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FA17 Cardio 2 > Arrythmias + Devices > Flashcards

Arrythmias + Devices Flashcards

1
Q

risk factors for AFib

A 
Age 
valvular heart Dz 
dilated cardiomyopathy 
arteriosclerotic ht dz 
genetics 
COPD 
Anemia 
HTn DM 
CKD 
obesity
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2
Q

triggering factors for AF

A 
thyrotoxicosis 
pericarditis 
chest trauma
sx
EtOH intake 
EtOH withdrawal
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3
Q

AF epidemiology

A

more common men, caucasians

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4
Q

pathophysiology of AF

A

sleeves of arrhythmogenic atrial tissue extends into pulmonary veins

they attempt to pace the heart, lots of different cells lead to the pace of the heart

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5
Q

electrical remodeling in AFib

A

atrial electrical and structural remodeling occurs which promotes the continuation of Afib

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6
Q

classification of AFib

A
  1. persistent AF
  2. Paroxysmal AF
  3. permentant AF
    4, Lone AF
  • AFib secondary to another cause
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7
Q

persistent AFib

A

Fib that fails to self terminate within 7 days

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8
Q

paroxysmal AFib

A

2+ episodes of self terminating or intermittent AF lasting less than 7 days

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9
Q

permanent AF

A

lasts > 1yr

cardio version has not been attempted or failed

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10
Q

Lone AF

A

young individuals <60

absence of structural heart disease

typically occurs in young males, associated with specific trigger

greater number of foci

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11
Q

clinical presentation of AF

why do they range in symptoms?

A

related to perfusion and ventricular control

uncontrolled (>100 bpm) causes backing up to lunch, decreased perfusion of brain and kidney

controlled (<100 bpm) no HF issues

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12
Q

diagnosis of Afib

A 
EKG 
TTE 
Cardiac Enzymes and BNP
TSH and free T4
Baseline CBC, renal function, glucose level, UA
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13
Q

EKG evaluates for AFib AND

A

LVH
Evidence of prior MI
conduction system issues
establishes baseline QT

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14
Q

TTE

A

transTHORACIC

looks for valvular dz, atrial size, LVH, systolic and diastolic issues

unable to exclude L. atrial thrombus

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15
Q

tx of unstable AFib

A

immediate synchronized cardio version

load medications and pt still remains unstable

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16
Q

management of a stable patient

A
  1. telemetry bed
  2. rate control if RVR
  3. Begin evaluation
  4. anti coagulate
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17
Q

rate control of RVR stable AF

A

cardizem (10-20 mg IV bolus)

Metoprolol (cardiac ischemia and infarction)

Digoxin (hypotension)

Amiodarone

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18
Q

immediate anticoagulation for Afib

A

heparin IV infusion (kidney issues or recent bleeding0

LMWH (pregnancy, DOC)

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19
Q

other diseases that we need to consider when treating AFib

A

MI

Wet Lungs - Lasix

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20
Q

Tx strategies of new onset AFib

A

Rhythm control v. rate control

embolization risk

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21
Q

rate control strategy

A

get resting HR to 80 ppm

recommended 65+

typically use BB or non-DHP CCB

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22
Q

other medications used in rate control

A

acute systolic heart failure, treated with amiodarone or digoxin

must be careful of amiodarone - cardio version

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23
Q

pre-excitation syndrome

A

AV node blockage will promote tachyarrhythmias via accessory pathway

CCB and dig are C/I = amiodarone is DOC

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24
Q

rhythm control strategy

A

convert AF to SNR and medications to keep patient in NSR

methods: Cardioversion, radio frequency catheter ablation, maze procedure

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25
Q

when should cardio version most successful

A

AFib of less than 7 days in duration - less chance of remodeling

its must be anti-coagulated for 3+ weeks or TEE

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26
Q

cardioversion procedure

A

electrolytes K and O2 are normalized and pt is npc for 6 hrs

conscious sedation

electrical shock (120-200 j) via biphasic defibrillator

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27
Q

cardio version is highly recommended in….

A

younger patients with onset AF of short duration

function improves almost immediately after cardio version

anticoagulation should continue for at least 4 weeks

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28
Q

shocking chronic AFib?

A

AFFIRM and RACE

no benefit for patients with cardioversion in tx of chronic AF

pt plan needs to be individualized bc risks and benefits

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29
Q

RF catheter ablation indicated

A

lifestyle impairing aFIB and intolerability of at least 1 anti-rhythm agent

NOT always a cure but more effective than pharm tx

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30
Q

when is RF ablation most successful?

