[CK] WPW with Afib with RVR. Procainamide for WIde complex(WPW) !!! IV Procainamide. [QnA] [ ]

Ventricular arrhythmias: Hemodynamically stable, sustained monomorphic ventricular tachycardia (off label):   

      IV:100mg q5min -> 1mg/min.for WPW with Afib. (or even ventricular tachy) 

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Loading dose: 10 to 17 mg/kg at a rate of 20 to 50 mg/minute or 100 mg every 5 minutes; administer until arrhythmia is controlled, hypotension occurs, or QRS complex widens by 50% of its original width. Although manufacturer's labeling suggests a maximum total loading dose of 1 g, clinical evidence suggests higher weight based loading doses of up to 17 mg/kg may be needed (ACLS [Neumar 2010]; AHA/ACC/HRS [Al-Khatib 2017]). Note: Not recommended for use in ongoing ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) due to prolonged administration time and lack of efficacy (AHA 2005; AHA/ACC/HRS [Al-Khatib 2017]).

Maintenance infusion: 1 to 4 mg/minute (ACLS [Neumar 2010]; AHA/ACC/HRS [Al-Khatib 2017]). Manufacturer labeling suggests a maintenance infusion of 2 to 6 mg/minute.

Supraventricular arrhythmias:

Oral [Canadian product]: Sustained release formulation (Procan SR): Maintenance: 50 mg/kg/24 hours given in divided doses every 6 hours.

Suggested Procan SR maintenance dose:

<55 kg: 500 mg every 6 hours

55 to 91 kg: 750 mg every 6 hours

>91 kg: 1 g every 6 hours

Atrial fibrillation (preexcited) (off-label use): IV:

Loading dose: Up to 17 mg/kg at a rate of 20 to 50 mg/minute or 100 mg every 5 minutes; administer until arrhythmia is controlled, hypotension occurs, or QRS complex widens by 50% of its original width. Although manufacturer's labeling suggests a maximum total loading dose of 1 g, clinical evidence suggests higher weight-based loading doses of up to 17 mg/kg may be needed (ACLS [Neumar 2010]).

Maintenance infusion: 1 to 4 mg/minute (ACLS [Neumar 2010]; Hazinski 2015).

Dosing: Renal Impairment: Adult

Medical therapy of arrhythmias associated with Wolff-Parkinson-White syndrome

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Arrhythmia	Treatment options	Contraindicated therapies
Orthodromic AV reentrant tachycardia
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients: First line: Vagal maneuvers Second line: IV adenosine Third line: IV verapamil OR IV diltiazem Other therapies: IV procainamide OR IV beta blocker; synchronized cardioversion if other therapies are ineffective or not feasible
Chronic prevention¶	First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent OR oral amiodarone
Antidromic AV reentrant tachycardia
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients (if CERTAIN of the diagnosis): Same progression of therapies as acute termination of orthodromic AVRTΔ Stable patients (if NOT certain of the diagnosis): IV procainamide, synchronized cardioversion if procainamide is ineffective or not availableΔ	Adenosine, verapamil, diltiazem, beta blockers, digoxin should all be avoided if NOT certain of diagnosis
Chronic prevention¶	First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Other therapies: Oral IA antiarrhythmic agent OR oral amiodarone	Digoxin Beta blockers Verapamil, diltiazem
Pre-excited atrial fibrillation
Acute termination*	Unstable patients: Synchronized cardioversion Stable patients: First line: IV ibutilide or IV procainamide Other therapies: IC antiarrhythmic agent or dofetilide; synchronized cardioversion if other therapies are ineffective or not available	Amiodarone Digoxin Beta blockers Adenosine Verapamil, diltiazem
Chronic prevention¶	First line: Catheter ablation or the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent OR oral amiodarone	Oral digoxin