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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
After 4 weeks of anticoagulation post-cardioversion Which patients should not be on antithrombotic therapy? (3)
<65 years CHADS2 = 0 NO Vascular disease (CAD, PAD)
24
How much do OAC reduce risk of stroke by in patients with Afib?
60%
25
When is warfarin indicated over DOACs? (3)
Mechanical prosthetic valve Rheumatic mitral stenosis eGFR 15-30 mL/min
26
What does the RE-LY trial say about dabigatran high dose (150mg) & low dose (110mg) vs Warfarin Efficacy and safety?
- 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
27
What does the ROCKET AF trial say with rivaroxaban vs Warfarin Efficacy Safety: Major and minor bleeding Intracranial hemorrhage Fatal bleeding
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
28
What does the Aristotle trial say with apixaban vs Warfarin Efficacy Safety: Major bleed All-cause mortality Hemorrhagic stroke
Efficacy Apixaban was non-inferior to warfarin Safety: Major bleed All-cause mortality Hemorrhagic stroke - Warfarin worse for all
29
What does the ENGAGE AF-TIMI trial say with Edoxaban high (60mg) and low dose (30mg) vs Warfarin in CHADS = 2+ Efficacy Safety
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
30
What did systematic reviews say about DOACs vs Warfarin in: Total death CV death Stroke or clot Major bleed Brain bleed Ischemic stroke
Total death CV death Stroke or clot Major bleed Brain bleed - DOACs are better Ischemic stroke - no difference
31
What do trials say about risks concerning with dabigatran?
Increase MI risk
32
Dabigatran vs Warfarin safety observational study
Dabigatran increased all bleed risks, except ICH - it decreased it (this was observational!!, but still concerning)
33
OAC + ASA vs OAC in afib patients Efficacy Safety
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
When can warfarin + ASA be indicated
May be indicated and for MI prevention
35
What is the renal dosing for stroke prevention in AF for rivaroxaban and apixiban 15-30 mL/min <15 mL/min
Rivaroxaban 15-30mL/min 15mg approved <15 avoid Apixaban 15-24 mL/min 5mg (no dose approvement) <15 avoid
36
What do guidelines say for interrupting OAC for: Low bleed risk surgery Intermediate bleed risk surgery High bleed risk surgery
Low bleed risk surgery: no need to interrupt Intermediate bleed risk surgery: interrupt High bleed risk surgery: interrupt
37
What are examples of low bleed risk surgeries?
Laparoscopic chole Laparoscopic inguinal hernia repair Dental Ophthalmologic procedures Colonoscopy Cardiac implantable surgery Biopsy
38
When to stop ASA or clopidogrel Warfarin before surgery?
ASA or clopidogrel - 5-7 days - 7-10 days for high risk of major bleeding Warfarin - 5 days
39
When to consider bridging? (3)
CHADS2 3+ Stroke/TIA last 3 months Heart valve
40
What did the PERIOP trial say for mechanical valve patients bridging with dalteparin Efficacy Safety
No difference in clot, all death, No difference in major bleed risk.
41
What did the BRIDGE trial say for afib patients bridging with dalteparin Efficacy Safety
Efficacy No difference in [arterial clot = stroke + TIA + clot], [death], [MI], [DVT], or [PE] Safety but more major bleed
42
Contrast between ventricular rate control and rhythm control
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
Which strategy is better when done early? Rate/rhythm control AFNET-4
rhythm control
44
In patients with newly diagnosed Afib (within a year), which strategy is used first
Rhythm control
45
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
All cause death - no difference Composite (death + stroke + major bleed + cardiac arrest) - no difference Hospitalization - lower in RATE control group
46
Rate-control arm vs rhythm control arm in the AFFIRM trial Which patients achieved more sinus rhythm? which patients used radiofrequency ablation more?
Which patients achieved more sinus rhythm? - Rhythm control which patients used radiofrequency ablation more? - Rate control
47
What were issues with the affirm trial?
