Ventricular tachycardia VT Cluster (VTC)bull SAMIR EL ANSARY

bull ICU PROFESSOR

bull AIN SHAMS

bull CAIRO

VT Cluster (VTC)

bull A VTC is defined as ge 3 sustained VTs24 h

bull Ventricular tachycardia that repeatedly recurs and persists for more than half of a 24-h period despite repeated attempts

to terminate the arrhythmia is designated ldquoincessantrdquo

VT Cluster (VTC)

bull Irrespective of the number of VTs only 302 of patients survived and 155 survived

without heart transplantation four years after the first cluster

bull Incessant VT typically takes one of two forms The most common situation is for VT to be

sustained terminated by external cardioversions but recurrent

bull The time between cardioversion and recurrence may be seconds minutes or more

VT Cluster (VTC)

bull A second form common with the idiopathic VTs manifests as repeated

bursts with runs of VT that spontaneously terminate for a few

intervening sinus beats followed by the next tachycardia burst

bull Cardioversion is futile but may be periodically required if bursts of VT

occasionally degenerate to ventricular fibrillation

VT Cluster (VTC)

bull When incessant VT is polymorphic drug induced torsade de pointes associated with QT prolongation

or myocardial ischemia are the major concerns

bull Runs of polymorphic VT may even repeatedly initiate monomorphic VT in patients with reentry circuits in

regions of scar

bull Suppression of torsade de pointes with intravenous administration of magnesium sulfate andor

overdrive pacing may restore stability

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

VT Cluster (VTC)

bull A VTC is defined as ge 3 sustained VTs24 h

bull Ventricular tachycardia that repeatedly recurs and persists for more than half of a 24-h period despite repeated attempts

to terminate the arrhythmia is designated ldquoincessantrdquo

VT Cluster (VTC)

bull Irrespective of the number of VTs only 302 of patients survived and 155 survived

without heart transplantation four years after the first cluster

bull Incessant VT typically takes one of two forms The most common situation is for VT to be

sustained terminated by external cardioversions but recurrent

bull The time between cardioversion and recurrence may be seconds minutes or more

VT Cluster (VTC)

bull A second form common with the idiopathic VTs manifests as repeated

bursts with runs of VT that spontaneously terminate for a few

intervening sinus beats followed by the next tachycardia burst

bull Cardioversion is futile but may be periodically required if bursts of VT

occasionally degenerate to ventricular fibrillation

VT Cluster (VTC)

bull When incessant VT is polymorphic drug induced torsade de pointes associated with QT prolongation

or myocardial ischemia are the major concerns

bull Runs of polymorphic VT may even repeatedly initiate monomorphic VT in patients with reentry circuits in

regions of scar

bull Suppression of torsade de pointes with intravenous administration of magnesium sulfate andor

overdrive pacing may restore stability

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

VT Cluster (VTC)

bull Irrespective of the number of VTs only 302 of patients survived and 155 survived

without heart transplantation four years after the first cluster

bull Incessant VT typically takes one of two forms The most common situation is for VT to be

sustained terminated by external cardioversions but recurrent

bull The time between cardioversion and recurrence may be seconds minutes or more

VT Cluster (VTC)

bull A second form common with the idiopathic VTs manifests as repeated

bursts with runs of VT that spontaneously terminate for a few

intervening sinus beats followed by the next tachycardia burst

bull Cardioversion is futile but may be periodically required if bursts of VT

occasionally degenerate to ventricular fibrillation

VT Cluster (VTC)

bull When incessant VT is polymorphic drug induced torsade de pointes associated with QT prolongation

or myocardial ischemia are the major concerns

bull Runs of polymorphic VT may even repeatedly initiate monomorphic VT in patients with reentry circuits in

regions of scar

bull Suppression of torsade de pointes with intravenous administration of magnesium sulfate andor

overdrive pacing may restore stability

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

VT Cluster (VTC)

bull A second form common with the idiopathic VTs manifests as repeated

bursts with runs of VT that spontaneously terminate for a few

intervening sinus beats followed by the next tachycardia burst

bull Cardioversion is futile but may be periodically required if bursts of VT

occasionally degenerate to ventricular fibrillation

VT Cluster (VTC)

bull When incessant VT is polymorphic drug induced torsade de pointes associated with QT prolongation

or myocardial ischemia are the major concerns

bull Runs of polymorphic VT may even repeatedly initiate monomorphic VT in patients with reentry circuits in

regions of scar

bull Suppression of torsade de pointes with intravenous administration of magnesium sulfate andor

overdrive pacing may restore stability

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

VT Cluster (VTC)

bull When incessant VT is polymorphic drug induced torsade de pointes associated with QT prolongation

or myocardial ischemia are the major concerns

bull Runs of polymorphic VT may even repeatedly initiate monomorphic VT in patients with reentry circuits in

regions of scar

bull Suppression of torsade de pointes with intravenous administration of magnesium sulfate andor

overdrive pacing may restore stability

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

VT Cluster (VTC)

