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UBSPPS PHM601 Cardio/Renal Pharmacotherapeutics > Afib > Flashcards

Afib Flashcards

1
Q

True or False: Apixaban dosing for Afib is 10mg 2x/day for 1 week then 5mg 2x/day?

A

False, this is VTE dosing. In Afib, dosing is 5mg 2x/day.

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2
Q

What are the renal dosing adjustments for Afib in Apixaban?

A

2.5mg 2x/day if 2 of 3 items are met: 1)SCr:>1.5 2) Weight is under 60kg 3) Age: >80 years

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3
Q

True or False: Afib dosing of Rivaroxaban is 20mg daily?

A

True

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4
Q

What are the renal adjustments for rivaroxaban for Afib?

A

In Afib it is 15mg daily, as long as CCL is between 15-50ml/min; avoided if under that value

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5
Q

What is the generic name for Betapace?

A

Sotalol

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6
Q

What is the MOA of Sotalol (Betapace)?

A

(potassium channel blockade) Extends the refractory period (prolongs action potential
duration) + beta-blocker

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7
Q

Are there any DDI or metabolism concerns with Sotalol?

A

Additive QT prolongation with other medications

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8
Q

What needs to happen at the start of Sotalol initiation?

A

3 day hospital stay for initiation to monitor QT prolongation

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9
Q

What is the dosing scheme for Sotalol?

A

Dose: 40-120 mg depending on QT prolongation (start = 80)
Frequency: dependent on renal function
• CrCl > 60 mL/min: Q12H
• CrCl 40-60 mL/min: Q24H

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10
Q

Sotalol is contraindicated in what populations?

A

CrCl < 40 mL/min

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11
Q

What class of Antiarrhythmics is Sotalol in?

A

CLASS III ANTIARRHYTHMICS

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12
Q

Sotalol is part of a first line treatment option in _________ and can also be used to treat_________.

A

Patients with no structural Heart

Disease ; CAD

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13
Q

What type of administration should be used in ACUTE rate control?

A 
IV agents (bolus +/- IV infusion) 
Transition to oral agents
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14
Q

What type of administration should be used in CHRONIC rate control?

A

Oral agents

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15
Q

True or False: both acute and chronic rate control may require multiple agents in order to control symptoms.

A

True

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16
Q

What two agents used to control rate should NOT be used in combination if possible in both acute and chronic rate control?

A

Beta Blockers with Non-DHP Calcium Channel Blockers

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17
Q

Amiodarone:

What Class of antiarrythmic is Amiodarone/it’s MOA?

A

Amiodarone is a Class 3 antiarrhythmic, with class 3 being potassium channel blockers BUT amiodarone has characteristics of ALL classes as well (1,2,3,&4 ie Sodium, Beta [Receptor], Potassium, and Calcium channel Blockade)

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18
Q

What is the Half-Life of Amiodarone?

A

50 Days!

Hence why it needs a loading period

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19
Q

How effective is amiodarone compared to other antiarrhythmics?

A

Amiodarone is the Best One but…. it also comes with the most side effects

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20
Q

Which CYPs or Transporters does Amiodarone inhibit which lead to many of its DDI’s?

A

Amiodarone inhibits CYP3A4, 2D6, 2C9, and P-gp

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21
Q

Besides its enzyme/transporter inhibition, what other DDIs can amiodarone have?

A

It can have additive QT prolongation with other QT prolonging drugs (Can lead to Torsades de Pointes which is deadly!)

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22
Q

What are the side effects of Amiodarone?

A

The usual ones + Some unique ones
Usual:
•Bradycardia
•QT prolongation
Then:
•Pulmonary Fibrosis (Don’t use with COPD!)
•Hypo OR Hyperthyroidism (The hypothyroidism is relatively easy to treat but the hyperthyroidism can be a reason to stop amiodarone)
•Corneal Deposits (Adds up over time/years, can lead to progressive vision loss)
•Acute OR Chronic Hepatotoxicity (not as bad as dronedarone)
•Bluing/Graying of the skin (This is harmless but it is PERMANENT!- also it’s on by sun exposure!)

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23
Q

What’s the initial dosing for Amiodarone?

A

8-10 grams over 2-4 weeks –> varies by clinician but as long as you meet the total dosage and timeline its fine.

