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CardioPulm II > Afib > Flashcards

Afib Flashcards

1
Q

Selection of Agent: No Structural heart disease

First line

A

dronedarone

flecainide, propafenone, sotalol

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2
Q

Selection of Agent: No Structural heart disease

Second Line

A

amiodarone, Dofetilide

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3
Q

IC is contraindicated?

A

In all Structural heart disease

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4
Q

Selection of Agent: Hypertension (no LVH)

First Line

A

dronedarone

flecainide, propafenone, sotalol

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5
Q

Selection of Agent: Hypertension (no LVH)

Second line

A

amiodarone, dofetilide

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6
Q

Hypertension (with LVH)

First line ( only line)

A

amiodarone

Class IC: Contraindicated

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7
Q

Selection of Agent: CAD

First line

A

Dofetilide
dronedarone
Sotalol

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8
Q

Selection of Agent: CAD

Second Line

A

Amiodarone

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9
Q

Selection of Agent: CAD

Contraindication

A

Class IC

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10
Q

Selection of Agent: Heart failure

First Line

A

Amiodarone, dofetilide

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11
Q

Selection of Agent: Heart failure

Contraindication

A

Class IC
Sotalol
Dronedarone*

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12
Q

AF ablation: Potential cure

Indications

A

Have structurally normal heart

Very symptomatic

Failed at least one antiarrhythmic drug therapy

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13
Q

CHADS-2 Scoring System to Predict CVA Risk

A 
Risk Factor	                  Points
CHF	                                1
Hypertension                  	1
Age ≥ 75 years	                1
Diabetes                          	1
History of TIA/CVA  (Stroke)	2

0 points Use CHADS2-Vasc
≥ 1 point usually requires anticoagulation

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14
Q

CHADS-2 Scoring System: What to take

ASA, Nothing or anticoagulation???

A

CHA2DS2 Vasc
0= Choose nothing or ASA
1= Choose nothing, ASA or anticoagulation
≥2= Anticoagulation

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15
Q

Dabigatran

A

Pradaxa®

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16
Q

Rivaroxaban

A

Eliquis®

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17
Q

Edoxaban

A

Savaysa®

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18
Q

Antithrombotic Therapy:
Risk of CVA (stroke)

Factors which increase risk for stroke in pts with AFib

A

Prior stroke or transient ischemic attack

Age (> 65)

Hypertension

Diabetes Mellitus

Gender (female > male)

EF < 40%

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19
Q

Maintenance Antithrombotic TherapyAspirin or Anticoagulation

A

Anticoagulation is more effective than ASA for stroke prevention, but has higher bleeding risk and quality of life concerns

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20
Q

Maintenance Antithrombotic TherapyAspirin or Anticoagulation??

Drugs and dosing

A

Estimate stroke and bleeding risk first then choose:

Oral Anticoagulation Options
Warfarin: Treat to INR 2-3 
Dabigatran 150 mg PO BID 
Rivaroxaban 20 mg PO Daily with a meal
Apixaban 5 mg PO BID
Edoxaban 60 mg PO Daily
       OR
ASA: 81-325mg daily (usually 81 mg)
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21
Q

CHADS-2 Scoring System to Predict CVA Risk

Standards

A

0= Choose nothing or ASA

1= Choose nothing, ASA or anticoagulation

≥2= Anticoagulation

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22
Q

CHADS-2 Scoring System to Predict CVA Risk:

Point system

1pt each

A

CHF
Hypertension
Age ≥ 75 years
Diabetes

History of TIA/CVA 2pts
(Stroke)

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23
Q

Anticoagulation Options for Atrial Fibrillation

Warfarin

A

“Bridge” with UFH or LMWH only in** high risk** patients

Use lower initial UFH dose of 70 units/kg IV push then 15 units/kg/hr and adjust to PTT

May start warfarin monotherapy in low risk patients

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24
Q

Apixaban

A

Eliquis

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25
Q

Novel Oral Anticoagulants (NOACs)

Direct Thrombin Inhibitors

A

Dabigatran (Pradaxa®)

26
Q

Novel Oral Anticoagulants (NOACs)

Direct Xa Inhibitors

A

Rivaroxaban (Xarelto®)

Apixaban (Eliquis®)

Edoxaban (Savaysa®)

27
Q

Warfarin INR Goal?

28
Q

Warfarin over 3?

A

Intracranial bleeding

29
Q

Warfarin under 2?

A

Ischemic Stroke

30
Q

Benefits of NOACs

A

Similar or superior efficacy to warfarin

Similar or less bleeding in studies
–Less intracranial hemorrhage

No monitoring needed for efficacy

Rapid onset of action eliminates need for “bridge” therapy

Limited drug-drug interactions

No apparent drug-diet interactions

31
Q

Concerns With NOACs

A

New agents currently have no test to measure therapeutic effect and no antidote

  • Emergency surgery needed?
  • Serious bleeding?

Drugs accumulate in renal dysfunction

  • Dose reduce and/or avoid use in severe CKD
  • Check SCr at least yearly

Non-adherence in clinical practice
-Effects on efficacy?

Cost and Insurance Coverage

32
Q

NOACs: Contraindications

A

Hemodynamically significant valve disease

CrCl < 15 ml/min or dialysis (doxzyban?)

Dosing adjustments different for each med

Advanced liver disease (increased baseline INR)

33
Q

Antithrombotic therapy:

Initiation: When is anticoagulation appropriate

A

Always initiate anticoagulation before and after cardioversion (even in ASA patients)

34
Q

Antithrombotic therapy:

Initaiation: When is anticoagulation appropriate?

