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Cardiovascular > Arrythmias > Flashcards

Arrythmias Flashcards

1
Q

Whats the normal HR

A

60-100bpm

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2
Q

Whats the term used for <60bpm

A

Bradycardia

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3
Q

Whats the term used for >100bpm

A

Tachycardia

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4
Q

Whats paroxysmal AF

A

AF which comes and goes

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5
Q

Whats used to manage paroxysmal AF?
When do you take it?

A

Pill in the pocket
Flecainide or propafenone
Take it only when episode begins

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6
Q

Whats an arrhythmia

A

Abnormal rate or rhythm due to problems with the electrical conduction of the heart

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7
Q

How are arrhythmias detected

A

Via ECG

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8
Q

What are the symptoms of arrhythmias

A

SAD PALPITATIONS

Shortness of breath
Abnormal pulse
Dizziness/fainting
Palpitations

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9
Q

How long would the palpitations need to have been occurring for you to use an ECG

A

A couple of days

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10
Q

People with AF are at high risk of….
Why?

A

Stroke
Because blood pools in the chambers which increases the chance of thrombosis/clots

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11
Q

In AF patients assess for …… , …… and …..

A

Stroke
Bleeding
Thromboembolism (DVT/PE)

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12
Q

What is used to detect stroke risk?

A

Cha2dvasc tool

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13
Q

What do you give a patient with a high risk of stroke?

A

DOAC (READ)
Or
Warfarin

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14
Q

What tool is used to asses bleeding risk

A

ORBIT

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15
Q

If a patient is at risk of bleeding and stroke, what changes would you make to their medication?

A

Reduce DOAC/warfarin dose and monitor

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16
Q

Whats the two treatment options for non life threatening AF?

A

Rate and rhythm control

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17
Q

Whats used for life threatening haemodynamic instability caused by new onset AF?

A

Electrical Cardio version

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18
Q

What drugs are used in rate control?

A

DIVED BETA

Diltiazem
Verapamil
Digoxin
Beta blockers (not sotalol)

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19
Q

What drugs are used in rhythm control?

A

Flecainide
Amiodarone
Beta blockers inc sotalol

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20
Q

Whats preferred, rate or rhythm?

A

Rate control

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21
Q

Rhythm control can be ….

A

Cardio version or pharmacological

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22
Q

Cardioversion can be ……

A

Electrical or pharmacological

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23
Q

What are the causes of AF

A

Coronary heart disease
Heart valve disease
Hypertension
Ageing
Cardiomyopathy
Congenital (from birth) abnormalities in electrical pathway

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24
Q

Whats an ectopic beat
How long does it last

A

Heartbeats that suddenly become more noticeable pounding irregularly often few seconds to a minute

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25
Q

Whats the aim of treatment for AF?

A

Prevent complications such as stroke and to reduce symptoms

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26
Q

Patients without life threatening symptoms- give rate control when symptom onset is …..

A

> 48 hrs /days

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27
Q

Patients without life threatening symptoms - give rate or rhythm control when symptom onset is …..

A

<48 hours / days

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28
Q

In patients with no life threatening symptoms in AF, Give …….. if uncertain about symptom onset

A

Rate

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29
Q

In new onset of AF who arent taking anticoagulants what would you give….

Until?

A

Heparin injection until assessment is made and appropriate oral anticoagulation is started

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30
Q

When is parenteral heparin given?

A

Before rhythm or rate short term to prevent clotting.

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31
Q

Do you give heparin injection to life threatening or non life threatening AF or both?

If required you would switch to….

A

Both
Oral anticoagulants

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32
Q

The first line anticoagulants is …….. but if a patient has renal impairment give …… instead

A

DOAC

warfarin

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33
Q

When will oral anticoagulants be given in AF?

A

Confirmed AF

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34
Q

Whats given for the management of supra ventricular arrhythmias?

A

Adenosine

Verapamil, cardiac glycosides (digoxin)

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35
Q

Whats given for the management of ventricular arrhythmias

A

Lidocaine
Sotalol

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36
Q

Whats given for the management of supraventricular and ventricular arrhythmias?

A

Amiodarone
BB

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37
Q

What antiarrhythmic class is BB?

