15 AFib Flashcards
Normal ECG Values
PR ___ - ___ ms
QRS ___ - ___ ms
QT ___ - ___ ms
QTc ___ - ___ ms (men)
QTc ___ - ___ ms (women)
120-200
80-120
380-460
360-450
360-460
nervous for TdP around 500
Torsades de Pointes
when QTc interval is greater than ___ ms, there is increased risk of drug induced arrhythmia (TdP)
- drug induced
- cause sudden cardiac ___
500
death
what is this?
TdP
drugs that may cause TdP
- 5 A’s
- opioids
- antiarrhythmics
- antimicrobials
- antidepresents
- antipsychotics
- anticancer
superventricular arrhythmias
- sinus ___ and ___
- ___ block
- atrial ___
- supraventricular ___
- bradycardia, tachycardia
- AV
- fibriliation
- tachycardia
ventricular arrhythmias
- ___ ventricular compexes
- ventricular ___ and ___
premature
tachycardia, fibrillation
superventricular arrhythmias
sinus bradycardia
- HR < ___ bpm
- impulses originating in ___ node (decreased)
60
SA
automaticity
what is this
superventricular arrhythmias
- sinus bradycardia
supraventricular arrhythmias - sinus bradycardia
etiologies/risk factors
- MI/ischemia
- abnormal SNS/PSNS tone
- electrolytes abnormalities ( ___ and ___ )
drugs
- dig
- BB
- CCB ( ___ and ___ )
- amiodarone, dronedarone
- ivabradone
K, Mg
verapamil, diltiazem
supraventricular arrhythmias - sinus bradycardia
symptoms
hypotension
dizziness
syncope
supraventricular arrhythmias - sinus bradycardia
treatment
only necessary if patient is ___
- ___ 0.5-1 mg IV, repeat every 5 min
AE: ___ cardia, urinary retention, ___ vision, dry mouth, mydriasis
anti-muscarinic: cant pee, cant see, cant spit
symptomatic
atropine
tachycardia, blurred
supraventricular arrhythmias - sinus bradycardia
treatment is not responsive to atropine
- transcutaneous pacing
- ___ (5-20 mcg/kg/min) or ___ (0.1-0.5 mcg/kg/min)
- ___ 20-60 mcg IV bolus followed by doses of 10-20 mcg or infusion of 1-20 mcg/min
dopamine
epinephrine
isoproterenol
supraventricular arrhythmias - sinus bradycardia
treatment after heart transplant or spinal cord injury
- ___ 6 mg/kg IV over 20-30 min OR
- ___
- (heart transplant) 300 mg IV followed PO 5-10 mg/kg/day titrated to effect
- (spinal cord injury) PO 5-10 mg/kg/day titrated to effect
aminophylline
theophylline
supraventricular arrhythmias - sinus bradycardia
long term treatment
- some patients require a permanent ___
pacemaker
supraventricular arrhythmias - atrial fibrillation
- atrial activity - chaotic and disorganized
- ventricular rate: 120-180 bpm
- rhythm: irregularly irregular
- ___ waves: absnet
P
what is this?
Afib
Afib
stage 1) presence of modifiable and nonmodifiable risk factors assocaited with AF
stage 2) pre-atrial fib - ___ or ___ findings that further predispose patients to AF
stage 3)
- A) paroxysmal
- B) persistent
- C) long standing persistent
- D) successful ___
stage 4) permanent
electrical, structural
ablation
Afib
mechanisms
- abnormal atrial/pulmonary vein ___
- atrial ___
automaticity
re-entry
Afib
etiologies of reversible Afib
hyper ___
thoracic surgery
- CABG
- lung resection
- esophagectomy
hyperthyroidism
Afib
mortality
- stroke/systemic embolism - 5x increased risk
- HF - increased 3x risk
- dementia - 2x increased risk
- mortality - 2x increased risk
Afib goals of therapy
1) prevent ___ /systemic ___
___ ventricular response by inhibiting conduction of impulses to ventricles
convert Afib to ___
reduce ___ of episodes
stroke, embolism
slow
NSR
frequency
Afib - preventioini of stroke/systemic embolism
whats the CHAsDS2-VASc scoring
Afib - preventioini of stroke/systemic embolism
oral anticoag recommended for:
- ___ or greater (men)
- ___ or greater (women)
reasonable for
- ___ (men)
- ___ (women)
2
3
1
2
Afib - preventioini of stroke/systemic embolism
___ are preferred over warfarin for most patients
warfarin only preferred in Afib patients with
- ___ heart valves (INR 2.5-3.5)
- moderate to severe ___ valve stenosis (INR 2-3)
DOACs
mechanical
mitral
dabigitran, rivaroxaban, apixaban, edoxaban
Afib - preventioini of stroke/systemic embolism
warfarin or ___ are preferred in the following
- end stage CKD (CrCl < ___ )
- hemodialysis
abixaban
15
Afib - drugs of ventricular rate control
MOA: direct AV node inh
- CCB: ___ and ___
- BB: ___ , ___ , and ___
MOA: vagal stimulation/direct AV node inh
- ___
MOA: BB and CCB activity
- ___
- diltiazem, verapamil
- propranolol, metoprolol, esmolol
- digoxin
- amiodarone
Afib - drugs of ventricular rate control (IV)
if not stable, shock
if stable, do the have HF?
