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NRS 271B > Afib, AntiCoag, & NOAC reversal > Flashcards

Afib, AntiCoag, & NOAC reversal Flashcards

1
Q

intervals and rate of Afib

A

PR interval < 0.20 sec

atrial rate > 300bpm

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2
Q

What is the most common arrhythmia in clinical practice?

A

A.Fib

increases with advancing age

⅓ of hospitalizations are caused by Afib

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3
Q

Define Paroxysmal Afib

A

AF terminates spontaneously or with intervention within 7 days of onset

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4
Q

Define Persistent Afib

A

AF lasts > 7 days

requires meds or electrocardioversion

  • Subcategory:
    • long standing persistent: AF > 12 months
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5
Q

Define Permanent Afib

A

Persistent AF + Pt & provider have made the decision to no longer try to have rhythm control

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6
Q

Clinical Implications of AFib

A
  • decreased diastolic filling → decreased cardiac output
  • tachycardia -→ cardiomyopathy → decreased cardiac output
  • blood stasis & atrial clot formation → thromboembolism → increased stroke risk
  • ALL lead to INCREASED MORBIDITY & MORTALITY
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7
Q

Indications for Cardioversion in AFib

A
  1. hemodynamic instability
    1. acutely altered mental status
    2. SBP <90 mmHG or s/sxs of shock
    3. ischemic chest discomfort
    4. acute HF
  2. 1st episode:
    1. symptomatic only (<65yo)
    2. NOT for asymptomatic elderly (>80 yo) + comorbidities
  3. Long-Term rhythm control
  4. Symptomatic Persistent AFib
  5. Failure of Rate control
    1. d/t persistent symptoms despite adequate rate control
    2. or inability to attain rate control
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8
Q

Atrial Fibrillation Treatment Algorithm

A

No HF → PAID Fees: Propafenone, Amiodarone, Ibutilide, Dofetilide

HF → AID: Amiodarone, Ibutilide, Dofetilide

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9
Q

Class II Vaughan-Williams Antiarrhythmic Agents

A
  • Beta-adrenoreceptor antagonists: Esmolol, metoprolol, propanolol
  • MOA: predominant action on the sinus node →affect Rate & Rhythm
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10
Q

Class III Vaughan-Williams Antiarrhythmic Agents

A

Potassium blockers → widen the duration of the action potential

Rhythm

amiodarone, ibutilide, sotalol

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11
Q

Class IV Vaughan-Williams Antiarrhythmic Agents

A

non-dihydropyridine CCBs → diltiazem, verapamil

predominant action on the AV node → affect Rate & rhythm

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12
Q

Class Ia Vaughan-Williams Classification Antiarrhythmic Drugs and MOA

A
  • Drugs: procainamide, quinidine, disopyramide
  • MOA: Na+ channel blockade, prolonged repolarization → anti-arrhythmic not affecting rate
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13
Q

Class Ib Vaughan-Williams Classification Antiarrhythmic Drugs and MOA

A
  • Drugs: lidocaine, phenytoin
  • MOA: Na+ channel blockade, shorten repolarization → antiarrhythmic that does not affect rate
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14
Q

Class Ic Vaughan-Williams Classification Antiarrhythmic Drugs and MOA

A
  • Drugs: Flecainide, Propafenone
  • MOA: Na+ channel blockade, repolarization unchanged → antiarrhythmic that does not affect rate
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15
Q

Procainamide (Pronestyl)

A

Class Ia antiarrhythmic→ Na channel blockade, prolong repolarization

  • Indications: atrial & ventricular tachydysrhythmias
  • SEs:
    • ventricular dysrhythmia
    • agranulocytosis
    • Systemic-Lupus erythematosus (SLE) -like syndrome
    • Leukopenia, Maculopapular rash, flushing
    • Torsades from QT prolongation
  • Contraindications:
    • known hypersensitivity, heart block and SLE
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16
Q

Quinidine (Quinidex)

A

Class 1a Antiarrhythmic→ Na+ channel blockade, prolong repolarization

  • Indications: A.fib/flutter, life-threatening Ventricular arrhythmia, malaria
  • Quinidine gluconate (IV or PO) and Quinidine Sulfate (PO/Tab only)
  • SEs:
    • QT prolongation → torsades, AV block
    • tremor, nervousness, photosensitivity

Black Box Warning: increased mortality in tx of non-life threatening arrhythmias; increase risk of structural heart disease

  • DDI: lots of DDIs, will interact with drugs causing bradycardia or QT prolongation
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17
Q

Disopyramide (Norpace)

A

Class 1a antiarrhythmic→ Na+ channel blockade, prolong repolarization

  • Indications: 1. Ventricular arrhythmias
    • 2.A.fib conversion or prevention
  • SEs:
    • Torsades, CHF,
    • Agranulocytosis → just like procainamide
    • Hypokalemia

Black Box Warning: increased mortality

  • DDI: hypoglycemia, anticholinergic effects, 3A4 substrate
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18
Q

Phenytoin

A

Class 1b antiarrhythmic → Na+ channel blockade, faster repolarization

  • Indications: atrial and ventricular tachhycysrhtymias caused by digitalis toxicity or long QT syndrome
    • also seizure disorders
  • SEs:
    • bradycardia, pancytopenia, hepatotoxicity, SJS
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19
Q

