Arrythmias Flashcards
Whats the normal HR
60-100bpm
Whats the term used for <60bpm
Bradycardia
Whats the term used for >100bpm
Tachycardia
Whats paroxysmal AF
AF which comes and goes
Whats used to manage paroxysmal AF?
When do you take it?
Pill in the pocket
Flecainide or propafenone
Take it only when episode begins
Whats an arrhythmia
Abnormal rate or rhythm due to problems with the electrical conduction of the heart
How are arrhythmias detected
Via ECG
What are the symptoms of arrhythmias
SAD PALPITATIONS
Shortness of breath
Abnormal pulse
Dizziness/fainting
Palpitations
How long would the palpitations need to have been occurring for you to use an ECG
A couple of days
People with AF are at high risk of….
Why?
Stroke
Because blood pools in the chambers which increases the chance of thrombosis/clots
In AF patients assess for …… , …… and …..
Stroke
Bleeding
Thromboembolism (DVT/PE)
What is used to detect stroke risk?
Cha2dvasc tool
What do you give a patient with a high risk of stroke?
DOAC (READ)
Or
Warfarin
What tool is used to asses bleeding risk
ORBIT
If a patient is at risk of bleeding and stroke, what changes would you make to their medication?
Reduce DOAC/warfarin dose and monitor
Whats the two treatment options for non life threatening AF?
Rate and rhythm control
Whats used for life threatening haemodynamic instability caused by new onset AF?
Electrical Cardio version
What drugs are used in rate control?
DIVED BETA
Diltiazem
Verapamil
Digoxin
Beta blockers (not sotalol)
What drugs are used in rhythm control?
Flecainide
Amiodarone
Beta blockers inc sotalol
Whats preferred, rate or rhythm?
Rate control
Rhythm control can be ….
Cardio version or pharmacological
Cardioversion can be ……
Electrical or pharmacological
What are the causes of AF
Coronary heart disease
Heart valve disease
Hypertension
Ageing
Cardiomyopathy
Congenital (from birth) abnormalities in electrical pathway
Whats an ectopic beat
How long does it last
Heartbeats that suddenly become more noticeable pounding irregularly often few seconds to a minute
Whats the aim of treatment for AF?
Prevent complications such as stroke and to reduce symptoms
Patients without life threatening symptoms- give rate control when symptom onset is …..
> 48 hrs /days
Patients without life threatening symptoms - give rate or rhythm control when symptom onset is …..
<48 hours / days
In patients with no life threatening symptoms in AF, Give …….. if uncertain about symptom onset
Rate
In new onset of AF who arent taking anticoagulants what would you give….
Until?
Heparin injection until assessment is made and appropriate oral anticoagulation is started
When is parenteral heparin given?
Before rhythm or rate short term to prevent clotting.
Do you give heparin injection to life threatening or non life threatening AF or both?
If required you would switch to….
Both
Oral anticoagulants
The first line anticoagulants is …….. but if a patient has renal impairment give …… instead
DOAC
warfarin
When will oral anticoagulants be given in AF?
Confirmed AF
Whats given for the management of supra ventricular arrhythmias?
Adenosine
Verapamil, cardiac glycosides (digoxin)
Whats given for the management of ventricular arrhythmias
Lidocaine
Sotalol
Whats given for the management of supraventricular and ventricular arrhythmias?
Amiodarone
BB
What antiarrhythmic class is BB?
Class II
What antiarrhythmic class is membrane stabilising drugs (lidocaine, Flecainide)
Class I
What antiarrhythmic class is amiodarone?
Class III
What antiarrhythmic class is sotalol?
Class II and III
What antiarrhythmic class is potassium channel blockers?
Class III
What antiarrhythmic class is Na+ channel blockers?
Class I
What antiarrhythmic class is CCB (verapamil and diltiazem)
Class IV
In non life threatening AF, rate is preferred unless….
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
In rate control what drug is given initially? If it doesnt work then….
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
A patient is on rate control but monotherapy fails, what are their dual therapy options?
