Arrhythmias, Antiarrhythmic Treatment


• The use of anti-arrhythmic (AAR) requires a specialist opinion: indications, against-indications, cardiac side effects and extracardiac, surveillance.

• All antiarrhythmic has pro-arrhythmic effects, negative inotropic, humps conduction, sometimes bradycardia.

• Carefully assess the risk / benefit of treatment AAR.

• Specialist advice is necessary for explorations (echo, Holter, etc):

. assess the severity or otherwise of the arrhythmia,

. investigate the cause,

. evaluate the therapeutic indication and associated treatments (including antithrombotics)

. make associations AAR.

• Beware of drug interactions.

Settings to know before starting an anti-arrhythmic treatment:

– Nature disorder of rhythm, absolutely documented:

– 12-lead ECG (preferably at least 3 simultaneous tracks), rest and if possible crisis, Holter monitor (24-48 h), stress test or R-test,

– Questioning the patient, obviously useful, but may specify some details is not always reliable and does not allow an accurate diagnosis by ECG definition.

– Basic ECG: sinus rhythm (sinus rhythm) or atrial, appearance auriculogrammes (width, picking, fragmentation), atrioventricular conduction (possible block and degree), ventricular rate (if different from the atrial rate) existence of an intraventricular conduction disorder, QRS width, length and appearance of ventricular repolarization (QTU interval).

– Nature of the underlying heart disease, objectified by clinical and laboratory findings:

– Healthy or diseased heart?

– Coronary heart disease? myocardial sequelae?

– Type of valve disease?

– Hypertrophy and / or dilatation of the heart chambers?

– Left ventricular function: all AAR are depressants contractility +++

– Assessed by the clinic: functional impairment, heart failure history, pulmonary edema, age, physical examination,

– Possibly by fluoroscopy

– Especially by echocardiography +++ study of global and segmental kinetics, calculate fractional shortening and ejection fraction

– Another possibility: the ejection fraction has been evaluated in connection with an isotopic ventriculography or radiological (during catheterization).

– Biology to search:

– Hypokalemia, hypomagnesemia,

– Renal failure (approximate formula of Cockroft and Gault to assess creatinine clearance)

– Possible liver failure,

– Possible thyroid dysfunction (before the administration of CORDARONE) ++.

– Physiological or pathological conditions associated:

– Age, atypical body weight of the patient,

– Ongoing pregnancy,

– Glaucoma,

– Prostatic hypertrophy,

– Obstructive pulmonary disease,

– Raynaud’s syndrome, preexisting edema venous lower limb

– Hypotension / hypertension,

– Goiter, thyroid dysfunction,

– Diabetes …

Concomitant therapy:

– Drugs that prolong repolarization and the QT interval and increased risk of arrhythmia and torsades de +++ tips: kaliuretic diuretics, laxatives irritants, cerebral vasodilators derived from vincamine, some neuroleptic phenothiazines type butyrophenones and benzamides , certain antidepressants, lithium, some anticholinergic or not antihistamines, certain macrolide antibiotics and antivirals, and antimalarials some pesticides, some antifungals, and mineralocorticoid gluco …

– Digitalis: increased risk of bradycardia, risk elevation in plasma,

– Anticoagulants: may potentiate amiodarone and propafenone with hemorrhage

– Antihypertensive agents: risk of additive effect with low blood pressure,

– Cyclosporine: increased circulating levels of ciclosporin with diltiazem and verapamil,

– Combination with a beta-blocker eye drops … +++

Directions to supraventricular floor:

rhythm disorders Treatment on this floor is changing gradually from development techniques endocardial radiofrequency ablation or cryoablation. The situation changes rapidly and removal thus appears increasingly early in the therapeutic flutters, atrial tachycardia, junctional tachycardia by nodal re-entry or arrhythmias associated with the existence of an accessory pathway. specialist advice recommended ++.

Supraventricular extrasystoles:

Treat only if they are symptomatic, polymorphic, and supported by frequent bursts (see prevention of atrial fibrillation relapse).

Permanent atrial fibrillation:

– Specialized Notice before attempting a reduction +++.

– A reduction is conceivable only if fibrillation is permanent and non-paroxysmal (interest Holter +++).

