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PHRM 845: Therapeutics III > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What is the cardiac conduction system?

A
  • The electrical system that helps the heart pump; starts in the SA node, goes to the AV node, down the bundle of his with the Purkinje Fibers then to the ventricles.
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2
Q

Where at on the ECG does the action potential take place

A
  • Depolarization starts within the P wave
  • QRS complex is where the Action potential starts
  • Repolarization starts within the T wave
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3
Q

What is the normal value of ECG intervals?

A
  • PR Interval: 0.12 - 0.20 secs
  • QRS Duration: 0.08 - 0.12 secs
  • QT Interval: 0.38 - 0.46 secs
  • QTc Interval: 0.36 - 0.45 secs [MEN]
  • QTc Interval: 0.38 - 0.46 secs [WOMEN]
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4
Q

What is known as Torsades de Pointes?

A
  • It is a polymorphic ventricular tachycardia characterized on ECG by oscillatory changes of QRS with a QTc interval of > 500ms [CAN CAUSE SUDDEN DEATH]
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5
Q

What are some of the drugs that may cause Torsades de Pointes?

A
  • Antiarrhythmics: Procainamide, flecainide, Ibutilide, Dofetilide, Sotalol, Amiodarone, Dronedarone
  • Antimicrobials, Antidepressants, Antipsychotics, Anticancer, Opioids,…
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6
Q

What does supraventricular arrhythmias mean and are some examples?

A
  • Arrhythmias that are above the ventricles
  • Sinus Bradycardia, Atrioventricular [AV] Block, Sinus Tachycardia, Afib, Supraventricular Tachycardia
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7
Q

What is Sinus Bradycardia?

A
  • It is the decrease in automaticity of the SA node, typically a heart rate of about < 60 BPM
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8
Q

What are some of the causes of Sinus Bradycardia?

A
  • MI or Ischemia, Electrolyte inbalence [High K and Mg], Drugs [Digoxin, Beta-Blockers, CCBs,… - anything that will slow down the heart]
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9
Q

What are some of the symptoms related to Sinus Bradycardia?

A
  • Hypotension, Dizziness, Fainting [Syncope]
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10
Q

How do we treat a patient with Sinus Bradycardia?

A
  • ONLY if they are symptomatic
  • Atropine 0.5 -1mg IV, repeat every 5 mins until a max does of 3 mg
  • Unresponsive toward Atropine; use Dopamine, Epinephrine, Isoproterenol
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11
Q

Since Atropine is the main medication used in the treatment of Sinus Bradycardia, what are some of its side effects?

A
  • Tachycardia, Urinary Retention, Blurred Vision, Dry Mouth, Mydriasis [Anticholinergics]
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12
Q

What is the Treatment of Sinus Bradycardia after heart transplant or spinal cord injury?

A
  • NO Atropine because the nerves are cut
  • Aminophylline 6 mg/kg over 30 mins
  • OR Theophylline 300mg [Heart]/5-10mg [Spine]
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13
Q

What is a non-pharmacologic treatment for Sinus Bradycardia?

A
  • Pacemaker: will send a shock to the heart to keep it in normal rhythm
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14
Q

What is an important feature to know about Afib?

A
  • 120 to 180 BPM
  • Irregularly Irregular
  • NO P wave
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15
Q

What are some of the definiations that are related to Afib?

A
  • Paroxysmal, Persistent, Permanent, Long-standing persistent, Nonvalvular
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16
Q

What is Paroxysmal Afib?

A
  • Intermittent Episodes of AFib; episodes start suddenly and spontaneously, last for minutes to hours and terminate suddenly and spontaneously
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17
Q

What is Persistent AFib?

A
  • A continuous episode of AFib that DOES NOT terminate spontaneously [lasts > 7days]
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18
Q

What is Long-Standing Persistent AFib?

A
  • Continuous AFib > 12 months
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19
Q

What is Permanent AFib?

A
  • AFib is ALWAYS present, the patient is never again in sinus rhythm
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20
Q

What is Nonvalvular AFib?

