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IPFC 4 Final > Afib therapeutics > Flashcards

Afib therapeutics Flashcards

1
Q

Define acute Afib (2)

A
  1. AF of <48h
  2. Paroxysmal AF (occurring in critical care or causing the acute illness, i.e severe)
    OR
    First symptomatic persistent Afib
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2
Q

Once patient is diagnosed with acute afib,
What do you do if hemodynamically stable (2)

A

Rate control:
- Beta blocker
- Diltiazem/verapamil
- Digoxin

Consider anticoagulant

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3
Q

Once patient is diagnosed with acute afib,
and hemodynamically stable, what do you if patient remains in afib for:
<48 hours?
48+ hours ?

A

<48 hours?
- anti-arrhythmics +/- cardioversion

48+ hours
- TEE-guided cardioversion (look inside to make sure there is not clot first)
- 3 weeks anticoagulation then cardioversion

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4
Q

What defines hemodynamic instability (any of 5)

A
  • Ventricular rates > 150 bpm
  • Ongoing chest pain
  • Systolic <90 mmHg
  • Heart failure
  • Reduced consciousness
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5
Q

Once patient is diagnosed with acute afib,
and hemodynamically UNstable,
What do you if it is life-threatening?

A

Emergency electrical cardioversion

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6
Q

Once patient is diagnosed with acute afib,
and hemodynamically UNstable,
What do you if it is not life-threatening?

A

Check if they have Permanent Afib

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7
Q

Once patient is diagnosed with acute afib,
and hemodynamically UNstable, not life-threatening,
Patient has permanent Afib?

A

Rate control
- beta blocker
- NDHPs

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8
Q

Once patient is diagnosed with acute afib,
and hemodynamically UNstable, not life-threatening,
Patient does NOT have/unknown permanent Afib?

A
  • TEE-guided cardioversion (look inside to make sure there is not clot first)
  • 3 weeks anticoagulation then cardioversion
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9
Q

What is considered high risk where you need to have at least 3 weeks of OAC before cardioversion
or could perform a TEE to exclude left atrial thrombus? (4)

A
  1. Valvular Afib
  2. NVAF duration <12 AND recent stroke/TIA
  3. NVAF duration 12-48 AND chads 2+
  4. NVAF duration over 48h+

All high risk

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10
Q

When would you go directly to cardioversion and initiate OAC if possible before? (low risk) (3)

A
  1. Hemodynamically unstable acute Afib
  2. NVAF <12 AND NO recent stroke
  3. NVAF 12-48 hours AND chads 0-1
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11
Q

What do you initiate after cardioversion for everyone?

A

4 weeks anticoagulation

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12
Q

Pharmacologic cardioversion
Which class drugs are used for RHYTHM control?
Rate control?

A

Rhythm control
- class I (Na blockers)
- class III (K+ blockers)

Rate control
- Class II (BB)
- Class IV (NDHPs)

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13
Q

Which class of drugs share rate-controlling properties?

A

Class III

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14
Q

Which drugs specifically have demonstrated efficacy for cardioversion (rhythm control) (5)
Which are more efficacious?

A

Class 1c
- flecainide
- propafenone

Class 3
- ibutilide
- amiodarone
- dronedarone

Class 1c are better than class 3 for CARDIOVERSION

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15
Q

In stable patients, with no evidence of HF,
what drugs do we use?

A

Beta-blockers
NDHPs

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16
Q

When do we use both BB and NDHP for rate control?
What to monitor

A

If no evidence of rate control

Monitor for AV nodal blockade

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17
Q

In stable patients, with evidence of HF (acute),
what drugs do we use?

A

Digoxin
Amiodarone

(recall: do not use BB in acute HF)

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18
Q

What drugs can we use for wolff-parkinson-white syndrome patients (preexcitation) (2)
What is CI? why?

A

Contraindicated
- BB, CCB, Digoxin
- block AV conduction but NOT slow conduction through accessory pathway (can lead to ventricular fibrillation)

Use:
Procainamide (Class 1a)
OR
Ibutilide (Class 3)

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19
Q

What does CHADS2 score estimate?
What does it stand for

A

Annual risk of stroke in AFIB patients

C HF
H HTN
A Age over 75
D DM
S Previous stroke/TIA = 2 points

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20
Q

What does CHA2DS2VASc consider? Differences between CHADS?
When to use?