Lidocaine

A

Class 1b antiarrhythmic → Na+ channel blockade, faster repolarization

  • Indications: used for ventricular arrhythmias only
    • → raises the ventricular fibrillation threshold
  • SEs:
    • twitching, convulsions, confusion, Respiratory arrest/depression
  • Contraindications:
    • hypersensitivity
    • Heart block
    • Stokes-Adams Syndrome (fainting spell d/t arrhythmias)
    • Wolff-Parkinson-White → tachycardia
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20
Q

Flecainide (Tambocor)

A

Class 1c antiarrhythmics→ sodium channel blockade, no change in repolarization

  • Indications: used for SEVERE ventricular dysrhythmias
    • can be used in afib, a.flutter, Wolff-Parkinson White, & SVT
  • analogue of Procainamide
  • Negative inotropic effects and depresses left ventricular function
  • SEs:
    • QT prolongation, CHF, dyspnea etc
  • Contraindications:
    • hypersensitivity, cardiogenic shock
    • second or 3rd degree AV block
    • dysrhythmias
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21
Q

Beta-Blockers as Antiarrhythmics

A

reduce or block sympathetic NS stimulation → reducing transmission of impulses in the heart’s conduction system

affect Rate and Rhythm

  • Indication: myocardial depressant for both supraventricular dysrhythmias and ventricular dysrhythmias
    • antianginal
    • antihypertensive
  • Drugs: esmolol, metoprolol, propranolol
22
Q

Amiodarone

A

Class III antiarrhythmic → K+ channel blockers, increase action potential duration

  • MOA: blocks both the alpha and beta adrenergic receptors
  • indications: sustain V.tach, V.fib
    • drug of choice for V. dysrhythmias according to ACLS
  • SEs:
    • corneal deposits → visual halps
    • photophobia, and dry eyes
    • phototoxicity (uv light)
    • pulmonary toxicity → pulmonary fibrosis
  • DDI:
    • digoxin & warfarin (may have a delayed reaction)
  • Contraindication:
    • hypersensitivity, severe sinus brady, Heart Block
23
Q

Diltiazem & Verapamil as Antiarrhythmics

A
  • Class IV antiarrhythmics→ depress phase 4 of depolarization → affect RATE & rhythm
  • indications:
    • paroxysmal supraventricular tachycardia
    • rate control for atrial fib and flutter
  • Contraindications:
    • Acute MI
    • Pulmonary congestion
    • Wolff-Parkinson white
    • Severe Hypotension, cardiogenic shock
    • sick sinus syndrome
    • Heart Block
24
Q

General Antiarrhythmic SEs

A
  • All antidysrhythmic can cause dysrhythmias
  • hypersensitivity rxns
  • N/V/D
  • dizziness
  • headache & blurred vision
  • prolongation of the QT interval
  • DDI:
    • warfarin (Coumadin): monitor INR
    • Grapefruit Juice:
      • amiodarone (III), disopyramide (1a), and quinidine (1a)
25
Q

CHA2DS2-VASc

A
  • Congestive HF/LV dysfunction +1
  • Hypertension +1
  • Age 65-74 +1
  • Diabetes Mellitus +1
  • Stroke/TIA +2
  • Vascular disease ( previous MI, PAD, aortic plaque): +1
  • Age ≥ 75 +2
  • Sex category (female): +1
  • +Recommendations:
    • ≥ 2 for men = anticoag
    • ≥ 3 for women = anticoag
26
Q

General Anticoagulants

A

inhibit the clotting cascade, decrease fibrin formation

  • Vitamin K antagonists
  • Direct Thrombin Inhibitors
  • Factor Xa inhibitors
27
Q

When are Dabigatran (Direct thrombin inhibitor), Rivaroxaban (inhibit factor Xa), apixaban (inhibit factor Xa), or edoxaban (inhibit factor xa) preferred over warfarin?

A

for nonvalvular & non-cancer patients

28
Q

When is low molecular weight heparin preferred over vitamin K antagonists, dabigatran, rivaroxaban, apixaban, or edoxaban?

A

for pts with cancer-associated thrombosis

29
Q

When is aspirin recommended to prevent recurrent venous thromboembolism (VTE)?

A

for pts who stop anticoagulation therapy and do not have a contraindication to aspirin

30
Q

Thrombolytic Therapy and pulmonary embolism

A
  • generally not recommended in pts with acute PE
  • it is preferred in selected patients with acute PE who have no hypotension and a low bleeding risk (grade 2c)
31
Q

Warfarin (Coumadin): MOA, metabolism, & monitoring

A

vitamin K antagonist → affects factor II, VII, IX, X, and protein C & S → takes 48-72 hours for this med to take effect

  • R & S enantiomers primarily metabolized by CYP2C9
  • Excretion: primarily renal
  • Monitoring therapy:
    • narrow therapeutic window → use INR (monitors PT- prothrombin time)
32
Q

Warfarin (Coumadin) Dosing

A

Recommended patient admin time is every evening

*

33
Q

Warfarin and Disease State Interactions

A
34
Q

What common food group can increase vitamin K and affect Warfarin?

