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NAPLEX Review > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What do S1 and S2 represent?

A

S1 - first heart sound; beginning of ventricle contraction

S2 - second heart sound; end of ventricular contraction

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2
Q

What is the rate and rhythm of the heart set by?

A

sinoatrial node (SI node)

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3
Q

What 3 things can cause an arrhythmia?

A

1) SA node firing at an abnormal rate
2) Scar tissue from prior MI can block/divert signal transmission
3) Another part of the heart may act as the pacemaker

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4
Q

S/sx of arrhythmias

A

fluttering heart, skipping a beat, dizziness, shortness of breath, fatigue, being lightheaded

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5
Q

What is the electrical pathway through the heart?

A

Sinoatrial node –> AV node –> bundle of his –> bundle branches –> purkinje fibers

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6
Q

automaticity definition

A

cells that initiate their own action potential

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7
Q

Most common cause of cardiac arrhythimas

A

myocardial ischemia or infarction

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8
Q

What are non-cardiac causes of arrhythmias?

A

electrolyte imbalances, sympathetic states (hyperthyroidism, infection), drugs (illicit and antiarrhythmics)

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9
Q

2 categories of arrhythmias

A

supraventricular and ventricular

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10
Q

What is the most common type of arrhythmia?

A

AFib

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11
Q

What type of arrhythmia is referred to as a skipped heartbeat?

A

Premature ventricular contractions (PVCs)

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12
Q

What is it called when someone has multiple PVCs in a row causing a HR >100?

A

Ventricular Tachycardia (VT)

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13
Q

What antibiotics can cause increased QT interval?

A

Quinolones

Macrolides

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14
Q

What antifungals can cause increased QT interval?

A

All azoles except isavuconazonium

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15
Q

What antidepressants can cause increased QT interval?

A

Tricyclics, SSRIs, SNRIs, mirtazapine, and trazodone

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16
Q

What antiemetics can cause increased QT interval?

A

5HT3 antagonists, droperidol, phenothiazines

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17
Q

What antipsychotics can cause increased QT interval?

A

most of them

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18
Q

What is considered a prolonged QTc interval? When do we become worried?

A

Prolonged >440

Worrisome at >500 - can cause Torsades

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19
Q

What antiarrhythmics can cause increased QT interval?

A

Class I and class II

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20
Q

What drugs are Class I antiarrhythmics

A

Ia: Disopyramide, Quinidine, Procainamide
Ib: Lidocaine, Mexiletine
Ic: Flecainide, Propafenone

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21
Q

What drugs are Class II antiarrhythmics

A

Beta Blockers

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22
Q

What drugs are Class III antiarrhythmics

A

Dronedarone, Dofetilide, Sotalol, Ibutilide, Amiodarone

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23
Q

What drugs are Class IV antiarrhythmics

A

Verapamil, Diltiazem

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24
Q

Rate vs rhythm control in afib - what is the difference and what medications are used?

A

Rate: Patient remains in aFib and takes medications to control ventricular rate (HR)
Beta blockers, non-DHP CCBs, digoxin

Rhythm: goal is to restore NSR
Class Ia, Ic, or III antiarrhythmic or electric cardioversion

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25
Q

What is rhythm control and what medications are used for this purpose?

A

Restore and maintain NSR

A

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26
Q

If Afib is permanent, what medications should be avoided?

A

avoid rhythm control drugs (risk>benefit)

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27
Q

What type of afib is this:

Afib that terminates spontaneously or with intervention within 7 days of onset; episodes may recurr

A

Paroxysmal

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28
Q

What type of afib is this:

Continuous afib sustained >7 days

A

Persistent

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29
Q

What type of afib is this:

Continuous Afib of >12 months

A

Long-standing persistent

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30
Q

What type of afib is this:

When joint decision has been made by clinician and patient to further attempts to restore and/or maintain NSR

A

Permanent

*this is a treatment choice rather than a characteristic of the arrhythmia itself

31
Q

What type of afib is this:

Afib with moderate to sever mitral stenosis or with a mechanical heart valve

A

Valvular

*long term anti-coag indicated

32
Q

What type of afib is this:

Afib without moderate to severe mitral stenosis or a mechanical heart valve

A

Non-valvular

33
Q

Goal resting HR in patients with symptomatic/asymptomatic afib

A

<80 - symptomatic

<110 - asymptomatic

34
Q

What medications are preferred for rate control in patients with afib?

