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Cardio 1228 > Anti-arrhythmics (edited) > Flashcards

Anti-arrhythmics (edited) Flashcards

1
Q

What’s heart rate (u)

A

HR describes the frequency of depolarization of the ventricles

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2
Q

What’s the normal resting HR (normal sinus rhythm - NSR)?

A

60-100 beats per minute

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3
Q

Can Arrythmias be silent?

A

Yes-a small percentage are silent (asymptomatic)

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4
Q

In most pts that experience sx, what do they experience?

A
  • Palpitations (feeling like there’s fluttering or racing)
  • feeling like heart is skipping a beat
  • Dizziness
  • Lightheadedness
  • SOB
  • Chest pain
  • Fatigue
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5
Q

In severe cases, what sx may one experience?

A

Syncope

Heart failure

Death

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6
Q

What’s the most common etiology of arrhythmias?

A

Myocardial ischemia

OR

Infarction secondary to coronary artery dx

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7
Q

List the non-cardiac conditions that may trigger arrhythmias.

A

Electrolyte imbalances especially those involving potassium, magnesium, sodium and calcium

Elevated sympathetic states such as hyperthyroidism and infection

drugs- including illicit and antiarrythmics

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8
Q

List the electrolytes that may trigger arrhythmias when they are out of balance

A

Potassium

Magnesium

Sodium

Calcium

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9
Q

What’s QT prolongation?

A

Drug- induced slowing of the rate of ventricular depolarization and repolarization (from beginning of QRS complex-end of T wave) , which can result in a particularly dangerous ventricular tachyarrhythmia called Torsade de Pointes (TdP)-can cause sudden cardiac death

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10
Q

What’s the resting value?

A

-90 mV

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11
Q

What happens in phase 0 of action potential?

A

Depolarization (determines conduction velocity)

Na channels OPEN (entering cell)
Class 1a, 1b, 1c antiarrythmthmias target the open Na channel

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12
Q

What determines conduction velocity?

A

Depolarization

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13
Q

What’s the value of phase 1 of action potential?

A

+ 10mV

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14
Q

What happens in phase 1 of action potential?

A

PEAK

Na channels CLOSE

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15
Q

What happens in phase 2 (plateau)?

A

PLATEAU

Ca channels OPEN (entering cell)

K channels OPEN (EXITING cell)

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16
Q

What happens in phase 3?

A

Repolarization

Ca2+ channels CLOSE

K channel stays open (continue exiting cells)
-class III antiarrythmics target the open K channel
Na may enter cell (late inward Na current)
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17
Q

What happens in phase 4?

A

Automaticity

Slow increase in potential

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18
Q

When is refractory period of action potential?

A

Phase 1 to end of phase 3

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19
Q

How’s arrhythmias classified?

A

Based on their location of origin into:

Supraventricular

OR

Ventricular

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20
Q

What’s Supraventricular arrhythmias?

A

Arrhythmias originating ABOVE atrioventricular node

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21
Q

What’s ventricular arrhythmias?

A

Originating BELOW the atrioventricular node

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22
Q

What’s the most common Supraventricular arrhythmias? (U)

A

Atrial fibrillation (AFib)

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23
Q

What’s AFib?

A

Results from multiple waves of electrical impulses in the atria, resulting in an irregular and usually RAPID VENTRICULAR RESPONSE

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24
Q

Why does the mgt of AFib involve anticoagulation?

A

Due to disorganized depolarization of the atria, coordinated atrial contraction is impaired, blood becomes stagnant in atria increasing risk of clot formation, which increases the risk of thromboembolism and stroke

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25
Q

What type of ventricular tachycardia is a medical emergency?

A

Ventricular tachycardia without a pulse

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26
Q

What’s a risk factor for Torsade De Pointes (TdP)? (U)

A

Prolongation of the QT prolongation

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27
Q

What’s Torsade de Pointes (TdP)? What can it result in?

A

TdP is a particularly lethal ventricular tachyarrhythmia which is most commonly ass. with drugs and can result in SUDDEN CARDIAC DEATH

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28
Q

How is QT interval measured? What’s the measured space define?

A

From beginning of the QRS complex to the end of the T wave

Reflect ventricular depolarization and repolarization

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29
Q

What pre-existing condition may cause additive QT prolongation?

