mezatona. Rhythm disturbance
associated with emotional stress is treatable sedatives. When choosing a drug should
take into account the type and mechanism of arrhythmias, the cause, severity of
underlying disease, the presence of hemodynamic instability, concomitant diseases that
affect the pharmacokinetics and pharmacodynamics of antiarrhythmic drugs, the
possibility of their interaction with other drugs and adverse reactions
Sinus tachycardia
Sinus tachycardia is characterized by more frequent sinus impulses more than 95 (100),
1 min at rest with preservation of normal sequence elements EKG.Lechenie sinus
tachycardia is conducted when it is poorly tolerated by patients or becomes sustained,
that could affect the state of circulation. Should be considered an etiological factor. In
the psychogenic form requires settlement of the psychological status - therapy, auditory
training, psychological adaptation. Suitable rational mode, normalization of sleep,
exercise therapy, physiotherapy. We recommend rejection of strong tea, coffee, alcohol,
smoking. You can recommend acceptance or valokordin korvalola (20-30 drops 2-3
times a day), tinctures Leonurus, hawthorn, peony, infusion or decoction of valerian
root, occasionally, minor tranquilizers. Very effective beta-blockers - propranolol 20-40
mg, 20 mg trazikor, metoprolol 50 mg 2-4 times a day.
Sinus bradycardia
Sinus bradycardia - a decrease in heart rate less than 60 minutes to 1 with an
extension, but within normal limits, all intervals of the ECG. Sinus bradycardia often
observed in physically well-trained people. Treatment of sinus bradycardia is carried out
in cases where the frequency rate persistently falls below 50 per minute and there are
signs of hypoperfusion of vital organs - dizziness accompanied by decreasing blood
pressure, angina, ventricular premature beats. It is recommended to give the patient a
raised position with the lower half of the body to enhance venous return to heart and to
improve cerebral hemodynamics. Should conduct a test with atropine, if no
contraindications to its introduction. Atropine given intravenously at a dose of 0.5-1.0
mg (0.5-1.0 ml 0.1% solution). In the vagus-induced sinus bradycardia can be assigned
belloid (Bellataminal) itrop (ipratropium bromide), 10 mg 1 tab. 2-3 times per day or
miofedrin (oksifedrin) 8 mg 1-2 tab. 2-3 times a day. Sometimes useful to turn
methylxanthines, especially long-acting - teopek. If hypotension against a background of
sinus bradycardia is most commonly used dopamine (dopmin). 200 mg of dopamine (5
ml of 4% solution) diluted in 250 ml 5% glucose and injected at a rate of 15-30 ml / h (25 mg / kg / min). If necessary, the infusion rate gradually increased to 20 mg / kg / min.
Atrial fibrillation
Fibrillation (flicker) looks like a chaotic atrial very frequent atrial reduction as a result of
"overlapping" multiple waves of recurrent excitation. Treatment of resistant atrial
fibrillation conducted through the elimination of its settlement or ventricular rhythm.
Removal of persistent atrial fibrillation is most often carried out using electro-therapy
(EIT). The indications for EIT is a relatively recently emerged (1 year) atrial fibrillation.
Contraindications to the elimination of atrial fibrillation are the continued existence of an
arrhythmia (over 1 year), the presence of frequent paroxysms of arrhythmia prior to the
establishment of its shape resistant, active inflammatory process in the myocardium,
cardiomegaly, large size of the atria (atriomegaly), severe circulatory failure,
thromboembolic events in history. Prescribing potassium intravenously or orally - an
indispensable element of preparation for the planned cardioversion. In cases of inability
to eliminate atrial fibrillation to settle the frequency of ventricular rate using cardiac
glycosides, or their combination with beta-blockers. As for atrial fibrillation at high risk of
thromboembolic complications, it is the indication for anticoagulation or antiplatelet
indirect.
Ventricular extrasystoles
Treatment options and antiarrhythmics dictated by the origin of arrhythmia, its topics,
the impact on hemodynamics and prognostic value.
Functional neurogenic ventricular extrasystoles (psychogenic) origin of the settlement
require the psycho-emotional status using non-medicinal and medicinal effects. When
giperadrenergicheskih reactions demonstrates the use of beta-blockers (Inderal, 20 mg
3-4 times a day).