Treatment Options

bull Antiarrythmic drugs

bull Beta Blockade

bull General anesthesia (to reduce sympathetic tone)

bull Intra aortic balloon counterpulsation

bull Catheter ablation ndash percutaneous epicardial

bull LVAD

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Dosage

bull Amiodarone mdash Amiodarone is given as a 150 mg (or 5 mgkg) IV bolus over 10 minutes

additional boluses of 150 mg over 10 minutes are given every 10 to 15 minutes as needed

Alternatively an infusion of 360 mg (1 mgmin) over six hours followed by 540 mg

(05 mgmin) over the remaining 18 hours can be used

bull The maximum total dose (including doses given during resuscitation) is 22 grams in 24

hours

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Dosage

bull Lidocaine

bull Lidocaine is given by IV push in a dose of 05 to 075 mgkg repeated every 5 to

10 minutes as needed

bull

bull At the same time a continuous IV infusion of 1 to 4 mgmin is begun

bull The maximum total dose is 3 mgkg over one hour

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Dosage

bull Procainamide

bull Loading dose

bull 15-18 mgkg administered as slow infusion over 25-30 minutes or 100-200 mgdose repeated every 5 minutes as

needed to a total dose of 1 g

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Dosage

bull Procainamide bull Reduce loading dose to 12 mgkg in severe renal or

cardiac impairmentMaintenance dose 1-4 mgminute by continuous

infusion

bull Maintenance infusions should be reduced by one-third in patients with moderate renal or cardiac

impairment and by two-thirds in patients with severe renal or cardiac impairment

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Dosage

bull Procainamide ACLS guidelines Infuse 20

mgminute until arrhythmia is controlled hypotension occurs QRS

complex widens by 50 of its original width or total of 17 mgkg is

given

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

SHock Inhibition Evaluation

with AzimiLiDe (SHIELD) Investigators

bull uppression of ventricular tachycardiafibrillation (VTVF) leading to implanted cardioverter

defibrillator (ICD) therapies

bull Of 633 ICD recipients 148 (23) experienced at least one ES (electrical storm) over 1-year follow-up

bull Compared with placebo azimilide reduced the risk of recurrent ES by 37 (p=011) nonsignificantly

bull CONCLUSION ES is common and unpredictable in ICD recipients and it is a strong predictor of

hospitalization

Left stellate ganglionic blockade

bull Sympathetic blockade is superior to the antiarrhythmic therapy recommended by the

ACLS guidelines in treating ES patients bull The role of increased sympathetic activity in

the genesis of ES bull Sympathetic blockade not class 1

antiarrhythmic drugs should be the treatment of choice for ES

Therapies for VTABLATION

Ablation is indicated in patients who are otherwise at low riskfor SCD and have sustained predominantly monomorphic VTthat is drug resistant who are drug intolerant or who do not

wish long-term drug therapy

Ablation is indicated in patients with bundle-branch reentrant VT

Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustainedVT that is not manageable by reprogramming or changing drug

therapy or who do not wish long-term drug therapy

Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway

causing VF

Therapies for VT

Ablation

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have symptomatic

nonsustained monomorphic VT that is drug resistant whoare drug intolerant or who do not wish long-term drug

therapy

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have frequent

symptomatic predominantly monomorphic PVCs that aredrug resistant or who are drug intolerant or who do not wish

long-term drug therapy

Ablation can be useful in symptomatic patients with WPW syndrome who have accessory pathways with refractory periods less than

240 ms in duration

Incessant VT

Revascularization and beta blockade followed by

intravenous antiarrythmic drugs such as

procainamide or

amiodarone are recommended for patients with

recurrent

or incessant polymorphic VT due to acute MI

Intravenous amiodarone or procainamide followed by

VT

ablation can be effective in the management of

patients

with frequently recurring or incessant monomorphic

Acute Management of Specific Arrhythmias

Incessant VT

Intravenous amiodarone and intravenous beta

blockers

separately or together may be reasonable in

patients

with VT storm

Overdrive pacing or general anesthesia may

be considered for patients with frequently

recurring or incessant VT

Spinal cord modulation may be considered for

some

patients with frequently recurring or incessant

VT

Acute Management of Specific Arrhythmias

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Therapies for VTABLATION

Ablation is indicated in patients who are otherwise at low riskfor SCD and have sustained predominantly monomorphic VTthat is drug resistant who are drug intolerant or who do not

wish long-term drug therapy

Ablation is indicated in patients with bundle-branch reentrant VT

Ablation is indicated as adjunctive therapy in patients with an ICD who are receiving multiple shocks as a result of sustainedVT that is not manageable by reprogramming or changing drug

therapy or who do not wish long-term drug therapy

Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway

causing VF

Therapies for VT

Ablation

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have symptomatic

nonsustained monomorphic VT that is drug resistant whoare drug intolerant or who do not wish long-term drug

therapy

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have frequent

symptomatic predominantly monomorphic PVCs that aredrug resistant or who are drug intolerant or who do not wish

long-term drug therapy

Ablation can be useful in symptomatic patients with WPW syndrome who have accessory pathways with refractory periods less than