A

Any pre-existing cardiac condition

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30
Q

What class of antiarrhythmics also result in additive QT prolongation? (U)

A 
Class I
especially Ia (Disopyramide, Quinidine, Procainamide) double quarter pounder

and Class III (Amiodarone, Ibutilide, Dofetilide, Dronedarone, Sotalol) AIDDS

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31
Q

Name main antibiotics that may cause additive QT prolongation. (U)

A

Quinolones (Ciprofloxacin, Levo, Moxi, Nor, Ofloxacin, Gemi, Spar)

Macrolides (Azithromycin, Erythromycin, Clarithromycin, Telithromycin)

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32
Q

Which Azole antifungal is most responsible for causing additive QT prolongation? (U)

A

Voriconazole

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33
Q

Which anticancer is most responsible for causing additive QT prolongation? (U)

A

Nilotinib

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34
Q

Which SSRI is most responsible for causing additive QT prolongation? (U)

A

Citalopram (Celexa), escitalopram

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35
Q

What’s the max dose of citalopram to prevent additive QT prolongation?

A

40mg/d

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36
Q

When is 20mg citalopram the max dose to prevent additive QT prolongation?

A 
60+ years
Liver impairment
HF 
S/P MI
2C19 poor metabolizer
Pt on 2C19 inhibitors
Taking QT prolonging drugs
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37
Q

Whats the max dose in for Escitalopram (Lexapro) to prevent additive QT prolongation?

In the elderly?

A

20mg/d

Don’t exceed 10mg/d

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38
Q

What’s the preferred antidepressant in cardiac pts to prevent QT prolongation?

A

Sertraline (Zoloft)

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39
Q

What antidepressant should be avoided if pt has cardiac risk?

A

Citalopram

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40
Q

Which antiemetic agent is most responsible for causing additive QT prolongation? (U)

A

5-HT3-receptor antagonists (Dolasetron, Ondansetron, Granisetron, Palonosetron)

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41
Q

Which antipsychotic is most responsible for causing additive QT prolongation? (U)

A

Thioridazine

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42
Q

Which other agent is most responsible for causing additive QT prolongation? (U)

A

Methadone

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43
Q

What’s the 2 main reasons antiarrhythmic drugs are used?

A

Rhythm
Class I and III (used to terminate arrhythmias and restore and maintain normal sinus rhythm)
Rate
Class II and IV and Digoxin (used to slow ventricular rate during a Supraventricular arrhythmias)

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44
Q

What class of antiarrhythmic drugs is used to terminate arrhythmias and restore and maintain normal sinus rhythm? Cardioversion

A

Class I and III
Disopyramide, Quinidine, Procainamide,
Lidocaine, Mexiletine
Flecainide, Propafenone,

Amiodarone, Ibutilide, Dofetilide, Dronedarone, Sotalol (AIDDS)

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45
Q

What class of antiarrhythmic agent is used to slow ventricular rate during a Supraventricular arrhythmias?

A

Class II
Beta-blockers

Class IV
Verapamil, Diltiazem

Digoxin

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46
Q

What must be done prior to starting any medication for NON-LIFE-THREATENING arrhythmia? (U)

A

Check pts electrolytes

AND

Run a toxicology screen

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47
Q

What’s the Vaughan Williams classification of antiarrhythmics?

A

Class I a, b, c

Class II

Class III

Class IV

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48
Q

List drugs that are listed as class Ia.

A

Double Quarter Pounder

Disopyramide

Quinidine

Procainamide

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49
Q

List drugs that are listed as class Ib

A

Lettuce, Mayo

Lidocaine

Mexiletine

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50
Q

List drugs that are listed as class Ic

A

Fries Please

Flecainide

Propafenone

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51
Q

List drugs that are listed as class II

A

Beta-blockers

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52
Q

List drugs that are listed as class III

A

DDSIA
Dieting During Stress Is Awful

Dofetilide

Dronedarone

Sotalol

Ibutilide

Amiodarone

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53
Q

List drugs that are listed as class IV

A

Verapamil

Diltiazem

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54
Q

How are class I antiarrhythmics sub-classified?

