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
2
Q
triggering factors for AF
A
thyrotoxicosis pericarditis chest trauma sx EtOH intake EtOH withdrawal
3
Q
AF epidemiology
A
more common men, caucasians
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
5
Q
electrical remodeling in AFib
A
atrial electrical and structural remodeling occurs which promotes the continuation of Afib
6
Q
classification of AFib
A
- persistent AF
- Paroxysmal AF
- permentant AF
4, Lone AF
- AFib secondary to another cause
7
Q
persistent AFib
A
Fib that fails to self terminate within 7 days
8
Q
paroxysmal AFib
A
2+ episodes of self terminating or intermittent AF lasting less than 7 days
9
Q
permanent AF
A
lasts > 1yr
cardio version has not been attempted or failed
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
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
12
Q
diagnosis of Afib
A
EKG TTE Cardiac Enzymes and BNP TSH and free T4 Baseline CBC, renal function, glucose level, UA
13
Q
EKG evaluates for AFib AND
A
LVH
Evidence of prior MI
conduction system issues
establishes baseline QT
14
Q
TTE
A
transTHORACIC
looks for valvular dz, atrial size, LVH, systolic and diastolic issues
unable to exclude L. atrial thrombus
15
Q
tx of unstable AFib
A
immediate synchronized cardio version
load medications and pt still remains unstable
16
Q
management of a stable patient
A
- telemetry bed
- rate control if RVR
- Begin evaluation
- anti coagulate
17
Q
rate control of RVR stable AF
A
cardizem (10-20 mg IV bolus)
Metoprolol (cardiac ischemia and infarction)
Digoxin (hypotension)
Amiodarone
18
Q
immediate anticoagulation for Afib
A
heparin IV infusion (kidney issues or recent bleeding0
LMWH (pregnancy, DOC)
19
Q
other diseases that we need to consider when treating AFib
A
MI
Wet Lungs - Lasix
20
Q
Tx strategies of new onset AFib
A
Rhythm control v. rate control
embolization risk
21
Q
rate control strategy
A
get resting HR to 80 ppm
recommended 65+
typically use BB or non-DHP CCB
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
23
Q
pre-excitation syndrome
A
AV node blockage will promote tachyarrhythmias via accessory pathway
CCB and dig are C/I = amiodarone is DOC
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
25
when should cardio version most successful
AFib of less than 7 days in duration - less chance of remodeling
its must be anti-coagulated for 3+ weeks or TEE
26
cardioversion procedure
electrolytes K and O2 are normalized and pt is npc for 6 hrs
conscious sedation
electrical shock (120-200 j) via biphasic defibrillator
27
cardio version is highly recommended in....
younger patients with onset AF of short duration
function improves almost immediately after cardio version
anticoagulation should continue for at least 4 weeks
28
shocking chronic AFib?
AFFIRM and RACE
no benefit for patients with cardioversion in tx of chronic AF
pt plan needs to be individualized bc risks and benefits
29
RF catheter ablation indicated
lifestyle impairing aFIB and intolerability of at least 1 anti-rhythm agent
NOT always a cure but more effective than pharm tx
30
when is RF ablation most successful?
AFib of less than 7 days in duration - less chance of remodeling
31
process of RF ablation
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
32
complications of catheter ablation
cardiac perforation
tamponade
atrial flutter
vascualr access complications
33
RF catheter ablation mortality benefit
NO mortality benefit and NO change in anticoagulation
BUT they can improve rate/lifestyle
34
anti-arrhythmics used in AF therapy
1. Amniodarone *
2. Dronedarone *
3. Sotalol
4. Dofetilide
* use with caution bc lots of drug interactions
35
amniodarone brand and use
Pacerone, Cordarone
safe in persistent AF, better than other anti-arrythmics
36
in what patients is amniodarone the DOC?
patients with cardiac dz (CAD, systolic or diastolic HF)
decreased pro-arrhythmic effects
37
Class Ic anti-arrhythmics use
Propafenone and flecanide
indicated for patients with AF and SCT without structural heart disease
38
Dronedarone brand and use
Multaq
paroxysmal AF or after conversion of persistent AF
associated with INCREASED mortality in pts with PERMANENT AF
39
Dronedarone special patient population
properties of all 4 classes
paroxysmal or persistent AF/flutter
associated CV risk factors who are in sinus rhythm or will be converted
40
Dronedarone is CI in
permanent AF
class IV heart failure or recent episode of ANY HF
41
sotalol brand and s.e.
Betapace
class 3, QT interval prolongation and torsdae de pointes
MUST monitor QT and electrolytes
42
Sotalol is CI in, why?
HF pts, pts with prolonged QT
pro-arrhythmic effects are increased in HF
43
Dofetilide brand and use
Tikosyn
must hospitalize when starting
indicated for maintenance of sinus rhythm and conversion of AF in persistent AF
44
Dofetilide has NO effect on...