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24
Q

What’s the maintenance dosing of Amiodarone?

A

200mg QD –> 100-200mg QD technically but 100mg QD is rarely used

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25
Q

MOA of class IC antiarrhythmics (flecainide and propafenone)

A

sodium channel blockade (membrane stabilizers) decrease the excitability of cardiac tissue

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26
Q

metabolism of class IC antiarrhythmics (flecainide and propafenone)

A

metabolized by CYP2D6, some people can be fast or slow metabolizers

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27
Q

flecanide acute dosing

A

50mg BID (MDD 300mg)

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28
Q

propafenone acute dosing IR

A

150mg Q8H (MDD 900mg)

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29
Q

propafenone acute dosing ER

A

225mg BID (MDD 850mg)

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30
Q

propafenone AE

A

metallic taste

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31
Q

MOA of class 3 antiarrhythmic drugs (dofetilide, amiodarone, ibutilide)

A

potassium channel blockade, extends the refractory period preventing another depolarization/action potential

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32
Q

What’s required when starting a patient on a class 3 antiarrhythmic like dofetilide?

A

3 day hospital stay to monitor QT prolongation

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33
Q

drug interactions with dofetilide

A
  1. verapamil: increases absorption of dofetilide which can cause QT prolongation
  2. HCTZ: effects clearance and electrolytes (must maintain K>4 and Mg >2)
  3. metformin and trimethoprim will decrease the clearance of dofetilide from the body due to competing for active tubular secretion in the kidneys, increasing the risk of QT prolongation
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34
Q

dosing of dofetilide in someone with normal renal function

A

500mcg PO BID

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35
Q

dosing of dofetilide in someone with CrCL 40-60ml/min

A

250mcg PO BID

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36
Q

dosing of dofetilide in someone with CrCl 20-40ml/min

A

125mcg PO BID

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37
Q

dosing of dofetilide in someone with CrCl <20ml/min

A

contraindicated

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38
Q

amiodarone MOA

A

class 3 antiarrythmic, has all the properties of all the classes of antiarrythmics: sodium channel blocker, potassium channel blocker, calcium channel blocker. beta blocker: it is the most effective antiarrhythmic but comes with a lot of side effects

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39
Q

half life of amiodarone

A

about 50 days

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40
Q

metabolism of amiodarone

A

inhibits CYP3A4, CYP2D6, CYP2C9, and PGP

take caution with other medications that have QT prolongation

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41
Q

loading dose of amiodarone

A

8-10 grams over 2-4 weeks

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42
Q

maintenance dose of amiodarone

A

100-200mg PO daily

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43
Q

adverse effects of amiodarone

A

bradycardia, QTc prolongation, pulmonary fibrosis, thyroid dysfunction (hypo and hyperthyroidism), corneal deposits (blindness), hepatotoxicity, blue/gray skin color (permanent)

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44
Q

amiodarone monitoring

A
  1. ECG at baseline and every 3-6 months
  2. thyroid function tests at baseline and every 6 months
  3. LFTs at baseline and every 6 months
  4. Chest x ray at baseline and every 12 months
  5. pulmonary function tests at baseline and every 12 months
  6. eye tests (corneal deposits)
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45
Q 
All of the following can be used for chronic afib treatment in patients with coronary artery disease EXCEPT
A. Dofetilide
B. Propafenone
C. Dronedarone
D. Sotalol
E. Amiodarone
A

B. Propafenone

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46
Q

True or False: Propafenone is appropriate for acute cardioversion when DCCV is unsuccessful and the patient has an ejection fraction of AT LEAST 40%

A

true

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47
Q

Specific adverse effect of Propafenone

A

metallic taste

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48
Q

What is unique about Propafenone as a Class 1C antiarrhythmic?

A

Class 1C has the highest potency so they can also cardio convert

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49
Q

What antiarrhythmic class does Dronedarone belong to?

A

Class III

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50
Q

What is Dronedarone’s MoA?

A

Structural analog of amiodarone (minus the iodine), exhibits properties of all the classes of antiarrhythmics

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51
Q

Dronedarone is contraindicated in patients with ___?

A

Heart failure and permanent AF

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52
Q

Dronedarone inhibits ___?

