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Arrhythmia

Updated : March 6, 2023





Background

Epidemiology

Anatomy

Pathophysiology

Etiology

Genetics

Prognostic Factors

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

sotalol 

Oral:


The recommended starting dose for life-threatening ventricular arrhythmias is 80 mg taken orally twice daily (BID). The dose may be increased by increments of 80 mg/day every three days if the corrected QT interval (QTc) is less than 500 msec

Patients should be monitored until steady-state levels are achieved. The therapeutic dose is usually obtained at a total daily dose of 160-320 mg/day divided into BID or TID dosing

In refractory cases of life-threatening arrhythmias, doses of 480-640 mg/day have been utilized

For atrial fibrillation/flutter, the starting dose is also 80 mg taken orally BID. The dose may be increased by increments of 80 mg/day every three days if the QTc is less than 500 msec. The typical maintenance dose for atrial fibrillation/flutter is 120 mg taken orally BID

It is important to note that initiation of sotalol in patients with creatinine clearance less than 40 mL/min or QTc greater than 450 msec is contraindicated due to the increased risk of adverse effects

IV sotalol as a substitute for oral sotalol
When using IV sotalol as a substitute for oral sotalol, it is important to match the exposure to the drug as closely as possible

For an 80 mg oral dose of sotalol, substitute with 75 mg IV
For a 120 mg oral dose of sotalol, substitute with 112.5 mg IV
For a 160 mg oral dose of sotalol, substitute with 150 mg IV
For a loading dose of IV sotalol, it should be infused over 1 hour. The loading dose is typically higher than the maintenance dose and is given to rapidly achieve therapeutic levels of the drug

sotalol IV 0-80 mg
CrCl (>90 mL/min): 60 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 82.5 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 75 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 75 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

sotalol IV 0-120 mg

CrCl (>90 mL/min): 90 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 125 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 112.5 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 112.5 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

lower dose Reinitiating from 120-80 mg

If the QTc interval exceeds 500 ms or increases 20% from baseline when starting a 120-mg oral dose, discontinue the drug and consider a lower dose
CrCL (≥60 mL/min): to reinitiate maintain gap for 1 days
CrCL (≥30-<60 mL/min): to reinitiate maintain gap for 3 days
CrCL (≥10-<30 mL/min): to reinitiate maintain gap for 7 days

sotalol IV escalation 80-120 mg

CrCl (>90 mL/min): 75 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 82.5mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 82.5 IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 82.5 IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

sotalol IV escalation 120-160 mg

CrCl (>90 mL/min): 90 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 105 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 105 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 105 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)



atropine 

Indicated for Bradyarrhythmia:


0.4 to 1mg intravenous every 2 hours as needed



shepherd’s purse 


Indicated for Arrhythmias, epistaxis, PMS
1-4 gm of capsules orally three times a day
Or
10-15 gm of crushed herb every day orally divided three times a day
Or
5-8 gm of liquid extract every day orally in divided three times a day
Or
3-5 gm applied as topically



calcium chloride 

The emerging arrhythmias associated with hyperkalemia hypocalcemia, or hypermagnesemia
500-1000 mg intravenously for 5-10 minutes



hawthorn 

For brewed tea
Three times a day following meals and steep, take 1 teaspoon of leaves and blossoms in 8 ounces of boiling water
For leaf/flower
Extract: 160 to 900 mg daily orally divided two and three times a day
Powder: 200 to 500 mg orally three times a day
Tincture: 20 drops orally two and three times a day
For fruit
Dried powder: 300 to 1000 mg orally three times a day
Liquid extract: 0.5 to 1 ml orally three times a day
Tincture: 1 to 2 ml orally three times a day
Syrup: 1 teaspoon orally three times a day



propafenone 

150 mg orally every 8hours; may increase up to 225 mg every 8 hours after 3-4 days 
Do not exceed 300 mg every 8 hours 



