Arrhythmia 2

Question 1

WHat are the 2 primary complications that can happen in AF and AFL ?

Answer 1

1. Rapid ventricular response
   -Problematic in HF pt’s bc of reduced diastolic fill time
   -Problematic in IHD/anginal pt’s (increased MVO2)
2. Arterial embolization = STROKE

Question 2

What’s a general term to describe Atrial Fib?

-Multiple ___

Rapid atrial rate of ?
Ventricular rate of?

Answer 2

Irregularly IRREGULAR

atrial Re-entrant loops

400-600 beats/min
120-180 beats/min

Question 3

Atrial Flutter
-Does it occur more or less often than AF?

-Single, dominant reentrant substrate

What are the 2 types of AFL?

Rapid atrial rate of?

How would you describe AFL?

Answer 3

Less often than AF

Type 1 = more common, classic sawtooth form
Type 2 = faster and is a hybrid arrhythmia between AF and AFL

270-330 beats/min

Irregularly REGULAR

Question 4

What is VALVULAR AFIb?

Answer 4

Pt’s with AFIB and clinically signif valv heart disease (use of prosthetic mechanical heart valves or mod to severe mitral stenosis)

Question 5

Sx’s of AFIb and AFL?

What are the common sx’s? (5)
Severe sx’s?

Answer 5

Chest palpitations, SOB, Dizziness, Lightheadedness, reduced exercise tolerance

Anginal chest pain , Hypotension , pulm edema

Question 6

What are the 3 general tx steps for managing AFIB and AFL?

Answer 6

STep 1 : Evaluate need for acute tx using cardioversion vs rate control

Step 2 : Contemplate restoration of sinus rhythm taking into consideration risks or just control the ventric rate and leave pt in arrhythmia

Step 3 : Consider ways to prevent long term consequences of AF (Prevent thromboemb and recurrence of AF)

Question 7

STEP 1 : CARDIOVERSION ?

Ask yourself if the pt is ?

If Yes, what should you do?

If No, What should u do?

Answer 7

Hemodynamically unstable (Severe hypotension, angina, pulm edema)

-Cardiovert immed w/o regard to embolic risk
-Initiate IV heparin or SQ LMWH immed
-Post cardioversion 4 weeks warfarin (inr 2-3) or DOACS

Control ventric rate using AV nodal blocking agents
-Start therapeutic anticoag (IV heparin or SQ LMWH)

Question 8

Step 1 : HR control

1. what agents to avoid?
2. What if ur pt DOES NOT have decomp HF? (3)
3. What if they DO have decomp HF? (2)

IV amio might do what ?

4. For AF or AFL precipitated by states of increased adrenergic tone, they’re often resistant to digoxin…. what should u use?

Answer 8

1. Class 1a and 3 agents (Incr HR)
2. use diltiazem, verapamil, or IV beta blockers
3. Digoxin works but slow onset (24-48 hrs)
   -IV amiodarine is appropriate
   -IV amio might facilitate conversion to NSR, and place pt at risk for thromboembolic event if a clot is present
4. Beta blockers

Question 9

What medications are used for IMMEDIATELY controlling HR? (6)

Answer 9

1. Esmolol
2. Metoprolol
3. Diltiazem
4. Verapamil
5. Digoxin
6. AMiodarone

Question 10

AFIb/AFL Step 1

Start : Is patient hemodynam unstable? Do they have severe hypotension, angina, or pulm edema?

1. Yes
   a. What do you do first ?
   b. Whats the dosages for cardioversion using electricity?
   c. For anticoag, what agents to use?
   d. What if they’re likely to flip back into AF?
2. NO
   A. What do u do?
   -What agents to use if they DONT have decomp HF?
   -What agents to use if they DO have decomp HF?
   B. For anticoag to these patients, what should u use?