BB and diltiazem
BB and digoxin
When would you consider giving digoxin in rate control?
In non paroxysmal AF if a patient leads a sedentary lifestyle or if they also have congestive HF
What drugs are used in rhythm control post cardioversion?
Felcainide
Amiodarone
BB
Propefanone
Dronedarone
Sotalol
What does cardioversion do?
Restores sinus rhythm
Flecianide is CI in….
Ischaemic heart disease
Propafenone is CI in…..
Heart disease
What are the drugs used in pharmacological cardioversion?
Flecainide and amiodarone
If rhythm strategy is preferred, if its been longer than 2 days give…..
Electrical Cardioversion
If electrical cardioversion is given you need to give anticoagulation for….
If anticoagulation cant be delayed then give…..
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
Offer anticoagulation if a male has a cha2dvasc score of
1
Offer anticoagulation if a female has a cha2dvasc score of
2
What are the cha2dvasc risk factors? What are the scores for each?
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
Examples of vascular disease
Previous MI
Peripheral arterial disease
Aortic plaque
If a patient has both a stroke and TIA do they have a cha2dvasc score of 2 or 3
Only 2
What are the ORBIT risk factors?
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
Orbit scores 0-2 is classed as
Low risk
Orbit score of 3 is classed as …
Requires?
Medium risk
Monitoring
Orbit score of 4-7 is classed as …..
Which requires ….
High risk
Reduce DOAC, stop DOAC or give anti platelet or parenteral
Whats torsade de pointes
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
Causes of QT prolongation
Stress, hypokalaemia, strenous exercise, sudden noise, drugs such as sotalol
Which electrolyte imbalance can cause QT prolongation
Hypokalaemia
Whats the treatment for torsades de pointes/ QT prolongation
IV magnesium sulphate
Which drugs cause QT prolongation
ABCDDE
Antiarrhythmics
Antibiotics
Antipsychotics
Antidepressants
Diuretics
Antiemetics
What are examples of antiarrhythmics which can cause QT prolongation
Amiodarone
Sotalol
Felcainide
Examples of antiemetics which can cause QT prolongation
Ondansetron
Examples of antidepressants which can cause QT prolongation
SSRIs
TCA
Examples of antipsychotics which can cause QT prolongation
Haloperidol
Quetiapine
Risperidone
Examples of antibiotics which can cause QT prolongation
Quinolones
Macrolides
Aminoglycosides
Amiodarone arrhythmias dose
200mg TDS for 1 week then 200mg BD for 1 week then 200mg daily maintenance dose
SE of amiodarone
Im a photogenic bitch
Photosensitivity
Bradycardia
Interstitial lung disease/ pulmonary toxicity
Thyroid disorders
Corneal microdeposits
Hepatotoxicity
Optic neuropathy (can cause blindness)
Peripheral neuropathy
A patient is in Amiodarone and develops a dry cough or SOB, suspect ……
Pneumonitis
Why can amiodarone cause thyroid disorders?
Because it contains iodine
How does Amiodarone affect the skin
What to do to manage
Can cause slate grey skin
Wear SPF 30 to protect skin from sunlight
A patient is dazzled by headlights and is on an antiarrhythmic medication what is it?
Amiodarone
Corneal micro deposits
A patient is on an antiarrhythmic medication and develops jaundice, dark urine, malaise what is it and what did it cause?
Amiodarone
Hepatotoxicity
If a patient is on amiodarone and develops Hepatotoxicity how do you respond?
Discontinue
How do you manage vision impairment in Amiodarone
Discontinue
A patient is on an antiarrhythmic medication and develops tingling and numbness in hands and feet/extremities, what is it?