A

Class II

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38
Q

What antiarrhythmic class is membrane stabilising drugs (lidocaine, Flecainide)

A

Class I

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39
Q

What antiarrhythmic class is amiodarone?

A

Class III

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40
Q

What antiarrhythmic class is sotalol?

A

Class II and III

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41
Q

What antiarrhythmic class is potassium channel blockers?

A

Class III

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42
Q

What antiarrhythmic class is Na+ channel blockers?

A

Class I

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43
Q

What antiarrhythmic class is CCB (verapamil and diltiazem)

A

Class IV

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44
Q

In non life threatening AF, rate is preferred unless….

A

New onset AF
Rhythm control is more suitable
patient has HF caused by AF
A patient has AF with a reversible cause e.g., MI, hypothyroidism, excess caffeine/alcohol
Atrial flutter for an ablation strategy

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45
Q

In rate control what drug is given initially? If it doesnt work then….

A

BB (not sotalol)
Or rate limiting CCB as monotherapy
Or digoxin
If uncontrolled then give dual therapy
If dual therapy fails then give rhythm control

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46
Q

A patient is on rate control but monotherapy fails, what are their dual therapy options?

A

BB and diltiazem
BB and digoxin

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47
Q

When would you consider giving digoxin in rate control?

A

In non paroxysmal AF if a patient leads a sedentary lifestyle or if they also have congestive HF

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48
Q

What drugs are used in rhythm control post cardioversion?

A

Felcainide
Amiodarone
BB
Propefanone
Dronedarone
Sotalol

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49
Q

What does cardioversion do?

A

Restores sinus rhythm

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50
Q

Flecianide is CI in….

A

Ischaemic heart disease

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51
Q

Propafenone is CI in…..

A

Heart disease

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52
Q

What are the drugs used in pharmacological cardioversion?

A

Flecainide and amiodarone

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53
Q

If rhythm strategy is preferred, if its been longer than 2 days give…..

A

Electrical Cardioversion

54
Q

If electrical cardioversion is given you need to give anticoagulation for….
If anticoagulation cant be delayed then give…..

A

At least 3 weeks before and 4 weeks after

If it cant be delayed give heparin injection immediately before and oral anticoagulation for 4 weeks after

55
Q

Offer anticoagulation if a male has a cha2dvasc score of

A

1

56
Q

Offer anticoagulation if a female has a cha2dvasc score of

A

2

57
Q

What are the cha2dvasc risk factors? What are the scores for each?

A

Congestive HF -1
Hypertension -1
Age 75 or over - 2
Age 65 to 74 -1
Diabetes - 1
Stroke/TIA/thromboembolism - 2
Vascular disease - 1
Sex female - 1

58
Q

Examples of vascular disease

A

Previous MI
Peripheral arterial disease
Aortic plaque

59
Q

If a patient has both a stroke and TIA do they have a cha2dvasc score of 2 or 3

A

Only 2

60
Q

What are the ORBIT risk factors?

A

Over the age 74 - 1
Reduced haemoglobin (history of anaemia) - 2
Bleeding history -2
Inadequate renal function ( eGFR<60) - 1
Treatment with anti platelets - 1

61
Q

Orbit scores 0-2 is classed as

A

Low risk

62
Q

Orbit score of 3 is classed as …
Requires?

A

Medium risk

Monitoring

63
Q

Orbit score of 4-7 is classed as …..
Which requires ….

A

High risk
Reduce DOAC, stop DOAC or give anti platelet or parenteral

64
Q

Whats torsade de pointes

A

QT prologation, type of arrhythmia where the heart beats are irregular, fast and not enough oxygen is pumped around the body or brain which causes blackouts, fainting and deaths