A

V Vascular disease
Age 65-74 = 1 point
Age 75+ = 2 points
Sex = 1 point (female)

Used if CHADS score is 0 (good for truly low risk patients)

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21
Q

In the HASBLED score
What is hypertension defined as?
CKD function?
Labile INR?
Drugs or alcohol?

A

What is hypertension defined as?
- SBP >160 mmhg

CKD function?
- Dialysis
- SCr 200+ mmol/L

Labile INR?
- <60% TIR

Drugs or alcohol?
- antiplatelet agents
- NSAIDs
- alcohol abuse

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22
Q

What are additional risk factors to assess bleeding risk? (6)

A
  • Thrombocytopenia
  • Active bleeding or recent surgery
  • Prior severe bleeding (including ICH) while on OAC
  • Suspected aortic dissection
  • Malignant hyper tension
  • use of antiplatelet agents
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23
Q

After 4 weeks of anticoagulation post-cardioversion
Which patients benefit from OAC?

A

65+
or CHADS2 score of 1+

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24
Q

After 4 weeks of anticoagulation post-cardioversion
Which patients should be ONLY ASA? (3)

A

<65 years
CHADS2 = 0
Vascular disease (CAD, PAD)

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24
Q

After 4 weeks of anticoagulation post-cardioversion
Which patients should not be on antithrombotic therapy? (3)

A

<65 years
CHADS2 = 0
NO Vascular disease (CAD, PAD)

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24
Q

How much do OAC reduce risk of stroke by in patients with Afib?

A

60%

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25
Q

When is warfarin indicated over DOACs? (3)

A

Mechanical prosthetic valve
Rheumatic mitral stenosis
eGFR 15-30 mL/min

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26
Q

What does the RE-LY trial say about dabigatran high dose (150mg) & low dose (110mg) vs Warfarin
Efficacy and safety?

A
  • Dabigatran 110 mg BID was non-inferior to warfarin
  • dabigatran 150 mg BID was superior to warfarin for [stroke or clot],

Safety
Warfarin had more major bleeding than dabigatran

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27
Q

What does the ROCKET AF trial say with rivaroxaban vs Warfarin
Efficacy
Safety:
Major and minor bleeding
Intracranial hemorrhage
Fatal bleeding

A

Rivaroxaban was non-inferior to warfarin for [stroke or clot]

Major and minor bleeding: No difference
Intracranial hemorrhage: Warfarin had more
Fatal bleeding: Warfarin had more

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28
Q

What does the Aristotle trial say with apixaban vs Warfarin
Efficacy
Safety:
Major bleed
All-cause mortality
Hemorrhagic stroke

A

Efficacy
Apixaban was non-inferior to warfarin

Safety:
Major bleed
All-cause mortality
Hemorrhagic stroke
- Warfarin worse for all

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29
Q

What does the ENGAGE AF-TIMI trial say with Edoxaban high (60mg) and low dose (30mg) vs Warfarin in CHADS = 2+
Efficacy
Safety

A

Efficacy
Edoxaban (both high- and low dose) was non-inferior to warfarin

Safety
Warfarin had more major bleed than both high- and low-dose edoxaban

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30
Q

What did systematic reviews say about DOACs vs Warfarin in:
Total death
CV death
Stroke or clot
Major bleed
Brain bleed
Ischemic stroke

A

Total death
CV death
Stroke or clot
Major bleed
Brain bleed
- DOACs are better

Ischemic stroke
- no difference

31
Q

What do trials say about risks concerning with dabigatran?

A

Increase MI risk

32
Q

Dabigatran vs Warfarin safety observational study

A

Dabigatran increased all bleed risks, except ICH - it decreased it (this was observational!!, but still concerning)

33
Q

OAC + ASA vs OAC in afib patients
Efficacy
Safety

A

ASA + OAC resulted in less arterial clots but only in mechanical heart valve patients but not A fib patients.

More major bleed with ASA + OAC.

34
Q

When can warfarin + ASA be indicated

A

May be indicated and for MI prevention

35
Q

What is the renal dosing for stroke prevention in AF for rivaroxaban and apixiban
15-30 mL/min
<15 mL/min

A

Rivaroxaban
15-30mL/min 15mg approved
<15 avoid

Apixaban
15-24 mL/min 5mg (no dose approvement)
<15 avoid

36
Q

What do guidelines say for interrupting OAC for:
Low bleed risk surgery
Intermediate bleed risk surgery
High bleed risk surgery

A

Low bleed risk surgery: no need to interrupt
Intermediate bleed risk surgery: interrupt
High bleed risk surgery: interrupt

37
Q

What are examples of low bleed risk surgeries?

