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Circulation. 2018;138:e272–e391. DOI: 10.1161/CIR.0000000000000549 September 25, 2018 e291 CLINICAL STATEMENTS AND GUIDELINES

Table 7.  Pharmacological Characteristics of Available Antiarrhythmic Medications for Treating VA

Antiarrhythmic Medication (Class) and Dose Uses in VA/SCA Target Electrophysiological

Effects Pharmacological

Characteristics Common Adverse Effects

Acebutolol PO 200–1200 mg daily or up to 600 mg bid VT, PVCs Beta 1, Mild intrinsic sympathomimetic activity Sinus rate slowed

AV nodal refractoriness increased Active metabolite t1/2: 8–13 h

pProlonged with renal impairment) Metab: H Excr: F 60%, U 40% Cardiac: Bradycardia, hypotension, HF, AVB

Other: Dizziness, fatigue, anxiety, impotence, hyper/ hypoesthesia

Amiodarone (III) IV: 300 mg bolus for VF/pulseless VT arrest; 150-mg bolus for stable VT; 1 mg/min x 6 h, then 0.5 mg/min x 18 h PO: 400 mg* q 8 to 12 h for 1–2 wk, then 300–400 mg daily; reduce dose to 200 mg daily if possible VT, VF, PVC, INa, ICa, IKr, IK1, IKs, Ito,

Beta receptor, Alpha receptor nuclear T3 receptor Sinus rate slowed

QRS prolonged QTc prolonged AV nodal refractoriness increased; increased DFT t1/2: 26–107 d

Metab: H Excr: F Cardiac: Hypotension, bradycardia, AVB, TdP, slows VT below programmed ICD detection rate, increases defibrillation threshold

Other: Corneal microdeposits, thyroid abnormalities, ataxia, nausea, emesis, constipation, photosensitivity, skin discoloration, ataxia, dizziness, peripheral neuropathy, tremor, hepatitis, cirrhosis, pulmonary fibrosis or pneumonitis

Atenolol (II) PO: 25–100 mg qd or bid VT, PVC, ARVC, LQTS Beta 1 Sinus rate slowed

AV nodal refractoriness increased t1/2: 6–7 h

(prolonged with renal impairment) Metab: H Excr: F 50%, U 40% Cardiac: Bradycardia, hypotension, HF, AVB

Other: Dizziness, fatigue, depression, impotence

Bisoprolol (II) PO: 2.5–10 mg once daily VT, PVC Beta 1 receptor Sinus rate slowed

AV nodal refractoriness increased t1/2: 9–12 h

Metab: H Excr: U Cardiac: Chest pain, bradycardia, AVB

Other: Fatigue, insomnia, diarrhea

Carvedilol (II) PO: 3.125–25 mg q 12 h VT, PVC Beta 1 and 2 receptors, Alpha Sinus rate slowed

AV nodal refractoriness increased t1/2: 7–10 h

Metab: H Excr: F Cardiac: Bradycardia, hypotension, AVB, edema, syncope

Other: Hyperglycemia, dizziness, fatigue, diarrhea

Diltiazem (IV) IV: 5–10 mg qd: 15–30 min Extended release: PO: 120–360 mg/day VT specifically

RVOT, idiopathic LVT ICa-L Sinus rate slowed

PR prolonged AV nodal conduction slowed t1/2: Injection 2–5 h, immediate release 4.5– 12 h, extended release 12 h, and severe hepatic impairment 14–16 h

Metab: H Excr: U Cardiac: Hypotension, edema, HF, AVB, bradycardia, exacerbation of HFrEF

Other: Headache, rash, constipation

Esmolol (II) IV: 0.5 mg/kg bolus, 0.05 mg/kg/min VT Beta 1 receptor Sinus rate slowed

AV nodal refractoriness increased t1/2: 9 min

Metab: RBC esterases Excr: U Cardiac: Bradycardia, hypotension, HF, AVB

Other: Dizziness, nausea

Flecainide (IC) PO: 50–200 mg q 12 h VT, PVC (in the absence of structural heart disease). Has a role in treating patients with CPVT INa, IKr, IKur PR prolonged

QRS prolonged; increased DFT t1/2: 7–22 h

Metab: H Excr: U Cardiac: Sinus node dysfunction, AVB, drug-induced Brugada syndrome, monomorphic VT in patients with a myocardial scar, exacerbation of HFrEF

Other: Dizziness, tremor, vision disturbance, dyspnea, nausea

Lidocaine (IB) IV: 1 mg/kg bolus, 1–3 mg/min 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg bolus every 5–10 min (max cumulative dose 3 mg/kg). Maintenance infusion is 1–4 mg/min although one could start at 0.5 mg/min VT, VF INa No marked effect on most intervals; QTc can slightly shorten Initial t1/2 7–30 min; terminal 90–120 min. Prolonged in HF, liver disease, shock, severe renal disease Metab: H

Excr: U Cardiac: Bradycardia, hemodynamic collapse, AVB, sinus arrest

Other: Delirium, psychosis, seizure, nausea, tinnitus, dyspnea, bronchospasm

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