Answer 10

1a. Immediate electrical cardioversion to NSR
b. AFL = 50 J
AFIB = 200 J

c. Heparin IV 60 units/ kg fb 12 units/kg/hr or if known thrombus present us 80/18
-SQ LMWH works too

d. If no, discharge home with 4 weeks of oral AC like warfarin or eliquis
-if yes, proceed to step 3

2a. Control AV node to avoid RVR
-esmolol, metoprolol, diltiazem, verapamil
-amiodarone, digoxin

2B. Heparin IV 60/12 or 80/18
-SQ LMWH Enoxaparin 1mg/kg SQ q12 hrs
-

Question 11

Restoration of sinus rhythm is associated with an increased risk of ?
-Sinus rhythm promotes effective __ which may dislodge ___

Answer 11

thromboembolism

Atrial contractions, poorly adherent thrombi

Question 12

Step 2 : Anticoag prior to Cardioversion
-Prevents Clot growth

Several weeks of anticoag PRE cardioversion needed using ?

Exception ? Those with AF or AFL of recent onset (____) MAY NOT NEED ANTICOAG pre-cardioversion because ?

In general , how long anticoag POST cardioversion?

Answer 12

1. Warfarin dose to INR 2-3, or DOACs
2. < 48 hrs, usually takes > 48 hrs to effectively form a thrombus, however in clinical practice we likely will use anticoag
3. 4 weeks of anticoag

Question 13

How to see if theres a thrombus or clot in left atrial appendage? (What procedure to view it?)

Answer 13

TEE (Transesophageal echo)

Question 14

STEP 2 : If thrombus NOT present
-Initiate IV _____
-WHat to use 4 weeks post cardioversion?

2. If thrombus is present
   -Initiate anticoag using ?
   -Can use DOACS such as ___ at what dosing instead?
   -Which agents need 5-10 days parenteral therapy first ?
   -DO NOT ___ until ___ is gone

Answer 14

1. Heparin during TEE AND cardioversion
   -warfarin or DOAC
2. Heparin (80/18)/LMWH plus warfarin until inr 2-3 and then dc heparin or LMWH
   - eliquis or rivaroxaban (VTE DOSING)
   -Dabigatran and edoxaban
   -Cardiovert, thrombus

Question 15

Step 2 : Rhythm COntrol

WHat are the 2 methods u can use?

If using electricity, what might u need to do ? Small risk for?

When using AAD’s, what drugs will work ?
Which ones may work better?

Answer 15

1. DC cardioversion (Electricity) ( 50 J for AFL, 200 J for AFIB)
   Antiarrhythmic drugs
2. Need for mod sedation
   -Sinus arrest, or ventric arrhythmias
3. Class 1A, 1C and 3 all work
   - Class 1C and Class 3

Question 16

Pharm Conversion of AF to NSRhythm

If pt in AFIB with
1. Normal LV function ? (3)
2. HFrEF with LVEF <=40 ? (1)
3. AF occuring outside hospital in pt’s with normal LV function ? (2)

4. Make sure your pt is successfully ____ with AV nodal blocking drugs prior to giving AAD’s

Answer 16

1. IV amiodarone , Ibutilide
   -Procainamide (eh)
2. IV amio
3. Flecainide, Propafenone
4. rate controlled

Question 17

AAD’s used to Restore SINUS RHYTHM : For each, state class and Dosing

1. Procainamide
2. Flecainide
3. Propafenone
4. Ibutilide
5. Amiodarone
6. Which agent is less effective than class 1c and 3 agents?

Answer 17

1. 1a , 1000 mg IV over 30 min followed by 2 mg/min continuous for 60 mins
2. 1c
   -< 70 kg, 200 mg PO x1
   > 70 kg 300 mg PO x 1
3. 1c
   <70 kg 450 mg PO x1
   >70 kg 600 mg PO x 1
4. Class 3. 1 mg IV over 10 min if > 60 kg,
   0.01 mg/kg IV over 10 min (wt < 60 kg)
5. Class 3. 150 mg IV over 10 min then 1 mg/min x 6 hrs then 0.5 mg /min thereafter
6. Procainamide

Question 18

Step2 : RATE CONTROL
1. Continue to use ___ and ___ but convert to?
2. WHat kind of HR for those with LVEF < 40?
3. What kind of HR for those with LVEF > 40 and stable sx’s?

