AF Flashcards
What is the initial presentation of AF in the elderly?
May be asymptomatic/stroke
How de we treat a hemodynamically unstable AF?
Direct current cardioversion
How do we treat a hemodynamically stable AF?
Acute ventricular rate control
Select agent based on LV function
What medications are used for hemodynamically stable AF?
BB (monitor bradycardia, hypotension)
Non-DHP CCB (monitor constipation, hypotension)
According to the Beers list, how is rhythm control compared to rate control?
Rhythm control can have outcomes as good as or better than rate control
Is rate or rhythm control more important in symptomatic therapy?
Rhythm control
What type of therapy is used in symptomatic AF?
Pharmacologic or electrical cardioversion
What type of therapy is used in non-symptomatic AF?
Select agent to maintain HR
Non-DHP CCB, BB (alt: dig, amiodarone)
Is rate or rhythm control more important in non-symptomatic AF?
Rate control
What other therapy is recommended in AF along with rate/rhythm control?
Consider anticoagulation
What does the Beers list say about amiodarone use?
Avoid 1st line (because of increased risk of toxicities) unless pt has HF or substantial left ventricular hypertrophy
What does the Beers list say about dronedarone?
Avoid if permanent AF or severe/decompensated HF because potentially worse outcomes
What does the Beers list say about disopyramide?
Avoid because highly anticholinergic and as a potent negative inotrope may induce HF
What does the Beers list say have digoxin?
Avoid 1st line because other more effective alternatives exist and may be associated with increased mortality
What does the CHADSVASC score stand for and how many points go with which pieces?
Congestive HF/LV dysfunction = 1 HTN = 1 Age >/= 75 = 2 DM = 1 Stroke/TIA/systemic embolism = 2 Vscular disease (post-MI, PAD, aortic plaque) = 1 Age 64-75 years = 1 Female = 1
What dose the CHADS score stand for and how many points go with which pieces?
Congestive HF/LV dysfunction = 1 HTN = 1 Age >/= 75 = 2 DM = 1 Stroke/TIA = 2
What are the 2012 CHEST guidelines according to the CHADS score?
0 = No antithrombotic 1 = OAC > ASA + plavix > ASA > no treatment >/= 2 OAC > ASA + plavix > ASA > no treatment
Which OAC is preferred?
Dabigatran is preferred over warfarin
What are the 2014 AHA/ACC guidelines according to the CHASVASc Score?
0 = no antithrombotic
1 = No antithrombotic or ASA or OAC
>/=2 Warfarin, dabigatran, rivaroxaban, apixiban
If a patient has a mechanical heart valve, which OAC is avoided?
Dabigatran
Which OAC is used in patients with ESRD/hemodialysis?
Warfarin
What doses of warfarin do we start in older patients?
2.5-5mg
What is the reversal agent for warfarin?
Vitamin K
What is the reversal agent for dabigatran?
Idarucizumab (praxbind)
What is the dosing for dabigatran?
150mg BID
How is dabigatran adjust with CrCl?
CrCl 15-30 ml/min: 75 mg BID
What is the brand for dabigatran?
Pradaxa
What trial studied dabigatran?
RE-LY
What did the RE-LY trial prove?
Dabigatran is superior for decreased stroke, decreased IC bleed, and increased GI bleed
What does the Beers list say about dabigatran?
Caution in those 75 or older and CrCl < 30 d/t increased GI bleeds
What is the dose of Xarelto?
20mg QD
What is the dose of Xarelto with decreased renal clearance?
CrCl 30-49 ml/min: 15 mg daily
What trial studied Xarelto?
Rocket-AF
What did the ROCKET-AF trial prove?
Xarelto is noninferior for strokes, emboli, and bleeds
What is the brand for apixaban?
Eliquis
What is the dosing for apixaban?
5mg BID
How do we dose adjust apixaban?
2 of the following is 2.5mg BID:
>/= 80 years
= 60kg
SCr >/= 1.5 mg/dl
What trial studied apixaban?
ARISTOTLE
What did the ARISTOTLE trial prove?
Apixaban was superior for decreased stroke, emboli and bleeds
What is the generic of Savaysa?
Edoxaban
What was the trial for edoxaban?
ENGAGE-AF TIMI 48
What is the dosing for edoxaban?
> 50 ml/min = 60mg QD
15-50 ml/min = 30mg QD
Do not use if > 95 ml/min = increased risk of stroke
What does the Beers list say about edoxaban?
Avoid if CrCl < 30 = increased bleed
What did the ENGAGE-AF TIMI 48 trial prove in edoxaban 60mg?
Superior decrease in stroke, systemic emboli; decreased major/life-threatening bleed; increased GI bleed in those >/= 75 yo
What did the ENGAGE-AF TIMI 48 trial prove in edoxaban 30mg?
Non inferior for stroke, systemic emboli (except >/= 75 yo favors warfarin); decreased bleed in all areas (including >/= 75 yo)
What are RFs for AF?
HTN
CAD
HF
Rheumatic/valvular heart disease
What did the ACTIVE-A trial determine?
Plavix + ASA > ASA monotherapy for stroke and major bleeding
What did the BAFTA trial show?
Warfarin > ASA for stroke, ICH, arterial embolism
