Quinidine antiarrhythmic effects

Quinidine (6) and quinine (7) are diastereomeric quinoline alkaloids obtained from Cinchona spp. Quinidine (6) is included in many pharmacopeias for its antiarrhythmic effects.Quinine was the first antimalarial drug and served as an effective remedy for this deadly infectious disease in colonial times, making European settlement in many tropical and subtropical parts of the world possible.Owing to the development of resistance to synthetic antimalarials, quinine is still reverted to some extent for this... 

Serum concentrations have a major influence on the activity of quinidine on cardiac tissue. Low extracellular K+ concentrations antagonize the depressant effects of quinidine on membrane responsiveness, whereas high extracellular K+ concentrations increase quinidine s ability to depress membrane responsiveness. This dependency may explain why hypokalemic patients are often unresponsive to the antiarrhythmic effects of quinidine and are prone to develop cardiac rhythm disorders. 

Quinidine Similar class lA antiarrhythmic effect, leading to EKG parameter changes (e.g., longer QRS) Palpitations, bradycardia Need frequent monitoring of EKG parameters when drugs are used in combination Glassman and Preud homme, 1993... 

Lidocaine, similar to procaine, is an effective, clinically used local anesthetic (Fig. 26.11) (see Chapter 16). Its cardiac effects, however, are distinctly different from those of procainamide or quinidine. Lidocaine normally is reserved for the treatment of ventricular arrhythmias and, in fact, usually is the drug of choice for emergency treatment of ventricular arrhythmias. Its utility in these situations results from the rapid onset of antiarrhythmic effects on intravenous infusion. In addition, these effects cease soon after the infusion is terminated. Thus, lidocaine therapy may be rapidly modified in response to changes in the patient s status. Lidocaine is effective as an antiarrhythmic only when given parenterally, and the intravenous route is the most common. Antiarrhythmic activity is not observed after oral administration because of the rapid and efficient first-pass metabolism by the liver. Parenterally administered lidocaine is approximately 60 to 70% plasma protein bound. Flepatic metabolism is rapid (plasma half-life, -15-30 minutes) and primarily involves N-deethylation to yield monoethylglycinexylide, followed by amidase-catalyzed hydrolysis into N-ethylglycine and 2,6-dimethylaniline (2,6-xylidine) (Fig. 26.12). 

Quinidine inhibits the CYP2D6-dependent 5-hydroxylation of propafenone by the liver in those who are extensive metabolisers so that it is cleared more slowly. Its plasma levels are doubled as a result, but the overall antiarrhythmic effects remain effectively unchanged, possibly because the production of its active antiarrhythmic metabolite (5-hydroxypropafenone) is simultaneously halved. Quinidine increases the beta-bloctong effects of propafenone in extensive metabolisers because only the parent drug, and not the metabolites, has beta-blocking activity. ... 

All antiarrhythmic dra are used cautiously in patients with renal or hepatic disease. When renal or hepatic dysfunction is present, a dosage reduction may be necessary. All patients should be observed for renal and hepatic dysfunction. Quinidine and procainamide are used cautiously in patients with CHF. Disopyramide is used cautiously in patients with CHF, myasthenia gravis, or glaucoma, and in men with prostate enlargement. Bretylium is used cautiously in patients with digitalis toxicity because the initial release of norepinephrine with digitalis toxicity may exacerbate arrhythmias and symptoms of toxicity. Verapamil is used cautiously in patients with a history of serious ventricular arrhythmias or CHF. Electrolyte disturbances such as hypokalemia, hyperkalemia, or hypomagnesemia may alter the effects of the antiarrhythmic dru . Electrolytes are monitored frequently and imbalances corrected as soon as possible... 

When two antiarrhythmic dragp are administered concurrently the patient may experience additive effects and is at increased risk for drug toxicity. When quinidine and procainamide are administered with digitalis, tiie risk of digitalis toxicity is increased. Hiarmacologic effects of procainamide may be increased when procainamide is administered with quinidine When quinidine is administered with the barbiturates or cimetidine, quinidine serum levels may be increased. When quinidine is administered with verapamil, there is an increased risk of hypotensive effects. When quinidine is administered with disopyramide, there is an increased risk of increased disopyramide blood levels and/or decreased serum quinidine levels. 

Uses Rapid conversion of AF/artmal fluto Action Class III antiarrhythmic Dose Adults >60 kg. 0.01 mg/kg (max 1 mg) IV inf over 10 min may repeat x 1 <60 kg Use 0.01 mg/kg (ECC 2005 D/C cardioversion preferred) Caution [C, -] Contra w/ class I/III antiarrhythmics (Table VI-7) QTc >440 ms Disp Inj SE Arrhythmias, HA Interactions t Refractory effects W7 amiodarone, disopyra-mide, procainamide, quinidine, sotalol t QT int val W7 antihistamines, antidepressants, erythromycin, phenothiazines, TCAs EMS Use antihistamines w/ caution, may T QT interval OD May cause increased repolarization leading to arrhythmias, bradycardia, hypotension leading to cardiac arrest symptomatic and supportive... 

The depressant effects of propranolol on the A-V node are more pronounced than are the direct depressant effects of quinidine. This is due to propranolol s dual actions of p-blockade and direct myocardial depression. Propranolol administration results in a decrease in A-V conduction velocity and an increase in the A-V nodal refractory period. Propranolol does not display the anticholinergic actions of quinidine and other antiarrhythmic agents. 

Quinidine is readily absorbed from the GI tract and eliminated by hepatic metabolism. It is rarely used because of cardiac and extracardiac adverse effects and the availability of better-tolerated antiarrhythmic drugs. 

Toxic concentrations of disopyramide can precipitate all of the electrophysiologic disturbances described under quinidine. As a result of its negative inotropic effect, disopyramide may precipitate heart failure de novo or in patients with preexisting depression of left ventricular function. Because of this effect, disopyramide is not used as a first-line antiarrhythmic agent in the USA. It should not be used in patients with heart failure. 

In small doses, local anesthetics can depress posttetanic potentiation via a prejunctional neural effect. In large doses, local anesthetics can block neuromuscular transmission. With higher doses, local anesthetics block acetylcholine-induced muscle contractions as a result of blockade of the nicotinic receptor ion channels. Experimentally, similar effects can be demonstrated with sodium channel-blocking antiarrhythmic drugs such as quinidine. However, at the doses used for cardiac arrhythmias, this interaction is of little or no clinical significance. Higher concentrations of bupivacaine (0.75%) have been associated with cardiac arrhythmias independent of the muscle relaxant used. 

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