A

CYP3A4, CYP2D6, PGP

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53
Q

When taken with other medications, dronedarone can have additive ___?

A

QT prolongation

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54
Q

Dronedarone dosing

A

400mg PO q12h

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55
Q

Adverse effects of dronedarone

A

Bradycardia, QTc prolongation, hepatotoxicity

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56
Q

What kinds of patients would we use dronedarone in?

A

Patients with structurally normal hearts (and CAD is also okay)

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57
Q

Dronedarone brand name

A

Multaq

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58
Q

What rate control drugs are options in patients who have no other CV disease?

A

beta blockers, diltiazem, verapamil, and amiodarone

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59
Q

What rate control drugs are options in patients who have HTN or HFpEF?

A

beta blockers, diltiazem, verapamil, and amiodarone

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60
Q

MOA of edoxaban

A

factor Xa inhibitor

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61
Q

Afib dose of edoxaban

A

60mg daily

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62
Q

VTE dose of edoxaban

A

(after 5 days parenteral) > 60kg: 60mg daily; if < or = 60kg: 30mg daily

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63
Q

What is the route of administration for edoxaban?

A

oral

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64
Q

MOA of dabigatran

A

direct thrombin inhibitor

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65
Q

Afib dose of dabigatran

A

150mg twice daily

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66
Q

VTE dose of dabigatran

A

(after 5 days parenteral) 150mg twice daily

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67
Q

route of administration of dabigatran

A

oral

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68
Q

Edoxaban monitoring?

A

monitor hemoglobin, hematocrit, platelets & serum creatinine

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69
Q

Afib dosing for Edoxaban

A

60 mg daily

70
Q

What population do you want to avoid Edoxaban in?

A

> 120 kg or BMI > 40 kg/m^2 (basically obese pts)

71
Q

Clinical pearl of Edoxaban

A

it is rarely used

72
Q

What is the CHA2DS2VASc Score used for?

A

Anticoagulation: Determine Risk of Stroke

73
Q

What does the “C” stand for within the CHA2DS2VASc Score?

A

Congestive Heart Failure

74
Q

How many points is Congestive Heart Failure, “C,” worth?

A

1 Point

75
Q

What does the “H” stand for within the CHA2DS2VASc Score?

A

Hypertension

76
Q

How effective is direct current cardioversion (DCCV) in converting an irregular heart rhythm, into a sinus rhythm (normal heart rhythm)?

A

Almost 100%.

It can reset the heart to a sinus rhythm but the problem is keeping the patient in a sinus rhythm.

77
Q

What does the “A2” stand for within the CHA2DS2VASc Score?

A

Age > 75

78
Q

How many points is Age > 75, “A2,” worth?

A

2 Points

79
Q

What does the “D” stand for within the CHA2DS2VASc Score?

A

Diabetes Mellitus

80
Q

How many points is Diabetes Mellitus, “D,” worth?

A

1 Point

81
Q

What does the “S2” stand for within the CHA2DS2VASc Score?

A

Stroke/TIA/Systemic Embolism

82
Q

How many points is Stroke/TIA/Systemic Embolism, “S2,” worth?

A

2 Points

83
Q

What does the “V” stand for within the CHA2DS2VASc Score?

A

Vascular Disease

84
Q

How many points is Vascular Disease, “V,” worth?

A

1 Point

85
Q

What does the “A” stand for within the CHA2DS2VASc Score?

A

Age 65-74

86
Q

How many points is Age 65-74, “A,” worth?

A

1 Point

87
Q

What does the “Sc” stand for within the CHA2DS2VASc Score?

A

Sex Category (Female)

88
Q

How many points is being the Female sex, “Sc,” worth?

A

1 Point

89
Q

What score would indicate that a male patient would need to have an anticoagulation agent added?

A

> or equal to a score of 2

90
Q

What score would indicate that a female patient would need to have an anticoagulation agent added?

A

> or equal to a score of 3

91
Q

What is the Stroke Risk per Year?

A 
This would depend on the patient's CHA2DS2VASc Score.
1 Point = 1.3%
2 Points = 2.2%
3 Points = 3.2%
4 Points = 4.0%
5 Points = 6.7%
6 Points = 9.8%
7 Points = 9.6%
8 Points = 6.7%
9 Points = 15.2%
92
Q

Why would you want to delay cardioversion (ex. DCCV) in a patient with MILD symptoms who has AFIB for over 48 hours?

