arrythmias, VTE Flashcards
what is arrythmia?
abnormal rate and rhythm
what is the normal heart rate in beats per minute?
60-100
what does a heart rate of under 60 beats per min indicate?
what does a heart rate of over 100 beats per min indicate?
under 60 = bradycardia
over 100=tachycardia [taky taky rumba]
what is paroxysmal atrial fibrillation?
this is managed by something known as pill in pocket. explain this.
episodes of AF that stop within 7 days [usually 48 hours] without treatment
pt can just take anti-arrythmic drugs only when an episode of AF occurs
what are the signs and symptoms of arrythmia?
sad palpitations
shortness of breath
abnormal fast/slow heart rate
dizziness
palpitations
what are some causes of arrythmias?
anything that affects the heart
coronary heart disease valvue disease hypertension ageing cardiomyopathy congenital birth defects
list the different types of arrythmias and which is the most common one? [6]
artrial fibrillation - most common ectopic beats supraventricular arrhythmia's ventricular arrhythmia paroxysmal AF atrial flutter
what is the treatment aim for treating arrhythmias?
treat the underlying cause of the arrythmia eg hypertension
what are the treatment options for arrythmias?
medication
cardioversion: electrical [electrical shock] or pharmacological
artificial pacemakers
implantable cardioverter defibrillators
what is the treatment aim for atrial fibrillation?
what do patients with AF have a high risk of?
reduce symptoms and prevent complications
high risk of stroke
what 2 things must be assessed in patients with AF prior and during anticoagulation?
assess risk of stroke and bleeding
what tools are used to assess risk of stroke? what tools are used to assess risk of bleeding?
stroke: CHA2DS2VASC
Bleeding: HASBLED / orbit
when are anticoagulants considered for patients with AF?
when risk of stroke greater than risk of bleeding
what are the associated risk factors with stroke for the CHA2DS2VASC and the associated scored?
c - congestive heart failure 1 H - hypertension 1 A - age over 75 2 a - age 65-74 1 d- diabetes = 1 S - stroke/tia/thromboembolism 2 V - vascular disease - 1 s - sex / gender female 1
what does a score of 2 or more on the chadsvasc tool indicate?
you will need an anticoagulant regardless of gender
anTWOcoagulants
what is the chadsvasc score for males and females generally?
male = 0 female = 1
what score must you get for hasbled that would indicate high risk of bleeding?
3
THREE makes you BLEED so do not give anticoagulant
what are the risk factors for HASBLED and the associated score?
what is the maximum score?
hypertension. 1 abnormal renal/liver function. 1 or 2 stroke. 1 bleeding tendency. 1 labile INR. 1 age greater than 65. 1 drugs [nsaids, concomitant aspirin] or alcohol. 1 or 2
max score 9
what are the risk factors for ORBIT and the associated scores?
what is the max score for orbit?
older than 74 - 1 reduced haemoglobin - 2 bleeding history - 2 inadequate renal function - 1 treatment with antiplatelet - 1
max score = 7
interpret the following ORBIT scores:
0-2
3
4-7
0-2 low bleeding risk
3 medium
4-7 high bleeding risk
what drugs are used in RATE control AF [1st line]?
DI2 VE BETA
dilitiazem
digoxin
verapamil
beta blockers [not sotalol]
when is digoxin monotherapy for rate control AF considered? [4]
only when pt does little to no exercise
when all other rate limiting drugs were unsuccessful
those with congestive heart failure
those suffering with NON paroxysmal AF
what can you consider if monotherapy for rate control AF fails?
dual therapy with BB DD:
beta blockers
diltiazem
digoxin
what must you consider if a patient fails to have controlled AF with rate control monotherapy and dual therapy?
rhythm control strategy
which is 1st line treatment for AF: rhythm or rate control
rate
rate control is 1st line treatment in AF except in which types of people? [5]
- ppl with new onset AF
- ppl with atrial flutter suitable for surgery
- ppl with a reversible cause of their AF [eg MI, hyperthyroidism]
- ppl who have heart failure originally thought to be caused by AF
- ppl who rhythm control strategy would be better
what drug class must you AVOID in heart failure and AF?
