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Cardiology > Antiarrhythmic drugs > Flashcards

Antiarrhythmic drugs Flashcards

1
Q

How many classes of Antiarrhythmic drugs are there? List the mechanism of action?

A

Class: (4)

  1. I - Na Channel Blockade
  2. II - Beta receptor Agonist
  3. III - K Channel Blockers
  4. IV - Ca Channel blockers
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2
Q

How are Na blockers further divided?

A

1a, 1b and 1c

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3
Q

What are the disadvantages of this system?

A
  1. Some drugs have actions of more than one class
  2. Some drugs don’t fall into a class at all
  3. A drugs indication cannot always be easily deduced from its class
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4
Q

What is the primary effect on the action potential of Na Channel blockers?

A

Slows depolarization on fast action potential cells

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5
Q

What is the primary effect on the action potential of beta receptor agonists?

A

Slows depolarization in slow action potential cells

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6
Q

What is the primary effect on the action potential of potassium channel blockers?

A

Prolongs the action potential.

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7
Q

What is the primary effect of Calcium channel blockers on the action potential?

A

Slows depolarization in slow action potential cells

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8
Q

What is atrial fibrillation?

A

Supra ventricular tachycardia, characterized by ineffectice, chaotic, irregular and rapid (300-600 BPM) resulting in the deterioration atrial function

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9
Q

What is AF caused by?

A
  1. Rapidly firing cells located at the junction of the pulmonary veins with adjacent muscle
  2. Above responsible for disorganised arterial depolarisation and ineffective atrial contraction
  3. Results in irregular ventricular beat
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10
Q

What happens if AF occurs in where there is a large atrium eg in mitral stenosis?

A

This is a predisposing for thromboembolism

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11
Q

How is the long term stroke risk assessed in AF?

A

Collectively assessed CHADS2 score

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12
Q

What is the CHADS2 score?

A
  1. Congestive heart failure
  2. Hypotension
  3. Age>75
  4. Diabetes Melitus
  5. Prior stroke
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13
Q

How is anticoagulation based

on CHAD2 score?

A
  1. 0 = low risk: Aspirin or no treatment, no antithrombolytics
  2. 1 = moderate: Aspirin and warafarin, aspirin daily or raise INR to 2.0-3.0
  3. 2 or > = moderate or high risk warfarin, raise INR to 2-3 unless GI bleed risk
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14
Q

What is CHA2DS2-VAS2 score?

A

Inclusion of additional stroke risk modifier factor:

  1. include age 65-74, female gender and vascular disease
  2. In the CHA2DS2-VASc score > age 75 extra weight with 2 points
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15
Q

What is CHA2DS2-VAS2 score?

A

Inclusion of additional stroke risk modifier factor:

  1. include age 65-74, female gender and vascular disease
  2. In the CHA2DS2-VASc score > age 75 extra weight with 2 points
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16
Q

What is the pathology of AF?

A

Primary change is the progressive fibrosis of the atria

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17
Q

What is fibrosis due to?

A
  1. Atrial dilation
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18
Q

What is dilation of the atria due to?

A
  1. Any structural abnormality of the heart giving a rise in BP
  2. Hypertension, heart failure, MI, MS, thyrotoxicosis and alcohol
  3. Obesity, metabolic syndrome, diastolic days, sleep apnoea, stress, tall stature
  4. Genetic disposition
  5. Any inflammatory state
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19
Q

What does enlargement of the left atria result in?

A
  1. Turbulence and stasis of blood
  2. Thrombus may embolise in peripheral circ
  3. Thrombus may result in TIA or stroke of major organ
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20
Q

What does embolisation from the right atrium cause?

A

Pulmonary emboli

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21
Q

What chain of events does AF leas to?

A
  1. Activation of the RAA system
  2. Increase in matrix metaloproteinases
  3. Increase in disintigrin
  4. Leads to atrial remodelling
  5. Loss of atrial muscle mass
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22
Q

Where else does fibrosis occur?

A
  1. SA node
  2. AV node
  3. Correlates to sick sinus syndrome
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23
Q

What are the classification and clinical types of AF?

A
  1. Recent onset or first diagnosed
  2. Paroxysmal
  3. Persistent
  4. Long standing persistent
  5. Permanent AF
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24
Q

What is recent onset or first diagnosed AF?

A
  1. Patients who present for first time

2. May or may not reoccur

25
Q

What is paroxysmal AF?

A
  1. Self terminating
  2. Episodes last up to 10 days, 48hr time point critical since spontaneous conversion is low and anticoagulation needs to be considered
  3. Recurrent
26
Q

What is persistent AF?

A
  1. Does not self terminate

2. Cardio version by drugs or DCC needed to restore sinus rhythm

27
Q

What is permanent AF?

A
  1. Rhythm control interventions abandoned

2. Arrhythmia accepted

28
Q

What are the clinical features of AF?

A
  1. Asymptomatic
  2. Palpitations
  3. Chest pain
  4. Hypotension
  5. Dyspnoea
  6. Dizziness
29
Q

AF is common after?

A
  1. Stroke
  2. Thromboembolism
  3. HF
30
Q

Why is a manual pulse performed?

A

To detect the presence of an irregular pulse. following symtomsbof AF. Patients maybe:

  1. Breathless/Dyspnoea
  2. Palpitations
  3. Syncope/Dizziness
  4. Chest discomfort
  5. Symptoms associated with stroke and TIA
31
Q

How is AF clinically evaluated?

