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  • Image not available. The use of antiarrhythmic drugs (AADs) in the United States has declined because of major trials that show increased mortality with their use in several clinical situations, the realization of proarrhythmia as a significant side effect, and the advancing technology of nonpharmacologic therapies such as ablation and the implantable cardioverter-defibrillator (ICD).
  • Image not available. AADs frequently cause side effects and are complex in their pharmacokinetic characteristics. Close monitoring is required of all of these drugs to assess for adverse effects as well as potential drug interactions.
  • Image not available. The most commonly prescribed AAD is now amiodarone. This drug is effective in terminating and preventing a wide variety of symptomatic supraventricular and ventricular arrhythmias. However, because this AAD is plagued by frequent side effects, it requires close monitoring. The most concerning toxicity is pulmonary fibrosis; side effect profiles of the intravenous (IV) (acute, short-term) and oral (chronic, long-term) forms of amiodarone differ substantially.
  • Image not available. In patients with artial fibrillation (AF), therapy is traditionally aimed at controlling ventricular rate (digoxin, nondihydropyridine [non-DHP] calcium channel blockers [CCBs], β-blockers), preventing thromboembolic complications (warfarin, aspirin), and restoring and maintaining sinus rhythm (SR) (AADs, direct-current cardioversion [DCC]). Studies show there is no need to aggressively pursue strategies to maintain SR (i.e., long-term AAD therapy); rate control alone (leaving the patient in AF) is often sufficient in patients who can tolerate it. Nonetheless, chronic AAD therapy may still be needed in patients who continue to have symptoms despite adequate ventricular rate control.
  • Image not available. Paroxysmal supraventricular tachycardia (PSVT) is usually a result of reentry in or proximal to the atrioventricular (AV) node or AV reentry incorporating an extranodal pathway; common tachycardias can be terminated acutely with AV nodal-blocking drugs such as adenosine, and recurrences can be prevented by ablation with radiofrequency current.
  • Image not available. Patients with Wolff-Parkinson-White (WPW) syndrome may have several different tachycardias that are acutely treated by different strategies: orthodromic reentry (adenosine), antidromic reentry (adenosine or procainamide), and AF (procainamide or amiodarone). AV nodal-blocking drugs are contraindicated in patients with WPW and AF.
  • Image not available. Because of the results of the Cardiac Arrhythmia Suppression Trial (CAST) and other trials, AADs (with the exception of β-blockers) should not be routinely used in patients with prior myocardial infarction (MI) or left ventricular (LV) dysfunction and minor ventricular rhythm disturbances (e.g., premature ventricular complexes [PVCs]).
  • Image not available. Patients with hemodynamically significant ventricular tachycardia (VT) or ventricular fibrillation (VF) not associated with an acute MI who are successfully resuscitated (electrical cardioversion, vasopressors, amiodarone) are at high risk for sudden cardiac death (SCD) and should receive an ICD (“secondary prevention”).
  • Image not available. Implantation of an ICD should be considered for the primary prevention of SCD in certain high-risk patient populations. High-risk patients include those with a history of MI and LV dysfunction (regardless of whether they have inducible sustained ventricular arrhythmias), as well as those with New York Heart Association (NYHA) class II or III heart failure (HF) as a result of either ischemic or nonischemic causes.
  • Image not available. Life-threatening ventricular proarrhythmia generally takes two forms: sinusoidal or incessant monomorphic VT (class Ic ...

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