A
  • AFib in the absence of rheumatic mitral valve stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair
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21
Q

What is some of the causes towards AFib?

A
  • HTN, CAD, HF, Valvular Heart Disease
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22
Q

What are some of the symptoms of AFib?

A
  • Asymptomatic?, Palpitations, Dizziness, Fatigue, Lighthehadedness, SOB, Hypotension,…
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23
Q

What are the treatment goals for AFib?

A
  • Persistent Afib: Ventricular Rate Control, Prevention of Stroke, Conversion SInus Rhythm
  • Paroxysmal AFib: Ventricular Rate Control, Prevention of Stroke, Maintenance Sinus Rhythm
  • Permanent AFib: Ventricular Rate Control, Prevention of Stroke
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24
Q

What are the drugs that are used in Ventricular Rate Control for AFib?

A
  • Direct AV Node Inhibition
  • Diltiazem, Verapamil, Beta-Blockers [Esmolol, Propranolol, Metoprolol], Digoxin, Amiodarone
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25
Q

What is the algoritihm for Ventricular Rest Control for AFib?

A
  • No Other CV: Used Beta-Blockers, Diltiazem or Verapamil
  • Hypertension: Used Beta-Blockers, Diltiazem or Verapamil
  • HFrEF: Used Digoxin
    [When all else fails use Aminodarone]
  • COPD: Used Beta-Blockers, Diltiazem or Verapamil [NO Amiodarone]
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26
Q

What are the medications that are used for Conversion to sinus rhythm for AFib?

A
  • DCC, Aminodarone, Dofetilide, Ibutilide, Propafenone, Flecaintide
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27
Q

When is conversion safe in AFib and when is it not safe?

A
  • It is safe < 48 hours
  • It is NOT safe > 48 hours; there might be a clot
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28
Q

When is a patient classified as hemodynamically UNSTABLE?

A
  • SBP < 90, HR > 150, Current Chest Pain, Unconscious
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29
Q

What is some side effects for Amiodarone within AFib?

A
  • Hypotension, Bradycardia, Blue-Grey Skin Color, Photosensitivity, PULMONARY FIBROSIS, Hypo/Hyperthyroidism
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30
Q

What is important to know about Propafenone and Flecainide within AFib?

A
  • Should NOT be used in patient that have HFrEF; will exacerbate the symptoms
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31
Q

What is the dosing for Propafenone and Felcainide within AFib?

A
  • Propafenone: 450 - 600 mg once
  • Flecainide: 200 - 300 mg once
  • “Pill in the Pocket”: keep on body and take when having symptoms
32
Q

What is the Dosing for Dofetilide within AFib?

A
  • CrCL > 60 = 500 mcg BID
  • CrCl 40 - 59 = 250 mcg BID
  • CrCl 20 -39 = 125 mcg BID
  • CrCl < 20 = CONTRAINDICATED
33
Q

What is the Pathway for Conversion to sinus rhythm during AFib < 48 hours?

A
  • DCC? then Either HFrEF or NO HFrEF
  • NO EFrEF: Amiodarone, Dofetilide, Flecainide, Propafenone, Ibutilide
  • HFrEF: Amiodarone, Dofetilide, Ibutilide [NOT is EF < 30%]
34
Q

What is the pathway for Conversion to sinus rhythem during AFib > 48 hours?

A
  • DELAY CONVERSION: anticoag for 3 weeks then DCC
  • EARLY CONVERSION: TEE [checking for thrombi]
  • NO Thrombus: Go to other pathway [DCC]
  • Thrombus: Anticoag > 4 weeks then TEE again
35
Q

What medications are used in the maintenance of sinus rhythm for AFib?

A
  • Amiodarone, Sotalol, Propafenone, Flecainide, Dofetilide, Dronedarone
36
Q

What are some of side effects for Aminodarone for AFib?

A
  • Blue-grey color skin, Pulmonary Fibrosis, Hyper/Hypothyroidism, Bradycardia, Photosensitivity
37
Q

How is Aminodarone different than Dronedarone within AFib?

