Arrhythmias Flashcards
Define: paroxysmal AFib
terminates spontaneously or with intervention within 7 days, “episodic”
Define: Persistent AFib
continuously sustained > 7 days from onset
Define: Long-standing AFib
continuous sustained > 12 months
Define: Permanent AFib
not a pathophysiological state but stage of Afib aka Stage 4= no more attempts to restore or maintain normal sinus rhythm
What are the symptoms of AFib?
-fatigue
-palpitations
-dyspnea
-hypotension
-tachycardia induced cardiomyopathy
What are treatable risk factors for AFib?
-heart failure
-exercise
-tobacco
-obesity
-HTN
-ethanol
-diabetes
-sleep
What does CHA2DS2-VASc stand for?
point system for predicting stroke risk
-congestive HF: 1
-HTN: 1
-age 75+: 2
-DM: 1
-previous stroke, TIA, or thromboembolism: 2
-vascular disease (prior MI, PAD, aortic plaque): 1
-age 65-74: 1
-female: 1
When would oral anticoagulant therapy be recommended for stroke risk in AFib pts?
CHA2DS2VASc score of 2 or greater in men or 3 or greater in women OR moderate to severe mitral stenosis or mechanical valve
What does a HAS-BLED score 3 or greater mean?
high risk of bleeding
What is the recommended anticoagulant for stroke risk reduction?
DOAC > warfarin
When would Warfarin be preferred over DOAC for stroke reduction therapy?
ESRD (eGFR < 15mL/min) OR severe mitral stenosis or mechanical heart valve
What are the dosing recommendations for Apixaban?
-typically 5 mg po BID
-2.5mg po BID if pt has 2 of the following: 80+ yo, less than 60kg, SCr 1.5mg/dL or greater
What DOAC may be used in ESRD?
apixaban
What is the dosing recommendations of Edoxaban?
60mg po daily
When would you avoid using Edoxaban in a pt?
CrCl > 95mL/min due to increased risk of stroke
What are the monitoring parameters for DOACs?
-renal function
-hepatic function
-signs of bleeding
-signs of stoke
What may be used to reverse the effects of oral Xa inhibitors (apixaban, edoxaban, rivaroxaban)?
andexanet alfa
What can be done if pt is poor candidate for oral anticoagulation therapy?
watchman device
What is the target HR for a patient with AFib?
resting HR < 100-110
What are the rate control treatment options for AFib?
-beta blockers
-nonDHP CCB
-digoxin
-amiodarone
When would nonDHP CCB be used for AFib?
rate control in pt who do not have HF (LVEF > 40%)
How would you convert IV diltiazem to PO?
PO(mg)= [rate (mg/hr) x 3 + 3] x 10
What is the usual dosing for metoporol treatment of AFib?
2.5-5mg IV bolus over 2 minutes for up to 3 doses
What is the maintenance dosing of metoprolol?
-tartate: 25-100mg
-succinate: 50-400mg
What is the use of beta blockers in AFib?
may be used first line whether pt has HF or not
What is the risk of using Amiodarone for AFib?
lots of interactions and toxicity, chronic monitoring required so not preferred for long term therapy
What are the side effects of Amiodrone?
-CV= bradycardia, QTc prolongation
-CNS= impaired memory, tremor
-GI= N/V, anorexia, heptotoxicity
-Ocular= halovision, photophobia
-Pulmonary= interstitial pneuonitis, fibrosis
-Skin= photosensitivity, blue discoloration
-hyper or hypo thyroidism
What are the monitoring recommendations for Amiodarone?
-TSH
-hepatotoxicity= AST, ALT
-QT prolongation= ECG
-chest xray of lungs
-overall physical exam
What is the concern of using Digoxin?
small therapeutic window= risk of toxicity
What are the side effects of Digoxin?
-AV block
-arrhythmias
-toxicity= N/v, abdominal pain, diarrhea, yellow-green vision, fatigue, dizziness
What needs to be done before cardioversion (whether it is electrical or pharmacological)?
anticoagulation therapy 3 weeks before then 4 weeks after
When would rhythm control therapy be indicated for AFib?
-persistent symptoms
-cannot obtain rate control
-young
-tachycardia induced cardiomyopathy
-patient preference
-LV dysfunction
What drugs may be used for conversion to sinus rhythm?
-amiodarone
-ibutilide
-procainamide
-flecainide
-propafenone
What are the adverse effects of Ibutilide?
-QT prolongation, MUST MONITOR ECG
-TdP risk, do not give to patients with HFrEF
What cardioversion drug cannot be used in patients with MI in the past 2 years (Black Box Warning)?
procainamide
Which drugs for cardioversion can be given to patients as “pill in pocket” therapy?
propafenone and flecainide
What drugs can be used to maintain sinus rhythm?
-amiodarone
-dofetilide
-dronedarone
-flecainide
-propafenone
-sotalol
What drugs must be monitored before outpatient administration?
-propafenone
-flecainide
-dofetilide (at least 3 days to monitor ECG)
-sotalol
What drugs may be used for maintenance rhythm with HFrEF?
amiodarone and dofetilide
What are the adverse effects of Dofetilide?
QT prolongation (contraindicated if QT > 440 seconds) and must be monitored (ECG) for 3 days after initiation
What are the dosing considerations of Sotalol?
must be renally adjusted
What are the adverse effects of Sotalol?
QT prolongation (high risk!) must initiate inpatient to monitor ECG
What is the pros of using Dronedarone?
better safety profile compared to amiodarone