4. If LVEF > 40%, what kind of AV nodal blocking agents?
5. IF LVEF < 40%, what AV nodal blocking agents?

Answer 18

1. AV nodal blocking agents , anticoags, convert to orals
2. STRICT HR
   -At rest < 80 bpm
   -exercise < 100 bpm
3. LENIENT HR
   -HR at rest < 110 bpm
4. Oral B blockers, diltiazem, Verapamil +/- Digoxin
5. Metoprolol succinate or carvedilol +/- Digoxin

Question 19

STEP 2 AFIB or AFL CHART For Rate and Rhythm control

Answer 19

See chart

Question 20

Step 3 : Prevention of Long term Consequences (Thromboembolic events)

CHADSVASc Score
-What is it used for ?

Name all of the 7 risk factors and the points they add to the score!

Answer 20

Its used to predict /estimate risk of stroke in pt’s with NON -VALVULAR AFIB

1. Age
   -If >= 75 yrs =2 points, 65-74 years = 1 point
2. Diabetes = 1 point
3. Female sex is 1 point
4. HEART FAILURE (Right and left) 1 point
5. Hypertension is 1 point
6. Stroke, TIA, or thromboembolism is 2 points
7. Vascular Disease (PAD, SIHD/ACS, aortic plaque) is 1 point

Question 21

State the score that correlates with Low, intermediate, and high risk, and the suggestions towards anticoag use

1. Low
2. Intermed
3. high

Answer 21

1. Score = 0 (0 in men, 1 in women)
   - Reasonable to OMIT anticoag
2. Score = 1 (1 in men, 2 in women )
   -CONSIDER anticoag
3. Score 2-9, (2 in men, 3 in women)
   -STRONGLY RECCC anticoag

Question 22

Anticoag for Valvular vs NON valvular AF :

1. Which anticoags to use for valv vs non valv?
2. WHat’s the coumadin starting daily dose for < 70? >=70?

* Bridging??

Answer 22

VALVULAR : Mod to severe mitral stenosis or mechanical heart valves
-Warfarin to INR 2-3

NON : Warfarin INR 2-3
-Oral Factor XAI’s (Riva, apixa, edoxa),
-Oral DTI (Dabigatran)

< 70
1. AA = 7.5 mg
CAUC/HISP = 5 mg
ASIAN = 2.5 mg

2. AA = 5 mg
   CAUC/HISP Male = 5 mg, female 2.5 mg
   ASIAN = 2.5 mg

Question 23

Step 3 : Prevention of Recurrence of AF or AFL using AAD’s

1. If pt has normal LV function, no prior MI or signif structural HD, what drugs can u use? (6)
2. If prior MI or signif struc hd, including HFrEF (LVEF <= 40%) what agents? (3)
   - If NYHA FC 3 or 4 or recent decomp HF what should u avoid or use?

Answer 23

1. dofetilide
   -dronedarone
   -flecainide
   -propafenone
   -amiodarone
   -Sotalol (Last recc)
2. Amiodarone, dofetilide, sotalol (last recc)

• If yes , DONT USE DRONEDARONE
  -If NO, ok to use dronedarone

Question 24

If you’re in Step 3 and ur preventing stroke, what class of agents are you using?
-What if your pt has valvular vs non valvular hd? which Anticoag are u using then?

If you’re in step 3 and preventing recurrence or maintaining NSR, what agents will u be using?

See step3 chart

Answer 24

1. Strictly anticoags after assessing CHADSVASC score and HASBLED
   -Warfarin only!
2. AAD’s

** See chart **

Question 25

Paroxysmal Supraventric Tachycardia (PSVT) -Signs and sx's? (7) -Etiolgy ? (ALOT)

Answer 25

1. Anxiety chest tightness palpitations rapid pulse SOB Dizziness fainting 2. -Hyperthyroidism * Caffeinated beverages * Nicotine, alcohol, Ecstasy, cocaine, amphetamines * Anxiety * Digoxin toxicity * Myocardial infarction, pericarditis, myocarditis, cardiomyopathy * Pulmonary embolism * Rheumatic heart disease, mitral valve prolapse * Hypoxia

Question 26

Tx Algorithm PSVT 1. Start with ? (2) THEN 2. Hemodynamic Status a. if they're stable? (2) Dose -What if its AVRT vs AVNRT? b. If they're unstable? 3. PSVT usually has a narrow complex with QRS equal to ?

