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Lesson 7 of8
In Progress

Pharmacologic management

Riszel February 18, 2022
Drug Mechanism of Action Dose Pharmaco-kinetics Adverse Effects Pearls
Metropolol Acute beta blocker therapy for rate control strategy Intravenous,

2.5 – 5 mg/kg in 2 minutes to a maximum of 3 doses

Onset: 5 minutes Hypotension, bronchospasm, bradycardia, AV block, heart failure For patients with no significant HF, hypotension
Propranolol Acute beta blocker therapy for rate control strategy Intravenous, 0.15 mg/kg Onset: 5 minutes Hypotension, bronchospasm, bradycardia, AV block, heart failure For patients with no significant HF or hypotension
Esmolol Acute beta blocker therapy for rate control strategy Intravenous, 500 mcg/kg over 1 minute

 

Maintenance Dose:

0.05 – 0.2 mg/kg/min

Onset: 5 minutes

 

Duration of Action:
10 – 20 minutes

Hypotension, bronchospasm, bradycardia, AV block, heart failure Useful if uncertain that a beta blocker therapy will be tolerated
Verapamil Calcium channel blocker for management of AF Intravenous, 0.75 – 0.15 mg/kg in 2 minutes Onset: 3 – 5 minutes Hypotension, AV block, heart failure, bradycardia, interaction with digoxin Pronounced negative inotropic effects

 

Not for hypotensive and heart failure patients

Diltiazem Calcium channel blocker for management of AF Intravenous, 0.25 mg/kg over 2 minutes

 

Maintenance Dose: 5 –  5 mg/h

 

Onset: 2- 7 minutes Hypotension, AV block, heart failure, bradycardia For absent pre-excitation

 

Lesser negative inotropic effects than IV verapamil

 

Digoxin Cardiac glycoside Intravenous, 0.50 mg initially, then 0.25 mg q6h to max 1.5 mg

 

Maintenance Dose: 0.125 – 0.25 mg/day

Onset: 2 hours AV block, bradycardia, digitalix intoxication (GI, ocular, neurological, proarrhythmia) For patients whose heart rate cannot be adequately controlled by BB or CCB

 

Not for older patients

Amiodarone Heart rate control for patients with accessory  

 

Intravenous or Intraoral, 150mg over 10 minutes (repeat in 10 – 30 minutes if necessary)

 

Maintenance Dose: 0.5 – 1 mg/min IV, then 200mg daily, IO

 

Onset:

< 30 minutes

Hypotension, pulmonary toxicity, hepatotoxicity, photosensitivity, corneal deposits, skin discoloration Has long term side effects
Flecainide For rhythm control strategy Intravenous or Intraoral, 2 mg/kg IV over 10 minutes, or 200 – 300 IO

 

Maintenance Dose:

100 -150 mg q12h

Onset: 2 – 4 hours Decrease in BP, prolongs QRS duration, inadvertently increase ventricular rate Not suitable for patients with marked structural heart disease, branch block or wide WRS complex, postinfarction scar, heart failure
Ibutilide For rhythm control strategy Intravenous, 1 mg IV over 10 minutes

 

Maintenance Dose: 1 mg IV over 10 minutes after waiting 10 minutes (if AF persists)

Onset: < 90 minutes Prolongs QT interval, torsades de pointes, slows ventricular rate, AV block Causes LV hypertrophy, severe LV systolic dysfunction, ACS, and demands concurrent use of Class IA or III antiarrhythmics
Propafenone For rhythm control strategy Intravenous or Intraoral,

2 mg/kg IV over 10 minutes or 450 – 600 mg IO

 

Maintenance Dose: 150 – 300 mg or 8h IO

 

Onset: 3 – 4 hours Decreases BP, prolongs QRS duration, slightly slows ventricular rate Not for patients with marked structural heart disease

 

Contraindicated for coronoary heart disease

Vernakalant For rhythm control strategy Intravenous,3 mg/kg IV over 10 minutes
 

Maintenance Dose: Second infusion of 2 mg/kg IV over 10 minutes after 15 minutes first infusion

  Sneezing, dysgeusia, paresthesia, nausea, cough, pruritus, dizziness, hyperhidrosis, hypotension Contraindicated for moderate or severe HF and hypotension, caution in mild HF