A

To allow time (3 weeks) for anticoagulation therapy and reduce the risk of a clot being dislodged and causing a stroke in the patient.

93
Q

True of False: In early cardioversion, if a thrombus is observed on a transesophageal echocardiogram (TEE), we should immediately consider DCCV.

A

False: Anticoagulate the patient for 4 weeks, then repeat the TEE.

94
Q

A patient presents to the ER with a systolic blood pressure of 85 mmHg and an abnormal heart rhythm: Which cardioversion method should be used in this patient?
A) Chemical Cardioversion
B) Direct Current Cardioversion (DCCV)
C) Both

A

B) DCCV

Hemodynamically unstable

95
Q

What is DCCV?

A

Direct current cardioversion, and it involves utilizing a defibrillator to shock the patients heart into normal sinus rhythm

96
Q

How effective is direct current cardioversion(DCCV) in converting an irregular heart rhythm, into a sinus rhythm(normal heart rhythm)?

A

Almost 100%. Can reset the heart to a sinus rhythm but the problem is keeping the patient in a sinus rhythm.

97
Q

True or False: You can earn multiple points per section of the CHA2DS2VASc Score.

A

False

You would NOT count multiple disease states for each section.

For example, if a patient had PAD, DVT, CAD, and T2DM, and age >75, then the score would be 4.

2 Points = A2
1 Point = D
1 Point = V

PAD, DVT and CAD are all vascular diseases, however, they would not earn a point each; instead, the entire category of “V” would only earn 1 point regardless of the amount of vascular diseases present.

98
Q

Paroxysmal Atrial fibrillation

A

Terminates within 7 days of onset

99
Q

Persistent Atrial Fibrillation

A

Last > 7 days

100
Q

Longstanding, Persistent

A

Lasts > 12 months

101
Q

Permanent Atrial Fibrillation

A

Patient and Clinician have decided that there will be no more effort to restore or maintain sinus rhythm

102
Q

The following conditions require amiodarone as a second line option for rate control:

A

No other CV disease
HTN or HfPEF
LV dysfunction or HF

103
Q

Which condition does not require amiodarone as a second line option for rate control?

A

COPD

104
Q

True or false: we give IV bolus always in acute rate control

A

True, we +/- IV infusion

105
Q

What is the MOA for flecainide (how does it work)

A

Sodium Channel Blocker = membrane stabilizer. Decrease excitability of cardiac tissue.

106
Q

What class antiarrhythmic does flecainide fall into. Use the Vaughan-Williams classification.

A

Class 1C

107
Q

True or false. Flecainide is a high potency sodium channel blocker.

A

True

108
Q

True or false. Flecainide can be used for acute chemical cardioversion if a patient has a EF<40%

A

False

109
Q

When can flecainide be used for chronic rhythm control?

A

It can be used as a first line agent in patients with no structural disease.

110
Q

What are two structural heart disease conditions in which flecainide cant be used for chronic rhythm control?

A
  1. Heart failure

2. Coronary Artery Disease

111
Q

True or false. Flecainide is metabolized by CYP3A4

A

False. Metabolized by CYP2D6 and some of the population may be fast of slow metabolizers.

112
Q

How do we monitor dronedarone?

A

ECG- look out for QT prolongation

113
Q

Name the 4 types of Afib.

A

Paroxysmal, Persistent, Longstanding Persistent, Permanent Afib

114
Q

What are you able to conclude from knowing the type of Afib a patient has?

A

You are able to know how frequent the Afib occurs and how it will respond to treatment.

115
Q

How is Propafenone metabolized?

A

Metabolized by CYP2D6

116
Q

What is the mechanism of action of propafenone?

A

Sodium channel blocker → membrane stabilizer (decrease excitability of cardiac tissue). It has the highest potency in this specific antiarrhythmic class.

117
Q

Define Afib

A

Disorganized and irregular atrial electrical activity

-“quivering”

118
Q

What triggers Afib to occur?

A

-triggered by rapidly firing ectopic beats in the atria

119
Q

What the are risk factors for Afib?

