AFib - Arrhythmia

Question 1

Persistient / Permanent
- Heart Rate target

Answer 1

Less than 100 BPM
- HF patients may need lower target of 80

Question 2

Rate Control
- First Line

Answer 2

Negative dromotropic effects that slow AV node conduction
- Beta Blockers
- Non-Dihydropyridine

Question 3

Beta Blockers

Answer 3

First line is Bisoprolol
- Preferred in HFrEF

Question 4

Non-DHP CCBs

Answer 4

First line is Diltiazam, Verapamil

Negative Ionotropic, (Contraction)
- Avoided in HFrEF
Negative Chronotropic (Heart Rate)
Negative Dromotropic (Conduction)

Question 5

Digoxin

Answer 5

Second Line - Used If:
- Rate control is inadequate
- Symptom management
- Unable to tolerate first line

Positive Ionotropic (Contractility)
- Can be added on in HF
Negative Chronotropic (Heart Rate)
Negative Dromotropic (Conduction)

Question 6

Digoxin
- Toxicity

Answer 6

Narrow therapeutic index
- Drug interactions, Pgp substrate (amiodarone)
- Signs of toxicity (Confusion, arrhythmia, hallucinations)

Monitor renal functions

Question 7

Rhythm Control
- Mechanism

Answer 7

1. Restore normal sinus rhythm to minimize symptoms associated with excessive heart rate
2. Reduce complications caused by tachycardia

Question 8

Antiarrhythmic Drugs
- Mechanism

Answer 8

Prolong action potential
- Class I (Na+ Channel Blockers)

Prolong refractory period
- Class III (K+ Channel Blockers)

Slow conductions in atrial node
- Class II (Beta Blockers)
- Class IV (Calcium Channel Blockers)

Question 9

Flecainide
- Dose

Answer 9

50 - 75 mg BID
Up to 150 mg BID

Question 10

Flecainide
- Counseling

Answer 10

Avoid in patients with MI, CAD, HF

Question 11

Amiodarone
- Dose

Answer 11

100 - 400 mg (based on arrhythmia)

Very lipophilic = Large Vd
Long half life (3 months)

Question 12

When to do Rhythm Control

Answer 12

First year of Afib

Younger patients

Arrhythmia induced cardiomyopathy

Frequent paroxysmal AF

Patient preference

Question 13

When to do Pill In Pocket

Answer 13

Infrequent episodes of AF

Symptomatic and can recognize signs
- Not severe

Favourable anatomy

Able to present to ED for 1st time
- 1st dose should be observed in hospital

Question 14

Pill in Pocket

Answer 14

Single dose of flecanide (300 mg)
+ Beta blocker or Non-DHP CCB

Question 15

2,3,4 role

Answer 15

2: Anticoagulation if Afib is longer than 2 days

3: Therapeutic Oral Anticoagulation for 3 weeks before cardioversion

4: Anticoagulation for 4 weeks after cardioversion

Question 16

Catheter Ablation

Answer 16

Antiarrhythmics do not work

HFrEF

Atrial Flutter