A

AFib of less than 7 days in duration - less chance of remodeling

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31
Q

process of RF ablation

A

going thru intra-atrial septum

electrophysiologist makes a 3d map of atria using an electromagnetic probe

burns all small lesions in tissue to isolate pulmonary veins

possible meds can be taken to reduce recurrence

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32
Q

complications of catheter ablation

A

cardiac perforation
tamponade
atrial flutter
vascualr access complications

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33
Q

RF catheter ablation mortality benefit

A

NO mortality benefit and NO change in anticoagulation

BUT they can improve rate/lifestyle

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34
Q

anti-arrhythmics used in AF therapy

A
  1. Amniodarone *
  2. Dronedarone *
  3. Sotalol
  4. Dofetilide
  • use with caution bc lots of drug interactions
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35
Q

amniodarone brand and use

A

Pacerone, Cordarone

safe in persistent AF, better than other anti-arrythmics

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36
Q

in what patients is amniodarone the DOC?

A

patients with cardiac dz (CAD, systolic or diastolic HF)

decreased pro-arrhythmic effects

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37
Q

Class Ic anti-arrhythmics use

A

Propafenone and flecanide

indicated for patients with AF and SCT without structural heart disease

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38
Q

Dronedarone brand and use

A

Multaq

paroxysmal AF or after conversion of persistent AF

associated with INCREASED mortality in pts with PERMANENT AF

39
Q

Dronedarone special patient population

A

properties of all 4 classes

paroxysmal or persistent AF/flutter

associated CV risk factors who are in sinus rhythm or will be converted

40
Q

Dronedarone is CI in

A

permanent AF

class IV heart failure or recent episode of ANY HF

41
Q

sotalol brand and s.e.

A

Betapace

class 3, QT interval prolongation and torsdae de pointes

MUST monitor QT and electrolytes

42
Q

Sotalol is CI in, why?

A

HF pts, pts with prolonged QT

pro-arrhythmic effects are increased in HF

43
Q

Dofetilide brand and use

A

Tikosyn

must hospitalize when starting

indicated for maintenance of sinus rhythm and conversion of AF in persistent AF

44
Q

Dofetilide has NO effect on…

A 
cardiac output
cardiac index 
stroke volume index
systemic vascular resistance in VTACH 
HF 
LVEF
45
Q

Thrombus formation in AF

when and why

A

concerned about thrombus formation in pts with AF >48hrs

enough time for a thrombus to form and dislodge can go to brain for stroke

46
Q

AF and stroke risk

A

MANY strokes in US are caused by AF

+ larger and more likely to undergo conversion to hemorrhagic

(more likely to occur and more likely to have a worse outcome)

chances of AF are increased in valvular dz

increased in women, increasing age

47
Q

T or F

Patients with persistent AF are more likely to get a stroke than those with paroxysmal AF

A

FALSE

there is NO difference in rate of stroke bt paroxysmal and persistent AF

ALL AF pts should be anti-coagulated

48
Q

what do we use to calculate anticoagulation risk?

A

CHADS2 VAS

49
Q

CHADS 2 VAS

A 
C- congestive HF 
H- HTN
A- >75 
D- DM 
S- secondary prevention of embolic events (+2)

V- vascular dz
A- >65
S- sex (women +1)

50
Q

CHADS2VAS score 0-1

A

ASA alone

51
Q

CHADS2VAS score 2

A

individualize ASA v anticoagulation

52
Q

CHADS2VAS score 3+

A

anti-coagulate with warfarin or NOAC

53
Q

risk of CHADS2VAS score?

A

bleeding risk

use HAS-BLED

54
Q

HAS-BLED

A 
H - HTN
A- Abnormal renal/liver fxn
S- stroke 
B - bleeding history
L - labile INRs
E - elderly (65+) 
D- drugs (antiplatelet or alcohol)

each of these is +1

55
Q

what HAS-BLED score qualifies high risk of bleeding

A

> 3

use caution and review anticoagulation

56
Q

HAS-BLED or CHADS2VAS

A

risk of major bleeding can exceed benefits but no study has shown

57
Q

Warfarin/Coumadin, dose adjusted to/how

A

INR 2-3

overlap w IV heparin, 5 days

medium dose, check PT/INR after 48 hrs and adjust from there

58
Q

advantages of warfarin

A

Coumadin/Jantoven

cheap, insurance coverage
safe in CKD/renal failure

59
Q

disadvantages of warfarin

A

many Drug/Drug interactions

narrow therapeutic index (close monitoring)

requires a lot of diet control

60
Q

long-term Anti-Coagulation agents in AF

A

Warfarin/Coumadin/Jantoven

NOACs (Apixaban, Rivaroxaban, Dabigatran, Edoxaban)

61
Q

NOACs use in AF

A

NON-VALVULAR A-FIB

considered superior to warfarin if persons have CHADS2VAS > 2

if pt has valvular dz then warfarin is superior

62
Q

Apixaban (Eliquis)

