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A-a south africa - drug treatment for heart rhythm disorders booklet.indd
Drug Treatment for Heart
Rhythm Disorders (Arrhythmia)
Promoting better understanding, diagnosis, treatment and quality of
life for those aﬀ ected by heart rhythm disorders (cardiac arrhythmias)
Irregular or abnormal heart beat
Glossary of terms
An internal treatment involving
identifying the cause of the arrhythmia and making
What do the drugs
a very small burn inside the heart, oﬀ ering a chance
What can I expect?
Implantable cardioverter deﬁ brillator
Can I take an
A doctor who has specialised in the
diagnosis and treatment of patients with heart
if I get pregnant/
wish to breast feed?
An antiarrhythmic drug
What about any
What should I do if I
feel really ill with my
How long will I take
Heart rhythm disorders, or arrhythmias, can be treated in a variety of ways. Some require no
What happens if the
more than reassurance after diagnosis, but others may need drug therapy, implantation
tablets do not work?
of an electrical device such as a pacemaker or
ICD, internal treatment (ablation) to remove an abnormal circuit (a focus or pathway) within
the heart or even a combination of treatments.
The correct treatment for your particular problem will have been discussed with you by your cardiologist or arrhythmia nurse; this brochure will attempt to answer any queries or concerns that you may have with regard to drug treatment for arrhythmias.
What do the drugs do?
Just as there are many diﬀ erent antibiotics to treat diﬀ erent infections, there are many diﬀ erent drugs to treat arrhythmias. These drugs tend to be grouped into classes, according to how they act on your heart, but drugs within the same class may aﬀ ect diﬀ erent people in diﬀ erent ways.
All of these drugs, however, are prescribed with two main objectives in mind;
1. To suppress your arrhythmia, maintain a normal heart rhythm and hence minimise your symptoms.
2. To prevent the development of prolonged or serious rhythm disturbances which might result in you suﬀ ering a collapse or coming to harm.
As a general rule, most serious (life-threatening) arrhythmias are treated with an implantable device (ICD) or ablation, but some patients may need to take medication in addition.
What can I expect?
Before commencing your drug (or drugs), your doctor should explain how many tablets you need to take and any likely or possible side-eﬀ ects that you might experience. Almost all drugs have some side eﬀ ects, and these side eﬀ ects vary from patient to patient, but as a general rule the more potent a drug the more likely it is to produce some side eﬀ ects. Drugs to control heart rhythm are usually quite potent, so are likely to have some side eﬀ ects.
As a result, the treatment you are prescribed is very often a compromise between the risks and symptoms associated with your arrhythmia and the side eﬀ ects of your treatment. “Successful” treatment may mean achieving a situation where you can live with occasional mild arrhythmias in order to avoid constant, unpleasant side eﬀ ects. Some of these side eﬀ ects only occur when starting the drug, so your doctor may start at a low dose and build up gradually to get the desired response.
This does not mean that you should suﬀ er in silence, however! If you have side eﬀ ects that you feel are not tolerable, you should report them to your doctor as he/she may be able to oﬀ er another drug that suits you better.
When you receive your drug(s), you will ﬁ nd a leaﬂ et enclosed that details all possible side eﬀ ects of the prescribed drug. It is important to realise that mostpeople get few or no side eﬀ ects, so don’t be put oﬀ taking your tablets by reading the leaﬂ et!
Equally important is that you should not stop taking the tablets suddenlywithout contacting your doctor as this may result in a “rebound” worsening of your arrhythmia.
Occasionally your GP/doctor may give you advice about making small adjustments in your dosage according to your symptoms or side eﬀ ects. Do not vary outside any agreed variation as this may result in severe side eﬀ ects or loss of beneﬁ t from the drug.
Can I take an antiarrhythmic drug if I get pregnant /
wish to breast feed?
