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PHAR 253 Final > AFIB > Flashcards

AFIB Flashcards

1
Q

Compare AFib vs A flutter

A
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2
Q

Most common cardiac arrythmia

A

AFIB

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3
Q

What is AFIB

A

A supraventricular arrhythmia (above the ventricles) which results from continuous and chaotic atrial activity

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4
Q

Risks of AFIB

A

Rarely life-threatening;

increases the risk of stroke (most severe)

left ventricular dysfunction (loss of ventricular ejection –> fatigue, exercise intolerance, light headed, palpitations)

Non-anticoagulated patients have 3-5 fold increased risk of stroke (generally severe)

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5
Q

W\hat is lost on an EKG during Afib?

A

P- wave is lost

Distance between p waves should be the same

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6
Q

What is afib classified as:

A

an irregularly, irregular rhythm

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7
Q

Prevalence Afib

A

Prevalence increases with age

The age adjusted prevalence is greater in men

10-30% of heart failure patients have AF (lost the atrial kick)

Common and undiagnosed

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8
Q

Sx Afib

A

Fatigue
Palpitations
Chest Pain
dyspnea
Dizziness

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9
Q

afib pathophys

A

ectopic foci that generate electrical impulses

Atria experience rapid irregular and uncoordinated contractions

Because electrical impulses reach the AV node erratically, the ventricular rhythm is irregular

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10
Q

Initiating event of AFIB

A

Factors which destabilize the myocardium such as electrolyte disturbances, ischemic and excessive sympathetic stimulation can contribute to the initiating event

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11
Q

How can afib be classified based on structural disease?

A

Valvular (Warfarin) –> Very significant valve disease (rheumatic fever, valve replacement, or mitral valve repair)

Non-Valvular (DOACS here only)
Absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair

“Lone” AF  Young, no heart or pulmonary disease
Absence of clinical or echocardiographic findings of:
Other CVD (including hypertension)
Related pulmonary disease
Cardiac abnormalities; ex/ enlargement of the left atrium
Age under 60 years

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12
Q

Paraoxysmal AFib

A

lasting longer than 30 seconds and self-terminating within 7 days of recognized onset (jump in and jump out)

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13
Q

Persistent Afib

A

continuous AF episode lasting longer than 7 days but less than 1 year

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14
Q

Longstanding Afib

A

continuous AF equal or greater than 1 year in who rhythm control management is being pursued

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15
Q

Permenant Afib

A

continuous AF for which a therapeutic decision has been made not to pursue sinus rhythm restoration

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16
Q

What is a substrate?

A

a pre-existing condition that forms a prerequisite for the induction of an arrhythmia

Examples:

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17
Q

triggers

A

Stimulants
Alcohol
Sleep Depreivation
Emotional STress
Physical Exertiom
Sleep
Digestive

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18
Q

Risk factors

A

HTN
DM

Tobacco
Alcohol

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19
Q

Investigating AFib

A

12-lead ECG

Echocardiogram

LAb Investigations

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20
Q

Goals of tx and anticipated outcomes

A

Prevent stroke or systemic thromboembolism

Cardiovascular risk reduction

Improve symptoms, functional capacity and quality of life

Prevent complications (eg. LV dysfunction and falls)

Outcomes:

Improvement in survival
Reduction in healthcare utilization (ED visits or hospitalization)

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21
Q

Afib Diagnosus Scheme

A

Rate –> Let you be in AFIB but slow down the ventricular rhythym

Rhythym –> Put you back into sinus rhythym

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22
Q

CHad 65 Scores

A
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23
Q

Stroke Prevention ChadS 65

A

Anticoagulate AF in the presence of:

“Valvular AF”
–> Any mechanical heart valve
–> Moderate to severe mitral stenosis (rheumatic or non-rheumatic)
Hypertrophic cardiomyopathy
Hyperthyroidism
Amyloid cardiomyopathy
Non-Valvular AF

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24
Q

Stroke Prevention Obese

A

Higher BMI may be associated with lower stroke rates; higher bleeding rates (obesity paradox)

Standard DOAC dose is reasonable for BMI <40 kg/m2

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25
Q

DOAC Use Obese Guidelines

A
26
Q

Dose Warfarin And DOACS

A
27
Q

Apixaban when:

A

Consider Apixaban 2.5 mg po bid if 2 of

1) age 80 years or older,

2) body weight 60 kg or less

3) serum creatinine 133 𝜇mol/L or more;

28
Q

DOAC D.I.