– A reduction can only be conceived after echocardiogram (to detect atrial thrombus +++, take stock of the damage, measure the size of the atria, assess LV function).

– An AC / FA in a subject over 70-75 years asymptomatic should be respected.

– A drug reduction (under ECG monitoring) is possible only if the arrhythmia less than 24-48 hours +++ otherwise thromboembolic risk is great and put to the prior AVK, with correct hypocoagulability (INR between 2 and 3) for at least 1 month is +++ imperative.

– The reduction can be attempted by CORDARONE oral (15 mg / kg / day as an outpatient, 1 cp = 200 mg, about 24-48 hours followed by a decrease to 200 mg / day continuously) or during a hospital for infusion CORDARONE or flecainide, associated with a retarder of the nodal conduction to prevent ventricular acceleration.

– Notice to discuss specialized electrical cardioversion by external shock or a simple

slower ventricular rate, especially in case of rapid conduction arrhythmia, by DIGOXIN, CARDENSIEL, SECTRAL, Isoptine or only MONOTILDIEM; if failure, association or discussion of a “modulation” of the atrioventricular nodal conduction ablation.

Permanent atrial flutter and atrial tachycardia:

electrical cardioversion by external shock or endocardial stimulation (OD) or oesophageally (OG).

Atrial fibrillation, atrial flutter or paroxysmal atrial tachycardia, fibrillation relapse prevention after discount:

Anyway, under close ECG monitoring:

– Class IC: flecainide LP: 1 capsule of 100 to 200 mg daily, always associated with a node-type retarder beta blocker or diltiazem or digoxin,

– If the FA catecholinergic: Class II (beta-blockers), RYTHMOL,

– Class III: SOTALEX 80 mg x 2 per day,

– If failure CORDARONE cp 1 day 7 days / week or possible association between different classes (by lowering doses) or digitalis, or discussions of a possible “modulation” of atrioventricular conduction (cf. . supra)

– Indication of localized ablation endocavitary the headset is increasingly wide and depends on the patient, the functional impairment and recurrence. It notes highly specialized centers Rhythm. Ablation of atrial flutter is usually much easier than that of a fibrillation.

The antithrombotic treatment of atrial fibrillation and atrial flutter is discussed in Chapter Anticoagulants (see above).

Paroxysmal supraventricular tachycardia, junctional tachycardia, Bouveret’s disease:

– Reduction of the crisis: punch sternal, vagal maneuvers (Valsalva, ocular compression, gag reflex, rapid swallowing), otherwise hospitalization for administration of STRIADYNE 1 bulb rapid intravenous digitalis or intravenous antiarrhythmic (under strict supervision ECG) : class IC, II, III, IV. Exceptionally, endocardial atrial pacing or oesophageally or external shock.

– Relapse prevention: all classes can be used, ablation of the slow pathway radiofrequency there is also another treatment option to discuss, amiodarone is reserved for resistant cases or patient refusal. ++ expert advice.

Directions to the ventricular floor:

Premature ventricular:

– Do antiarrhythmic deal with if they are associated with heart disease +++.

– In fact, we must label the possible underlying heart disease: expert advice (eg, ischemia, ventricular hypertrophy, heart failure …).

– The ESV on healthy heart, say “benign”, although in some very numerous and sometimes symptomatic cases, require by antiarrhythmic +++. Try cardio-

sedatives such NATISEDINE, PALPIPAX, CARDIOCALM, on demand or at bedtime. Possibly low doses of beta blockers: Tenormine 50 mg 1 tablet per day or 100 1/2 SELOKEN tab daily or SECTRAL 1/2 cp 200 per day, Magne B6: 6 cp per day.

Ventricular tachycardia:

– The severity depends on the clinical tolerance.

– Permanently connected ECG.

– Chest Punch can stop tachycardia.

– Call the ambulance for emergency hospitalization in intensive care unit (electric shock, ventricular pacing, anti-arrhythmic drugs intravenously).

Torsades de pointes

– Favored by bradycardia, hypokalemia, prolongation of the QT interval, antiarrhythmic treatment +++.

– Call the ambulance to hospital also (short-term risk of fatal ventricular fibrillation).