Like most drugs, antiarrhythmic drugs should be used with caution duringpregnancy or breast feeding. Although some drugs are quite safe, others should be avoided as they can have an adverse eﬀ ect on a baby’s development.
If you are planning a pregnancy, you should mention this to your cardiologist orarrhythmia nurse. They will be able to advise you what is the safest option. Your pharmacist might also be able to give helpful advice. If you have an unplanned pregnancy, it is important to seek medical advice straight away as there may be a safer alternative drug for you to take.
What about any other medication?
Because arrhythmias often (but by no means always) occur in association with other heart conditions, you may well be on a number of drugs. These drugs are necessary and contribute to controlling your arrhythmia by treating the underlying heart problem, so must be continued. This may mean that you are taking a complicated “cocktail” of drugs and it can be hard to remember which tablets to take and when.
Consider investing in a tablet box which sets out all the tablets you need for the day or week and helps you to take them correctly and on time.
Please remember to always take your prescription or the original packets/boxes for ALL your tablets whenever you visit a doctor or nurse. “I take three of the pink ones a day” is not much help when there are hundreds of pink tablets that contain diﬀ erent drugs! This approach helps to reduce mistakes in prescribing and helps when doctors and nurses need to communicate about your treatment.
It is also worth checking your tablets every time you have a new prescription – pharmacists occasionally make mistakes and sometimes your tablets may look diﬀ erent because they have come from a diﬀ erent manufacturer (eventhough the drug is the same!).
What should I do if I feel really ill with my tablets?
Contact your doctor (ring the surgery or hospital and ask for his/her secretary) BEFORE stopping any medication, as sudden cessation of treatment can sometimes result in an unpleasant return of your arrhythmia, perhaps worse than before treatment.
Your doctor will either see you quickly or send advice about what to do. If you feel very unwell and are unable to contact your GP/cardiologist, you should consider attending your local Accident and Emergency Unit, taking all of your tablets with you.
Some drugs used for arrhythmias stay in the body for quite a long time after stopping them, so any side eﬀ ects may take a while to diminish or disappear. Amiodarone (Cordarone X) is the most prominent drug that causes this problem; it takes many weeks to reach stable levels in the body and may take at least three months to be removed from your body once stopped. This means, of course, that changes in dose will take some time to take eﬀ ect as well as side eﬀ ects continuing for some time after stopping the drug. Most other drugs are not as persistent as this, but it may take several days for a change in dose to have eﬀ ect. See appendix for more details on this drug.
IF IN DOUBT, CONTACT YOUR GP, CARDIOLOGIST OR ARRHYTHMIA
If you have not been referred to a cardiologist specialising in heart rhythm disorders, it is reasonable to request this.
How long will I take these tablets?
Unlike antibiotics or some other drugs, this is not a “course” of drugs as the treatment is intended to suppress, rather than cure, your arrhythmia.
As such, you should expect to continue the tablets indeﬁ nitely unless your doctor changes them or recommends another form of treatment.
Remember that new arrhythmia treatments are being developed all the time, so there may be other options in the future.
What happens if my tablets don’t work?
Treatment of arrhythmias has improved enormously in the last decade, with new drugs and other treatments becoming available.
If your ﬁ rst drug does not work or results in intolerable side eﬀ ects, there is likely to be another one available. It may be that your doctor will need to try several drugs before ﬁ nding the right one for you. This is not trial and error – he/she will know the right type of drug to use, but predicting which one gives you the least side eﬀ ects whilst controlling your arrhythmias is rarely possible with any individual patient.
When all suitable drugs have been tried or if your rhythm is considered to be likely to result in you coming to harm, other treatments will be discussed. These include ablation (actually destroying a very small area inside the heart that is causing the arrhythmia) or implanting a device such as an ICD. Because these are more specialised treatments, it may be necessary for you to be referred to another specialist cardiologist at a larger hospital. Your cardiologist will discuss this with you if this situation arises.
