Drug-induced arrhythmias

The article provides a scientific review based on the proceedings of the 2020 American Heart Association consensus on drugs that may cause arrhythmias on a risk-sensitive basis and a guidance on strategies for monitoring, prevention methods and therapeutic approaches.

The risk factors for drug-induced arrhythmias are divided into modifiable and non-modifiable. Among the non-modifiable risk factors are congenital anomalies (changes in the conduction system, ion channel polymorphism) and heart diseases (cavity dilatation, myocardial ischemia). Among the modifiable risk factors are various electrolyte disorders (hypo/hyperkalemia, hypo/hypermagnesemia, hypocalcemia). Certain drugs can lead to electrolyte disorders, which require management with potassium and magnesium supplements. The drug-induced arrhythmias can be caused by conditions leading to altered drug pharmacokinetics and increased plasma concentrations and metabolites having proarrhythmogenic effects, as well as drug-drug interactions.

Beta-blockers, non-dihydropyridine calcium channel blockers, other antiarrhythmic drugs, ivabradine, digoxin, anesthetics (bupivacaine, propofol) are the most common culprits in causing drug-induced bradyarrhythmias. The drug-induced atrial fibrillation frequently occurs in patients receiving antiarrhythmics, various sympathomimetics, psychotropic and antineoplastic drugs, anti-inflammatory (NSAIDs, corticosteroids) and immunotropic agents (interleukin-2, fingolimod). Various sympathomimetics and inotropic drugs, some antipsychotic drugs can produce drug-induced atrial and nodal tachyarrhythmias.

The drug-induced ventricular tachycardia can be caused by antiarrhythmics, inotropics and various sympathomimetics, antipsychotic and antineoplastic drugs, as well as herbal drugs (aconite, ginkgo biloba). The list of drugs that cause a long QT syndrome includes antiarrhythmics, antimicrobial drugs (macrolides, fluoroquinolones, aminoquinolines, fluconazole), antipsychotics, antineoplastic drugs, antiemetics, etc. For a complete list of drugs that prolong a QT interval, see the CredibleMeds website (Arizona, USA). The drug-induced arrhythmia prevention strategies include rising awareness among doctors about risk factors and potentially dangerous drugs, sufficient monitoring of patients at risk of developing arrhythmias (ECG monitoring, electrolyte balance, kidney and liver function), maintenance of electrolyte balance, primarily potassium and magnesium. The therapeutic approach includes discontinuation of a causative drug; relief and maintenance therapy are carried out based on the modern international clinical guidelines for various forms of arrhythmias. 

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