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Clin Med - Cardio II > A Fib Lecture > Flashcards

A Fib Lecture Flashcards

1
Q

A Fib is the loss of what

A

atrial contractility

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2
Q

Afib results in what?

A

irregular ventricular response

rapid heart rate

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3
Q

what is the HR with A fib

A

120-160

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4
Q

what can A fib lead to

A

clot formation and subsequent thromboembolic events (leading cause of stroke)

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5
Q

what is the most common sustained arrhythmia

A

A fib

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6
Q

what populations does A fib affect most

A

risk increases with age >65
men >women
whites > blacks, hispanics, asians

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7
Q

etiologies of atrial fibrillation

A
  1. acute hyperthyroidism
  2. acute vagotonic episode
  3. acute alcohol intoxication
  4. post operatively after major surgery
  5. atrial enlargement
  6. disruption of electrical conduction system (scarring or infiltration)
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8
Q

pathophys of afib

A

elevation in atrial pressure
majority of episodes of PAF are triggered by atrial premature beats
can be triggered by other supraventricular arrhythmia: atrial flutter or atrial tachycardia

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9
Q

what is A Fib

A

disorganized rapid and irregular atrial activation

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10
Q

ectopic foci in afib are most often located where

A

ostial portion of pulmonary veins (site of ablation)

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11
Q

risk factors for Afib

A
  1. age >64
  2. male
  3. HTN
  4. elevated BMI
  5. PR interval prolonged
  6. valvular dz
  7. CHF
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12
Q

classifications of Afib

A
  1. paroxysmal - intermittent
  2. persistent - fails to self terminate within 7 days and requires intervention in order to convert
  3. permanent - >12 months & no longer pursue rhythm control
  4. Lone AF - without structural heart dz, lowest risk of complications (term not used much anymore)
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13
Q

Dz associations with Afib

A
  1. valvular heart dz (significant stenosis or regurgitation; rheumatic heart dz)
  2. heart failure
  3. HTN heart dz
  4. acute myocardial infarction (probably due to atrial ischemia or stretch)
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14
Q

symptoms of afib

A
  1. asymptomatic
  2. heart palpitations
  3. light headedness, pre syncope, syncope
  4. SOB and exercise tolerance
  5. chest pain - rare unless concomittant CAD
  6. fatigue
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15
Q

common triggers of afib episodes

A 
sleep deprivation
physical illness
post surgery
stress
hyperthyroidism
physical exertion/exercise
stimulant medications
alcohol
caffeine
dehydration
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16
Q

initial presentation of new onset of a fib

A 
heart palpitations
fatigue or lightheadedness
SOB
angina
incidental
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17
Q

what do you want to control in new onset of afib

A
  1. rate and rhythm control

2. prevention of systemic emboli

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18
Q

diagnostic studies for afib

A

EKG
echo
stress test
labs: CBC, BMP, TSH

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19
Q

history taking for afib

A

symptoms: onset, frequency, duration, quality, severity (tachy and fatigue)
precipitating causes (alcohol, exercise)
underlying dz:
CAD, CHF, CVA/TIA, DM, HTN, COPD, thyroid disorder

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20
Q

phyiscal exam in afib

A

complete cardiovascular exam

  • BP and pulse
  • murmurs
  • evidence of heart failure (JVP etc)
  • extremity pulses
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21
Q

EKG for Afib

A 
needed to make the diagnosis
-LVH
-pathologic Q waves
delta waves, short PR interval
QT interval duration
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22
Q

echo for afib

A 
size of atria
size and functino of R/L ventricles
valvular heart dz
pericardial dz
atrial thombus**low sensitivity
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23
Q

TEE for afib

A

transesophageal echocardiogram
far more sensitive for detecting atrial thrombus
-prior to cardio conversion
-could throw a clot

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24
Q

when to do exercise stress test with afib

A

assess for ischemic heart dz

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25
Q

differences of ST segments bw ischemia and MI

A

ischemia - ST segment depressed in ischemia (no death of tissue yet, just not being perfused)
MI - ST elevation

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26
Q

why give pt home heart monitors?