Amiodarone is used to help keep the heart in its normal (sinus) rhythm. It is also used when the heart has changed its rhythm (arrhythmia) to help it return to normal rhythm. Amiodarone has a low risk of proarrhythmia and is commonly used in patients with structural heart disease.
Side eﬀ ects: Although generally well tolerated amiodarone does have side eﬀ ects that can aﬀ ect many diﬀ erent parts of our body.
Skin: When taking amiodarone the skin can take on a greyish/blue tinge. This will settle on stopping amiodarone.
While taking amiodarone you may become more sensitive to the harmful eﬀ ects of sunlight. Using sunblock and hats appears to prevent this side eﬀ ect. As amiodarone remains in the body for a long time it may be necessary to continue using sunblock for a few months after stopping amiodarone.
Thyroid gland: The thyroid gland produces a hormone which controls the body’s metabolism. Amiodarone can aﬀ ect this gland making it both over active (this occurs in about two percent of people taking amiodarone) or under active (this occurs in about six percent of people taking amiodarone). Your doctor will take regular blood tests to check if either of these has developed. If you experience symptoms of extreme tiredness or restlessness you should contact your general practitioner in normal surgery to discuss this. The doctor may wish for you to have a blood test if this has not been recently performed. Both an overactive and underactive thyroid can easily be treated with medicines.
Eyes: Small deposits can form in the cornea of the eye (the clear surface that covers the pupil, iris and white of the eye). These deposits are not harmful. However, you may notice the eﬀ ect of these eye deposits if looking at bright lights at night e.g. when driving a car. Of people taking amiodarone one in ten will experince a bluish halo. Again, this is not harmful.
Lungs: Amiodarone can cause problems with thickening (ﬁ brosis) of the structures of the lungs. If you feel you have problems with shortness of breath then you should arrange to see your general practitioner straight away.
Liver: On rare occasions amiodarone causes problems with the function of the liver. Your doctor will check for any eﬀ ect on the liver when performing routine blood tests every six months.
Monitoring: Amiodarone is a very useful medication and will only have been commenced in your clinical best interest. The eﬀ ects listed above, although not common do mean that monitoring is important.
You will be reviewed by your general practitioner every six months whilst on amiodarone. They will need to arrange blood tests to ensure that your thyroid and liver function is normal and ensure that you are displaying no other problems.
Questions to consider
1. Is there no other alternative treatment (drug or otherwise)?
2. What advice can be given to minimise side eﬀ ects (for example, avoiding strong sunlight or using potent sunblock as this drug makes the skin more sensitive to burning, especially in fair-skinned patients)?
3. What arrangements will be made to check your thyroid, liver and lung function before, and during the treatment?
4. How will the initial (loading) dose be given? (Your body will require approximately 10 grams of the drug before it takes full eﬀ ect – each tablet is 0.2 grams - 200 milligrams)
5. Will it inﬂ uence any other drugs I may be taking? (It can particularly upset warfarin
Do remember, however, that this drug can be a life-saver when used carefully and correctly and so, as with other antiarrhythmic drugs, should not be stopped or the dosage changed without consulting your GP/doctor.
Our heartbeat is regulated by special cells that conduct electricity. An irregular heartbeat can be caused by these cells conducting electricity too quickly. Atenolol, which is a beta blocker, reduces the over activity in these cells and so helps the heart to beat more regularly.
Some medicines can cause unwanted side eﬀ ects, however these usually improve as we adjust to the new medication. The side eﬀ ects that have been associated with atenalol are: nausea, blurred vision, vomiting, cold hands or toes, lightheadedness, shortness of breath, fatigue, sexual problems.
If you experience any of these side eﬀ ects, please speak with your doctor or pharmacist.