240 ms in duration

Incessant VT

Revascularization and beta blockade followed by

intravenous antiarrythmic drugs such as

procainamide or

amiodarone are recommended for patients with

recurrent

or incessant polymorphic VT due to acute MI

Intravenous amiodarone or procainamide followed by

VT

ablation can be effective in the management of

patients

with frequently recurring or incessant monomorphic

Acute Management of Specific Arrhythmias

Incessant VT

Intravenous amiodarone and intravenous beta

blockers

separately or together may be reasonable in

patients

with VT storm

Overdrive pacing or general anesthesia may

be considered for patients with frequently

recurring or incessant VT

Spinal cord modulation may be considered for

some

patients with frequently recurring or incessant

VT

Acute Management of Specific Arrhythmias

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Therapies for VT

Ablation

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have symptomatic

nonsustained monomorphic VT that is drug resistant whoare drug intolerant or who do not wish long-term drug

therapy

Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have frequent

symptomatic predominantly monomorphic PVCs that aredrug resistant or who are drug intolerant or who do not wish

long-term drug therapy

Ablation can be useful in symptomatic patients with WPW syndrome who have accessory pathways with refractory periods less than

240 ms in duration

Incessant VT

Revascularization and beta blockade followed by

intravenous antiarrythmic drugs such as

procainamide or

amiodarone are recommended for patients with

recurrent

or incessant polymorphic VT due to acute MI

Intravenous amiodarone or procainamide followed by

VT

ablation can be effective in the management of

patients

with frequently recurring or incessant monomorphic

Acute Management of Specific Arrhythmias

Incessant VT

Intravenous amiodarone and intravenous beta

blockers

separately or together may be reasonable in

patients

with VT storm

Overdrive pacing or general anesthesia may

be considered for patients with frequently

recurring or incessant VT

Spinal cord modulation may be considered for

some

patients with frequently recurring or incessant

VT

Acute Management of Specific Arrhythmias

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Incessant VT

Revascularization and beta blockade followed by

intravenous antiarrythmic drugs such as

procainamide or

amiodarone are recommended for patients with

recurrent

or incessant polymorphic VT due to acute MI

Intravenous amiodarone or procainamide followed by

VT

ablation can be effective in the management of

patients

with frequently recurring or incessant monomorphic

Acute Management of Specific Arrhythmias

Incessant VT

Intravenous amiodarone and intravenous beta

blockers

separately or together may be reasonable in

patients

with VT storm

Overdrive pacing or general anesthesia may

be considered for patients with frequently

recurring or incessant VT

Spinal cord modulation may be considered for

some

patients with frequently recurring or incessant

VT

Acute Management of Specific Arrhythmias

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Incessant VT

Intravenous amiodarone and intravenous beta

blockers

separately or together may be reasonable in

patients

with VT storm

Overdrive pacing or general anesthesia may

be considered for patients with frequently

recurring or incessant VT

Spinal cord modulation may be considered for

some

patients with frequently recurring or incessant

VT

Acute Management of Specific Arrhythmias

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Digitalis Toxicity

An antidigitalis antibody is recommended for patients who

present with sustained ventricular arrhythmias advanced AV

block andor asystole that are considered due to digitalistoxicity

Patients taking digitalis who present with mild cardiactoxicity (eg isolated ectopic beats only) can be

managedeffectively with recognition continuous monitoring of

cardiacrhythm withdrawal of digitalis restoration of normalelectrolyte levels (including serum potassium greater

than 4 mML) and oxygenation

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Digitalis Toxicity

Magnesium or pacing is reasonable for patients

who take digitalis and present with severe

toxicity (sustained ventricular arrhythmias

advanced AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Digitalis Toxicity

Dialysis for the management of hyperkalemia may be

considered for patients who take digitalis and present with

severe toxicity (sustained ventricular arrhythmias advanced

AV block andor asystole)

VA amp SCD Related to Specific Populations

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Digitalis Toxicity

Management by lidocaine or phenytoin is not recommended

for patients taking digitalis and who present with severe

toxicity (sustained ventricular arrhythmias advanced AVblock andor asystole)

VA amp SCD Related to Specific Populations

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

Drug Interacting Drug Effect

QT-prolonging

antiarrhythmics

Diuretics Increased T de P risk due to

diuretic-induced hypokalemia

Beta blockers Amiodarone clonidine digoxin dilitiazem

verapamil

Bradycardia when used in

combination

Digoxin Amiodarone beta blockers clonidine

dilitiazem verapamil

Verapamil Amiodarone beta blockers clonidine digoxin

dilitiazem

Diltiazem Amiodarone beta blockers clonidine digoxin

verapamil

Sildenafil Nitrates Increased and persistent

vasodilation risk of

myocardial ischemia

Clonidine Amiodarone beta blockers digoxin dilitiazem

verapamil

Amiodarone Beta blockers clonidine digoxin dilitiazem

verapamil

Drug Interactions Causing Arrhythmias

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

httpswwwfacebookcomgroups1451610115129555groups1451610115129555

Wellcome in our new group DrSAMIR EL ANSARY

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom

GOOD LUCK

SAMIR EL ANSARYICU PROFESSOR

AIN SHAMSCAIRO

elansarysamiryahoocom