A 
Beta blockers (preferred), non-DHP CCBs, can also add digoxin
If patient has HFrEF they should NOT receive non-DHP CCBs
35
Q

What can be used for conversion to NSR?

A 
Direct cardioversion (shock) is most effective
Can use amiodarone, dofetilide, flecainide, ibutilide, and propafenone
36
Q

What can be used for maintenance of NSR after conversion?

A

dofetilide, dronedarone, flecainide, propafenone, or sotalol

Can use amiodarone but is last line d/t toxicities

37
Q

Anticoagulation and cardioversion - when to anticoagulate and for how long

A

Start 3 weeks before cardioversion and continue for 4 weeks after
If using warfarin INR should be 2-3

38
Q

Antiarrhythmic MOA and result on heart rhythm

Class I

A

MOA: Na-channel blocker
Result: negative inotrope potential, decreasing force of heart’s contraction

39
Q

Antiarrhythmic MOA and result on heart rhythm

Class II

A

MOA: beta-blockers
Result: Slow ventricular rate

40
Q

Antiarrhythmic MOA and result on heart rhythm

Class III

A

MOA: K-channel blockers
Result: slows electrical impulses through heart

41
Q

Antiarrhythmic MOA and result on heart rhythm

Class IV

A

MOA: Ca-channel blockers, non-DHP CCB
Result: Slow rate in ventricular tachycardia, decreases contraction force

42
Q

When should Class IV antiarrhythmics not be used?

A

Do not use verapamil or diltiazem with HFrEF

43
Q

Antiarrhythmic MOA and result on heart rhythm

Digoxin

A

MOA: Na-K-ATPase blocker
Result: suppresses AV node conduction (decrease HR) by enhancing vagal tone and increase force of contraction

44
Q

Antiarrhythmic MOA and result on heart rhythm

adenosine

A

MOA: activates adenosine receptors
Result: decrease AV node conduction

45
Q

How long does it take to see peak effect from amiodarone? What is it’s halflife?

A

1 week to 5 months for peak response

Half-life 40-60 days

46
Q

Amiodarone BBW, CI, warnings, SE

A

BBW: pulmonary toxicity, hepatotoxicity
CI: Iodine hypersensitivity, severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope
Warnings: Hyper and hypothyroidism, optic neuropathy, photosensitivity, neuropathy, SJS
SE: hypotension, bradycardia, corneal microdeposits, photosensitivity

47
Q

What are the antiarrhythmic DOC in HF?

A

amiodarone and dofetilide

48
Q

True or false:

amiodarone is teratogenic

A

true

49
Q

Digoxin, warfarin, simvastatin, and lovastatin dose adjustments needed when initiating amiodarone

A

Digoxin: decrease by 50%
Warfarin: decrease by 30-50%
Simvastatin: max 20mg/d
Lovastatin: max 40mg/d

50
Q

What medication can enhance the bradycardic effect of amiodarone and should not be used with amiodarone?

A

Sofosbuvir

51
Q

CCBs CI, warnings, SE

A

CI: severe hypotension, 2nd/3rd degree heart block, cardiogenic shock, HFrEF
Warnings: Hypotension, HF (may worsen)
SE: Edema, arrhythmias, constipation (verapamil), gingival hyperplasia, HA, dizzines

52
Q

Digoxin CI, warnings, SE

A

CI: ventricular fibrillation
Warnings: 2nd/3rd degree heart block, vesicant
SE: dizziness, mental disturbances, N/V/D

53
Q

S/sx digoxin toxicity

What can increases the risk of digoxin toxicity?

A

Initial: N/V, loss of appetite, bradycardia
Severe: blurred/double vision, greenish-yellow halos around lights, altered color perception, abdominal pain, confusion, delirium, arrhythmias
Increase risk of dig toxicity: low potassium and magnesium; high calcium

54
Q

What is the antidote for digoxin toxicity?

A

DigiFab or Digibind

55
Q

Disopyramide BBW, CI, Warnings, SE, w/ w/o food?

A

BBW: Only for patients with life-threatening ventricular arrhythmias
CI: 2nd/3rd degree heart block, cardiogenic shock, congenital QT syndrome, sick sinus syndrome
Warnings: Proarrhythmic, hypotension, HF, anticholinergic
SE: Anticholinergic effects
Take on an empty stomach

56
Q

Quinidine BBW, CI, Warnings, SE, w/ w/o food?

