Key messages

• Antiarrhythmic drugs are still the first therapeutic modality in the treatment of cardiac arrhythmias despite impressive advances in non-pharmacological approaches such as radiofrequency catheter ablation and the implantable cardioverter defibrillator for long-term arrhythmia management.

• Cardiac arrhythmias in critically ill patients are often the consequence of non-cardiac states such as sepsis, electrolyte imbalance, and hypoxia, and any therapy designed to restore sinus rhythm must address such factors.

• Vaughan Williams class I drugs are not commonly used because of adverse effects on myocardial contractility and significant risk of proarrhythmia.

• Beta-blockers are useful in certain situations, and the action of ultra-short-acting agents such as esmolol has enabled b-blocker therapy to be attempted in a wider range of clinical situations.

• Amiodarone is perhaps the most useful acute agent for both ventricular and supraventricular arrhythmias, but there is considerable concern about long-term usage when side-effects are common and potentially serious.

• Magnesium in pharmacological doses is useful in the treatment of torsade de pointes (a variant of ventricular tachycardia).

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