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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 6, Arrhythmias.



  • imageThe use of antiarrhythmic drugs (AADs) in the United States has declined because clinical trials have shown increased mortality with their use due to proarrhythmic side effects. AADs have been increasingly replaced by nonpharmacologic approaches such as ablation and the implantable cardioverter-defibrillator (ICD).

  • imageAADs 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.

  • imageThe most commonly prescribed AAD is amiodarone. This drug is effective in terminating and preventing a wide variety of symptomatic supraventricular and ventricular arrhythmias. However, amiodarone is plagued by frequent side effects and requires close monitoring. The most concerning toxicity is pulmonary fibrosis. The side effect profiles of the intravenous (IV) (acute, short-term) and oral (chronic, long-term) forms of amiodarone differ substantially.

  • imageIn patients with atrial fibrillation (AF), therapy is traditionally aimed at controlling ventricular rate, preventing thromboembolic (TE) complications, and restoring and maintaining sinus rhythm (SR). Studies show there is no need to aggressively pursue strategies to maintain SR; 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.

  • imageParoxysmal supraventricular tachycardia (PSVT) is usually a result of reentry in or proximal to the atrioventricular (AV) node or AV reentry incorporating an accessory pathway; common tachycardias can be terminated acutely with AV nodal blocking drugs such as adenosine, and recurrences can be prevented by catheter ablation using radiofrequency current.

  • imagePatients 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 ibutilide). AV nodal blocking drugs are contraindicated in patients with WPW syndrome and AF.

  • imageBased on the results of the Cardiac Arrhythmia Suppression Trial (CAST) and other trials, AADs (with the exception of beta blockers) should no longer routinely be used in patients with prior myocardial infarction (MI) or left ventricular (LV) dysfunction and minor ventricular rhythm disturbances (eg, premature ventricular complexes [PVCs]).

  • imagePatients with hemodynamically significant ventricular tachycardia (VT) or ventricular fibrillation (VF) not associated with an acute MI who are successfully resuscitated (with electrical cardioversion, epinephrine, amiodarone, lidocaine) are at high risk for sudden cardiac death (SCD) and should receive an ICD (“secondary prevention”).

  • imageImplantation 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 with reduced ejection fraction ...

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