A

They are Na channel blockers. Proarrhythmic (increase arrhythmia risk). -Inotrope (decrease force of heart contraction)

They are divided based on the DURATION of time they bind to Na channel

Ia - Intermediate Na channel blockers and they also block K channel

Ib - Fast Na channel blockers

Ic - Long Na channel blockers

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55
Q

Define class Ia antiarrhythmics

A

INTERMEDIATE Na + K channel blockers

Double Quarter Pounder

Disopyramide

Quinidine

Procainamide

56
Q

Define class Ib antiarrhythmics

A

FAST Na channel blockers

Lettuce, Mayo

Lidocaine

Mexiletine

57
Q

Define class Ic antiarrhythmics

A

LONG Na channel blocker

Fries Please

Flecainide

Propafenone

58
Q

MOA of class Ia antiarrhythmics?

A

REDUCE conduction velocity and automaticity

INCREASE refractory period

59
Q

What’s the black box warning associated with Quinidine (class Ia)?

A

Control AV conduction BEFORE initiating-may increase mortality in AFib or flutter

Warning: DILE- avoid G6PD deficient-can cause positive Coombs test

60
Q

SE of quinidine (class Ia)? (U)

A

Diarrhea (35%)

Stomach cramping (22%)

QT prolongation

Hepatotoxicity

Nausea/vomiting

Lightheadedness

Cinchonism (tinnitus, hearing loss, blurred vision, headache, delirium)

61
Q

Are the different salts of quinidine interchangeable

A

No!

267mg of gluconate = 200mg of sulfate form

62
Q

What’s unique about Procainamide injection?

A

Has a active metabolite - N-acetyl Procainamide (NAPA)

NAPA is really cleared

63
Q

What’s the black box warning associated with Procainamide injection?

A

Fatal blood dyscrasias e.g. Agranulocytosis

Long-term use -> Positive antibody (ANA) in 50% of pts which may result in DILE

64
Q

SEs of Procainamide injection?(u)

A

Hypotension

Rash

DILE

QT prolongation

Agranulocytosis

65
Q

What’s the SE of Disopyramide?

A

Anticholinergics effect (xerostomia, constipation, urinary constipation)

Can cause HF, BPH, urinary retention, narrow angle glaucoma, and myasthenia gravis (due to anticholinergic effects

66
Q

Effect of class Ia agents (double quarter pounder) on QT prolongation?

A

ALL class Ia can have additive QT prolongation with other agents that also prolong the QT interval

67
Q

What are class Ib agents (Mayo, Lettuce) ONLY used for?

A

Ventricular arrhythmias (no efficacy for Supraventricular arrhythmias such as AFib)

68
Q

When are class Ic agents absolutely contraindicated?

A

Structural Heart issues:

Patients with heart failure (HF)
OR
myocardial infarction (MI)

69
Q

MOA of class II antiarrhythmics?

A

Block beta-blockers (block the sympathetic activity that may be causing the arrhythmia)

AND

Indirectly block Ca channels= decrease in ion conduction speed

slows the rate

70
Q

What are class II antiarrhythmics used for?

A

To slow the ventricular rate in Supraventricular tachyarrhythmia (eg. AFib)

71
Q

MOA of class III agents? (AIDDS)

A

Blocks K channels -> significant increase in refractory period

72
Q

What’s the exception to the MOA of class III agents?

A

Ibutilide - works by activating the late inward Na current which also results in increased refractory period

73
Q

In addition to blocking K channel, what other channels/receptors do Amiodarone and Dronedarone act on?

A

They also block

Alpha & beta adrenergic receptors

Ca channels

Na channels

74
Q

In addition to blocking K channel, what other channels/receptors do Soltalol act on?

A

Significant B-adnerergic receptor blocker

75
Q

What’s the class of amiodarone? And brand name?

A

Class III

Pacerone
Nexterone

76
Q

What’s the black box warning of amiodarone?

A

Pulmonary toxicity, hepatotoxicity, proarrhythmic- use ONLY for life-threatening arrhythmias. Pts should be hospitalized when LOADING DOSE is given

77
Q

SE of amiodarone (cordarone/pacerone)

A 
WARNING:
hyper/HYPO thyroidism (inhibits T3->T4)
----chemical structure contains iodine(like    thyroid hormone)
Optic neuropathy
photosensitivity- SLATE BLUE SKIN
neurotoxicity-(peripheral neuropathy)
SJS/TEN
Hypotension 
Bradycardia
Corneal microdeposits
Dizziness 
Ataxia
GI upset N/V
Constipation
Tremor
Photosensitivity
DILE

Hypo/hyperthyroidism (more hypo than hyper)

Bradycardia

78
Q

What considerations are taken when amiodarone (cardarone, pacerone, nexterone) will be infused over 2 hrs?

