Arrhythmia 2 Flashcards
WHat are the 2 primary complications that can happen in AF and AFL ?
- Rapid ventricular response
-Problematic in HF pt’s bc of reduced diastolic fill time
-Problematic in IHD/anginal pt’s (increased MVO2) - Arterial embolization = STROKE
What’s a general term to describe Atrial Fib?
-Multiple ___
Rapid atrial rate of ?
Ventricular rate of?
Irregularly IRREGULAR
atrial Re-entrant loops
400-600 beats/min
120-180 beats/min
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?
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
What is VALVULAR AFIb?
Pt’s with AFIB and clinically signif valv heart disease (use of prosthetic mechanical heart valves or mod to severe mitral stenosis)
Sx’s of AFIb and AFL?
What are the common sx’s? (5)
Severe sx’s?
Chest palpitations, SOB, Dizziness, Lightheadedness, reduced exercise tolerance
Anginal chest pain , Hypotension , pulm edema
What are the 3 general tx steps for managing AFIB and AFL?
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)
STEP 1 : CARDIOVERSION ?
Ask yourself if the pt is ?
If Yes, what should you do?
If No, What should u do?
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)
Step 1 : HR control
- what agents to avoid?
- What if ur pt DOES NOT have decomp HF? (3)
- What if they DO have decomp HF? (2)
IV amio might do what ?
- For AF or AFL precipitated by states of increased adrenergic tone, they’re often resistant to digoxin…. what should u use?
- Class 1a and 3 agents (Incr HR)
- use diltiazem, verapamil, or IV beta blockers
- 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 - Beta blockers
What medications are used for IMMEDIATELY controlling HR? (6)
- Esmolol
- Metoprolol
- Diltiazem
- Verapamil
- Digoxin
- AMiodarone
AFIb/AFL Step 1
Start : Is patient hemodynam unstable? Do they have severe hypotension, angina, or pulm edema?
- 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? - 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?
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
-
Restoration of sinus rhythm is associated with an increased risk of ?
-Sinus rhythm promotes effective __ which may dislodge ___
thromboembolism
Atrial contractions, poorly adherent thrombi
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?
- Warfarin dose to INR 2-3, or DOACs
- < 48 hrs, usually takes > 48 hrs to effectively form a thrombus, however in clinical practice we likely will use anticoag
- 4 weeks of anticoag
How to see if theres a thrombus or clot in left atrial appendage? (What procedure to view it?)
TEE (Transesophageal echo)
STEP 2 : If thrombus NOT present
-Initiate IV _____
-WHat to use 4 weeks post cardioversion?
- 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
- Heparin during TEE AND cardioversion
-warfarin or DOAC - 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
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?
- DC cardioversion (Electricity) ( 50 J for AFL, 200 J for AFIB)
Antiarrhythmic drugs - Need for mod sedation
-Sinus arrest, or ventric arrhythmias - Class 1A, 1C and 3 all work
- Class 1C and Class 3
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)
- Make sure your pt is successfully ____ with AV nodal blocking drugs prior to giving AAD’s
- IV amiodarone , Ibutilide
-Procainamide (eh) - IV amio
- Flecainide, Propafenone
- rate controlled
AAD’s used to Restore SINUS RHYTHM : For each, state class and Dosing
- Procainamide
- Flecainide
- Propafenone
- Ibutilide
- Amiodarone
- Which agent is less effective than class 1c and 3 agents?
- 1a , 1000 mg IV over 30 min followed by 2 mg/min continuous for 60 mins
- 1c
-< 70 kg, 200 mg PO x1
> 70 kg 300 mg PO x 1 - 1c
<70 kg 450 mg PO x1
>70 kg 600 mg PO x 1 - Class 3. 1 mg IV over 10 min if > 60 kg,
0.01 mg/kg IV over 10 min (wt < 60 kg) - Class 3. 150 mg IV over 10 min then 1 mg/min x 6 hrs then 0.5 mg /min thereafter
- Procainamide
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?
- If LVEF > 40%, what kind of AV nodal blocking agents?
- IF LVEF < 40%, what AV nodal blocking agents?
- AV nodal blocking agents , anticoags, convert to orals
- STRICT HR
-At rest < 80 bpm
-exercise < 100 bpm - LENIENT HR
-HR at rest < 110 bpm - Oral B blockers, diltiazem, Verapamil +/- Digoxin
- Metoprolol succinate or carvedilol +/- Digoxin
STEP 2 AFIB or AFL CHART For Rate and Rhythm control
See chart
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!