A
29
Q

DOAC antidote

A
30
Q

Dosing DOAC differences

A
31
Q

Dual Tx Doses

A

1 antiplatlet (P12Y or ASA)

32
Q

Triple Therapy

A

ASA + P12Y +

33
Q

Do Not use DOACS if:

A

Mechanical heart valves and significant mitral valve stenosis

Use of strong P-gp and 3A4 inhibitors or inducers* (check current product monographs)

Pregnancy and lactation (no safety – more heparin product here)

Expert bodies indicate need for clinical judgement in extremes of body weight (<50kg; >120kg)**

Pediatrics

Caution when combined with dual antiplatelets – triple therapy**

34
Q

Monitoring of anticoag

A

Adherence

Frequency of adverse effects (affects adherence)

Signs and symptoms of bleeding and bleeding risk factors

Regular SCr, CrCl, Hgb

35
Q

Acute Management

A

Determine if AF is the primary concern or secondary to another acute medical illness

Consider hemodynamic stability (blood pressure)

Determine whether rate vs rhythm control is appropriate

In newly diagnosed AF – rhythm control has been associated with reduced CV death and stroke

Determine need for hospitalization

Determine need for OAC – start as soon as possible (in ED) if required – CCS algorithm

Early follow up

36
Q

Define Rate Control

A

allow the patient to remain in Atrial Fibrillation, however ensure that the ventricular rate is slowed sufficiently to minimize negative outcomes

37
Q

Benefit of Rhthym COntrol

A

used in stable patients with recent-onset AF with the decision made on the basis of patient symptoms and goals of care, recognizing that early rhythm control has been associated with a lower risk of stroke and CV death

38
Q

Rhythym control in who:

A

Recently diagnosed (<1 year)
Highly asymptomatic
Multiple recurrences
Difficulty to achieve rate control
Arrthymia-induced cardiomyopathy

(Rhythym has more anti death)

39
Q

Acute rate control:

A
40
Q

Goal of rate control

A

Reduction in HR of greater than 20% with control of symptoms

41
Q

ND-CCB Examples

A

Verapamil

Diltazem

42
Q

Targets of Rate Control

A

Resting heart rate < 100 bpm at rest

B-blockers or ND-CCBs first line agents

Selection of BB vs CCB should be on the basis of patient comorbidities, contraindications and side effects

Achieved goal at rest/exercise

43
Q

Ventricular Rate control Choice

A

Hemodynamic instability
–> Digoxin is a poor choice – delayed onset

AF associated with exercise, thyrotoxicosis, fever etc.
–> ß-blockers are first line
–> CCBs are more effective than digoxin

Age
CCB preferentially used in the young

44
Q

Long term RAte Control

A
45
Q

Cardioversion and AFIB ANticoagulation

A

AFIB for more than 48 hours –> need to anticoagulated for 3 weeks before put back into sinus rhthym

Do not want to push the clot to the brain

Transesophageal ECHO  see if blood clot in atria

46
Q

Risky Rhythym Control

A

increased the risk of systemic embolism, it is important to start appropriate anticoagulation as time allows for all patients

47
Q

Rhythym COntrol Objectives

A

Relief of symptoms such as palpitations, fatigue and dyspnea

Improve CO and exercise tolerance

Prevention of tachycardia-induced myocardial remodeling and heart failure

Hemodynamic improvements may take days to weeks

48
Q

Ways to achieve Sinus Rhthym

A

Rate Control & Await Spontaneous Conversion

Electrical (Direct Current) Cardioversion
–> Treatment of choice with ventricular rate >150 bpm who are hemodynamically unstable or have serious signs/symptoms
i.e., chest pain, pulmonary edema

Chemical (pharmacologic) Cardioversion

49
Q

Cardioversion Risk

A

Must anticoagulate if AF>48 hours (therapeutic INR for 3 weeks before and 4 weeks post conversion to NSR)

50
Q

Patients most likelky to maintain normal sinus rhthym after cardioversion?

A

Short duration of AF and absence of left atrial dilation

51
Q

Patients who NSR should be attempted?

A

Recent onset of AF
Heart failure
Angina
Hypotension

52
Q

Cardioversion benefit and risk vs Pharm Conversion

A

Electrical cardioversion is more effective than pharmacologic cardioversion especially for more prolonged AF episode durations

Pharmacologic has the advantage of being immediately feasible in a nonfasting patient as well as avoiding the delays and risks associated with procedural sedation

53
Q

Treatment Indications

A
54
Q

Before and after cardioversion

A

OAC for 3 weeks before and 4 weeks after for patients with valvular AF or NVAF >48h

55
Q

Cardioversion acute management Guide

A
56
Q

Drugs used for pharmacological conversion

A

Sodium Channel Blockers (Class I agents) and amiodarone are superior to placebo in acute and chronic AF

Digoxin, ß-Blockers or CCBs are NOT effective for the conversion of AF to sinus rhythm (Not effective)

57
Q

Side effects pharmacologic conversion

A

GI related

Left Ventricular Depression

Negative inotropic effects with many agents

Pro-Arrhythmia (life-threatening) ~1-2%

Accelerated ventricular response can be seen if converted to atrial flutter

Slowing of atrial rate & vagolytic effects of some agents can lead to 1:1 AV conduction

58
Q

Recommendation managing s/e

A

Concurrent rate control agent

59
Q

Drugs used for Achieveing sinus rhthym

A

In Paris, friends party

60
Q

Long Term Rhthym Control

A

PHAR 253 Final (8 decks)

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