arrythmias

Question 1

Sotalol

Indications

Answer 1

• Symptomatic ventricular tachycardia
• Atrial tachycardia/fibrillation
• maintenance of sinus rhythm after cardioversion
  *

Question 2

Sotalol

MOA

Answer 2

• Non-selective BB
• Sotalol has both Class II (Beta blocking effect) and Class III (cardiac action potential duration prolongation- lengthens PR, QT and QTc)
• Its B-adrenergic effect causes a reduction in BP, HR and negative inotropic effect which reduces myocardial oxygen consumption and cardiac work

Question 3

Sotalol

Adverse effects

Answer 3

• Prolongation of QT can cause life-threatening ventricular arrhythmias- advised to reduce or discontinue if QT >550 msec
• STOPP criteria (Bradycardia, low BP)
• Cold peripheral
• Abdo pain
• ED
• Fatigue

Question 4

Sotalol

Warnings

Answer 4

• Contraindications: Asthma, cardiogenic shock, metabolic acidosis, uncontrolled HF
• Hyper/Hypokalaemia (with or without hypomagnesaemia)- due to QT prolongation- should not be given until K imbalance is sorted
• Cautions
  
  • Diabetes (Mask symptoms of hypoglycaemia)
  • COPD
  • Myasthenia gravis
  • Portal HTN (Risk of deterioration of liver function)
  • Mask symptoms of thyrotoxicosis

Question 5

Sotalol

Interactions

Answer 5

• B-agonists
• Non-dihydropyridine calcium channel blockers (e.g. diltiazem and verapamil)- When used in combination this can cause HF, bradycardia and asystole

Question 6

Sotalol

Monitoring

Answer 6

• BP (120+)
• HR (50-90)
• Monitor lung function in patients with a history of obstructive airway disease)
• ECG
• U&E (K, Mg)

Question 7

Flecainide

Common indications

Answer 7

• Supraventricular arrhythmias
• Ventricular arrhythmias
• NB- reduce dose by half when concurrent use with amiodarone

Question 8

Flecainide

MOA

Answer 8

• Class IC agent- local anaesthetic type
• Characteristics: Marked depression of the fast Na channel in the heart, slow association and dissociation from Na channels, mainly affects Purkinje fibres (as opposed to ventricular muscle)
• These properties leads to depression in conduction velocity with a modest increase in the refractory period
• Flecanide leads to prolongation of PR, QRS duration on ECG

Question 9

Flecainide
Adverse effects

Answer 9

• Arrhythmias, dizziness, fever, oedema, visual disturbances

Question 10

flecainide

Warnings

Answer 10

• Abnormal LV function
• HF
• Elderly (accumulation can occur)

Question 11

DOAC’s

Indications

Answer 11

• Prophylaxis of VTE following Knee and hip replacement
• Prophylaxis (10mg) and Treatment of DVT + PE- 15mg BD for 21 days then 20mg OD maintenance
• Prophylaxis of stroke in patients with AF (With HF, HTN, previous stroke/tia, >75yrs or diabetes)- 20mg
• Prophylaxis of ACS (in combo with antiplatelets)- 2.5mg

Question 12

DOAC’s

Contra-indications

Answer 12

• Active bleeding
• Antiphospholipid syndrome
• Oesophageal varices
• GI ulcers
• Intracranial haemorrhage
• Recent brain and ophthalmic surgery

Question 13

DOAC’s

Cautions

Answer 13

• Bronchiectasis
• Elderly
• Prosthetic heart valve
• Risk of bleeding
• BW<60kg

Question 14

DOACs

Renal impairment

Answer 14

• Rivaroxaban- with 15-49mL- reduce 20mg to 15mg. Avoid <15mL
• Dabigatran- 30-50mL reduce 150mg to 75mg. Avoid if <30mL
• Edoxaban- with 15-50mL reduce 60mg to 30mg. Avoid <15mL
• Apixaban
  
  • Avoid <15mL
  • With 15-29mL (AND has Cr=133 or over 80 or <60kg) reduce to 2.5mg BD for stroke

Question 15

DOAC’s

Interactions

Answer 15

• CYP3A4 inducers (rifampicin, AEDs)
• Other anti-coagulants + anti-platelets
• Meds that increase risk of bleeding- NSAIDs, SSRI

Question 16

DOACs

Monitoring

Answer 16

• Signs of bleeding- including anaemia
• U+E- particularly CrCl

Question 17

DOAC

MOA

Answer 17

• Highly selective direct factor Xa inhibitor
• Inhibition of factor Xa interrupts the intrinsic and extrinsic pathway of the coagulation cascade