Arrhythmias Flashcards
What is meant by ectopic beats
Spontaneous and rarely requires treatment
If treatment is needed then use beta blockers
What is meant by AF
Can lead to complications such as a stroke (blood doesn’t fully eject- clotting forms)
Patients should be assessed and treated for stroke risk
Manage AF through ventricular rate control and sinus rhythm control
What is meant by ACUTE AF
Patients with life threatening haemodynamic instability caused by AF
- emergency electrical cardioversion without delaying to achieve anticoagulation
Patients with life threatening haemodynamic instability
- if onset AF is < 48hrs = rate or rhythm control
- if onset of AF is > 48hrs = rate control
If cardioversion (rhythm) has also been agreed on:
- pharmacological: flecanide or amiodarone
- electrical: start IV anticoagulation and rule out a left arterial thrombus
What is the maintenance treatment for AF
1)Rate control monotherapy:
- standard beta blocker (not sotalol) or
- rate limiting calcium channel blockers: diltiazem or verapamil
- digoxin (in predominantly sedentary patients with non paroxysmal AF)
2)Rate control with dual therapy
-beta blocker, RL-CCB (diltiazem only) or digoxin
3) rhythm control
- sinus rhythm can be restored by electrical or pharmacological cardioversion
— pharmacological: antiarrhythmic drugs such as flecanide/ amiodarone
If Af is still present >48 hours, electro cardioversion is preferred although there is a risk of clotting therefore:
-patient must be fully anticoagulated for at least 3 weeks
-give oral anticoagulation- continued for at least 4 weeks after cardioversion
Drug treatment may be required post cardioversion
-standard beta blocker
-sotalol, propafenone, amiodarone or flecanide (SPAF)
— amiodarone can be started 4 weeks before and continuing for up to 12 months after electrical cardio version to increase success of the procedure
How do you treat paroxysmal AF
Ventricular rhythm is controlled with a standard beta blocker
- if symptoms persists or a beta blocker is not appropriate
Sotalol, propafenone, amiodarone or flecanide (SPAF)
-patients with episodes of symptomatic paroxysmal AF
-sinus rhythm can be restored using the pill in the pocket approach
-patients take oral flecanide/ propafenone when required on symptoms
What do we have to treat when dealing with AF
Clots
What is the stroke prevention strategy
Assess all patients for risk of stroke nd need for thomboprophylaxsis
Use the CHA2DS2-VASc assessessment tool for stroke risk
Maximum score is 9
C congestive heart failure. 1
H hypertension 1
A2 age= 75+. 2
D diabetes 1
S2 stroke/TIA. 2
V vascular disease 1
A age 65-74. 1
Sc sex= female 1
Thromboprophylaxsis is not needed if:
Men score= 0
Women with score of 1
Thromboprphylaxsis: warfarin or NOACs in non vascular AF
How do you treat atrial flutter
Aim to treat with rhythm or rate control- however atrial flutter reacts less effectively to drug treatment
Rate control is normally temporary until sinus rhythm is restored
- similar rate control drugs: beta blockers to RL-CCB
Rhythm control can be restored with wither
-direct current cardio version- when rapid control is needed (haemodynamic compromise)
-pharmacological cardioversion
-catheter ablation- recurrent atrial flutter
Assess patient for stroke risk
Still need to ensure that the patient is anti-coagulated for 3 weeks if flutter has lasted longer than 48hrs
How do you treat paroxysmal supraventricular tachycardia
1) terminate spontaneously alone
2) reflex vagaries stimulation
- valsalva manoeuvre/ immerse face in ice cold water/ carotid sinus massage
-such manoeuvre should be performed with ECG monitoring
3) IV adenosine
4) IV verapamil
- treat recurrent symptoms with Catheter ablation
- prevent future episodes with beta blockers or RL-CCB
How do you treat ventricular tachycardia
Puleless venticylar tachycardia or ventricular fibrillation = resuscitation
Unstable unsustained ventricular tachycardia
-direct current cardioversion- Iv amiodarone - repeat current cardioversion
Stable ventricular tachycardia
-IV amiodarone- direct current cardioversion
-non-sustained ( doesn’t last long) ventricular tachycardia = beta blocker
Patients at high risk of cardiac arrest require maintenance therapy
-implantable cardioverter defibrillator
- can add b-blockers/amiodarone (in combination with standard b-blocker)
How do you treat Torsade de pointes (QT prolongation)
Can be drug induced or caused by hypokalaemia and severe bradycardia
- drugs such as amiodarone, sotalol, macrolides, haloperidol, SSRIs, TCAs and antifungals
Usually self limiting but can be recurrent- leads to impaired consciousness
If not controlled- ventricular fibrillation and then death
Treat with IV magnesium sulphate
Beta blockers (not sotalol) and atrial/ventricular pacing may be considered
Antiarrhythmics - prolong QT interval - worsen condition
What are the different classes of anti-arrhythmic drugs
Classified clinically into acting on: supraventricular and ventricular arrhythmias or both
Classified in accordance of their electrical behaviour:
Class 1: membrane stabilising drugs (lidocaine, flecanide)
Class 2: beta blockers
Class 3: amiodarone and sotalol
Class 4: CCB (verapamil and diltiazem not -pines)
What is the side effects of amiodarone
Avoid in bradycardia and heart block
Corneal micro deposits
-reversible when treatment ends- if vision is impaired then stop
Thyroid problems
- can cause hypo or hyperthyroidism due to iodine content
Photosensitivity reactions
Avoid sunlight exposure and use sunscreen for months after treatment ends
Hepatotoxicity
Stop if pt is showing signs of liver disease (dark urine, yellow skin, abdominal pain, nausea and vomiting light stools)
Pulmonary toxicity
Report in cases of new/progressive SOB or coughs
Driving and skilled tasks
Micro deposits may lead to blurred vision
What is the loading dose regimen for amiodarone
200mg TDS for 7 days
200mg BD for 7 days
200mg OD maintenance
What are the interactions of amiodarone
Very long half life- potential for interactions after several weeks or months
Drugs that cause hypokalaemia
Drugs that cause QT prolongation
CYP450 enzyme substrates (amiodarone = inhibitor
-other enzyme inhibitors (grapefruit ) and inducers will affect amiodarone
Such as warfarin contraceptive statins etc
Drugs that can cause bradycardia
-beta blockers or RL-CCB
