TABLE 33-2 -- Classification of Drug Actions on Arrhythmias Based on

Modification of Vulnerable Parameter

Vulnerable Parameter
Mechanism Arrhythmia (Effect) Drugs (Effect)
Automaticity
Enhanced normal Inappropriate sinus Phase 4 depolarization Beta-adrenergic
tachycardia (decrease) blocking agents
Some idiopathic Na+ channel
ventricular blocking agents
tachycardias
Abnormal Atrial tachycardia Maximum diastolic Muscarinic receptor
potential subtype 2 (M2)
(hyperpolarization) agonists
Phase 4 depolarization Ca2+ or Na+ channel
(decrease) blocking agents M2
agonists
Accelerated Phase 4 depolarization Ca2+ or Na+ channel
idioventricular (decrease) blocking agents
rhythms
Triggered Activity
Early Torsades de pointes Action potential Beta-adrenergic
afterdepolarization duration (shorten) agonists; vagolytic
(EAD) agents (increase rate)
EAD (suppress) Ca2+ channel
blocking agents;
Mg2+; beta-
adrenergic blocking
agents
Delayed Digitalis-induced Calcium overload Ca2+ channel
afterdepolarization arrhythmias (unload) blocking agents
(DAD) DAD (suppress) Na+ channel
blocking agents
Right ventricular Calcium overload Beta-adrenergic
outflow tract (unload) blocking agents
ventricular
tachycardia
DAD (suppress) Ca2+ channel
blocking agents;
 Vulnerable Parameter
Mechanism Arrhythmia (Effect) Drugs (Effect)
adenosine
Na+ ChannelDependent Reentry
Long excitable gap Typical atrial flutter Conduction and Types IA, IC Na+
excitability (depress) channel blocking
agents
Circus movement Conduction and Types IA, IC Na+
tachycardia in excitability (depress) channel blocking
agents
Wolff-Parkinson-
White syndrome
(WPW)
Sustained uniform Conduction and Na+ channel
ventricular excitability (depress) blocking agents
tachycardia
Short excitable gap Atypical atrial flutter Refractory period K+ channel blocking
(prolong) agents
Atrial fibrillation Refractory period K+ channel blocking
(prolong) agents
Circus movement Refractory period Amiodarone, sotalol
tachycardia in WPW (prolong)
Polymorphic and Refractory period Type IA Na+ channel
uniform ventricular (prolong) blocking agents
tachycardia
Bundle branch Refractory period Type IA Na+ channel
reentry (prolong) blocking agents;
amiodarone
Ventricular Refractory period
fibrillation (prolong)
Ca2 + Channel-Dependent Reentry
Atrioventricular Conduction and Ca2+ channel
nodal reentrant excitability (depress) blocking agents
tachycardia
Circus movement Conduction and Ca2+ channel
tachycardia in WPW excitability (depress) blocking agents
Verapamil-sensitive Conduction and Ca2+ channel
 Vulnerable Parameter
Mechanism Arrhythmia (Effect) Drugs (Effect)
ventricular excitability (depress) blocking agents
tachycardia
From the Task Force of the Working Group on Arrhythmias of the European Society of
Cardiology: The Sicilian gambit: A new approach to the classification of antiarrhythmic
drugs based on their actions on arrhythmogenic mechanisms. Circulation 84:1831, 1991.
Copyright 1991, American Heart Association.