A

Should be admin in a non-polyvinyl chloride (non-PVC) container such as polyolefin or glass

Recommended to be added to D5W

79
Q

What’s the advantage of premixed IV bag? (U)

A

Comes in GALAXY container (nonPVC, nonDEHP)
Longer stability-24 months at room temp

PVC bag not an issue

Comes in commonly used concentrations

80
Q

What’s the half- life of amiodarone?

A

40-60 days

81
Q

When’s amiodarone recommended?

A

Commonly used antiarrhythmic despite all it’s side effects

Antiarrhythmic drug of choice in pts with heart failure

82
Q

Which is the class III agent has to be given with meals?

A

Dronedarone - 400mg PO BID with meals

83
Q

What’s the black box warning of Dronedarone?

A

Increased risk of death, stroke, or HF in pts with decompensated HF (class IV or any class with a recent hospitalization) or permanent AFib

84
Q

SE of Dronedarone? (U)

A

Warning: hepatic failure, pulmonary disease (including fibrosis and pneumonitis)

QT prolongation
Bradycardia
Increased SCr (and possibly BUN)
N/V/D
ab pain
Hypokalemia
Hypomagnesemia

note: no iodine in structure so little/no thyroid effects

85
Q

What’s the pregnancy cat. of Dronedarone?

A

X

86
Q

When’s Dronedarone used?

A

Only in pts who can be converted to normal sinus rhythm

87
Q

What’s the monitoring parameters for Tikosyn (Dofetilide)?

A

Box: continuous ECG monitoring

and CrCl monitoring for a minimum of 3 days after initiation or re-initiation

88
Q

What’s the effect of ALL class III agents on QT prolongation?

A

Can have additive QT prolongation with other agents that also prolong the QT interval

89
Q

What should be considered wrt to electrolytes and ALL anti-arrhythmic?

A

Electrolyte abnormalities (k, Na, Ca, Mg) should be corrected before any antiarrhythmics is initiated

90
Q

What’s the consequence of not correcting electrolyte before initiating antiarrhythmics?

A

Risk of arrhythmia is increased

91
Q

What should be avoided with use of class III antiarrhythmics?

A

Grapefruit juice/pdts

Ephedra

St. John’s wort (P-glycoprotein inducer)

92
Q

What meds should be reduced when starting amiodarone? By how much?

A

Digoxin (reduce by 50%) and Warfarin (reduce by 30%-50%)

93
Q

What class of drugs should use lower doses with amiodarone?

A

Simvastatin, Lovastatin, Atorvastatin

94
Q

T/F? Monitor INR after initiating Dronedarone in pts with Warfarin

A

True

95
Q

MOA of class IV agents?

A

They block L-type Ca channels, slowing SA and AV nodal conduction velocity

96
Q

Uses of class IV agents?

A

Used to slow ventricular rate in Supraventricular tachyarrhythmia

97
Q

List agents under class IV antiarrhythmics?

A

Diltiazem (Cardizem)

Verapamil (Calan/ Verelan/ Covera HS)

98
Q

What type of CCBs are used in antiarrhythmics?

A

Only non-dihydropyridine CCBs are used

99
Q

When is CCB is preferred over b-blocker in pts with arrhythmias?

A

If co- existing asthma/COPD in pts

100
Q

Other antiarrhythmics not included in Vaughan Williams classification?

A

Adenosine (Adenocard)

Digoxin (Lanoxin)

101
Q

MOA of adenosine?

A

Slows conduction through the AV node via activation of adenosine-1 receptors

102
Q

Uses of adenosine in arrhythmias?

A

Used to restore normal sinus rhythm in Supraventricular re-entrant tachyarrhythmia

103
Q

Effects of digoxin?(u)

A

Digoxin enhances vagal tone, resulting in decrease ventricular rate in atrial tachyarrhythmia

104
Q

What’s the brand name of digoxin? (U)

A

Lanoxin, Digitek, Digox

105
Q

What’s the therapeutic range of digoxin (lanoxin) for AFib?

A

0.8-2 ng/mL

106
Q

What’s the antidote for Digoxin (lanoxin)?