- if yes: ___
- if no: __ , ___ , or ___ (if that doesnt work, dig, if that doesnt work, ___ )
- amiodarone
- BB, verap, dilt
- ami
Afib - drugs of ventricular rate control (IV)
goal: < ___ - ___ bpm AND ___
do not administer ___ or ___ to patients with decomp HF
100-110, asymptomatic
- dilt, verap
Afib - drugs of ventricular rate control (PO)
EF < 40
- ___
- if doesnt work: ___
EF >40
- ___ , ___ , or ___
- if doesnt work: ___
do not administer ___ or ___ to patients with HFrEF
- BB
- dig
- BB, dilt, vera
- dig
dilt, verap
T or F: we can convert pateints with stage 4 Afib back to NSN
F
they are permanently stuck like that
Afib - conversion to NSN
if AF has been present < 48 hours, conversion is safe
if > 48 hours, conversion to NSN chould not be performed until patient has been ___ for 3 weeks (TEE can also rule out clot)
anticoagulated
Afib - conversion to NSN
DC cardioversion
drugs (5)
___ (class I-IV)
___ (class III) - risk of TdP
___ (class 1A) - risk of TdP
pill in pocket
___ and ___ (class 1C)
- amiodarone
- ibutilide
- procainamide
- flecanide, propafenone
Afib - conversion to NSN drugs
normal LVEF
- IV ___ or ___
- or ___
EF < 40
- IV ___
AF occuring outiside of hospital in patients with normal LVEF (pill in the pocket)
- ___ and ___
- amiodarone, ibutilide
- procainamide
- amiodarone
- felcainide, propafenone
Afib - conversion to NSN drugs
do not administer procainamide if patient has already recieved amiodarone or ibutilide due to the risk of excessive ___ prolongation and ___
QTc, TdP
Afib - maintenance of sinus rhythm/prevention of recurrence
drugs (6)
___ and ___(class I-IV)
___ and ___ (class III)
___ and ___ (class 1C)
- amiodarone, dronedarone
- sotalol, dofetilide
- flecainide, propafenone
Afib - dofetilide dose
CrCl > 60: ___ mcg PO BID
CrCl 40-60: ___ mcg PO BID
CrCl 20-39: ___ mcg PO BID
CrCl < 20: ___
2-3 h after 1st dose, check ___ interval
- less than 15% increase, continue current dose
- greater than 15% or greater than 500 ms, cut dose in half
if > 500 ms any time after 2nd dose, D/C
proceed with first dose only if < 440 ms
500
250
125
CI
Amiodarone - monitoring
- hyper/hypo ___
- hepatotoxicity
- ___ interval prolongation
- pulmonary ___
- ___ microdeposits
- dermatologic blue/grey, photosensitivty
- thyroidism
- QTc
- fibrosis
- corneal
Afib - maintenance of NSR following conversion/paroxysmal AF
normal LV, no prior MI or structutal HD
- ___ , ___ , ___ , or ___
- if doesnt work: ___
- if doesnt work: ___ (least preferred)
prior MI, structial HD, HFrEF
- ___ or ___
- if doesnt work: ___
NYHA III or IV or recent decom HF
- no: ___
- yes ___ CI
- dofetilide, dronedarone, flecainide, propafenone
- amiodarone
- sotalol
- amiodarone, dofetilide
- sotalol
- dronedarone, dronedarone
neither ___ nor ___ should be administered to patients with prior MI, significant structrual HD, and/or HFrEF
flecainide, propafenone
negative inotropes
Afib - sotalol dose
- CrCl > 60 - 80 mg ___
- CrCl 40-60 - 80 mg ___
2-4 h after, check ___ interval
- if < 500 ms after 3 days, increase, pt can be discharged or dose can increase to ___ daily
- if > 500 ms: ___
only do first dose if < 450 ms
- BID
- daily
- QTc
- 120
- D/C
Afib
catheter ablation
- used for pts who found anti-arrhythmic drugs ineffective, CI, or not preferred
- selected patients are younger, less comorbidities
- symptomatic ___ Afib first line to prevent from progression to persistent
paroxysmal