A
  1. History
  2. Determination of European Heart Rhythm Assoc (EHRA) score
  3. Estimation of CHADS2/CHA2DS2-VASc
  4. Predisposing issues, Hypertension, valvular HD, cardiomyopathy
    5.
32
Q

What do NICE suggest?

A
  1. Determine stroke risk

2. Bleeding risk

33
Q

How do you use stroke risk?

A

Use CHA2DS2-VASc in people with the following:

  1. Symp or asymp paroxysmal, persistent or permanent AF
  2. Atrial flutter
  3. Risk of AF after car diversion after sinus rhythm
34
Q

How do you use bleeding risk to evaluate AF?

A

Use HAS-BLED to assess risk of bleeding in people starting anticoagulation. Offer monitoring of the following?

  1. Uncontrolled hypertension
  2. Poor control of INR
  3. Concurrent medication ie aspirin
  4. Harmful alcohol consumption
35
Q

What is the European Heart Rhythm Association EHRA score?

A
  1. EHRA I - No symptoms
  2. EHRA II - Mild symp, daily activity not affected
  3. ERHA III- Severe symp, daily activity affected
  4. EHRA IV- Disabling symp, daily activities ceased
36
Q

How is the HAS-BLED therapeutic bleeding risk stratification score for those on anticoagulation calculated?

A
  1. Hypertension sys>=160mmHg = 1
  2. Abnormal renal function. = 1
  3. Abnormal liver function. = 1
  4. Age >= 65. = 1
  5. Stroke in past. = 1
  6. Bleeding. =1
  7. Labile INRs. =1
  8. Taking other drugs. =1
  9. Alcohol at the same time. =1
37
Q

What does the HAS-BLED. score mean?

A

Score of above 3 or more indicates increased one year bleed risk on anticoagulation sufficient to justify caution or mor regular review

38
Q

What is the anticoagulation based on the CHA2DS2 score?

A
  1. Score 0 - Aspirin or no treatment, no anthrombotic therapy
  2. Score 1 - Aspirin or warfarin daily or raise INR to 2 - 3
  3. Score 3 or> Warfarin raise INR to 2/3 unless contraindicated is GI bleed
39
Q

Why was CHA2DS2-VASc introduced?

A

Additional stroke risk modifiers were were developed:

  1. Age 65-75 females
  2. Vascular disease
  3. Age >= 75 additional 2 points
40
Q

What anticoagulation. therapy can be offered?

A
  1. Apixiban, dabigatran, riveroxaban, etexilate or. vitamin K antagonist
    2.
41
Q

When is anticoagulation offered?

A
  1. Men - consider anticoagulation in CHA2DS2-VASc score of 1. Take bleeding risk into consideration.
  2. Offer anticoagulation to people with CHA2DS2-VASc score of 2
42
Q

How does AF affect pulse?

A

Apex/radial pulse deficit

43
Q

What is the principle investigation for AF?

A
  1. ECG - 24 hour ambulatory in suspected asymptomatic cases

2. Event recorder for those with symptomatic episodes

44
Q

What other investigations are done ?

A
  1. FBC
  2. U/E
  3. TFTs
  4. CXR
  5. Echo
45
Q

What are the key differential diagnoses

A
  1. Multiple atrial or ventricular ectopics

2. AV block

46
Q

What are the management considerations?

A
  1. Control of AV rate during paroxysmal or persistent AF
  2. Restoration of sinus rhythm (electrical/drug)
  3. Prevention of thromboembolism
  4. Prevention of reoccurrence
  5. Long term rate control of those with permanent AF
47
Q

What are the three main therapeutic aims in drug treatment of AF?

A
  1. Control of ventricular rate
  2. Chemical cardioversion to sinus rhythm
  3. Prevention of thromboembolism
48
Q

What drugs are used in ventricular rate control of AF?

A
  1. Beta blockers or rate limiting Ca antagonists should be initial monotherapy
49
Q

What drugs are used in chemical cardioversion

A

Class IV, I and III drugs

50
Q

What are the class I drugs for AF?

A
  1. Class 1a: duration of AP is increased
  2. Class 1b: duration of AP decreased
  3. Class 1c: duration of AP is unchanged
51
Q

What are class 1a drugs in AF?

A
  1. Quinidine
  2. Procainamide
  3. disopyrimide
52
Q

What are the class 1b drugs in AF?

A
  1. Lignocaine

2. Phenytoin

53
Q

What are class 1c AF drugs?

A
  1. Flecainide
54
Q

What are class III AF drugs?

A
  1. Amiodarone
  2. Bretylium
  3. Sotalol (also appears in group II)
55
Q

What are class IV AF drugs?

A

These are the channel blockers:

  1. Verapamil (not nifedipine group)
  2. Should be not be used for tachyarrhythmias with wide QRS complex
  3. Also not in AF with pre-exitation eg Wolf Parkinson syndrome
56
Q

In AF when is rate control offered?

A

Offer rate control as a first line strategy in AF:

  1. Where AF is reversible
  2. Who have heart failure (primary cause)
  3. New onset AF
  4. With atrial flutter ( considered suitable for ablation)
57
Q

What rate control drugs are used in AF?

A
  1. Standard Beta blocker other than sotalol
  2. Ca channel blocker
  3. Digoxin only in sedentary patients
  4. Do not offer amiodarone for long term
58
Q

What ate the non drugs treatment for AF?

A
  1. DC cardio version
  2. Pacemaker implantation
  3. Radio frequency ablation
  4. Surgical intervention

Cardiology (23 decks)

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