Arrythmia treatment of organic nature is largely determined by the nature of the
underlying disease. In the acute period of myocardial infarction, ventricular
extrasystoles is an indication for intravenous lidocaine 80-120 mg bolus, followed by its
infusion at a rate of 1-2 mg / Ministry of Industry need to be used ritmilen 100-200 mg 3
times a day, other drugs a class beta-blockers.
In chronic ischemic heart disease, various antiarrhythmic drugs, empirically selected
individually or in acute pharmacological test. It should again be noted that prolonged
use of antiarrhythmic drugs of class 1C, and 1A is associated with the risk of
arrhythmogenic action, and drugs 1B class, which can be used inside (tokainid,
phenytoin) are not highly effective. Sometimes, after the suppression of arrhythmias and
the subsequent relatively non-durable applications (2-4 weeks) drug class 1 arrhythmia
is not renewed. But if there is a need for long-term maintenance therapy, the preferred
drug classes II-IV. With a combination of supraventricular and ventricular extrasystoles
are applied drugs 1A, 1C class, beta-blockers. In those cases, when other
antiarrhythmics are ineffective kordaron used, but due to the fact that kordaron often
causes side effects, it should be used only in cases of severe or threatening the
development of sudden death, arrhythmias.
Appointment of antiarrhythmic drugs should be combined with preparations of
potassium (1-2 Asparcam tab. 3 times a day). Ventricular premature beats is considered
one of the major contraindications to treatment with cardiac glycosides.
Ventricular fibrillation
VF is fatal if not eliminate electrical defibrillation. VF is caused by the coexistence of
many small waves recurrent excitation and manifests on the ECG chaotic waves
(without constant cycle time, activation time or a vector). Treatment of atrial fibrillation
and ventricular flutter is their immediate removal and resuscitation. conducted
emergency electrical defibrillation, if necessary with repeated shocks while maintaining
atrial fibrillation (flutter) ventricles. Defibrillation begins with a discharge of 200 J with an
increase in repeated discharges of up to 300-360 G. In the first attempts to failure of
electrical defibrillation, can be used ornid (bretiliya tosilat). The initial dose ornida 5 mg /
kg intravenously (usually 500 mg). After the introduction of jet ornida resuscitation held
for 1-2 minutes, after which electrical defibrillation is repeated. In the intensive care unit
as soon as possible to enter the adrenaline, as a basic drug that improves coronary and
cerebral blood flow during chest compressions. The use of epinephrine increases the
effectiveness of follow-up. The standard dose of adrenaline - 1 mg intravenously, if
necessary introduction is repeated every 3-5 minutes.
Treatment of sinus tachycardia with heart rate> 120 beats per minute in patients with
normal numbers of blood pressure without symptoms of heart failure.
1. Propranolol 1-3 mg intravenously for 10-15 minutes or
- Diltiazem 20 mg in 20 ml of saline solution intravenously for 2 minutes or
- Verapamil 5 mg intravenously at 1 mg / min, but no more than 20 mg (in case of
intolerance of propranolol) or
2. After 30 minutes - novokainamid 50 mg / min, but no more than 1.5 g intravenously in
saline.
If there are symptoms of congestive heart failure drug of choice - digoxin 0.25 mg in 10
ml of saline intravenously.
Treatment of supraventricular tachycardia in patients with normal blood pressure
numbers.
1. Paroxysm of tachycardia with sustained carotid sinus massage performed.
2. Verapamil 5 mg in 10 ml of saline solution intravenously (in ineffectiveness of
massage) or
- Diltiazem 20 mg in 20 ml saline bolus for 5 minutes or
- Propranolol 1-3 mg intravenously for 10-15 minutes or
3. After 30 minutes - verapamil 5 mg in 10 ml of saline intravenously or
- Diltiazem 25 mg in 20 ml of saline solution intravenously over 5 minutes, or
- Propranolol 1-3 mg intravenously over 10-15 minutes or
4. After 60 minutes - 10% -10 novokainamid ml in 10 ml of saline intravenously over 3-5
minutes.
5. 2 hours - are increasing eletrokardiostimulyatsiya (transesophageal or transvenous).
6. With the ineffectiveness of the therapy - electrical defibrillation.
- With an increase in signs of left ventricular failure - electrical defibrillation.
Treatment of supraventricular tachycardia in patients with signs of circulatory failure.
1. Strophanthin 0.05% 0.5 ml and 10 ml of saline intravenously over 3-5 minutes or
- Digoxin 0.25 mg in 10 ml of saline intravenously over 3-5 minutes.