A
  • Dronedarone DOES NOT have as many severe side effects like Aminodarone does
38
Q

What is important to know about Sotalol’s dosing for maintenance of sinus rhythm in AFib?

A
  • QTc < 450ms?
  • CrCl >60 = 80 mg BID OR CrCL 40-60 = 80 mg qd
  • NO sotalol CrCl < 40
  • QTc < 500ms = discharge or increase dose
  • QTc > 500ms = D/C sotalol
39
Q

For AFib and NO heart disease, what medication do you use for maintenance?

A
  • Dofetilide, Propafenone, flecainide, Sotalol, Dronedarone [Amiodarone for last last line]
  • Catheter Ablation
40
Q

For AFib WITH heart disease, what medication do you use for maintenance?

A
  • CAD: Dofetilide, Dronedarone, Sotalol [Catheter Ablation]
  • HFrEF: Amiodarone, Dofetilide [Catheter Ablation]
  • Amiodarone last line
41
Q

What is important to know about Dofetilide’s dosing for maintenance of sinus rhythm during AFib?

A
  • QTc < 440 ms
  • The same as other one 500 to 250 to 125
  • <15% QTc Increase = good; >15% QTc increase = 1/2 the dose
42
Q

What are the following factors for the CHADsVASc score?

A
  • CHF = 1pt
  • HTN = 1pt
  • Age > 75 = 2pt
  • DM = 1pt
  • Stroke = 2pt
  • Vascular Disease = 1pt
  • Age 65-74 = 1pt
  • Sex [F] = 1pt
43
Q

When should patients get an anticoag based on their CHADsVASc score for prevention of stroke during AFIb?

A
  • RECOMMENDED: > 2 in men & > 3 in women
  • CONSIDERED: 1 in men & > 2 in women
  • NO: 0 in men & 0 - 1 in women
44
Q

When is Warfarin perferred over NOACs in AFib stroke prevention?

A
  • Warfarin > NOAC: patients that have Mechanical Heart Valves and Valvular AFib
  • NOAC > Warfarin: use in general?
45
Q

What are the NOACs used in AFib stroke prevention?

A
  • Dabigatran, Rivaroxaban, Apixaban, Endoxaban
46
Q

What is the doing for Dabigatran for Stroke Prevention during AFib?

A
  • CrCl > 30 = 150 mg BID
  • CrCL 15 - 30 = 75 mg BID
  • CrCl < 15 = NONE
47
Q

What is the dosing for Rivaroxaban for Stroke Prevention during AFib?

A
  • 20 mg once with evening meal
  • CrCl 30 - 50 = 15 mg once with evening meals
  • CrCl 15 - 30 = 15 mg once with evening meals
48
Q

What is the dosing for Apixaban for Stroke Prevention during AFib?

A
  • 5 or 2.5 mg BID
  • CAN be used during ESKD
49
Q

What is the dosing for Endoxaban for Stroke Prevention during AFib?

A
  • CrCl > 95 = NONE
  • CrCl 50 - 95 = 60 mg qd
  • CrCl 15 - 50 = 30 mg qd
  • CrCl < 15 = NONE
50
Q

What are the antidotes for each of the Anticoag medications?

A
  • Dabigatran: Idarucizumab
  • “-Xaban”: Andexanet Alfa
51
Q

What is Supraventricular Tachycardia?

A
  • Regular Rhythms with narrow QRS complexes
  • HR 110 - 250 BPM
  • Mostly takes place in the AV node
52
Q

What is the mechanism of SVT?

A
  • Normally the impulse will around the AV node and down the Bundle of His; in SVT the impulse will travel around the AV node depolarizing the atrium
53
Q

What are some of the symptoms of SVT?

A
  • “Neck Pounding”, Palpitations, Dizziness, Weakness, Lightheadedness, Increase Urination
54
Q

What is important to note about SVT?