lily of the valley 

Cardiac Glycosides
Take a dose of 600 mg orally daily
Tincture: take a dose of 6 g daily orally divided three times a day
Liquid extract: take a dose of 600 mg daily orally divided three times a day
Dried extract: take a dose 150 mg orally daily



quinidine 

Take a dose of 100 to 600 mg orally each 4 to 6 hours
Start with dose of 200 mg and titrate to desired effect
Daily dose should not be more than 3 to 4 g
for Extended Release:
Take a dose of 324 to 648 mg (as gluconate form) orally each 8 to 12 hours OR
Intravenous:
Dose of 800 mg of quinidine gluconate diluted up to 50 ml and administer at a rate not more than 1 ml/min



indecainide 



Dose Adjustments

(Discontinued)
1-5 mg/kg intravenously
4-5mg/kg orally, resulting in instant absorption by 15 minutes

oxprenolol 

Take a dose of 40 to 240 mg orally daily in 2 or 3 divided doses



 

sotalol 

Age >2 years:

30

mg/m²

Orally 

3 times a day

in patients with normal renal function which is equivalent to an initial total daily dose of 90 mg/m2 for adults

This initial dose can be titrated up to a maximum of 60 mg/m2 TID, which is equivalent to a total daily dose of 320 mg for adults
The titration should be guided by clinical response, heart rate, and corrected QT interval (QTc), with increased dosing preferably carried out in the hospital

It is important to allow at least 36 hours between dose increments to attain steady-state plasma concentrations of the drug in patients with age-adjusted normal renal function

Steady-state levels of sotalol are necessary to achieve a consistent therapeutic effect and to avoid potential adverse effects associated with rapid dose increases



atropine 

Indicated for Bradyarrhythmia:


0.02mg/kg/dose intravenous, which can repeat every 5 minutes



quinidine 

Take dose of 30 mg/kg daily orally given in 5 divided doses
Take dose of 2 mg/kg orally of quinidine sulfate and test dose should not be more than 200 mg



 

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References

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Arrhythmia

Updated : March 6, 2023




sotalol 

Oral:


The recommended starting dose for life-threatening ventricular arrhythmias is 80 mg taken orally twice daily (BID). The dose may be increased by increments of 80 mg/day every three days if the corrected QT interval (QTc) is less than 500 msec

Patients should be monitored until steady-state levels are achieved. The therapeutic dose is usually obtained at a total daily dose of 160-320 mg/day divided into BID or TID dosing

In refractory cases of life-threatening arrhythmias, doses of 480-640 mg/day have been utilized

For atrial fibrillation/flutter, the starting dose is also 80 mg taken orally BID. The dose may be increased by increments of 80 mg/day every three days if the QTc is less than 500 msec. The typical maintenance dose for atrial fibrillation/flutter is 120 mg taken orally BID

It is important to note that initiation of sotalol in patients with creatinine clearance less than 40 mL/min or QTc greater than 450 msec is contraindicated due to the increased risk of adverse effects

IV sotalol as a substitute for oral sotalol
When using IV sotalol as a substitute for oral sotalol, it is important to match the exposure to the drug as closely as possible

For an 80 mg oral dose of sotalol, substitute with 75 mg IV
For a 120 mg oral dose of sotalol, substitute with 112.5 mg IV
For a 160 mg oral dose of sotalol, substitute with 150 mg IV
For a loading dose of IV sotalol, it should be infused over 1 hour. The loading dose is typically higher than the maintenance dose and is given to rapidly achieve therapeutic levels of the drug

sotalol IV 0-80 mg
CrCl (>90 mL/min): 60 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 82.5 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 75 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 75 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

sotalol IV 0-120 mg

CrCl (>90 mL/min): 90 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 125 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 112.5 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 112.5 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

lower dose Reinitiating from 120-80 mg

If the QTc interval exceeds 500 ms or increases 20% from baseline when starting a 120-mg oral dose, discontinue the drug and consider a lower dose
CrCL (≥60 mL/min): to reinitiate maintain gap for 1 days
CrCL (≥30-<60 mL/min): to reinitiate maintain gap for 3 days
CrCL (≥10-<30 mL/min): to reinitiate maintain gap for 7 days

