antiarrhythmic

[APACHE3]

If you are transferring a patient from the ICU to the floor, which antiarrhythmic would you use? Amiodarone? or is it just hospital specific? Thanks. Sorry, silly question i know.

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[lurkerboy]

antiarrythmic for what arrythmia?

If you are transferring a patient from the ICU to the floor, which antiarrhythmic would you use? Amiodarone? or is it just hospital specific? Thanks. Sorry, silly question i know.

 

[APACHE3]

lets say a-fib, or asymptomatic VT. I was only wondering because I overheard one of the residents say they liked it because it "hung around" a long time and there would unlikely be pt "bounce-backs" (to ICU) at least due to arrhythmia problems. Thanks

 

[powermd]

lets say a-fib, or asymptomatic VT. I was only wondering because I overheard one of the residents say they liked it because it "hung around" a long time and there would unlikely be pt "bounce-backs" (to ICU) at least due to arrhythmia problems. Thanks

For a-fib, likely PO diltiazem, because it lacks the nasty long-term side effects of amio, and the patient can go home on it. For asymptomatic VT would probably want an EP study and an echo to figure out whether or not the patient needs a PM or AICD. Actually, an EKG would be nice too.

 

[lurkerboy]

lets say a-fib, or asymptomatic VT. I was only wondering because I overheard one of the residents say they liked it because it "hung around" a long time and there would unlikely be pt "bounce-backs" (to ICU) at least due to arrhythmia problems. Thanks

I think it is probably a style-thing. Sure, if you were just rate controlling them for afib, metoprolol +/- dilt are first line. I don't think they'd be in the ICU just to start either of those meds, though. If rhythm control was the goal, it would probably be amio. It has got lots of side effects but most of them come with long-term use. Once you've properly loaded the patient, the drug stays in their system for months. (although just because its in your system, doesn't mean it will prevent them from bouncing back!)

For symptomatic VT, you'd probably use amio as well. The rest of the antiarrythmics for VT that I can think of have shorter half-lives.

 

[APACHE3]

I appreciate the responses. I'll do some more homework.

 

[mellow yellow]

For rate control of afib, your three choices are cardizem, B-blockers, and digoxin. Consider dig if the patient has a low EF (<30%) for rate control, otherwise, a cardizem drip is best followed closely by beta blockers. For rhythm control in the setting of structural heart disease, amio is commonly used but it take several months to achieve steady state as its half life is 45-60 days. Even with a large loading dose, you won't get anywhere close to steady state. Sotalol can also be used for rhythm control but it's contraindicated in patients with CHF. Remember, the AFFIRM trial which was published in the NEJM in 2002 demonstrated no benefit of rhythm over rate control in terms of mortality. In fact, patients who were rate controlled had fewer medication related side-effects, fewer hospitalizations, and there was a trend toward decreasing mortality but didn't reach statistical significance.

For patients in the periinfarction period, there is NO EVIDENCE to support the use of prophylactic antiarrhythmics (lidocaine, amio) to suppress VT!!! In fact, several studies have shown that the use of prophylactic antiarrhythmics to suppress VT in the periinfarction period is associated with INCREASED MORTALITY! Never forget that one of the side effects of all antiarrhythmics is proarrhythmia! Also, the presence of VT/VF <48 hours s/p MI is NOT a poor prognosticator, but if >48h, it is a poor prognosticator! The indications for an AICD includes patients who are s/p MI >30 days with an EF <30%, patients with inducible VT on EP study, patients who survived cardiac arrest, NSVT, and a few others....

In patients with STEMI who undergo reperfusion, arrhythmias are commonly observed and this is an EXCELLENT SIGN!!! Why??? But this means that viable myocardium is present! The lack of a reperfusion arrhythmia is a poor prognosticator as it means that there is no viable myocardium left! One of the most common reperfusion arrhythmias is AIVR (accel idiovent rhythm). Don't confuse this rhythm with VT and give your pt lidocaine (unless you want to kill your patient)! The treatment of AIVR is to wait for sinus node fxn to return; atropine won't work here!