ASA and Warfarin COMBO??

A

Warfarin and ASA may be used in combo if patient has embolic event on warfarin alone or compelling indication for both meds

  • -Combo always increases risk of bleeding
  • -Newer anticoagulants have increasing data in combo with antiplatelet agents
35
Q

Acute AFIB treatment

A

HR control
Consider cardioversion
Antithrombotic therapy

36
Q

Chronic AFIB treatment

A

HR control
Antithrombotic therapy
Consider antiarrhythmic to maintain NSR
Consider ablation

37
Q

Atrial Fibrillation Ablation

A

Ablation entails destruction of myocardial tissue necessary for the tachycardia “reentry circuit

38
Q

What’s the benefit of Ablation therapy?

A

Potential Cure

39
Q

Ablation indications?

A

Have structurally normal heart

Very symptomatic

Failed at least one antiarrhythmic drug therapy

40
Q

Should anticoagulation be stopped forAblation?

A

No data on whether anticoagulation can eventually be stopped

41
Q

Ablation Complications?

A

Stroke, perforation, pulmonary vein stenosis, death

Recurrence of Afib or Aflutter

Should be performed in experienced centers

42
Q

Permanent Atrial Fibrillation:

A

May decide NOT to attempt cardioversion

May be unable to maintain sinus rhythm

Long-term management
-Rate Control

-Antithrombotic therapy

43
Q

How long should AFib patient be anticoagulation prior to cardioversion?

A

3 weeks of anticoagulation prior to cardioversion

or

Anticoagulation with TEE to rule out thrombus

44
Q

How long should AFib patient be anticoagulation after cardioversion?

A

And for 4 weeks following!!!

45
Q

Whats the restrictions of cardioversion?

A

All patients with AF > 48 hours must be anticoagulated prior to cardioversion to prevent stroke

46
Q

Prior to elective cardioversion must determine if thrombus has developed in left atrium?

TWO OPTIONS

A

Transesophageal echocardiogram (TEE)

—>If thrombus present – 3 weeks of anticoagulation, then attempt cardioversion

–>If no thrombus is present – initiate anticoagulant and attempt cardioversion as soon as therapeutic

  1. Treat with anticoagulation, in therapeutic range, for at least 3 weeks then attempt cardioversion
    - Can use warfarin (INR 2-3), dabigatran, rivaroxaban, apixaban, edoxaban or LMWH (treatment doses)
47
Q

CVA Prevention with Elective Cardioversion.

How long must you coagulate after cardioversion?

A

Following cardioversion it can take up to 4 weeks for mechanical contraction of the atrium to return to normal, “atrial stunning

Regardless whether a thrombus was present prior to cardioversion, you MUST anticoagulate for 4 weeks following cardioversion

Warfarin (Target INR 2 – 3), dabigatran, rivaroxaban , apixaban, edoxaban or LMWH (treatment doses)

48
Q

Ion Block: IA

A

Na (intermediate)

49
Q

Ion Block: IC

50
Q

Ion Block: III

51
Q

Meds: IA

A

quinidine,
procainamide,
disopyramide

52
Q

Meds: IC

A

propafenone

flecainide

53
Q

Meds: III

A

amiodarone, dofetilide, ibutilide, sotalol,dronedarone

54
Q

Use for Atrial Fibrillation

IA

A

Cardioversion and Maintenance NSR

55
Q

Use for Atrial Fibrillation

IC

A

Cardioversion and Maintenance of NSR

56
Q

Use for Atrial Fibrillation

III

A

Cardioversion and Maintenance NSR
Ibutilide-Cardiovers
Sotalol-Maintenance

57
Q

Indications for Oral Pharmacologic Cardioversion

A

Patients with paroxysmal Afib and unbearable symptoms despite rate control

Patients with persistent Afib, and unbearable symptoms, who return to Afib after electrical cardioversion.

-Oral agents have low chance of restoring NSR, may repeat DCC and use meds for maintenance if needed.

58
Q

Who should be Returned to NSR?

A

People who still feel sick even after rate control.

May try one electrical cardioversion in most persistent Afib patients

Relief of severe symptoms
–>Especially CHF and syncope
Intolerable palpitations

Prevention of cardiac remodeling- a fib alone

59
Q

Why not Cardiovert Everyone Immediately?

A

Cardioversion and maintenance of NSR has not been shown to improve mortality:

-Electrical and/or pharmacologic cardioversion has risks associated with use (ie proarrhythmia)
Pharmacologic > Electrical

-Anti-arrhythmics decrease AFib burden, may not eliminate Afib and stroke risk – They redcue burden only symtomatic eposoides only

Risk of stroke is highest at time of cardioversion

60
Q

What is Electrical Cardioversion?

A

Direct current cardioversion (DCC)

Initially preferred over oral meds for persistent Afib due to efficacy and lack of long-term adverse effects

–>Ibutilide can be used instead to avoid anesthesia, but decreased efficacy vs DCC

61
Q

Rhythm Control =Restoring and/or Maintaining NSR

A

Restore atrial kick.

Restore NSR.

Heart will return to normal beat

Restoration of NSR or Cardioversion:
Electrical: Direct Current Cardioversion (DCC) -DCC-Depolarize whole heart, hope sinus can be re-instated

Pharmacologic alternative: Ibutilide -10 minute infusion??? -Ibutilide is a 10 min infusion that has a high rate of cardioversion (not a s high as DCC), Requires no anesthesia

Restoration AND Maintenance of NSR:
Pharmacologic: Oral antiarrhythmic agents in classes IA, IC and III (sotalol only maintains NSR, does not restore

CardioPulm II (11 decks)

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