sotalol IV escalation 80-120 mg

CrCl (>90 mL/min): 75 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 82.5mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 82.5 IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 82.5 IV; maintain 12 hours gap for first PO dose (48 hours oral dose)

sotalol IV escalation 120-160 mg

CrCl (>90 mL/min): 90 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (60-90 mL/min): 105 mg IV; maintain 4 hours gap for first PO dose (12 hours oral dose)
CrCl (30-60 mL/min): 105 mg IV; maintain 6 hours gap for first PO dose (24 hours oral dose)
CrCl (10-30 mL/min): 105 mg IV; maintain 12 hours gap for first PO dose (48 hours oral dose)



atropine 

Indicated for Bradyarrhythmia:


0.4 to 1mg intravenous every 2 hours as needed



shepherd’s purse 


Indicated for Arrhythmias, epistaxis, PMS
1-4 gm of capsules orally three times a day
Or
10-15 gm of crushed herb every day orally divided three times a day
Or
5-8 gm of liquid extract every day orally in divided three times a day
Or
3-5 gm applied as topically



calcium chloride 

The emerging arrhythmias associated with hyperkalemia hypocalcemia, or hypermagnesemia
500-1000 mg intravenously for 5-10 minutes



hawthorn 

For brewed tea
Three times a day following meals and steep, take 1 teaspoon of leaves and blossoms in 8 ounces of boiling water
For leaf/flower
Extract: 160 to 900 mg daily orally divided two and three times a day
Powder: 200 to 500 mg orally three times a day
Tincture: 20 drops orally two and three times a day
For fruit
Dried powder: 300 to 1000 mg orally three times a day
Liquid extract: 0.5 to 1 ml orally three times a day
Tincture: 1 to 2 ml orally three times a day
Syrup: 1 teaspoon orally three times a day



propafenone 

150 mg orally every 8hours; may increase up to 225 mg every 8 hours after 3-4 days 
Do not exceed 300 mg every 8 hours 



lily of the valley 

Cardiac Glycosides
Take a dose of 600 mg orally daily
Tincture: take a dose of 6 g daily orally divided three times a day
Liquid extract: take a dose of 600 mg daily orally divided three times a day
Dried extract: take a dose 150 mg orally daily



quinidine 

Take a dose of 100 to 600 mg orally each 4 to 6 hours
Start with dose of 200 mg and titrate to desired effect
Daily dose should not be more than 3 to 4 g
for Extended Release:
Take a dose of 324 to 648 mg (as gluconate form) orally each 8 to 12 hours OR
Intravenous:
Dose of 800 mg of quinidine gluconate diluted up to 50 ml and administer at a rate not more than 1 ml/min



indecainide 



Dose Adjustments

(Discontinued)
1-5 mg/kg intravenously
4-5mg/kg orally, resulting in instant absorption by 15 minutes

oxprenolol 

Take a dose of 40 to 240 mg orally daily in 2 or 3 divided doses



sotalol 

Age >2 years:

30

mg/m²

Orally 

3 times a day

in patients with normal renal function which is equivalent to an initial total daily dose of 90 mg/m2 for adults

This initial dose can be titrated up to a maximum of 60 mg/m2 TID, which is equivalent to a total daily dose of 320 mg for adults
The titration should be guided by clinical response, heart rate, and corrected QT interval (QTc), with increased dosing preferably carried out in the hospital

It is important to allow at least 36 hours between dose increments to attain steady-state plasma concentrations of the drug in patients with age-adjusted normal renal function

Steady-state levels of sotalol are necessary to achieve a consistent therapeutic effect and to avoid potential adverse effects associated with rapid dose increases



atropine 

Indicated for Bradyarrhythmia:


0.02mg/kg/dose intravenous, which can repeat every 5 minutes



quinidine 

Take dose of 30 mg/kg daily orally given in 5 divided doses
Take dose of 2 mg/kg orally of quinidine sulfate and test dose should not be more than 200 mg



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