- 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
What does the subgroup of AFFIRM show for digoxin?
increase in all-cause mortality ASSOCIATED with patients always or never on digoxin in the study AND patients on digoxin at baseline
49
What is the general appropriate first step with patients recently diagnosed with symptomatic AF to keep the heart rate <100 bpm?
Rate control
50
What did EAST-AFNET 4 trial tell us about treatment?
Early rhythm control is better for patients with early
51
What is the inclusion criteria for EAST-AFNET 4 trial 2 options (2) (8)
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
When is rhythm control preferred over rate-control in persistent AF?
- Recently diagnosed AF (within 1 year) - Highly symptomatic or sig QOL impairment - Multiple recurrences - Difficulty to achieve rate control - Arrhythmia-induced cardiomyopathy
53
What is the target ventricular rate for rate control therapy?
<100 bpm
54
What did the RACE II trial say when compared <80 bpm to <110 bpm for resting heart rate
No difference
55
What did AFFIRM trial show for digoxin use? What refused this?
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
Is it safe to combine BB and NDHP in Afib for suboptimal response
Yes
57
When is amiodarone used in Afib
Antiarrhythmic drug - added as last option
58
If patient has HF (LVEF <40%) and afib, what drugs do we use? Avoid?
BB and digoxin - avoid NDHP
59
What is the last line if unable to get rate control
Catheter Ablation for AF - (surgically removing (killing) the AV node + inserting a pacemaker to create pulses and send them to atrium AND ventricle)
60
Goals of rate control (2) vs rhythm control (2)
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
What to do if patient is high risk for rhythm control and TEE is: Positive? Negative?
TEE positive: - OAC for 3+ weeks before cardioversion TEE negative: - proceed with cardioversion
62
What are the most common drugs used to maintain sinus rhythm in Afib?
1C - flecainide - propafenone Class III - Amiodarone - Dronedarone - Sotalol
63
If choosing Flecainide and propafenone, what should it be combined with? Why? When are these drugs contraindicated?
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
When should dronedarone be avoided according to the PALLAS trial (2)
- Not used in HF - Not used in permanent Afib
65
When should sotalol be avoided? (2)
- In patients at high risk of torsade de pointes - HF (EF <40%)
66
What did the CAST trial tell us about antiarrythmic drugs (flecainide) in MI patients
Increased deaths in ACS
67
What did the PROBE trial tell us in short term (4 weeks) vs long term (6 months) flecainide (post successful cardioversion)
Use Cardioversion + 4 weeks of post-cardioversion flecainide to help maintain sinus rhythm (not reduce mortality)
68
When is pill in the pocket anti-arrhytmic strategy used? What is it?
Paraxosymal afib lasting several hours with low reccurence burden What - 1 dose of Flecainide or proapfenone - must also use AV nodal blocker
69
What are some factors that predispose to drug-induced pro-arrhythmia
- 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
Differentiate between QT and QTc
QTc is corrected for HR
71
What is the Cellular mechanisms of Acquired Long QT Syndrome (ALQTS) Other mechanisms? (3)
- 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
What are some symptoms of Acquired Long QT Syndrome (ALQTS) (6)
- Heart palpitations - Tachycardia - Syncope/fainting - Dizziness/light-headedness - SOB - Convulsions
73
What are some QT prolonging drugs associated with Torsade de pointes
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
Tachy/Brady which is the risk factor Which is the sx of QT and
Risk factor: Brady Sx: Tachy
75
In the TISDALE risk score, what is the most points given to (4) What is considered low, moderate, high total score
Highest risk scores (=3) - 2+ QTc prolonging drugs - sepsis - HF - 1 QTc prolonging drug Low: 0-6 Mod: 7-10 High: 11-21
76
What to do if given a known QT prolonger
recommend ECG pre and post initiation + monitor for symptoms (fatigue, palpitations, etc…)

IPFC 4 Final (6 decks)

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