A

Laparoscopic chole
Laparoscopic inguinal hernia repair
Dental
Ophthalmologic procedures
Colonoscopy
Cardiac implantable surgery
Biopsy

38
Q

When to stop
ASA or clopidogrel
Warfarin before surgery?

A

ASA or clopidogrel
- 5-7 days
- 7-10 days for high risk of major bleeding

Warfarin
- 5 days

39
Q

When to consider bridging? (3)

A

CHADS2 3+
Stroke/TIA last 3 months
Heart valve

40
Q

What did the PERIOP trial say for mechanical valve patients bridging with dalteparin
Efficacy
Safety

A

No difference in clot, all death,

No difference in major bleed risk.

41
Q

What did the BRIDGE trial say for afib patients bridging with dalteparin
Efficacy
Safety

A

Efficacy
No difference in [arterial clot = stroke + TIA + clot], [death], [MI], [DVT], or [PE]

Safety
but more major bleed

42
Q

Contrast between ventricular rate control and rhythm control

A

Rate control:
- accept that patients may remain in irregular heart rhythm, just focus on controlling ventricular rate
- BB, NDHPs, digoxin

Rhythm control
- try to restore and maintain sinus rhythm
- Antiarrythmic meds, catheter ablation and/or surgical procedure

43
Q

Which strategy is better when done early? Rate/rhythm control
AFNET-4

A

rhythm control

44
Q

In patients with newly diagnosed Afib (within a year), which strategy is used first

A

Rhythm control

45
Q

AFFIRM trial rhythm (class Ia, Ic, III) vs rate control for HR <80 and 6-min walk
All cause death
Composite (death + stroke + major bleed + cardiac arrest)
Hospitalization

A

All cause death
- no difference

Composite (death + stroke + major bleed + cardiac arrest)
- no difference

Hospitalization
- lower in RATE control group

46
Q

Rate-control arm vs rhythm control arm in the AFFIRM trial
Which patients achieved more sinus rhythm?
which patients used radiofrequency ablation more?

A

Which patients achieved more sinus rhythm?
- Rhythm control

which patients used radiofrequency ablation more?
- Rate control

47
Q

What were issues with the affirm trial?

A
  • mean age was 70
  • crossover: many switched fro rhythm to rate but less switched from rate to rhythm
  • most patients had 1 episode/month (little symptomatic relief expected from baseline if baseline is already so mild)
  • Catheter ablation was not very available at this time, radiofrequency ablation was used
48
Q

What does the subgroup of AFFIRM show for digoxin?

A

increase in all-cause mortality ASSOCIATED with patients always or never on digoxin in the study AND patients on digoxin at baseline

49
Q

What is the general appropriate first step with patients recently diagnosed with symptomatic AF to keep the heart rate <100 bpm?

A

Rate control

50
Q

What did EAST-AFNET 4 trial tell us about treatment?

A

Early rhythm control is better for patients with early

51
Q

What is the inclusion criteria for EAST-AFNET 4 trial
2 options (2) (8)

A

75+ and had a previous TIA or stroke
OR
any of the 2:
- 65+
- female
- HF
- HTN
- DM
- Severe CAD
- CKD <60 mL/min
- Left ventricular hypertrophy 15+mm

52
Q

When is rhythm control preferred over rate-control in persistent AF?

A
  • Recently diagnosed AF (within 1 year)
  • Highly symptomatic or sig QOL impairment
  • Multiple recurrences
  • Difficulty to achieve rate control
  • Arrhythmia-induced cardiomyopathy
53
Q

What is the target ventricular rate for rate control therapy?

A

<100 bpm

54
Q

What did the RACE II trial say when compared <80 bpm to <110 bpm for resting heart rate

A

No difference

55
Q

What did AFFIRM trial show for digoxin use?
What refused this?

A

AFFIRM trial:
- showed increase in all-cause mortality ASSOCIATED with patients always or never on digoxin in the study AND patients on digoxin at baseline

Refuted:
However, propensity-matching and statistical “trimming” refuted this. Still a worrisome result - (don’t use digoxin first line in rate control of AF)

56
Q

Is it safe to combine BB and NDHP in Afib for suboptimal response

A

Yes

57
Q

When is amiodarone used in Afib

A

Antiarrhythmic drug
- added as last option

58
Q

If patient has HF (LVEF <40%) and afib, what drugs do we use? Avoid?