A

Green leafy vegetables

→ counsel patients on the importance of a CONSISTENT diet

35
Q

Warfarin SEs

A

BLEEDING→ nosebleed, gum bleed, unexplained brusing, etc

  • warfarin-induced skin necrosis
  • Purple-toe syndrome
  • Teratogen (pregnancy category X)
36
Q

Dabigatran (Pradaxa)

A
  • MOA: direct thrombin inhibitor (Prodrug)
  • NOT recommended in severe ESRD or those on hemodialysis
  • Do not require drug level monitoring but EXPENSIVE!
  • SEs:
    • GI sxs
      • bleeding
  • Monitoring: renal funx prior to initiation & at least annually
  • Important Pt info:
    • do NOT open, chew, or break the capsule
      • ***store in the original package to protect from moisture***
  • better than warfarin for stroke or systemic embolism prevention
  • AVOID in pts with Mechanical Heart Valves
37
Q

Rivaroxaban (Xarelto)

A
  • MOA: inhibits Factor Xa
  • metabolism: by the liver
  • monitoring: renal funx prior to initiation & at least annually
  • Not better than warfarin for stroke or systemic embolism prevention
  • AVOID in pts with Prosthetic Heart Valves
38
Q

Apixaban (Eliquis)

A
  • MOA: factor Xa inhibitor
  • metabolism: liver
  • monitoring: Renal funx prior to initiation & at least annually
  • Better than warfarin for stroke or systemic embolism prevention
  • CAN be used in ESRD patients on hemodialysis
  • CYP3A4 substrate → monitor for DDIs

AVOID in pts with Prosthetic Heart Valves

39
Q

Edoxaban (Savaysa)

A
  • MOA: factor Xa inhibitor
  • Dosing: CrCl 50 - 95 mL/min
    • Pts with CrCl > 95 mL/min: AVOID use – drug level too low
  • AVOID in pts with Prosthetic Heart Valves
40
Q

Black box warning for all NOAC agents

A

Dabigatran, Rivaroxaban, apixaban, edoxaban, betrixaban

Premature d/c increases risk of thrombosis; spinal/epidural hematomas

41
Q

What is the reversal agent for Dabigatran (Pradaxa) overdose?

A
  • Activated charcoal if used within 1-2 hours of ingestion
  • dialysis: removes 62% at 2 hours; 68% at 4 hours
  • idarucizumab (Praxbind) -
    • humanized monoclonal antibody fragment
42
Q

What is the reversal agent for factor Xa inhibitors

A

Andexanet alfa (Andexanet)/(Andexxa)

reverses both Rivaroxaban & Apixaban

during life threatening or uncontrolled bleeding

43
Q

What is the reversal agent for warfarin?

A

Vitamin K

44
Q

Andexxa Dosing (general), SEs, and Black box warning

A
  • Dose based on rivaroxaban or apixaban dose
  • SEs:
    • infusion related rxns
    • thromboembolic events
    • bleeding
    • cardiogenic shock, sudden death, CHF, acute respiratory failure
    • Black Box Warning: Arterial & Venous thromboembolic events; ischemic events including MI and stroke; Cardiac Arrest; sudden death
45
Q

Heparin vs LMWH

A
46
Q

Fibrin Specific Thrombolytics

A

decrease systemic activation of plasminogen → prevent degradation of circulating fibrinogen

  • do not have significant lytic action when exposed to fibrinogen with plasminogen
  • tissue plasminogen activator (t-PA) = Alteplase (recombinant t-PA)
  • Reteplase (Retevase)
  • Tenecteplase (TNKase)
47
Q

Non-Fibrin Specific Thrombolytics

A

cause both fibrinolysis and fibrinogenolysis

Streptokinase

urokinase

48
Q

Alteplase (Activase)

A

Fibrin specific thrombolytics

  • indications;
    • acute MI, acute ischemic stroke, Acute PE
  • SEs:
    • Bleeding (severe), thromboembolism, cholesterol embolism, hypersensitivity rxn
49
Q

Reteplase (Retavase)

A

2nd gen recombinant t-PA from E.coli

  • does not bind to fibrin as tightly as t-PA
    • penetrates clots better
    • dissolve clots faster
  • indications: STEMI
  • Contraindications:
    • active bleeding
    • recent stroke
    • intracranial/spinal surgery within 3 months
    • severe uncontrolled HTN
  • SEs:
    • bleeding, hypersensitivity (less than t-PA), cholesterol embolism
50
Q

Tenecteplase (TNKase)

A

fibrin specific thrombolytics

  • recombinant with modification of alteplase (from hamster ovary cells)
  • indication: Acute MI
  • SEs:
    • bleeding, choelsterol embolism, arrhythmias (brady or tachy) → antiarrhythmic tx be ready during TNKase tx
    • Anaphylaxis
  • Contraindications:
    • active internal bleeding
    • hx of cerebrovascular accident
    • intracranial/spinal surgery or trauma within 2 months
    • severe uncontrolled HTN

NRS 271B (10 decks)

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