A
  • concomitant cardiac disease
  • DM
  • obesity
  • obstructive sleep apnea
  • hyperthyroidism
  • smoking
  • etc.
120
Q

What portion of the ECG will appear abnormal during Afib

A

No visible P waves and an irregular QRS complex

121
Q

What is the HASBLED score?

A

Determines Bleed Risk during anticoagulation

122
Q

What does each letter in HASBLED stand for?

A 
H= Hypertension (SBP >160mmHg)
A= Abnormal liver or kidney function 
S= Stroke history
B= Bleeding risk
L= Labile INR
E= Elderly (> 65)
D= Drug or Alcohol abuse
123
Q

How do you score each letter in HASBLED?

A 
H= 1
A= 1 each (If patient has both abnormal liver function and abnormal kidney function they score 2)
S= 1
B= 1
L= 1
E= 1
D= 1 each (If patient abuses both drugs and alcohol then they score 2)
124
Q

How does the HASBLED score correlate to bleed risk?

A 
0= 1.13 bleeds/ 100 patient years
1= 1.02 bleeds/ 100 patient years
2= 1.88 bleeds/ 100 patient years
3= 3.74 bleeds/ 100 patient years
4= 8.70 bleeds / 100 patient years
5= 12.5 bleeds/ 100 patient years
125
Q

HASBLED pearls

A
  • No “threshold for withholding anticoagulation
  • Only validated for Warfarin (not DOACs)
  • Can be used in a risk-benefit discussion to determine safety of anticoagulation
126
Q

What first line rate control drugs are options in patients who have HFrEF?

A

beta blockers or digoxin

127
Q

What rate control drugs are options in patients who have COPD?

A

beta blockers, diltiazem, verapamil

128
Q

True/False: dabigatran is recommended for patient with Afib and ESRD

A

False. Direct thrombin inhibitor is not recommended.

129
Q

True/False: Dabigatran is used as a chronic anticoagulation for patients w/ A.fib

A

True

130
Q

What are the clinical manifestations of AFIB?

A 
Fatigue
Palpitations
Shortness of breath
Hypotension
Dizziness, light-headedness
Syncope
131
Q

True or False, a patient can have AFIB and be asymptomatic

A

True

132
Q

When are dabigatran and edoxaban recommended?

A

For patients with Afib and an elevated CHA2DS2VASc score of 2 or greater in men or 3 or greater in women

(oral anticoagulation is recommended)

133
Q

What chronic rhythm control options are available for CAD patients with Afib?

A

Dofetilide, dronedarone, sotalol, amiodarone

134
Q

What is a second line option for chronic rhythm control in patients with CAD?

A

amiodarone

135
Q

What are first line options for chronic rhythm control in patients with CAD?

A

dofetilide, dronedarone, sotalol, amiodarone

136
Q

When do patients require conversion to sinus rhythm?

A

When they are:

  1. ) Hemodynamically unstable (SBP<90, or patient loses a pulse)
  2. ) Symptomatic despite rate control
  3. ) Inability to achieve rate control (when you’ve tried everything & patient is still not able to achieve goal).
137
Q

What treatment options are available to patients who have chronic rhythm control and NO structural heart disease?

A 
ALL 5 of them!
Dofetilide
Dronedarone
Flecainide
Propafenone
Sotalol
138
Q

Why is Amiodarone second line in chronic rhythm control with NO structural heart disease?

A

Because of all its side effects (Bradycardia, QTc prolongation, pulmonary fibrosis, thyroid dysfunction, corneal deposits, hepatotoxicity, blue/gray skin color)

139
Q

What is first line treatment for chronic rhythm control with no structural heart disease?

A

First line treatment is pending patient preference: we could do a catheter ablation or dofetilide, dronedarone, flecainide, propafenone, sotalol treatment

140
Q

What is ablation?

A

Catheter inserted through groin or neck and guided through the vessel until they reach the heart.

141
Q

When is ablation not feasible?

A

When many areas/the whole heart has diseased tissue.

142
Q

What are the two methods used to treat chronic rhythm control?

A

Chemical (treat with antiarrhythmic drugs to keep sinus rhythm)
&
Ablation

143
Q

What does HASBLED stand for?