Answer 26

1. Vagal maneuvers (valsalva maneuver, or carotid massage) and or IV adenosine (6mg IV push over 1-3 secs f/b 20-30 mL saline flush) 2a. IV beta blocker or IV non DHP CCB , Metoprolol 5 mg IV or diltiazem 5-10 mg IV +/- drip -AVRT : electricity 50-100 J -AVNRT : IV AMIO (150 mg IV over 10 mins fb 1 mg/min x 6 hrs then 0.5 mg /min 18 hrs) OR Electricity using 50-100 J 2b. Synchronized cardioversion 50-100 J 3. QRS < 0.12 secs

Question 27

Prophylactic Therapy needed to Prevent PSVT recurrence 1. WHen should you use prophylaxis? 2. What NON AAD options can u use? 3. AAD options to prevent recurrence? (7)

Answer 27

1. If frequent episodes require interventions if infreq episodes but severe sx's 2. Radiofreq catheter ablation (RFCA) 3. Amio, beta blockers, dofetilide, flecainide, non DHP CCBS, propafenone, sotalol

Question 28

Ventricular Tachycardia (VT) 1. Wide complex with QRS >= ? 2. What can the onset be related to?

Answer 28

1. 0.12 seconds 2. Hypoxemia, severe electrolyte abnorms like hypokalemia MI Digoxin toxicity

Question 29

TX of STABLE, Monomorphic VT *** 1 . Unstable pt with altered mental status, chest pain and hypotension? 2. Stable pt's WITH structural HD State 5 tx's options in their designated recc order 3. Stable Pt's WITHOUT Structural HD (2 options)

Answer 29

1. Direct Current electrical cardioversion 2. DC cardioversion ** -IV Procainamide ** -IV Amio ** -IV sotalol ** -IV Magnesium if TdP suspected 3. DC cardioversion IV verap or Beta blocker

Question 30

TdP 1. which class is notorious for precipitating TDP? 2. If Hemodynamically UNSTABLE do what 3. If Hemodym stable? -Replace ___ to high norm values of ___ -What drug and what dose? -May repeat once, 5-15 mins later if refractory TdP -Consider repeat doses every ___ hrs if QTc > 500 ms 4. What are some other approaches as secondary tx? ** See chart for conditions that cause long QT**

Answer 30

1. 1A (quinidine) and Class 3 2. DC cardioversion 120 J, 150 J, 200 J 3. Potassium, 4.5-5 mEq/L -Magnesium sulfate 2 grams IV over 1 min - 6 hrs 4. Cardio acceleration with ISOPROTERENOL

Question 31

Bradyarrhythmias 1. Caution with using which drugs? (2) 2. Sx's?

Answer 31

1. SA or AV Nodal blockers such as B blockers or CCB's 2. Hypotension, dizziness, syncope, fatigue, confusion, worsening HF sx's

Question 32

TX of AV block 1. For acute symptomatic AV block? 2. What drugs can u give? (4)

Answer 32

1. Immediate transcutaneous pacing 2. Atropine epinephrine dopamine Isoproterenol

Question 33

CARDIAC ARREST ** 1. Rhythms WITHOUT a pulse A. Shockable (3) B. Unshockable (2) 2. Rhythms WITH a pulse (3)

Answer 33

1A. Pulseless VT -Ventric fibrillation -TDP 1B. Pulseless electrical activity (PEA) --> Use epi 1mg IV push q3-5 mins and Vasopress 40 units IV Push -Asystole --> USe epi and Vasopress 2. Ventric Tachycardia -PSVT Sinus Bradycardia

Question 34

Advanced Cardiac Life support 1. Start ___, give ___ DO this for how long ? 2. If ___ or ___ can give shock 3. If Ventric Fib , or pulseless VT give ___ 4. If pulseless electric activity (PEA) and cant identify etiology manage them with ? 5. What if your pt's in asystole?

Answer 34

1. CPR, oxygen, 2 mins 2. VT, VF 3. AMIOdarone ** See chart for dose 4. Good CPR and Epinephrine, alternating with vasopressin 5. Focus on good CPR, treat with epinephrine , alternating with vasopressin