A
  • Its not necessarily life threatening but it can lead to VT which is VERY life threatening
55
Q

What are some of the medications used in terminating SVT?

A
  • Adeonsine, Beta-Blockers, Verapamil, Diltiazem
56
Q

What is important to know about Adeonsine for termination of SVT?

A
  • May cause chest pain, flushing, SOB, Sinus Pause, Bronchospasm
  • These should only last about 30 secs
57
Q

What is the dosing for Adeosine?

A
  • Start with 6 mg IV rapidly
  • Flush with saline
  • Wait 2 mins
  • 12 mg IV rapidly
  • Flush
  • Wait 2 mins
  • 12mg IV rapidly
  • Flush
58
Q

What is the way we terminate SVT?

A
  • Try Vagal Manuevers and/or Adenosine
  • Work?
  • Try Beta-Blockers, Verapamil, Diltiazem
  • Work?
  • DCC [Last line]
59
Q

What is the way that we prevent the recurrence of SVT?

A
  • Symptomatic?
  • Catheter Ablation?
  • No: then NO HFrEF or HFrEF
  • NO HFrEF: Beta-blocker, Diltiazem, Verapamil, Propafenone, Flecainide
  • HFrEF: Digoxin, Amiodarone, Dofetilide
60
Q

What are Premature ventricular complexes?

A
  • Wide QRS Complexes
  • Electrical fibers that are activated within the ventricular muscle instead of the Bundle of His
61
Q

What are the types of PVCs?

A
  • Simple: Single PVC
  • Couplets: Pair of PVC
  • Every 2nd Beat: Bigeminy
  • Every 3rd Beat: Trigeminy
  • Every 4th Beat: Quadrigeminy
62
Q

Should Asymptomatic PVCs be treated?

A

NO!
- no known treatment

63
Q

What is the treatment strategy for symptomatic PVCs?

A
  • NO CAD or HF: beta-blocker, diltiazem, verapamil [Catheter Ablation if drug no do goo]
  • CAD: beta-blockers, diltiazem, verapamil
  • HF: beta-blockers
64
Q

What is Ventricular Tachycardia?

A
  • Regular Rhythm; back to back PVC
  • Wide QRS complexes
65
Q

What are the main risk factors that cause VT?

A
  • CAD
  • MI
  • HFrEF
66
Q

What are some drugs that may cause VT?

A
  • Flecainide, Propafenone, Digoxin [High Dose]
67
Q

What are some of the drug use in the termination of VT?

A
  • Procainamide, Amiodarone, Sotalol, Verapamil [Only for Verapamil-VT], Beta-Blockers [Only for Outflow-VT]
68
Q

What are some of the adverse affects with Procainamide for VT?

A
  • Hypotension, QT interval prolongation, Torsades de Pointes
69
Q

What is the treatment plan for termination of VT?

A
  • Heart Disease?
  • DCC [haven’t eaten in 8 hours] or Procainamide [DoC] or Amiodarone/Sotalol
  • VT?
  • Yes: DCC; NO: prevetn recurrence
70
Q

What are some fo the medication used to prevent recurrence and sudden cardiac death in VT?

A
  • Implantable Cardioverter defibrillator [ICD], Amiodarone, Sotalol, Catheter Ablation
71
Q

Where is the ICD implanted and where does it go to in the body?

A
  • It is implanted right below the collar bone and goes down the vein into the the heart; connects to the AV Node and into the ventricle muscle
  • Doesn’t prevent the arrhythmia it just prevent death
72
Q

What is Ventricular Fibrillation?

A
  • It irregular, disorganized, chaotic electrical activity
  • No P wave or QRS wave
  • No Pulse and No Blood Pressure
73
Q

What are some of the risk factors that cause VFib?

A
  • MI
  • HFrEF
  • CAD
74
Q

What is the only really effective treatment for terminating VFib?

A
  • Electric Shock via defib
75
Q

What are some of the medications that are used in VFib?

A
  • Epinephrine, Amiodarone, Lidocaine

PHRM 845: Therapeutics III (25 decks)

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