A

BB and digoxin
- avoid NDHP

59
Q

What is the last line if unable to get rate control

A

Catheter Ablation for AF
- (surgically removing (killing) the AV node + inserting a pacemaker to create pulses and send them to atrium AND ventricle)

60
Q

Goals of rate control (2) vs rhythm control (2)

A

Rate control
- reduce symptoms (palpitations, dizziness)
- Reduce cardiomyopathy risk

Rhythm control
- to enhance quality of life
- to enhance the ability to perform physical acivity

61
Q

What to do if patient is high risk for rhythm control and TEE is:
Positive?
Negative?

A

TEE positive:
- OAC for 3+ weeks before cardioversion

TEE negative:
- proceed with cardioversion

62
Q

What are the most common drugs used to maintain sinus rhythm in Afib?

A

1C
- flecainide
- propafenone

Class III
- Amiodarone
- Dronedarone
- Sotalol

63
Q

If choosing Flecainide and propafenone, what should it be combined with? Why?
When are these drugs contraindicated?

A

Contraindicated
- CAD (ACS) (can use in “minimal structural heart disease)
- HF

Combined with:
- AV nodal blocking agent (BB or NDHP)
- If we reduce SA node firing (through Class 1 antiarrhythmics), the refractory time in the AV node is reduced (due to “concealment effect”) -> MORE impulses will actually make it through the AV node (paradoxical) (can lead to Ventricular fibrilation)-> need AV blocking agent (Class 2 or 4)

64
Q

When should dronedarone be avoided according to the PALLAS trial (2)

A
  • Not used in HF
  • Not used in permanent Afib
65
Q

When should sotalol be avoided? (2)

A
  • In patients at high risk of torsade de pointes
  • HF (EF <40%)
66
Q

What did the CAST trial tell us about antiarrythmic drugs (flecainide) in MI patients

A

Increased deaths in ACS

67
Q

What did the PROBE trial tell us in short term (4 weeks) vs long term (6 months) flecainide (post successful cardioversion)

A

Use Cardioversion + 4 weeks of post-cardioversion flecainide to help maintain sinus rhythm (not reduce mortality)

68
Q

When is pill in the pocket anti-arrhytmic strategy used?
What is it?

A

Paraxosymal afib lasting several hours with low reccurence burden

What
- 1 dose of Flecainide or proapfenone
- must also use AV nodal blocker

69
Q

What are some factors that predispose to drug-induced pro-arrhythmia

A
  • Long QT interval
  • Structural heart disease
  • LV dysfunction
  • Hypokalemia/hypomagnesemia
  • female
  • renal dysfunction
  • bradycardia
  • rapid dose increase
  • high dose of class III drugs
  • previous proarrhythmia
70
Q

Differentiate between QT and QTc

A

QTc is corrected for HR

71
Q

What is the Cellular mechanisms of Acquired Long QT Syndrome (ALQTS)

Other mechanisms? (3)

A
  • inhibition of hERG channel preventing Ikr entry (through rapid potassium current which is what blocks it)

Other mechanisms
- inhibition of Iks
- upregulation of depolarizing INa current
- impaired ion channel trafficking

72
Q

What are some symptoms of Acquired Long QT Syndrome (ALQTS) (6)

A
  • Heart palpitations
  • Tachycardia
  • Syncope/fainting
  • Dizziness/light-headedness
  • SOB
  • Convulsions
73
Q

What are some QT prolonging drugs associated with Torsade de pointes

A

Antiarrhythmic durgs (class I and III)

Non-cardiac
- antihistamines (terfendadine, astemizole)
- Antipsychotic and antidepressent (amitriptyline, fluoxetine, -ine)
- Haloperidol
- atypical antipsychotics (risperidone, citalopram)

Antibiotics
- quinolone (levofloxacin, all -floxacins)
- Macrolide (erythromycin, clarithryomycin)

Antimalarials (quinine, halofantrine)
Antifungals
Antimotality agents
Methadone

74
Q

Tachy/Brady

which is the risk factor
Which is the sx of QT and

A

Risk factor:
Brady

Sx:
Tachy

75
Q

In the TISDALE risk score, what is the most points given to (4)
What is considered low, moderate, high total score

A

Highest risk scores (=3)
- 2+ QTc prolonging drugs
- sepsis
- HF
- 1 QTc prolonging drug

Low: 0-6
Mod: 7-10
High: 11-21

76
Q

What to do if given a known QT prolonger

A

recommend ECG pre and post initiation + monitor for symptoms (fatigue, palpitations, etc…)

IPFC 4 Final (6 decks)

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