A

DigiFab

107
Q

Whats the first signs of digoxin (lanoxin) toxicity? (U)

A

Nausea/vomiting

Loss of appetite

Bradycardia

108
Q

Other signs of digoxin (lanoxin) toxicity? SEVERE

A

Blurred/ double vision

Altered color perception

Greenish-yellow halos around lights or objects

Abdominal pain

Confusion

Delirium

Arrhythmia (prolonged PR interval, accelerated junctional rhythm, bidirectional ventricular tachycardia)

109
Q

Is digoxin (lanoxin) used alone?

A

Not usually

Used in combo with b-blockers or CCB

110
Q

Since digoxin is mostly renally cleared, whats the concern with digoxin (lanoxin) use here?

A

In decreased renal fxn -> reduce digoxin dose

In acute renal failure -> hold digoxin

111
Q

What increases risk of digoxin (lanoxin) toxicity?

A

Hypokalemia (K < 3.5 mEq/L)

Hypomagnesemia

Hypercalcemia

112
Q

Role of medication guide in amiodarone dosing?

A

Dispense medication guide with amiodarone

113
Q

Should amiodarone be taken with food?

A

Amiodarone can be taken with/ without food.

BUT, if you should stick to which ever method you use e.g. If you start taking amiodarone with food, then you need to continue taking it with food, while on the med

114
Q

What body organs need to be monitored while in amiodarone?

A

ECG BP HR

electrolytes

pulmonary function (chest x-ray)

Thyroid- baseline q 3-6 mo

LFTs- baseline and q 6 mo

eye exams

115
Q

Photosensitivity and amiodarone?

A

Amiodarone may cause your skin to be more sensitive to the sun.

Stay out of the sun

Can cause skin to turn blue-gray (not harmful & goes away months after drug is stopped)-infrequent

116
Q

What’s the brand name for Dronedarone?

A

Multaq

117
Q

What’s the potassium safe range for pt on digoxin?

A

3.5-5 mEq/L

118
Q

What’s arrhythmias?

A

Caused by abnormalities in the formation and/or conduction of these electrical impulses

119
Q

Amiodarone unique injection info

A

Incompatible with heparin-use saline flush

Use 0.22 micron filter

120
Q

adenosine brand?

A

Adenocard

t 1/2 less than 10 seconds
used in paroxysmal supra ventricular tachycardia (PSVT)-activates adenosine receptors=decrease AV node conduction

121
Q

dofetilide brand?

A

Tikosyn

122
Q

Ibutilide brand?

A

Corvert

123
Q

Sotalol brand?

A

Betapace, Sotylize, Sørine

Non-selective beta blocker

Box: adjust dosing interval based on CrCl (QT prolongation directly related to stall concentration)

124
Q

Propafenone brand

A

Rythmol

Note: can cause metallic taste disturbance

125
Q

lidocaine brand

A

Xylocaine

used for refractory VT/ cardiac arrest

126
Q

disopyramide brand

A

Norpace

127
Q

non-DHP CCB side effects

A

edema, HA, dizzy, hypotension, arrhythmia, HF, constipation (more with verapamil), gingival hyperplasia

128
Q

Amiodarone inhibits

A

2C9, 2D6, 3A4, P-gp

129
Q

Amiodarone is a substrate of

A

3A4, 2C8, and p-gP

Avoid strong inducers/inhibitors

130
Q

amiodarone + digoxin

A

when starting amiodarone decrease Digoxin by 50%

131
Q

amiodarone+ warfarin

A

when starting amiodarone decrease warfarin by 30-50%

132
Q

amiodarone + statin

A

simvastatin max 20mg/d

lovastatin max 40 mg/d

133
Q

Do NOT use amiodarone with

A

sofosbuvir (Sovaldi) used for Hep C

it enhances the bradycardia effect of amiodarone

134
Q

statins that are not 3A4 metabolized

A

prava, rosuva, pitava

135
Q

typical digoxin dose

A

0.125-0.25 mg PO daily

when CrCl<50 decrease dose or decrease dose frequency

136
Q

oral to IV

A

decrease oral 20-25% when going to IV

137
Q

digoxin use

A

to help heart beat at more regular RATE

Na-K-ATPase blocker: blocking that pump=
Increase force (+inotrope)
Decrease HR (-chronotrope)

Cardio 1228 (17 decks)

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