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344 final > AF3 > Flashcards

AF3 Flashcards

1
Q

Antithrombotic Options: AF
ASA, Warfarin, ASA + Clopidogre

summary

A 
Efficacy: 
u ASA reduces risk of ischemic
stroke by 19%
u Warfarin reduces risk of
stroke by 64%
u ASA + Clopidogrel are more
effective than ASA, but not
as effective as warfarin 
Safety:
u Bleeding is higher with
Clopidogrel + ASA than
either ASA alone or Warfarin
alone

ASA + Clopidogrel
not best treatment
options

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2
Q

compare DOACs tp warfarin

A

Dabigatran 150mg bid is
superior to warfarin with a
similar rate of major
bleeding; 110mg is noninferior with lower bleed

Rivaroxaban is non-inferior
to warfarin
with similar rates of
bleeding

Apixaban is superior to
warfarin with a
significantly lower rate
of major bleeding

Edoxaban 60mg daily
is non-inferior to
warfarin with a
significantly lower rate
of major bleeding
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3
Q

Role of Pharmacist in AF
Assessment of Patient with AF
Management of Medications

A 
Is antithrombotic therapy indicated?
q Is the treatment option effective?
q Is the treatment option safe?
q Is the patient able to be compliant?
Monitoring of Medications and of Patient
q How is the patient being monitored for safety
and efficacy?
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4
Q

Major Goals and Expected Outcomes

Rapid Heart Rate
Loss of Atrial Kick:

A 
Rapid Heart Rate:
• Improvement of
Symptoms,
Functional
Capacity and
Quality of Life
Loss of Atrial Kick:
• Prevent
Complications
such as LV
Dysfunction
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5
Q

Rate Control Medications

A

Rate control agents prolong refractory period of the AV
node and act to slow AV node conduction
u βB and non-hydropyridine CCB (verapamil,
diltiazem)will prolong refractory period and slow heart
rate

u Digoxin prolongs refractory period of AV
node by enhancing vagal tone
u As vagal tone is withdrawn, digoxin is not usually
effective during exertion or stress
u Digoxin is therefore generally reserved for older or
sedentary patients or as an add-on to in patient
without adequate rate control on βB or CCB

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6
Q

Rhythm Control: Anti Arrhythmic Drugs (AAD)

A

IC:
PropafenoneFlecainide

III: amiodarone
dronedarone

III: sotalol

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7
Q

PropafenoneFlecainide
MOA
comments

A 
MOA:
• Strong Na+ blockers
• Extended refractory
period of AV node and
accessory tracts
comment
• AV node blocker (βB, diltiazem, verapamil)
required concurrently/in advance to
prevent rapid ventricular rate
• Risk of Ventricular Tachycardia (VT)
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8
Q

III: amiodarone

dronedarone

A 
MOA
• Multichannel blocker
(including K+ and β
blockade)
• Prolong action potential
and refractoriness of slow
and fast channel tissues

amiodarone:
• Extremely long t1/2 with increased risk of
extracardiac toxicities (skin, thyroid,
pulmonary, liver, neurologic)
• Prolong QT interval therefore have risk of TdP
• Many drug interactions
sometimes high loading doses

dronedarone: • Similar to amiodarone with shorter t1/2
• Increased risk of mortality in patients with HF
• Increased risk of hepatotoxicity

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9
Q

Sotalol

A 
MOA
• Increases AV node
refractoriness at higher
doses and β blockade at
all doses

• Risk of TdP (torsades de pointes) due to QT
prolongation
• Accumulates in renal failure and can lead to
heart block

it is a BB but rarely used just for HTN/BB effects?

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10
Q

Rate vs. Rhythm

Anti Arrhythmic Drugs (AAD)
monitoring

Would it be better for a
patient to be in SR?
That would improve
symptoms and reduce risk of
stroke…
A 
Efficacy Outcomes:
• Improvement of
symptoms/restoration of SR
• Reduction in Stroke
• Improve survival

Safety Outcomes:
• Side effects (including arrhythmias)
• Mortality

efficacy: not improving, should contact cardiologist and may increase dose, if no benefit, med should be discontinued

anticoagulantis continued

see slide 16

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11
Q

Rate Control vs. Rhythm Control:
AFFIRM

ž Patients > 65 years with AF + ≥ 1 other risk factor for stroke
ž Mean age = 70; no mean CHADS2 score reported – ~½ hypertensive, 23%
CHF, 5% valvular disease

A

Intervention / Comparator:

  • Choice of rate control (by clinician)
    Digoxin 70.6%
    Beta blockers 68.1%
    Non-hydropyridine CCB 62.9%
- Choice of rhythm control
Amiodarone 39%
Sotalol 33%
Propafenone 10%
Procainamide 6%

+ Anticoagulation with warfarin but it could be
stopped in rhythm control if SR (sinus rhythm) maintained
X 4 weeks