```
cardiac output
cardiac index
stroke volume index
systemic vascular resistance in VTACH
HF
LVEF
```
45
Thrombus formation in AF
when and why
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
AF and stroke risk
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
T or F
Patients with persistent AF are more likely to get a stroke than those with paroxysmal AF
FALSE
there is NO difference in rate of stroke bt paroxysmal and persistent AF
ALL AF pts should be anti-coagulated
48
what do we use to calculate anticoagulation risk?
CHADS2 VAS
49
CHADS 2 VAS
```
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
CHADS2VAS score 0-1
ASA alone
51
CHADS2VAS score 2
individualize ASA v anticoagulation
52
CHADS2VAS score 3+
anti-coagulate with warfarin or NOAC
53
risk of CHADS2VAS score?
bleeding risk
use HAS-BLED
54
HAS-BLED
```
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
what HAS-BLED score qualifies high risk of bleeding
> 3
use caution and review anticoagulation
56
HAS-BLED or CHADS2VAS
risk of major bleeding can exceed benefits but no study has shown
57
Warfarin/Coumadin, dose adjusted to/how
INR 2-3
overlap w IV heparin, 5 days
medium dose, check PT/INR after 48 hrs and adjust from there
58
advantages of warfarin
Coumadin/Jantoven
cheap, insurance coverage
safe in CKD/renal failure
59
disadvantages of warfarin
many Drug/Drug interactions
narrow therapeutic index (close monitoring)
requires a lot of diet control
60
long-term Anti-Coagulation agents in AF
Warfarin/Coumadin/Jantoven
| NOACs (Apixaban, Rivaroxaban, Dabigatran, Edoxaban)
61
NOACs use in AF
NON-VALVULAR A-FIB
considered superior to warfarin if persons have CHADS2VAS > 2
if pt has valvular dz then warfarin is superior
62
Apixaban (Eliquis)
5mg bid
Xa inhibitor
dose adjusted to 2.5 if: CR >1.5, >80 age, wt <60 kg
safest NOAC for the kidney ***
63
Rivaroxaban (Xarelto)
Xa inhibitor must dose adjust
can't use in CKD IV (GFR < 30)
64
Dabigatran (Pradaxa)
direct thrombin inhibitor
reversal agent is available (COSTLY)
used until stage IV CKD (GFR < 30)
65
dabigatran TRADE
Pradaxa
66
rivaroxaban TRADE
Xarelto
67
apixaban TRADE
Eliquis
68
Edoxaban (Savaysa) kidney
dose adjust if GFR < 50
can't be used in GFR >90 or GFR <30
69
watchman device
what is it, who gets it
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
NSVT
"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
reversible causes of NSVT (7)
electrolyte derangements (esp. K, Mg)
myocardial ischemia (troponin)
hypoxia
anemia
hypotension
heart failure
ADRs
72
a single episode of NSVT diagnostic testing
12 lead EKG and evaluation of reversible causes is enough
73
symptomatic or recurrent NSVT
2D echo
stress testing
74
physiologic response to stress that may be seen in many illnesses
sinus tachycardia
75
symptoms of Sinus Tach
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
Inappropriate Sinus Tachycardia definition and epidemiology (AKA)
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
Inappropriate Sinus Tachycardia patho and dx/tx
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
Inappropriate Sinus Tachycardia v. Atrial Tach
sinus tach is in response to stress or illness
a tach is paroxysmal and unrelated to events
79
POTS def + epidemiology
exaggerated HR response to STANDING but rare orthostasis
teen and young adult women
80
POTS proposed mechanisms
```
genetics
hypovolemia
cardiac deconditioning
distal extremity denervation
decreased venous return
```
81
POTS symptoms
CNS (dizziness, weakness, blurred vision, fatigue while standing)
orthostatic (palpitations, tremors, anxiety)
GI (n/c/d, cramps)
82
defibrillation
cardioversion with LOTS of joules
usually used in VENTRICULAR issues
83
cardioversion
synchronized v. unsynchronized
fewer joules, ATRIAL issues
84
synchronized
uses patients natural heartbeat
finds R wave and shocks them at just the right time
85
types of pacemakers (3 types + 3 subtypes)
```
Transcutaneous (temp + painful)
Transvenous (temp + NOT painful)
permenant
-single
-dual chamber
-biventricular
```
86
single permanent pacemaker
one lead connected to either atria or ventricles
87
dual chamber permanent pacemaker
two loads
one to atria and one to ventricle
88
biventricular
3 leads, one to RA and one to ea. ventricle
89
pacemaker + ICD when?
brugada
patients prone to VTach, VFib
EF < 30%
90
Pacemaker code
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
response mode of pacemaker letter meanings
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
permanent pacemaker placement
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
pacer precautions
patients with pacemakers CAN"Thave MRIs
ACLS defib can be safely performed