A

BBW: increased mortality in Afib or aFlutter
CI: concurrent use with FQ or ritonavir (increased QT), 2nd/3rd degree heart block or idioventricular conduction delays, thrombocytopenia, myasthenia gravis
Warnings: Proarrhythmic, hepatotoxicity, hemolysis risk
SE: drug-induced lupus erythematosus, diarrhea, stomach cramping, cinchonism

57
Q

S/sx of quinidine toxicity and what can increase risk of toxicity?

A

S/sx: tinnitus, hearing loss, blurred vision, HA, delirium, rash, lightheadedness
Changes in Na intake; decreased Na intake increase quinidine levels
Alkaline foods increase quinidine levels

58
Q

Procainamide BBW, CI, Warnings, SE

A

BBW: Blood dyscrasias, long-term use can lead to positive antinuclear antibody (ANA) which can cause drug-induced lupus erythematosus
CI: Heart block, systemic lupus erythematosus, TdP
Warnings: proarrhythmic
SE: hypotension, rash

59
Q

Procainamide active metabolite and renal adjustments

A

Metabolite: N-acetyl procainamide (NAPA) is renally cleared

Decrease dose when CrCl <50

60
Q

What is lidocaine used for with regards to arrhythmias?

A

Refractory ventricular tachycardia and cardiac arrest

61
Q

Lidocaine CI, Warnings

A

CI: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome, Adam-stokes syndrome, allergy to corn or corn-related products
Warnings: Caution in elderly and hepatic impairment

62
Q

Mexiletine BBW, CI, Warnings, w/ w/o food?

A

BBW: abnormal liver function in patients with CHF or ischemia
CI: 2nd/3rd degree heart block, cardiogenic shock
Warnings: Caution in elderly, hepatic impairment, HF, blood dyscrasias, DRESS
Take with food

63
Q

Flecainide BBW, CI, warnings, SE

A

BBW: Proarrhytmic effects, reserved for life-threatening ventricular arrhythmias
CI: 2nd/3rd degree heart block, cardiogenic shock, structural heart disease (HF, MI), concurrent use of ritonavir
Warnings: Avoid in severe hepatic impairment
SE: dizziness, visual disturbances, dyspnea

64
Q

Propafenone BBW, CI, Warnings, SE

A

BBW: reserve for life-threatening ventricular arrhythmias
CI: sinoatrial and atrioventricular disorders, sinus bradycardia, cardiogenic shock, hypotension, strucutral heart disease bronchospasmic disorders
Warnings: proarrhythmic
SE: taste disturbance (metallic), dizziness, visual disturbances, N/V

65
Q

Dronedarone BBW, CI, Warnings, SE, w/ w/o food?

A

BBW: Increased risk of death, stroke and HF in patients with HF or permanent AFib
CI: concurrent use of strong CYP3A4 inhibitors and QTc prolonging drugs, pregnancy, QTc >500, nursing mothers
Warnings: hepatic failure, pulmonary disease, increased SCr, decreased Mg and K
SE: QT prolongation, increased SCr, diarrhea, bradycardia, asthenia
Take with food

66
Q

How should digoxin dose be adjusted when initiating dronedarone

A

Decrease dig by 50%

67
Q

Sotalol BBW, CI, SE

A

BBW: initiation should be done in hospital with ECG monitoring
CI: heart block, congenital or acquired long QT syndrome, uncontrolled HF, shock
SE: bradycardia, palpitations, chest pain, dizziness, fatigue, torsades

68
Q

Sotalol renal adjustments

A

Non-selective BB
CrCl <60 –> decrease frequency
CrCl < 40 - varies by formulation

69
Q

Ibutilide BBW, SE

A

BBW: proarrhythmic
SE: ventricular tachycardia, hypotension, QT prolongation, torsades

70
Q

Dofetilide BBW, CI, SE

A

BBW: must be initated with continuous ECG monitoring and CrCl assessment for 3 days
CI: QTc >440
SE: ventricular tachycardia, increased QT interval, torsades

71
Q

Adenosine CI, SE, half-life

A

CI: Heart block, sick sinus syndrome, symptomatic bradycardia
SE: transient new arrhythmia, flushing, chest pain/pressure, GI distress, dyspnea
Half-life: <10 seconds

72
Q

Key counseling for amiodarone

A

Can cause lung, liver, eye damage, thyroid problems, photosensitivity, skin discoloration
Avoid grapefruit
MANY drug interactions

73
Q

Key counseling for digoxin

A

Toxicity: loss of appetite and nausea; vision changes, confusion, hallucinations
Avoid dehydration
MANY drug interactions

NAPLEX Review (79 decks)

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