2. After 5 minutes - the polarizing mixture containing 1-1.5 g of potassium chloride
intravenously.
3. After 30 minutes - kordaron 150-300 mg in 10 ml of saline solution intravenously.
- With an increase in signs of circulatory failure, intravenous bolus IZOKET and Lasix,
then continued intravenous infusion IZOKETA, after failure - electrical defibrillation.
Treatment of paroxysmal atrial flutter with a heart rate> 100 beats per minute.
The preferred method of treatment - cardioversion.
1. Verapamil 5 mg in 10 ml of saline intravenously or
- Diltiazem 20 mg intravenously for 2 minutes or
- Kordaron 300 mg intravenously over 1-3 minutes or
- Propranolol 1-3 mg intravenously over 10-15 minutes
- Novokainamid 10% 10 ml in 10 ml saline bolus over 3-5 minutes.
In the presence of heart failure: strophanthin 0.05% -0.5 ml in 10 ml of saline or 0.25 mg
of digoxin 1mg in 10 ml of saline solution for 3-5 minutes. Parallel Lasix intravenously,
intravenously IZOKET.
2. After 30 minutes - verapamil 5 mg in 10 ml of saline intravenously or
- Propranolol 1-3 mg in 10 ml of saline intravenously ratvora for 10-15 minutes.
3. After 60 minutes - strophanthin 0.05% -0.5 ml in 10 ml of saline or ratvora
- 1 ml of digoxin-0, 25 mg in 10 ml of saline solution for 3-5 minutes
4. 2 hours - more frequent pacing.
5. With the ineffectiveness of the therapy - electrical defibrillation
- With an increase in signs of circulatory failure, electrical defibrillation.
By reducing the ventricular rate <100 beats per minute, continuing treatment with
cardiac glycosides, possibly, their combination with propranolol 10-20 mg.
Treatment of paroxysmal atrial tachyarrhythmia with a heart rate> 100 beats per minute
with normal blood pressure.
When an unstable state - emergency cardioversion in the absence of contraindications.
The preferred method of treatment - diltiazem intravenously at a dose of 20 mg for 2
minutes, with no effect after 15 minutes, 25 mg administered over 2 minutes, then begin
infusion at 5-15 mg / hour.
If you have symptoms of chronic circulatory failure to begin therapy with digoxin.
1. Diltiazem 20 mg intravenously for 2 minutes or
- 10% -10 novokainamid ml in 20 ml of saline solution intravenously for 10 minutes or
- Propranolol 3-5 mg intravenously over 3-5 minutes or
- Verapamil 5.10 mg intravenous bolus of 10 mL of saline solution for 15-20 seconds or
- Amiodarone 300 mg intravenously over 3-5 minutes.
2. After 60 minutes - digoxin 0.25 mg intravenously in 10 ml of saline for 5 minutes.
3. After 6 hours - diltiazem 25 mg intravenous bolus of 10 mL of saline solution for 2
minutes or
- Verapamil 5 mg-10 mg undiluted intravenously over 15-20 seconds or
- Novokainamid 10% 10 ml in 10 ml of saline solution intravenously for 10 minutes or
- Propranolol 3-5 mg intravenously over 3-5 minutes or
- Amiodarone 300 mg intravenously over 3-5 minutes.
4. After 12 hours, digoxin 0.25 mg intravenously in 10 ml of saline for 5 minutes.
5. After 24 hours - electrical cardioversion.
When restoring sinus rhythm is carried out drug prevention:
- Diltiazem into 60-90 mg 3 times daily or
- Kordaron 200 mg per day or
- Novokainamid into 500 mg 6 times a day or
- Propranolol 10-20 mg by mouth 4 times daily or
- Quinidine 200 mg by mouth per day
TREATMENT OF CARDIAC RHYTHM DISORDERS IN CHILDREN
The choice of therapy of arrhythmias in children, to some extent affect the mechanism
of arrhythmia. If ventricular arrhythmias that occurred on the basis of the trigger activity
or rientri, but not related to exercise or adrenergic stimulation, a good effect makes the
use of calcium channel antagonists. Patients adrenochuvstvitelnye tachyarrhythmias
can cut the introduction of p-blockers or calcium channel blockers.
In cases where the arrhythmia is poorly docked using one drug, you can use the
combination therapy.
Pharmacodynamics of antiarrhythmic drugs are commonly used in pediatric cardiology
Encainide - sodium channel blocker, is a derivative of benzo-namida, effective in atrial
and ventricular tachycardia, resistive nilpotent to most traditional treatment methods.