65
Q

Causes of QT prolongation

A

Stress, hypokalaemia, strenous exercise, sudden noise, drugs such as sotalol

66
Q

Which electrolyte imbalance can cause QT prolongation

A

Hypokalaemia

67
Q

Whats the treatment for torsades de pointes/ QT prolongation

A

IV magnesium sulphate

68
Q

Which drugs cause QT prolongation

A

ABCDDE

Antiarrhythmics
Antibiotics
Antipsychotics
Antidepressants
Diuretics
Antiemetics

69
Q

What are examples of antiarrhythmics which can cause QT prolongation

A

Amiodarone
Sotalol
Felcainide

70
Q

Examples of antiemetics which can cause QT prolongation

A

Ondansetron

71
Q

Examples of antidepressants which can cause QT prolongation

A

SSRIs
TCA

72
Q

Examples of antipsychotics which can cause QT prolongation

A

Haloperidol
Quetiapine
Risperidone

73
Q

Examples of antibiotics which can cause QT prolongation

A

Quinolones
Macrolides
Aminoglycosides

74
Q

Amiodarone arrhythmias dose

A

200mg TDS for 1 week then 200mg BD for 1 week then 200mg daily maintenance dose

75
Q

SE of amiodarone

A

Im a photogenic bitch

Photosensitivity
Bradycardia
Interstitial lung disease/ pulmonary toxicity
Thyroid disorders
Corneal microdeposits
Hepatotoxicity

Optic neuropathy (can cause blindness)
Peripheral neuropathy

76
Q

A patient is in Amiodarone and develops a dry cough or SOB, suspect ……

A

Pneumonitis

77
Q

Why can amiodarone cause thyroid disorders?

A

Because it contains iodine

78
Q

How does Amiodarone affect the skin
What to do to manage

A

Can cause slate grey skin
Wear SPF 30 to protect skin from sunlight

79
Q

A patient is dazzled by headlights and is on an antiarrhythmic medication what is it?

A

Amiodarone
Corneal micro deposits

80
Q

A patient is on an antiarrhythmic medication and develops jaundice, dark urine, malaise what is it and what did it cause?

A

Amiodarone
Hepatotoxicity

81
Q

If a patient is on amiodarone and develops Hepatotoxicity how do you respond?

A

Discontinue

82
Q

How do you manage vision impairment in Amiodarone

A

Discontinue

83
Q

A patient is on an antiarrhythmic medication and develops tingling and numbness in hands and feet/extremities, what is it?

A

Amiodarone

84
Q

Amiodarone CI

A

Thyroid dysfunction
Iodine sensitivity
Liver disease

85
Q

Amiodarone monitoring

A

Thyroid function
Liver function test
Serum potassium concentration
Chest xray
Annual eye test
ECG with IV use
Blood pressure

86
Q

What electrolyte imbalance leads to QT prolongation

A

Hypokalaemia

87
Q

How frequently do you monitor LFTs and thyroid function tests when on Amiodarone

A

Before and every 6 months

88
Q

How does Amiodarone cause QT prolongation

A

It can cause hypokalaemia which leads to it

89
Q

Amiodarone patient and carer advice

A

Wide spectrum sunscreen - SPF 30 to shield skin from sun during and several months after

90
Q

Amiodarone red flags

A

SOB/ dry cough - pneumonitis

Jaundice, malaise, vomiting, abdominal pain, dark urine - Hepatotoxicity

Palpitations, Fainting, blacking out - QT prolongation

Dazzled by headlights - corneal microdeposits

Chest pain

91
Q

Amiodarone interactions

A

Drugs which increase QT prolongation- ABCDDE

Statins

Lithium

Warfarin, digoxin, ciclosporin
Phenytoin

92
Q

How does Amiodarone interact with statins

A

Increased risk of myopathy

93
Q

How does Amiodarone interact with lithium

A

Increased risk of arrhythmias

94
Q

How does Amiodarone interact with warfarin

A

It increases warfarins anticoagulant effect

95
Q

How does Amiodarone interact with phenytoin

A

Increases phenytoin concentration

96
Q

How does Amiodarone interact with ciclosporin

A

Increases concentration of ciclosporin

97
Q

How does Amiodarone interact with digoxin

A

Increase risk of bradycardia

Amiodarone increases exposure to digoxin

98
Q

Why can interactions still occur months after Amiodarone is stopped

A

Long half life

99
Q

Digoxin therapeutic range

A

0.8-2
Shouldnt exceed 2!
1.5-3 —> toxicity is likely

100
Q

What electrolyte needs to be monitored with digoxin?

