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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
Whats the aim of treatment for AF?
Prevent complications such as stroke and to reduce symptoms
26
Patients without life threatening symptoms- give rate control when symptom onset is …..
>48 hrs /days
27
Patients without life threatening symptoms - give rate or rhythm control when symptom onset is …..
<48 hours / days
28
In patients with no life threatening symptoms in AF, Give …….. if uncertain about symptom onset
Rate
29
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
30
When is parenteral heparin given?
Before rhythm or rate short term to prevent clotting.
31
Do you give heparin injection to life threatening or non life threatening AF or both? If required you would switch to….
Both Oral anticoagulants
32
The first line anticoagulants is …….. but if a patient has renal impairment give …… instead
DOAC warfarin
33
When will oral anticoagulants be given in AF?
Confirmed AF
34
Whats given for the management of supra ventricular arrhythmias?
Adenosine Verapamil, cardiac glycosides (digoxin)
35
Whats given for the management of ventricular arrhythmias
Lidocaine Sotalol
36
Whats given for the management of supraventricular and ventricular arrhythmias?
Amiodarone BB
37
What antiarrhythmic class is BB?
Class II
38
What antiarrhythmic class is membrane stabilising drugs (lidocaine, Flecainide)
Class I
39
What antiarrhythmic class is amiodarone?
Class III
40
What antiarrhythmic class is sotalol?
Class II and III
41
What antiarrhythmic class is potassium channel blockers?
Class III
42
What antiarrhythmic class is Na+ channel blockers?
Class I
43
What antiarrhythmic class is CCB (verapamil and diltiazem)
Class IV
44
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
45
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
46
A patient is on rate control but monotherapy fails, what are their dual therapy options?
BB and diltiazem BB and digoxin
47
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
48
What drugs are used in rhythm control post cardioversion?
Felcainide Amiodarone BB Propefanone Dronedarone Sotalol
49
What does cardioversion do?
Restores sinus rhythm
50
Flecianide is CI in….
Ischaemic heart disease
51
Propafenone is CI in…..
Heart disease
52
What are the drugs used in pharmacological cardioversion?
Flecainide and amiodarone
53
If rhythm strategy is preferred, if its been longer than 2 days give…..
Electrical Cardioversion
54
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
55
Offer anticoagulation if a male has a cha2dvasc score of
1
56
Offer anticoagulation if a female has a cha2dvasc score of
2
57
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
58
Examples of vascular disease
Previous MI Peripheral arterial disease Aortic plaque
59
If a patient has both a stroke and TIA do they have a cha2dvasc score of 2 or 3
Only 2
60
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
61
Orbit scores 0-2 is classed as
Low risk
62
Orbit score of 3 is classed as … Requires?
Medium risk Monitoring
63
Orbit score of 4-7 is classed as ….. Which requires ….
High risk Reduce DOAC, stop DOAC or give anti platelet or parenteral
64
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
65
Causes of QT prolongation
Stress, hypokalaemia, strenous exercise, sudden noise, drugs such as sotalol
66
Which electrolyte imbalance can cause QT prolongation
Hypokalaemia
67
Whats the treatment for torsades de pointes/ QT prolongation
IV magnesium sulphate
68
Which drugs cause QT prolongation
ABCDDE Antiarrhythmics Antibiotics Antipsychotics Antidepressants Diuretics Antiemetics
69
What are examples of antiarrhythmics which can cause QT prolongation
Amiodarone Sotalol Felcainide
70
Examples of antiemetics which can cause QT prolongation
Ondansetron
71
Examples of antidepressants which can cause QT prolongation
SSRIs TCA
72
Examples of antipsychotics which can cause QT prolongation
Haloperidol Quetiapine Risperidone
73
Examples of antibiotics which can cause QT prolongation
Quinolones Macrolides Aminoglycosides
74
Amiodarone arrhythmias dose
200mg TDS for 1 week then 200mg BD for 1 week then 200mg daily maintenance dose
75
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
76
A patient is in Amiodarone and develops a dry cough or SOB, suspect ……
Pneumonitis
77
Why can amiodarone cause thyroid disorders?
Because it contains iodine
78
How does Amiodarone affect the skin What to do to manage
Can cause slate grey skin Wear SPF 30 to protect skin from sunlight
79
A patient is dazzled by headlights and is on an antiarrhythmic medication what is it?
Amiodarone Corneal micro deposits
80
A patient is on an antiarrhythmic medication and develops jaundice, dark urine, malaise what is it and what did it cause?