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12
Q

AFFIRM Outcomes:
Mortality
restoration of sr
prevention of stroke

A

1o End Point Mortality:
Rate Control: 25.9%
Rhythm Control 26.7%

rhythm control hgiher mortality

Efficacy: Restoration of SR
SR in Rate Group: <40%
SR in Rhythm Group: >60%

Efficacy: Prevention of Stroke
Stroke Incidence inRate Group:5.5%
Stroke Incidence inRhythm Group: 7.1%

Key Take-Aways:
u In older patients, rhythm controloffers no survivalbenefit over rate control
u Anti Arrhythmic therapy does not completely suppress AF
u Patients are still at risk of stroke and require stroke prevention therapy

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13
Q

Early Rhythm Control in Patients with AF:
EAST-AFNET 4 Trial

u Patients >18 years old with recent onset AF (<1 year prior to enrollment)
u CHAD2 score of > 2
u Excluded: not suited for rhythm control, severe mitral stenosis, prior AF ablation or
surgical therapy of AF, disease that limits life expectancy to < 1year

A

ntervention / Comparator:
® Early rhythm control
Usual Care – Initially rate control without rhythm control (rhythm control only used to mitigate uncontrolled AF symptoms during adequate rate control therapy

Outcomes:
ž 10 outcome: composite of death
from CV causes, stroke (ischemic or
hemorrhagic), or hospitalization
with worsening of HF or ACS
ž 10 safety outcome: composite of
death from any cause, stroke, or
pre specified serious adverse effect
Patients followed for 5 years

stroke: Early Rhythm
Control: 91.2%mreceived anticoagulation
Usual Care: 89.7% received anticoagulation

less death in early rhythm

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14
Q

Principles Guiding Rate or Rhythm

Control Selection:

A

Safety of Anti Arrhythmic Drugs (AAD):
u AAD have only been associated with beneficial effect when initiated in patients with recent onset AF (< 1 year)
u AAD are associate with many adverse effects and selection of AAD is driven by safety and tolerability
u If AAD not providing benefit, it should be discontinued

Efficacy of AAD:
u Long-term AAD may not completely suppress AF (i.e. patient may still have symptoms and would continue to have risk of stroke)
u Patients on both AAD and rate control need to
receiveantithrombotic stroke prevention therapy

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15
Q

Approach to Rate and Rhythm Management of AF

Paroxysmal AF
Self-terminating within 7 days

A

Low recurrence
burden: observe, if AFib do Pill-in-Pocket AAD

high recurrence burden: maintain AAD tx, keep them on normal sinus rhythm

catheter ablation is an option

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16
Q

Pill In Pocket Approach

which pts
which meds

A 
Which Patients?
u Paroxysmal AF, symptomatic with a
sustained AF episode (e.g. > 2 hours)
u AF usually occurs less frequently than
monthly
u Symptoms not severe or disabling that require ER visit (e.g. fainting, severe chest pain or breathlessness)

u Which medications?
u AV Nodal Blocker X 1 dose (Diltiazem 60mg X 1
Verapamil 80mg X 1 Metoprolol 25mg X 1)
u 30 minutes later – Class IC Anti Arrhythmic Drug (Flecainade 200 or 300mg X 1
Propafenone 450 or 600mg X1
(lower dose used if <70kg))

17
Q

Pill In Pocket Approach

pt instructions

A 
u Rest X 4 hours (laying down, seated)
u Proceed to ER if:
u AF does not terminate within 6- 8
hours
u Feel unwell after taking
medication
u >1 episode in 24 hour period
u Severe symptoms (e.g. fainting,
severe chest pain or
breathlessness) or
symptoms of stroke
18
Q

Non-Pharmacologic Conversion

Options: Catheter Ablation

A 
u Catheter guided ablation of the re-entry
loops causing the AF
OR
u Catheter guided AV node ablation so
that rapid impulses in atria not carried to
ventricles
u Ventricular Pacemaker would be
required

pt would be pt dependent

19
Q

persistent AF flowchart
Persistent AF: > 7 days but <1 year
Long-standing Persistent: > 1 year,
rhythm control being pursued

A

slide 31

Initiate Rate-control and
consider Long-term treatment

Rhythm-Control preferred with: • Recently diagnosed AF (within 1 year)
• Highly symptomatic or significant QOL impairment
• Multiple recurrences
• Difficulty to achieve rate control
• Arrhythmia-induced cardiomyopathy

20
Q

Non-Pharmacologic Conversion

Options: Cardioversion

A

u DC (Direct Current) cardioversion can be
used to electrically convert a patient from AF
to NSR
u Has shown to initially effective in converting >
80% of patients
u Patients must be therapeutically
anticoagulated for at least 3 weeks prior to
cardioversion and at least 4 weeks after
cardioversion (Exception: emergent situations)

21
Q

see slide 33

A

34 35

344 final (16 decks)

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