Initial dose is typically 30-60 mg/m2 per day in 3-4 doses. Dose may be increased to a
maximum of 120 mg/m2 a day. The drug is used-, under the control of the ECG, and the
dynamics of the duration of the QRS complex is an indicator of therapeutic effect. The
broadening of the QRS complex should be not more than 20% increase in the duration
of the QRS complex of more than 50% indicates a drug overdose.
Flecainide - sodium channel blocker, is a type 1C protivok: arrhythmic drugs (classified
Vaughan Williams), a derivative; procainamide. The children used for supraventricular
and ventricular arrhythmias that are resistant to conventional antiarrhythmic therapy. In
pediatric practice, flecainide is effective in treating both supraventricular and ventricular
arrhythmias. In the treatment of flecainide may develop side effects. In children, it
manifests neurological symptoms and signs of lesions of the gastrointestinal tract. The
drug can cause pronounced bra-dikardiyu, particularly with concomitant disease or
sinus node dysfunction.
Treatment is usually begin flecainide in a hospital. Initial dose is 60-100 mg/m2 in 2
divided doses. After 3 days the dose is increased to the maximum reaching 225 mg/m2
in children a day. Later srednetera peticheskaya-dose usually is 150 mg/m2 per day.
Atenolol - beta-1 adrenergic receptors, an analog izoprotereno la. Atenolol has a longer
half-life and greater selectivity with respect to the myocardium in comparison with other
beta-blockers. The drug belongs to a class II antiarrhythmic funds (classified Vaughan
Williams).
Atenolol is used primarily in pediatric patients in the treatment of supraventricular
arrhythmias forms: nodal supraventricular tachycardia (SVT), SVT due to ectopic
primary focus in the atria, atrial, and atrial flutter, atrial premature beats. The drug is
effective in some forms of ventricular arrhythmias induced by catecholamines in
particular, ischemia or digitalis toxicity. Atenolol, as when taken orally and by
intravenous administration, eliminates ventricular extrasystoles, flushing complexes,
ventricular tachycardia (VT). The drug is effective in treating children with the syndrome
of elongated interval QT, polymorphic VT with (torsades de pointes). Side effects of the
drug in children are rare and occur weakness and headache. Perhaps the development
of persistent bradycardia and hypotension. Atenolol administered orally at a high
therapeutic dose in the range 0.8-1.5 mg / kg a day.
Amiodarone - benzofuran derivative, has structural similarities to thyroid hormones T4
and TK. While taking the drug orally, as opposed to intravenous administration, a
significant depression in myocardial contractility was observed. From the
gastrointestinal tract into the systemic circulation receives only 50% of the injected drug.
Peak plasma concentrations after a single application remains 3-7 hours. Antiarrhythmic
effect develops gradually over 1-7 days. The half-life of the drug ranges from 40 to 55
days. Amiodarone is metabolized in the liver and in small amounts in the kidney. In
pediatric practice, amiodarone is used to treat supraventricular and ventricular
arrhythmias forms. The efficiency of the drug in the treatment of atrial flutter and flicker,
ectopic pre-serdnoy tachycardia, arrhythmias associated with hypertrophic
cardiomyopathy, her ventricular tachycardia. The effectiveness of treatment does not
depend on the presence of concomitant organic heart disease. Initial dose in children is
10 mg / kg body weight for 7-10 days. Then gradually reduce the dose to 5 mg / kg per
day. A few months later, with good effect and the elimination of arrhythmia drug can be
administered intermittently five days a week. Because amiodarone increases the
concentration of digoxin in the blood by 70%, in their joint use must be carefully
corrected appointive dose of digoxin.
Verapamil - a synthetic derivative of papaverine. Verapamil successfully used to treat
angina, hypertension, and hypertrophic Cardy-omiopatii. Verapamil is used when a
node reentry SVT is the most effective drug in this form of tachycardia in children. The
effect occurs rapidly with recovery rate of 80-100% of cases. For cupping SVT
recommended intravenous 0.1 mg / kg of verapamil for 2 minutes every 30 minutes
between infusions. Cupping should be performed in intensive care, it is recommended
to avoid asystole type calcium (10 mg / kg) and atropine (0.01 mg / kg). When
administered therapeutic dose of verapamil for children from 3 to 5 mg / kg body weight
per day in 3 divided doses.