Division of Cardiology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
Copyright © 2023 Korean Society of Cardiovascular Disease Prevention; Korean Society of Cardiovascular Pharmacotherapy.
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The classification of antiarrhythmic drugs (AADs) according to Vaughan-Williams system and their effects on targets according to the Sicilian Gambit system. Class I AADs are subdivided into three groups of actions characterized by fast (IB), medium (IA), and slow (IC) offset kinetics for recovery from the blockade. The relative potency is classified as high (filled circle), moderate (striped circle), or low (open circle).
α, α-adrenoceptor; β, β-adrenoceptor; M2, muscarinic receptor subtype 2.
Based on data from Dan et al. [7].
Variable | TdP | VFa) | VTa) | AFL 1:1 AV conduction | Bradyarrhythmia |
---|---|---|---|---|---|
Procainamide | 1%–2% | ++ | + | + | + |
Quinidine | 0.02 | ++ | + | ++ | |
Lidocaine | Rare | Rare | Rare | Rare | |
Mexiletine | Rare | Rare | Rare | ||
Propafenone | Rare | + | ++ | +++ | ++ |
Flecainide | Rare | + | ++ | +++ | ++ |
Sotalol | 2–5% | + | + | + | +++ |
Amiodarone | <1% | + | + | + | +++ |
TdP, torsade de pointes; VF, ventricular fibrillation; VT, ventricular tachycardia; AFL, atrial flutter; AV, atrioventricular; +, frequency of occurrence relative to other drugs.
a)Most common in patients with structural heart disease and/or preexisting ventricular arrhythmias.
Adapted from Friedman and Stevenson [8] with permission from Elsevier.
TSH, thyroid stimulation hormone; DLCO, diffusion capacity of carbon monoxide.
Based on data from Goldschlager et al. [65].
Class | Drug | Channel blockade | Receptor blockade | ||||||
---|---|---|---|---|---|---|---|---|---|
Na+ | Ca2+ | K+ | α | β | M2 | ||||
Fast | Medium | Slow | |||||||
IA | Disopyramide | ● | ○ | ||||||
Procainamide | ● | ||||||||
Quinidine | ● | ○ | |||||||
IB | Lidocaine | ○ | |||||||
Mexiletine | ○ | ||||||||
IC | Flecainide | ● | |||||||
Propafenone | ● | ||||||||
III | Amiodarone | ○ | |||||||
Dronedarone | ○ | ||||||||
Sotalol | ● | ● |
Variable | TdP | VF |
VT |
AFL 1:1 AV conduction | Bradyarrhythmia |
---|---|---|---|---|---|
Procainamide | 1%–2% | ++ | + | + | + |
Quinidine | 0.02 | ++ | + | ++ | |
Lidocaine | Rare | Rare | Rare | Rare | |
Mexiletine | Rare | Rare | Rare | ||
Propafenone | Rare | + | ++ | +++ | ++ |
Flecainide | Rare | + | ++ | +++ | ++ |
Sotalol | 2–5% | + | + | + | +++ |
Amiodarone | <1% | + | + | + | +++ |
Drug | Adverse effect | Precaution |
---|---|---|
Flecainide | AFL with 1:1 AV conduction, bradyarrhythmia, sustained monomorphic VT, conduction velocity slowing, widening of QRS complex, negative inotropic effect, hepatotoxicity | Contraindication (structural heart disease, ischemic heart disease), DDI with CYP2D6 inhibitors (SSRI, amiodarone), synergistic hypotension combined with propranolol, dose reduction during combined with digoxin or amiodarone, and when GFR <35 mL/min/1.73m2 |
Propafenone | AFL with 1:1 AV conduction, bradyarrhythmia, sustained monomorphic VT, conduction velocity slowing, widening of QRS complex, negative inotropic effect, hepatotoxicity | Contraindication (structural heart disease, ischemic heart disease), dose reduction during combination with warfarin or digoxin |
Amiodarone | QT prolongation, TdP, bradyarrhythmia, extracardiac toxicity (liver, lung, eye, thyroid) | DDI with CYP3A4 inhibitors (cyclosporine, some statins such as lovastatin or simvastatin), dose reduction during combining with warfarin or digoxin |
Dronedarone | Bradyarrhythmia, QT prolongation, gastrointestinal adverse effect, fatigue, asthenia, hepatotoxicity | Contraindication (heart failure with EF<40%, combining with antifungal and macrolide antibiotic agents), DDI with CYP3A4 inhibitors (verapamil/diltiazem), dose reduction of digoxin, edoxaban, or dabigatran during concomitant therapy, avoid combining of rivaroxaban when CrCl <80 mL/min |
Sotalol | QT prolongation, TdP, bradyarrhythmia, adverse effect related with β-blocking effect (fatigue, weakness, dizziness) | Dose reduction in patients with renal insufficiency (half-dose in patients with chronic renal insufficiency, 25% dose when GFR <30 mL/min/1.73m2) |
Type of test | Monitoring |
---|---|
Thyroid function test (free T4 and TSH) | Baseline and every 6 mo |
Liver function test | Baseline and every 6 mo |
Chest X-ray | Baseline and then yearly |
Pulmonary function test (including DLCO) | Baseline and repeat if there is a clinical concern for pulmonary toxicity |
Ophthalmologic evaluation | At baseline, if visual impairment |
Electrocardiogram | Baseline and every year (at least) |
The classification of antiarrhythmic drugs (AADs) according to Vaughan-Williams system and their effects on targets according to the Sicilian Gambit system. Class I AADs are subdivided into three groups of actions characterized by fast (IB), medium (IA), and slow (IC) offset kinetics for recovery from the blockade. The relative potency is classified as high (filled circle), moderate (striped circle), or low (open circle). α, α-adrenoceptor; β, β-adrenoceptor; M2, muscarinic receptor subtype 2. Based on data from Dan et al. [
TdP, torsade de pointes; VF, ventricular fibrillation; VT, ventricular tachycardia; AFL, atrial flutter; AV, atrioventricular; +, frequency of occurrence relative to other drugs. Most common in patients with structural heart disease and/or preexisting ventricular arrhythmias. Adapted from Friedman and Stevenson [
AFL, atrial flutter; AV, atrioventricular; VT, ventricular tachycardia; DDI, drug-drug interaction; CYP, cytochrome P450; SSRI, selective serotonin reuptake inhibitor; GFR, glomerular filtration rate; TdP, torsade de pointes; EF, ejection fraction; CrCl, creatinine clearance.
TSH, thyroid stimulation hormone; DLCO, diffusion capacity of carbon monoxide. Based on data from Goldschlager et al. [