Considerations:Family planning and pregnancy
• Ensure that your doctor or pharmacist is aware that
you are pregnant, trying for a baby or breast feeding
• Ensure that your doctor or pharmacist is aware of
all the other medications you take before
commencing treatment. Beta blockers can interact
with other medications causing alterations in the
Bisoprolol is a class II beta blocker in the Vaughan-Williams Classiﬁ cation of antiarrhythmic drugs and is used to slow an abnormally high heart rate. Beta blockers protect the heart from the eﬀ ects of adrenaline, slowing down the activity of the heart muscle which also reduces blood pressure. Bisoprolol is used to treat hypertension (high blood pressure), angina and in some cases heart failure, due to the protective eﬀ ects it has on the heart from adrenaline stimulation.
Side eﬀ ects: As with all medications, there are possible side eﬀ ects. Although not everyone experiences side eﬀ ects, those known that can occur are: Dizziness/light headedness or feeling faint, sickness or nausea, diarrhoea, tiredness, hypotension (low blood pressure) or bradycardia (slow heart beat).
It is important to speak to your doctor if you experience any side eﬀ ects from medication.
Considerations: Bisoprolol can interact with other drugs, ensure that your doctor or pharmacist is fully aware of all the medications you are taking.
Dronedarone is a newly introduced drug that is similar to amiodarone in structure but has modiﬁ cations to make its metabolism more clinically useful and reduce the chance of thyroid problems. Its main mechanism of action is inhibition of potassium channels leading to a decrease in atrial excitability. It has been shown to be eﬀ ective in reducing the risk of AF recurrence by 25% and has also been shown to reduce ventricular response rates. It has been demonstrated to reduce hospitalisations in AF in a large randomised clinical trial. Dronedarone should be initiated and monitored by an appropriate hospital consultant or specialist nurse practitioner.
Contra-indications: An increased incidence of heart failure has been seen with exposure to this drug, therefore dronedarone should not be prescribed in patients with heart failure or impaired heart function and monitoring should be carried out in all those using it. Dronedarone should also be avoided in patients with signiﬁ cant liver disorders.
Guidance on monitoring has been issued by the Medicines and Healthcare products Regulatory Agency. Patients with heart block, or sick sinus syndrome (unless used in conjunction with a functioning pacemaker), or corrected QT interval >500ms should not be given dronedarone.
Side eﬀ ects: Dronedarone is generally well tolerated but common side eﬀ ects are diarrhoea, abdominal discomfort, nausea and vomiting.
There is an increased incidence of skin rash, bradycardia and prolonged QT interval although torsade de pointes is very rare.
Most side eﬀ ects are resolved within the ﬁ rst two weeks after drug commence-ment but in a proportion of patients, dronedarone may need to be discontinued because of intolerance.
Flecainide slows conduction in cardiac cells decreasing their excitability; both preventing and under some circumstances terminating atrial ﬁ brillation (AF). It also slows conduction in the accessory pathways responsible for the Wolﬀ Parkinson White (WPW) syndrome that can be associated with AF. Flecainide is especially useful in patients with paroxysmal AF without structural or coronary heart disease. In which case it must be used in conjunction with an agent such as a beta blocker or calcium channel blocker (verapamil or diltiazem) that slow the AV node to protect against rapid conduction to the ventricle. Such a situation can potentially arise if there are slowing and organisation of the AF waves in the atria.
Flecainide is metabolised in the liver with a half-life of around 14 hours so it is usually administered twice daily. In some patients with heart disease and in those with poor kidney function it can accumulate so dose reductions may be needed. Flecainide may be used in pregnancy following appropriate discussions and after consideration of other approaches.
Contraindications: Flecainide has a variable half-life and often causes QRS prolongation and PR prolongation. The British National Formulary recommends that ﬂ ecainide is only given on the advice of a hospital consultant. Additionally, in patients with renal failure, plasma levels also have to be monitored regularly. Flecainide is contraindicated in patients with sinus node disease, atrioventricular block or bradycardia (without pacemaker support) and it should also be used with caution in those who have received pacemakers.
