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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
What is rhythm control and what medications are used for this purpose?
Restore and maintain NSR | A
26
If Afib is permanent, what medications should be avoided?
avoid rhythm control drugs (risk>benefit)
27
What type of afib is this: | Afib that terminates spontaneously or with intervention within 7 days of onset; episodes may recurr
Paroxysmal
28
What type of afib is this: | Continuous afib sustained >7 days
Persistent
29
What type of afib is this: | Continuous Afib of >12 months
Long-standing persistent
30
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
Permanent | *this is a treatment choice rather than a characteristic of the arrhythmia itself
31
What type of afib is this: | Afib with moderate to sever mitral stenosis or with a mechanical heart valve
Valvular | *long term anti-coag indicated
32
What type of afib is this: | Afib without moderate to severe mitral stenosis or a mechanical heart valve
Non-valvular
33
Goal resting HR in patients with symptomatic/asymptomatic afib
<80 - symptomatic | <110 - asymptomatic
34
What medications are preferred for rate control in patients with afib?
``` Beta blockers (preferred), non-DHP CCBs, can also add digoxin If patient has HFrEF they should NOT receive non-DHP CCBs ```
35
What can be used for conversion to NSR?
``` Direct cardioversion (shock) is most effective Can use amiodarone, dofetilide, flecainide, ibutilide, and propafenone ```
36
What can be used for maintenance of NSR after conversion?
dofetilide, dronedarone, flecainide, propafenone, or sotalol | Can use amiodarone but is last line d/t toxicities
37
Anticoagulation and cardioversion - when to anticoagulate and for how long
Start 3 weeks before cardioversion and continue for 4 weeks after If using warfarin INR should be 2-3
38
Antiarrhythmic MOA and result on heart rhythm | Class I
MOA: Na-channel blocker Result: negative inotrope potential, decreasing force of heart's contraction
39
Antiarrhythmic MOA and result on heart rhythm | Class II
MOA: beta-blockers Result: Slow ventricular rate
40
Antiarrhythmic MOA and result on heart rhythm | Class III
MOA: K-channel blockers Result: slows electrical impulses through heart
41
Antiarrhythmic MOA and result on heart rhythm | Class IV
MOA: Ca-channel blockers, non-DHP CCB Result: Slow rate in ventricular tachycardia, decreases contraction force
42
When should Class IV antiarrhythmics not be used?
Do not use verapamil or diltiazem with HFrEF
43
Antiarrhythmic MOA and result on heart rhythm | Digoxin
MOA: Na-K-ATPase blocker Result: suppresses AV node conduction (decrease HR) by enhancing vagal tone and increase force of contraction
44
Antiarrhythmic MOA and result on heart rhythm | adenosine
MOA: activates adenosine receptors Result: decrease AV node conduction
45
How long does it take to see peak effect from amiodarone? What is it's halflife?
1 week to 5 months for peak response | Half-life 40-60 days
46
Amiodarone BBW, CI, warnings, SE
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
What are the antiarrhythmic DOC in HF?
amiodarone and dofetilide
48
True or false: | amiodarone is teratogenic
true
49
Digoxin, warfarin, simvastatin, and lovastatin dose adjustments needed when initiating amiodarone
Digoxin: decrease by 50% Warfarin: decrease by 30-50% Simvastatin: max 20mg/d Lovastatin: max 40mg/d
50
What medication can enhance the bradycardic effect of amiodarone and should not be used with amiodarone?
Sofosbuvir
51
CCBs CI, warnings, SE
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
Digoxin CI, warnings, SE
CI: ventricular fibrillation Warnings: 2nd/3rd degree heart block, vesicant SE: dizziness, mental disturbances, N/V/D
53
S/sx digoxin toxicity | What can increases the risk of digoxin toxicity?
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
What is the antidote for digoxin toxicity?
DigiFab or Digibind
55
Disopyramide BBW, CI, Warnings, SE, w/ w/o food?
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
Quinidine BBW, CI, Warnings, SE, w/ w/o food?
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
S/sx of quinidine toxicity and what can increase risk of toxicity?
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
Procainamide BBW, CI, Warnings, SE
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
Procainamide active metabolite and renal adjustments
Metabolite: N-acetyl procainamide (NAPA) is renally cleared | Decrease dose when CrCl <50
60
What is lidocaine used for with regards to arrhythmias?
Refractory ventricular tachycardia and cardiac arrest
61
Lidocaine CI, Warnings
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
Mexiletine BBW, CI, Warnings, w/ w/o food?
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
Flecainide BBW, CI, warnings, SE
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
Propafenone BBW, CI, Warnings, SE
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
Dronedarone BBW, CI, Warnings, SE, w/ w/o food?
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
How should digoxin dose be adjusted when initiating dronedarone
Decrease dig by 50%
67
Sotalol BBW, CI, SE
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
Sotalol renal adjustments
Non-selective BB CrCl <60 --> decrease frequency CrCl < 40 - varies by formulation
69
Ibutilide BBW, SE
BBW: proarrhythmic SE: ventricular tachycardia, hypotension, QT prolongation, torsades
70
Dofetilide BBW, CI, SE
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
Adenosine CI, SE, half-life
CI: Heart block, sick sinus syndrome, symptomatic bradycardia SE: transient new arrhythmia, flushing, chest pain/pressure, GI distress, dyspnea Half-life: <10 seconds
72
Key counseling for amiodarone
Can cause lung, liver, eye damage, thyroid problems, photosensitivity, skin discoloration Avoid grapefruit MANY drug interactions
73
Key counseling for digoxin
Toxicity: loss of appetite and nausea; vision changes, confusion, hallucinations Avoid dehydration MANY drug interactions

NAPLEX Review (79 decks)

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