Amiodarone
Amiodarone CI
Thyroid dysfunction
Iodine sensitivity
Liver disease
Amiodarone monitoring
Thyroid function
Liver function test
Serum potassium concentration
Chest xray
Annual eye test
ECG with IV use
Blood pressure
What electrolyte imbalance leads to QT prolongation
Hypokalaemia
How frequently do you monitor LFTs and thyroid function tests when on Amiodarone
Before and every 6 months
How does Amiodarone cause QT prolongation
It can cause hypokalaemia which leads to it
Amiodarone patient and carer advice
Wide spectrum sunscreen - SPF 30 to shield skin from sun during and several months after
Amiodarone red flags
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
Amiodarone interactions
Drugs which increase QT prolongation- ABCDDE
Statins
Lithium
Warfarin, digoxin, ciclosporin
Phenytoin
How does Amiodarone interact with statins
Increased risk of myopathy
How does Amiodarone interact with lithium
Increased risk of arrhythmias
How does Amiodarone interact with warfarin
It increases warfarins anticoagulant effect
How does Amiodarone interact with phenytoin
Increases phenytoin concentration
How does Amiodarone interact with ciclosporin
Increases concentration of ciclosporin
How does Amiodarone interact with digoxin
Increase risk of bradycardia
Amiodarone increases exposure to digoxin
Why can interactions still occur months after Amiodarone is stopped
Long half life
Digoxin therapeutic range
0.8-2
Shouldnt exceed 2!
1.5-3 —> toxicity is likely
What electrolyte needs to be monitored with digoxin?
Potassium
Is digoxin a positive inotropic or negative?
Positive
Increases force of contraction
What electrolyte imbalance indicates digoxin toxicity risk?
Hypokalaemia
What is given to prevent digoxin toxicity? How does it prevent it?
Hypokalaemia caused by digoxin can cause toxicity. Give a potassium sparing diuretic to prevent hypokalaemia hence to prevent toxicity
Signs of digoxin toxicity
Diarrhoea, nausea, dizziness, Vomiting/emesis
Yellow vision
Skin reactions
Digoxin moa
Increases force of contraction and decreases HR
Digoxin indications
Atrial flutter, AF, HF
How is the maintenance dose of digoxin in AF determined
Ventricular rate at rest which shouldnt fall persistently below 60bpm
Is digoxin used for rapid HR control?
Rarely because response may take several hours even with IV
Is digoxin IM route used?
No Not recommended
Which antiarrhythmic requires loading
Amiodarone
Does digoxin require loading in HF patients
A loading dose is not required for sinus rhythm in HF
How long does it take to achieve a satisfactory digoxin concentration
Over a period of a week
Whats the digoxin maintenance dose of atrial flutter of AF
125-250mcg OD - loading dose required
Reduce dose in elderly
When is a loading dose for digoxin required
It is required in atrial flutter/AF
It isnt required in worsening/severe HF
Whats the dose of digoxin for worsening/severe HF?
Is a loading dose required?
62.5-125mcg OD
Reduce dose in elderly
No loading dose required
Why do we need to reduce digoxin dose in the elderly?
Digoxin is excreted renally so risk of renal impairment and toxicity
A patient is on digoxin and has been suffering from nausea lately, what would you do?
Higher doses need to be divided to BD
Dose of digoxin is based on …..
Renal function
Does digoxin have a short or long half life
Long half life
How freq is the maintenance dose given daily
Once daily
Whats the maintenance dose of digoxin if the patient has Both AF and HF
125mcg once daily
Digoxin is a narrow therapeutic drug, what does this mean?
If the dose is not within the range ( >2) it increases risk of digoxin toxicity
Digoxin formulations have different bioavailability, whats the bioavailability percentages for
IV
Elexir
Tablet
IV 100%
Elexir 75%
Tablet 90%
What electrolyte imbalances predispose you to digoxin toxicity
Hypomagnesia
Hypokalaemia
Hypoxia
Hypercalcaemia
How do you manage digoxin toxicity
Withdraw digoxin or if life threatening reverse with digoxin specific antibody fragments.
Digoxin specific fragment antibodies are used for …..
Digoxin reversal in life threatening toxicity associated with ventricular arrhythmias
Whats DIGIFAB
Antidote given to reverse digoxin toxicity
Digoxin monitoring requirements
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
When should plasma concentration be taken when taking digoxin
6 hours after taking the dose
Digoxin interactions
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