A

Potassium

101
Q

Is digoxin a positive inotropic or negative?

A

Positive
Increases force of contraction

102
Q

What electrolyte imbalance indicates digoxin toxicity risk?

A

Hypokalaemia

103
Q

What is given to prevent digoxin toxicity? How does it prevent it?

A

Hypokalaemia caused by digoxin can cause toxicity. Give a potassium sparing diuretic to prevent hypokalaemia hence to prevent toxicity

104
Q

Signs of digoxin toxicity

A

Diarrhoea, nausea, dizziness, Vomiting/emesis
Yellow vision
Skin reactions

105
Q

Digoxin moa

A

Increases force of contraction and decreases HR

106
Q

Digoxin indications

A

Atrial flutter, AF, HF

107
Q

How is the maintenance dose of digoxin in AF determined

A

Ventricular rate at rest which shouldnt fall persistently below 60bpm

108
Q

Is digoxin used for rapid HR control?

A

Rarely because response may take several hours even with IV

109
Q

Is digoxin IM route used?

A

No Not recommended

110
Q

Which antiarrhythmic requires loading

A

Amiodarone

111
Q

Does digoxin require loading in HF patients

A

A loading dose is not required for sinus rhythm in HF

112
Q

How long does it take to achieve a satisfactory digoxin concentration

A

Over a period of a week

113
Q

Whats the digoxin maintenance dose of atrial flutter of AF

A

125-250mcg OD - loading dose required

Reduce dose in elderly

114
Q

When is a loading dose for digoxin required

A

It is required in atrial flutter/AF

It isnt required in worsening/severe HF

115
Q

Whats the dose of digoxin for worsening/severe HF?

Is a loading dose required?

A

62.5-125mcg OD
Reduce dose in elderly
No loading dose required

116
Q

Why do we need to reduce digoxin dose in the elderly?

A

Digoxin is excreted renally so risk of renal impairment and toxicity

117
Q

A patient is on digoxin and has been suffering from nausea lately, what would you do?

A

Higher doses need to be divided to BD

118
Q

Dose of digoxin is based on …..

A

Renal function

119
Q

Does digoxin have a short or long half life

A

Long half life

120
Q

How freq is the maintenance dose given daily

A

Once daily

121
Q

Whats the maintenance dose of digoxin if the patient has Both AF and HF

A

125mcg once daily

122
Q

Digoxin is a narrow therapeutic drug, what does this mean?

A

If the dose is not within the range ( >2) it increases risk of digoxin toxicity

123
Q

Digoxin formulations have different bioavailability, whats the bioavailability percentages for
IV
Elexir
Tablet

A

IV 100%
Elexir 75%
Tablet 90%

124
Q

What electrolyte imbalances predispose you to digoxin toxicity

A

Hypomagnesia
Hypokalaemia
Hypoxia
Hypercalcaemia

125
Q

How do you manage digoxin toxicity

A

Withdraw digoxin or if life threatening reverse with digoxin specific antibody fragments.

126
Q

Digoxin specific fragment antibodies are used for …..

A

Digoxin reversal in life threatening toxicity associated with ventricular arrhythmias

127
Q

Whats DIGIFAB

A

Antidote given to reverse digoxin toxicity

128
Q

Digoxin monitoring requirements

A

Serum electrolytes (hypokalaemia, hypomagnesia, hypercalcaemia, hypoxia)
- toxicity increased by electrolyte imbalance

Renal function- reduce in renal impairment because renally excreted)

Plasma -digoxin concentration - monitor to prevent toxicity

129
Q

When should plasma concentration be taken when taking digoxin

A

6 hours after taking the dose

130
Q

Digoxin interactions

A

Drugs which reduce renal impairment- NSAIDs, ACEi, ARBs

enzyme inducers - reduce digoxin concentration

Enzyme inhibitors - increase digoxin concentration

Increased QT prolongation -ABCDDE

Drugs which reduce potassium concentration- diuretics, theophylline, steroids

CRASED

CCB
RIFAMPICIN
AMIODARONE
ST JOHNS WORT
ERYTHROMYCIN
DIURETICS

Cardiovascular (9 decks)

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