Amiodarone Hepatotoxicity
81
If a patient is on amiodarone and develops Hepatotoxicity how do you respond?
Discontinue
82
How do you manage vision impairment in Amiodarone
Discontinue
83
A patient is on an antiarrhythmic medication and develops tingling and numbness in hands and feet/extremities, what is it?
Amiodarone
84
Amiodarone CI
Thyroid dysfunction Iodine sensitivity Liver disease
85
Amiodarone monitoring
Thyroid function Liver function test Serum potassium concentration Chest xray Annual eye test ECG with IV use Blood pressure
86
What electrolyte imbalance leads to QT prolongation
Hypokalaemia
87
How frequently do you monitor LFTs and thyroid function tests when on Amiodarone
Before and every 6 months
88
How does Amiodarone cause QT prolongation
It can cause hypokalaemia which leads to it
89
Amiodarone patient and carer advice
Wide spectrum sunscreen - SPF 30 to shield skin from sun during and several months after
90
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
91
Amiodarone interactions
Drugs which increase QT prolongation- ABCDDE Statins Lithium Warfarin, digoxin, ciclosporin Phenytoin
92
How does Amiodarone interact with statins
Increased risk of myopathy
93
How does Amiodarone interact with lithium
Increased risk of arrhythmias
94
How does Amiodarone interact with warfarin
It increases warfarins anticoagulant effect
95
How does Amiodarone interact with phenytoin
Increases phenytoin concentration
96
How does Amiodarone interact with ciclosporin
Increases concentration of ciclosporin
97
How does Amiodarone interact with digoxin
Increase risk of bradycardia Amiodarone increases exposure to digoxin
98
Why can interactions still occur months after Amiodarone is stopped
Long half life
99
Digoxin therapeutic range
0.8-2 Shouldnt exceed 2! 1.5-3 —> toxicity is likely
100
What electrolyte needs to be monitored with digoxin?
Potassium
101
Is digoxin a positive inotropic or negative?
Positive Increases force of contraction
102
What electrolyte imbalance indicates digoxin toxicity risk?
Hypokalaemia
103
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
104
Signs of digoxin toxicity
Diarrhoea, nausea, dizziness, Vomiting/emesis Yellow vision Skin reactions
105
Digoxin moa
Increases force of contraction and decreases HR
106
Digoxin indications
Atrial flutter, AF, HF
107
How is the maintenance dose of digoxin in AF determined
Ventricular rate at rest which shouldnt fall persistently below 60bpm
108
Is digoxin used for rapid HR control?
Rarely because response may take several hours even with IV
109
Is digoxin IM route used?
No Not recommended
110
Which antiarrhythmic requires loading
Amiodarone
111
Does digoxin require loading in HF patients
A loading dose is not required for sinus rhythm in HF
112
How long does it take to achieve a satisfactory digoxin concentration
Over a period of a week
113
Whats the digoxin maintenance dose of atrial flutter of AF
125-250mcg OD - loading dose required Reduce dose in elderly
114
When is a loading dose for digoxin required
It is required in atrial flutter/AF It isnt required in worsening/severe HF
115
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
116
Why do we need to reduce digoxin dose in the elderly?
Digoxin is excreted renally so risk of renal impairment and toxicity
117
A patient is on digoxin and has been suffering from nausea lately, what would you do?
Higher doses need to be divided to BD
118
Dose of digoxin is based on …..
Renal function
119
Does digoxin have a short or long half life
Long half life
120
How freq is the maintenance dose given daily
Once daily
121
Whats the maintenance dose of digoxin if the patient has Both AF and HF
125mcg once daily
122
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
123
Digoxin formulations have different bioavailability, whats the bioavailability percentages for IV Elexir Tablet
IV 100% Elexir 75% Tablet 90%
124
What electrolyte imbalances predispose you to digoxin toxicity
Hypomagnesia Hypokalaemia Hypoxia Hypercalcaemia
125
How do you manage digoxin toxicity
Withdraw digoxin or if life threatening reverse with digoxin specific antibody fragments.
126
Digoxin specific fragment antibodies are used for …..
Digoxin reversal in life threatening toxicity associated with ventricular arrhythmias
127
Whats DIGIFAB
Antidote given to reverse digoxin toxicity
128
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
129
When should plasma concentration be taken when taking digoxin
6 hours after taking the dose
130
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

Cardiovascular (9 decks)

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