A 
Hypertension
Abnormal liver or kidney function
Stroke history
Bleeding history
Labile NR
Elderly >65
Drug or acohol abuse
144
Q

What does the HASBLED score measure?

A

Determines patietn’s bleeding risk

145
Q

If a patient has been in Afib for more than 48 hours what is the treatment regimen for acute cardioversion?

A

anticoagulate for 3 weeks then DCCV

146
Q

Why does Amoidarone need close monitoring?

A

The half-life of Amiodarone is 50 days, and there are many potential drug interactions with drugs metabolized with CYP3A4, CYP2D6, CYP2D9, PGP, and other QT elongating drugs.

147
Q

What are the necessary monitoring tests during Amoidarone therapy?

A
  • ECG at baseline and every 3-6 months
  • Thyroid function tests at baseline and every 6 months
  • Liver function tests at baseline and every 6 months
  • Chest X-ray at baseline and every 12 months
  • Pulmonary function tests at baseline and every 12 months
148
Q

What are some adverse effects associated with Amiodarone therapy?

A
  • Bradycardia
  • QTc Prolongation
  • Pulmonary fibrosis
  • Thyroid dysfunction
  • Corneal deposits
  • Hepatotoxicity
  • Irreversible Blue/gray skin tone
149
Q

How fast do adverse effects from Amiodarone culminate? (AE other than Bradycardia & AV block)

A

AEs like pulmonary fibrosis, corneal deposits, the skin tone change & thyroid dysfunction generally develope slowly over 10 years. Bradycardia & AV block develops quickly.

150
Q

what is the extremely common type of A.fib?

A

Paroxysmal A.fib

151
Q

Is DRONEDARONE commonly used?

A

no

152
Q

DRONEDARONE brand name

A

multaq

153
Q

DRONEDARONE MOA

A

Structural analog of amiodarone (without the iodine) -

exhibits properties of all the classes of antiarrhythmics

154
Q

DRONEDARONE ci

A

Contraindicated in patients with HF and permanent AF

155
Q

DRONEDARONE adverse effects

A

Bradycardia, QTc prolongation, hepatoxicity

156
Q

DRONEDARONE okay to use in patients with structurally abnormal heart rates?

A

no- normal only

157
Q

DRONEDARONE okay in CAD?

A

yes

158
Q

T/F:

The first-line agents for No Structural Heart Disease are Dofetilide, Dronedarone, Sotalol, and Amiodarone

A

False because Amiodarone is second line agent

159
Q

What is the minimal duration of hospital monitoring when initiating Dofetilide

A

3 days to monitor QT prolongation

160
Q

Dofetilide

A

Class 3

extends refractory period (repolarization)

161
Q

When to DCCV?

A

Symptomatic despite rate control, OR unable to reach rate control, OR hemodynamically unstable.

162
Q

When to DCCV ONLY

A

Hemodynamically unstable, sbp greater than 90 or no pulse (syncope)

163
Q

DCCV success rate in cardioverting?

A

100%

164
Q

What are the two methods of chronic rhythm control?

A

Chemical and Ablation

165
Q

What is the chemical method?

A

Utilizes antiarrhythmic drugs to maintain sinus rhythm

166
Q

What is the Ablation method?

A

Utilizes a procedure to block conduction in the tissue causing the arrhythmia.

167
Q

What are the three types of ablation?

A

Radiofrequency, cryotherapy, and thermal.

168
Q

Chronic rhythm control class I drug

A 
Sodium Channel Blockade =
membrane stabilizers (decrease excitability
of cardiac tissue)
Ia. Moderate potency:
Disopyramide, quinidine, procainamide
Ib. Low potency:
Lidocaine, mexiletine
Ic. High potency:
Flecainide, propafenone
169
Q

Chronic rhythm control class II drug

A

Beta-Blockade = blocks sympathetic input

All beta-blockers

170
Q

Chronic rhythm control class III drug

A

Potassium Channel Blockade = extends refractory period

Sotalol, dofetilide, amiodarone,
dronedarone, ibutilide

171
Q

Chronic rhythm control class IV drug

A

Calcium Channel Blockade =
negative inotrope and chronotrope

Verapamil, diltiazem

UBSPPS PHM601 Cardio/Renal Pharmacotherapeutics (32 decks)

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