Hope this helps.

 

[yesh]

rate control- dig
rhythm control- amio

uptodate.com

 

[undecided05]

Don't use Dig alone... it should be used as an adjunct. Don't have the papers in front of me now, but 1st line for rate control would be IV metop and then Dilt. I personally love using Amiodarone loading... anecdotally, just seems to work and the fibrosis and other issues are usually with long-term use. Also, the CT surgeons at our institution use it like it's going out of style.

 

[King Arthur]

For rate control of afib, your three choices are cardizem, B-blockers, and digoxin. ...

Hope this helps.

thanks for the informative response!

 

[ITE]

thanks for the informative response!

Just wanted to add a few more words about AF:

AFib: rate control => B-Blocker, CCB or Dig (all advantages and disadvantages are in the above posts)

AFib: rythm control => First line Rx is class Ic drugs (Flecainide, Propafenone). However they are CI in structrally abnormal heart and in MI (CAST trial). If MI or structural abnormality exist => class III drugs (Amiodarone) so amiodarone is not the DOC for maintenance of rythm always.

Rate control = rythm control (AFFIRM trial)

New onset AFib(48hr): try cardioversion:
1. DC cardioversion: anticoagulate pt for 3 wks prior or do TEE and R/O thrombus or smoke (ACUTE trial) and then 4 wks of anticoagulation (b/c the heart still rremain mechanically in failure status).
2. Chemical cardioversion: Ibutilide is the most commonly used (there are some alternatives such as amiodarone, procainamide).

Of course, we should try to correct the underlying etiology of AFib if it's not a lone AFib.

If permanent and refractory, in selected cases => referal for trans-septal pulmonary veins RF ablation

Pacemaker:
1. AV nodal ablation and pacemaker placement in refractory cases(RF ablation is the other option in these cases if it is not a chronic AF and LA diameter is not very enlarged - usually less than 4.5cm- so there is a chance for cure),
2. in case if bradycardia develops as side effect of medical thrapy (pacemaker for bradycardia and then aggressive rate control)

Prevent postop AFib with b-blocker, sotalol, or amiodarone.

AFib in MI is a poor prognostic sign and a sign of multi-vessel disease.

AFib and WPW => procainamide (B-blocker, CCB, Dig are CI).

Good luck

 

[Mumpu]

The implication of AFFIRM was actually that rate control is better than rhythm control because you avoid the cost and the nasty side effects of antiarrhythmics with the same clinical outcomes.

I think we'll be seeing a big change in the prevalence of afib in the near future because of the ablation techniques.

 

[skeedo]

rate control- dig
rhythm control- amio

uptodate.com

Beg to differ. Dig is okay ,but the drawback with it is that it's sympatholytic activity is usually overridden when pt engages in activity due to sympathetic overdrive. Use best if there is low CHF as mentioned above. Beta blockers and cardizem better for rate control. Mellow yellow has said it all!

 

[ITE]

The implication of AFFIRM was actually that rate control is better than rhythm control because you avoid the cost and the nasty side effects of antiarrhythmics with the same clinical outcomes.

I think we'll be seeing a big change in the prevalence of afib in the near future because of the ablation techniques.

-Thanks for ur comment. Yes, I meant CLINICAL OUTCOME was equal b/w rate and rythm control in AFFIRM (of course antiarrhythmic meds have more side effects). Definitely rate control is prefered if the pt does not have discomfort and problem with AFib (despite rate control, some pts may have discomfort and palpitation with AFib) and esp if the AFib is chronic with less chance to keep the rythm under control.
- Regarding prevalence of AFib: RF ablation cure AFib in 70 to 80% of the cases with no recurrence, so it will help to decrease AFib prevalence. On the other hand as people live longer and survive after MI with developing more CHF and chamber dilatation, increased age and CHF may not let the prevalence of AFib to be reduced easily.