Side eﬀ ects: Adverse side eﬀ ects are usually temporary and can include, nausea, blurred vision, dizziness, constipation, diarrhoea and headaches.
Occasionally ﬂ ecainide may cause shortness of breath, skin irritation and chest pains. If you are concerned that ﬂ ecainide is causing any problems, it is important to seek medical advice promptly.
Sotalol is a beta blocker and as such is probably eﬀ ective because it counteracts the arrhythmogenic eﬀ ect of adrenaline and similar inﬂ uences that may trigger attacks of AF. Sotalol has other actions to make the atrial cells less excitable through blocking heart potassium channels, but only at high doses between 80mg - 120mg, twice per day, however side eﬀ ects are common. This second action is beneﬁ cial in the atria but may have adverse eﬀ ects on the ventricle so the dose of sotalol should be increased with great caution and with periodic ECG monitoring.
Cautions: Sotalol by prolonging the recovery phase of the cardiac action potential can predispose to ventricular arrhythmias (torsade de pointes) that can be risky, and may be life-threatening if there is a situation with low potassium and low magnesium levels, as with diarrhoea and vomiting. To minimise the likelihood of this problem if there is evidence of renal impairment the dose needs review and reduction.
Side eﬀ ects: The main side eﬀ ects from beta-blockers in general are due to slowing of the heart and depression of the contraction of the heart. Accordingly an unduly slow pulse (bradycardia) or symptoms of heart failure can result in other eﬀ ects including fatigue, sleep disturbance, shortness of breath, sexual dysfunction and depression.
Interactions: Associated intravenous administration of a calcium channel blocker that aﬀ ects conduction (verapamil, diltiazem) increases the risk of bradycardia and should in general be avoided.
Verapamil is a class IV Calcium Channel blocking drug that is used to slow the heart rate. Verapamil works in treating arrhythmias by stopping calcium entering the electrical cells of the heart, slowing abnormally fast heart rates. Reduced amounts of calcium entering the muscle cells of the heart also relax the arteries and improve blood ﬂ ow which lowers blood pressure. Due to this eﬀ ect, verapamil is used to treat angina and hypertension (high blood pressure).
Side eﬀ ects: As with all medication, there are possible side eﬀ ects. Not everyone will have side eﬀ ects, but when taking this medication you may experience: constipation, dizziness, headaches, feeling nauseous or being sick,swollen ankles.
If any of these symptoms become problematic to you, it is important to see your doctor.
Considerations: It is advised that you DO NOT drink grapefruit juice whilst taking Verapamil as this can increase the eﬀ ect of the drug and you are more likely to experience side eﬀ ects. Verapamil should not be used with beta blockers. Patients should have regular blood pressure and heart rate checks whilst on this medication.
In all matters regarding medication, your doctor will advise you on what is right for you.
A list of useful sites can be found at:- www.heartrhythmcharity.org.uk This list is not exhaustive and it is constantly evolving. If we have excluded anyone, please accept our sincerest apologies and be assured that as soon as the matteris brought to the attention of the Arrhythmia Alliance, we will quickly act toensure maximum inclusiveness in our endeavours.
If you wish to contact us email: [email protected]
: Arrhythmia Alliance would like
to thank all those who helped in the development
and review of this publication. Particular thanks is
given to Dr Kim Rajappan, (Consultant Cardiologist and
Electrophysiologist, John Radcliﬀ e Hospital, Oxford) and
Dr Adam Fitzpatrick, (Consultant Cardiologist and Electrophysiologist, Manchester Royal Inﬁ rmary).
Professor A John Camm
Professor Hein J J WellensProfessor Silvia G PrioriMr W B Beaumont OBE
Founder & Trustee
Mrs Trudie Lobban MBE
If you would like further information or would like to provide feedback please contact Arrhythmia Alliance. Please remember that this publication provides general information only. Individuals should always discuss their own condition with a healthcare professional.
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