A

to determine if persistent or paroxysmal

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27
Q

lab testing for afib

A

TSH - all patients with first episode of afib or incr frequency
CBC
chemistries/electrolytes (incld kidney function tests)

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28
Q

4 goals for afib

A
  1. rhythm control (if not yet permanent)
  2. reduce the risk of stroke and other peripheral emboli (prevention of systemic embolization)
  3. prevent tachycardia mediated cardiomyopthy and ischemia (rate control)
  4. alleviate symptoms (usually d/t increased HR)
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29
Q

management decisions for new afib

A

is cardioversion indicated and should it be urgent?
does the pt need rate control
does the pt need to be anticoagulated for emobolization prevention
does the pt need to be hospitalized
are tehre correctable causes of afib (drugs)

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30
Q

possible indications for urgent direct current cardioversion

A
  1. active ischemia
  2. unstable hemodynamics
  3. evidence of organ hypoperfusion
  4. severe manifestations of heart failure (pulm edema)
  5. the presence of WPW
    * *risks and benefits of cardioversion must be weighed carefully
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31
Q

indications for nonurgent DC cardioversion

A

new onset or newly recognized atrial fibrillation

pts with persistent AF who are limited by their symptoms

32
Q

reasons not to cardioconvert in afib

A
  1. known afib and minimally symptomatic
  2. multiple comorbities
  3. unlikely to maintain NSR
  4. benefits of cardioversion decrease after 80yo
  5. paroxysmal AF (go in and out on their own)
33
Q

what do you give a pt prior to cardioversion

A

IV heparin

control ventricular RATE

34
Q

what happens in afib duration >48hrs

A

hold off bc its too risky to do cardioversion d/t clot, need full anticoags (3weeks) and do transesophageal echo to look for clot

35
Q

afib with rapid ventricular response can reach what bpm

A

> 150

36
Q

complications of rapid afib

A

symptoms - fatigue, chest pain
ischemia
pulm edema
tachycardia induced cardiomyopathy (LV dilation, cellular morphologic changes)

37
Q

4 classes of pharm tx of afib

A
  1. beta blockers
  2. calcium channel blockers
  3. digoxin
  4. amiodarone
38
Q

beta blockers for tx of rapid afib

A
  1. immediate control: IV metoprolol start at 5mg IVP can give 2nd dose of 5mg if first didnt work or if it wears off
  2. long term control: oral metoprolol (tartrate: short acting: every 6hrs OR succinate: long acting: 1/day)
39
Q

what beta blockers would be used in afib with the following comorbidities?

  1. liver failure
  2. heart failure
A
  1. nadolol

2. carvediolol

40
Q

what beta blocker is better for BP but can also be used to try and treat rapid afib

A

atenolol

41
Q

calcium channel blockers for rapid afib

A
  1. immediate control: IV diltiazem (5-10mg IVP); can also do a Dilt drip: continuous infusion that is titrated up until target HR reached
  2. oral diltiazem - 3/day for short acting or 1/day for long acting
42
Q

digoxin for rapid afib

A

can be IV or oral
-less effective for rate control particularly during exercise
can be added to beta blockers if insufficient or intolerant
-initial dose is loading dose (higher) then daily maintenance dose
-plasma digoxin levels should be monitored periodically d/t risk of dig toxicity

43
Q

amiodarone for afib

A
  • maintains sinus rhythm in AF pts (antiarrhythmic)
  • can also slow rate for refractory afib with RBR after maximizing BB and CCB
  • immediate use: IV
  • long term maintenance: oral
  • less likely to cause hypotension
  • SEs: abnormal LFTs, pulm toxicity (months to years after initiation so dont use long term), chronic interstitial pneumonitis (scarring thruout lungs = restrictive dz)
44
Q

arterial embolization from atrial fibrillation

A

risk 0.5% per year to 6.9% per year

  • stasis of atrial blood leads to clot formation
  • especially in left atrial appendage (LAA)
  • ischemic stroke is the most frequent
  • can occur at any point in time
  • valvular heart dz increased risk
45
Q

what scoring system is used to assess pts need to be on anticoagulants with afib

A

CHADS2 score
0: no anticoags
1-2: consider next scoring system
>=3: high risk, def need anticoags

46
Q

what scoring system do you use if CHADS2 score is 1-2 (intermediate)

A

CHA2DS2 VASc model

pts with a score >=2 are recommended to have long term anticoagulation

47
Q

what factors does the CHADS2 system use

A

HTN = 1pt
Age >75 = 1pt
DM = 1pt
prior stroke/TIA = 2pts**

48
Q

what factors does CHADS2-VASc model use

A 
age 65-74 = 1
age >=75 = 2
female = 1
CHF = 1
HTN = 1
Stroke/TIA = 2
vascular dz = 1
DM = 1
49
Q

warfarin for anticoag for afib

  • how often is it used?
  • how effective?
  • cost?
  • downside
A 
most commonly used
effective
inexpensive
significant risk of bleeding
frequent blood draws
50
Q

how does warfarin work?