A

5mg bid

Xa inhibitor

dose adjusted to 2.5 if: CR >1.5, >80 age, wt <60 kg

safest NOAC for the kidney ***

63
Q

Rivaroxaban (Xarelto)

A

Xa inhibitor must dose adjust

can’t use in CKD IV (GFR < 30)

64
Q

Dabigatran (Pradaxa)

A

direct thrombin inhibitor

reversal agent is available (COSTLY)

used until stage IV CKD (GFR < 30)

65
Q

dabigatran TRADE

A

Pradaxa

66
Q

rivaroxaban TRADE

A

Xarelto

67
Q

apixaban TRADE

A

Eliquis

68
Q

Edoxaban (Savaysa) kidney

A

dose adjust if GFR < 50

can’t be used in GFR >90 or GFR <30

69
Q

watchman device

what is it, who gets it

A

given to pts who can’t be maintained on anticoagulation

umbrella device deployed to L ATRIAL APPENDAGE, allows tissue to grow over the device and seal off the appendage

blocks the “nook” where clots like to form

70
Q

NSVT

A

“10 beat run of VT”

non-sustained V-Tach that can be a marker for sustained ventricular dysrhythmia

typically asymptomatic

immediate 12 lead EKG

71
Q

reversible causes of NSVT (7)

A

electrolyte derangements (esp. K, Mg)

myocardial ischemia (troponin)

hypoxia

anemia

hypotension

heart failure

ADRs

72
Q

a single episode of NSVT diagnostic testing

A

12 lead EKG and evaluation of reversible causes is enough

73
Q

symptomatic or recurrent NSVT

A

2D echo

stress testing

74
Q

physiologic response to stress that may be seen in many illnesses

A

sinus tachycardia

75
Q

symptoms of Sinus Tach

A

may have palpitations

majority of symptoms are usually related to underlying illness

if sinus tach is from underlying cause, tx is aimed at that

76
Q

Inappropriate Sinus Tachycardia definition and epidemiology (AKA)

A

aka chronic non-paroxysmal sinus tach

dx of exclusions in persons without structural heart disease or other cause for sinus tach

exaggerated HR response to exercise

often young. female patients

77
Q

Inappropriate Sinus Tachycardia patho and dx/tx

A

hyperactivity of SA node, depressed vagal response, and beta-adrenergic hypersensitivity

confirm with 12 lead EKG

tx with low dose metoprolol

ivabridine is more efficacious (off lable)

78
Q

Inappropriate Sinus Tachycardia v. Atrial Tach

A

sinus tach is in response to stress or illness

a tach is paroxysmal and unrelated to events

79
Q

POTS def + epidemiology

A

exaggerated HR response to STANDING but rare orthostasis

teen and young adult women

80
Q

POTS proposed mechanisms

A 
genetics 
hypovolemia 
cardiac deconditioning 
distal extremity denervation 
decreased venous return
81
Q

POTS symptoms

A

CNS (dizziness, weakness, blurred vision, fatigue while standing)

orthostatic (palpitations, tremors, anxiety)

GI (n/c/d, cramps)

82
Q

defibrillation

A

cardioversion with LOTS of joules

usually used in VENTRICULAR issues

83
Q

cardioversion

A

synchronized v. unsynchronized

fewer joules, ATRIAL issues

84
Q

synchronized

A

uses patients natural heartbeat

finds R wave and shocks them at just the right time

85
Q

types of pacemakers (3 types + 3 subtypes)

A 
Transcutaneous (temp + painful) 
Transvenous (temp + NOT painful) 
permenant 
-single 
-dual chamber
-biventricular
86
Q

single permanent pacemaker

A

one lead connected to either atria or ventricles

87
Q

dual chamber permanent pacemaker

A

two loads

one to atria and one to ventricle

88
Q

biventricular

A

3 leads, one to RA and one to ea. ventricle

89
Q

pacemaker + ICD when?

A

brugada
patients prone to VTach, VFib
EF < 30%

90
Q

Pacemaker code

A

first letter: chamber being PACED (A, V, D)
2nd letter: chamber being SENSED (A, V, D, O)
3rd letter: response mode (I, T, D, O)

fourth = programmability and rate 
fifth= IF ICD
91
Q

response mode of pacemaker letter meanings

A

I = inhibited by native beat

T = triggered by native beat (addative)

D= triggered after sensed atrial event but inhibited after ventricular response

O= none

92
Q

permanent pacemaker placement

A

general anesthesia and run wires to R heart via veins (cephalic, axillary, subclavian)

placed in SubQ pocket

return for wound check, interrogation

battery life 7-10 years

93
Q

pacer precautions

A

patients with pacemakers CAN”Thave MRIs

ACLS defib can be safely performed

FA17 Cardio 2 (10 decks)

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