Its used to predict /estimate risk of stroke in pt’s with NON -VALVULAR AFIB
- Age
-If >= 75 yrs =2 points, 65-74 years = 1 point - Diabetes = 1 point
- Female sex is 1 point
- HEART FAILURE (Right and left) 1 point
- Hypertension is 1 point
- Stroke, TIA, or thromboembolism is 2 points
- Vascular Disease (PAD, SIHD/ACS, aortic plaque) is 1 point
State the score that correlates with Low, intermediate, and high risk, and the suggestions towards anticoag use
- Low
- Intermed
- high
- Score = 0 (0 in men, 1 in women)
- Reasonable to OMIT anticoag - Score = 1 (1 in men, 2 in women )
-CONSIDER anticoag - Score 2-9, (2 in men, 3 in women)
-STRONGLY RECCC anticoag
Anticoag for Valvular vs NON valvular AF :
- Which anticoags to use for valv vs non valv?
- WHat’s the coumadin starting daily dose for < 70? >=70?
* Bridging??
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
- AA = 5 mg
CAUC/HISP Male = 5 mg, female 2.5 mg
ASIAN = 2.5 mg
Step 3 : Prevention of Recurrence of AF or AFL using AAD’s
- If pt has normal LV function, no prior MI or signif structural HD, what drugs can u use? (6)
- 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?
- dofetilide
-dronedarone
-flecainide
-propafenone
-amiodarone
-Sotalol (Last recc) - Amiodarone, dofetilide, sotalol (last recc)
- If yes , DONT USE DRONEDARONE
-If NO, ok to use dronedarone
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
- Strictly anticoags after assessing CHADSVASC score and HASBLED
-Warfarin only! - AAD’s
** See chart **
Paroxysmal Supraventric Tachycardia (PSVT)
-Signs and sx’s? (7)
-Etiolgy ? (ALOT)
- Anxiety
chest tightness
palpitations
rapid pulse
SOB
Dizziness
fainting - -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
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?
- PSVT usually has a narrow complex with QRS equal to ?
- 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
- QRS < 0.12 secs
Prophylactic Therapy needed to Prevent PSVT recurrence
- WHen should you use prophylaxis?
- What NON AAD options can u use?
- AAD options to prevent recurrence? (7)
- If frequent episodes require interventions
if infreq episodes but severe sx’s - Radiofreq catheter ablation (RFCA)
- Amio, beta blockers, dofetilide, flecainide, non DHP CCBS, propafenone, sotalol
Ventricular Tachycardia (VT)
- Wide complex with QRS >= ?
- What can the onset be related to?
- 0.12 seconds
- Hypoxemia,
severe electrolyte abnorms like hypokalemia
MI
Digoxin toxicity
TX of STABLE, Monomorphic VT ***
1 . Unstable pt with altered mental status, chest pain and hypotension?
- Stable pt’s WITH structural HD
State 5 tx’s options in their designated recc order - Stable Pt’s WITHOUT Structural HD
(2 options)
- Direct Current electrical cardioversion
- DC cardioversion **
-IV Procainamide **
-IV Amio **
-IV sotalol **
-IV Magnesium if TdP suspected - DC cardioversion
IV verap or Beta blocker
TdP
1. which class is notorious for precipitating TDP?
- If Hemodynamically UNSTABLE do what
- 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 - What are some other approaches as secondary tx?
** See chart for conditions that cause long QT**
- 1A (quinidine) and Class 3
- DC cardioversion 120 J, 150 J, 200 J
- Potassium, 4.5-5 mEq/L
-Magnesium sulfate 2 grams IV over 1 min
- 6 hrs - Cardio acceleration with ISOPROTERENOL
Bradyarrhythmias
- Caution with using which drugs? (2)
- Sx’s?
- SA or AV Nodal blockers such as B blockers or CCB’s
- Hypotension, dizziness, syncope, fatigue, confusion, worsening HF sx’s
TX of AV block
1. For acute symptomatic AV block?
2. What drugs can u give? (4)
- Immediate transcutaneous pacing
- Atropine
epinephrine
dopamine
Isoproterenol
CARDIAC ARREST **
- Rhythms WITHOUT a pulse
A. Shockable (3)
B. Unshockable (2) - Rhythms WITH a pulse (3)
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
- Ventric Tachycardia
-PSVT
Sinus Bradycardia
Advanced Cardiac Life support
- Start ___, give ___ DO this for how long ?
- If ___ or ___ can give shock
- If Ventric Fib , or pulseless VT give ___
- If pulseless electric activity (PEA) and cant identify etiology manage them with ?
- What if your pt’s in asystole?
- CPR, oxygen, 2 mins
- VT, VF
- AMIOdarone ** See chart for dose
- Good CPR and Epinephrine, alternating with vasopressin
- Focus on good CPR, treat with epinephrine , alternating with vasopressin