A

competively depletes functional vit K reserves and hence reduces synthesis of many active clotting factors

51
Q

how to reverse warfarin

A

administer vitK

52
Q

how long does warfarin take to start working

A

24-72hrs

53
Q

full therapeutic effect starts when on warfarin

A

5-7 days

54
Q

how is warfarin monitored

A

INR - 2.5 goal

55
Q

how is warfarin metabolized

A

hepatically via CYP2C9 = lots of DI’s

56
Q

what options can you use for anticoag for immediate use

A

IV heparin or lovanox

57
Q

when to bridge warfarin with heparin or LMWH in pts with afib

A

not usually necessary
recent or ongoing stroke or other embolus
known arterial thrombus
currently hospitalized (bc its easy)

58
Q

warfarin compared to newer agents

A 
-newer anticoags:
direct thrombin and factor Xa inhibitors
similar or lower rates of ischemic stroke
similar or lower rates of major bleeding
do not require frequent lab draw
EXPENSIVE**
59
Q

indications for hospitalization for afib

A

immediate anticoagulation (bridge)
ablation of accessory pathway (WPW)
tx of associated medical problem that may trigger afib (infection, COPD, CHF)
management of rate or sick sinus syndrome

60
Q

is afib common?

A

yes

61
Q

what does afib put the pt at risk for

A

stroke and other embolic events

62
Q

goals of afib

A

management of symptoms, rate vs rhythm control, and stroke prevention

63
Q

occurence of aflutter vs afib

A

less common than afib

64
Q

aflutter sometimes leads to

A

afib

65
Q

aflutter commonly occurs after

A

initiation of an antiarrhythmic drug for afib

66
Q

aflutter is associated with what

A

Left atrial enlargement

67
Q

what are the rates like in aflutter

A 
rapid ventricular rate (150bpm)
atrial rate (250-350bpm) - f waves
68
Q

associated disorders with aflutter

A
  1. hyperthyroidism
  2. heart failure
  3. obesity
  4. obstructive sleep apnea
  5. sick sinus syndrome
  6. pericarditis
  7. pulm dz
  8. pulm embolism
69
Q

clinical manifestations of aflutter

A 
palpitations
lightheaded
SOB
tachycardia
evidence of CHF
70
Q

diagnostic studies for aflutter

A

EKG
echo
TEE
exercise stress test

71
Q

complications of aflutter

A

cardiac ischemia
pulmonary edema
tachycardia induced cardiomyopathy
thromboembolism

72
Q

treatment considerations in aflutter

A

control ventricular rate
convert to NSR
maintain NSR
prevent systemic embolization

73
Q

rate control in aflutter

A

more difficult than afib
use BB or CCB (digoxin can be added)
amiodarone is rarely used
radiofrequency catheter ablation

74
Q

what is radiofrequency catheter ablation

A

type 1 aflutter
large macroreentrant pathway in right atrium involving obligatory pathway bw inferior vena cava and the tricuspid annulus
ablation of IVC-TA area
maintains sinus rhythm after procedure
65-100% success rate
7-44% have recurrent atrial arrhythmia, usually afib

75
Q

pharm therapy for conversion to NSR

A

only 20-30% effective at maintaing NSR

  • dronedarone
  • flecainide
  • sotalol
  • dofetilide
  • amiodarone
76
Q

anticoagulation for aflutter

A
  • prior to RF catheter ablation - 4 weeks or consider TEE
  • after RF catheter ablation - anticoagulation x 1month
  • recurrent aflutter or afib after ablation plan indefinite anticoagulation if CHADS2 score >=1
77
Q

aflutter pts at risk for

A

strok and other embolism

Clin Med - Cardio II (12 decks)

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