calcium channel blockers
what is the 1st line treatment for rhythm control in AF?
beta blockers not sotalol
what is the 2nd line treatment options for rhythm control in AF?
consider flecainide , amiodarone, sotalol, propafenone and dronedarone
rhythm control
which 2 drugs must be AVOIDED in people with ischaemic or structural heart disease?
flecainide and propafenone
rhythm control
which drug should be CONSIDERED for people with heart failure or left ventricular impairment?
amiodarone
when should ELECTRICAL cardioversion be considered?
when AF has been present for more than 48 hours
what kinds of treatment should the patient be on before electrical cardioversion is attempted?
what is the alternative if this is not possible?
anticoagulants 3 weeks before electrical cardioversion bc risk of stroke
alternative: heparin just before
what 2 medications MUST a patient be given after electrical cardioversion and for how long?
oral anticoagulants for at least 4 weeks after
amiodarone to control sinus rhythm
what is acute atrial fibrilation?
someone who has just had a new onset AF less than 48 hours
what is the treatment for a patient with new onset AF and life threatening haemodynamic [abnormal BP and heart rate]?
emergency electrical cardioversion
what should patients with NON life threatening haemodynamic instability be offered?
rate or rhythm control if arrythmia occurred LESS than 48 hours
rate control if arrythmia occurred more than 48 hours or unsure how long they had it
what should be offered to a patient with new onset AF who are receiving no oral anticoagulation yet?
parenteral anticoagulant eg heparin
which oral anticoagulants are 1st line recommended for patients with AF?
what should be given if this is contraindicated eg pt has renal impairment?
DOAC first line
vitamin K antagonists second line eg warfarin
what drugs should be used to treat supraventricular arrythmias? [3]
verapamil
cardiac glycosides eg digoxin
adenosine
which drugs should be used to treat ventricular arrythmias? [2]
lidocaine
sotalol
which drugs should be used to treat supraventricular and ventricular arrythmias [2]
amiodarone
beta blockers
what are the 4 classes of anti-arrythmic drugs and give examples of each?
class 1: sodium channel blockers [flecainide, lidocaine] class 2: beta blockers class 3: potassium channel blockers [amiodarone] class 4: calcium channel blockers [verapamil]
sotalol is in 2 classes of anti-arrythmic drugs. which are they?
it is in class 2 beta blockers and class 3 potassium channel blockers
what is torsade de pointes?
A type of arrythmia caused by QT interval prolongation. not enough oxygen gets pumped around body and brain becomes starved of oxygen
what is the treatment of torsade de pointes?
iv magnesium sulphate
what are the causes of torsade de pointes? [4]
- stress
- strenous exercise
- drugs
- sudden noises
which drugs cause torsade de pointes? [6]
ANTI ABCDDE
anti arrythmics [sotalol, amiodarone] anti biotics [macrolides, quinolones] antipsychotics [haloperidol] Diuretics anti depressants [SSRIs, TCAs] anti emetics [ondansetron]
is amiodarone an enzyme inhibitor or inducer?
what is the adult dose of amiodarone to treat arrythmia?
enzyme inhibitor
200mg three times a day for 1 week then 200mg twice daily for 1 week. maintenance dose 200mg once daily
what are the side effects of amiodarone?
ami is a photogenic bitch?
photosensitivity
bradycardia
interstitual lung disease [shortness of breath]
thyroid [hyper or hypo bc amiodarone contains iodine]
corneal micro deposits [dazzled headlights]
hepatic [liver]
phototoxicity [skin reaction slate grey skin]
optic neuropathy [blurred vision]
peripheral neurotoxicity [numbness/tingling]
pulmonary toxicity [lungs]
what are the 2 contraindications of amiodarone?
iodine deficiency
thyroid dysfunction
what are the monitoring requirements with amiodarone?
CASTLE
chest x ray before treatment
annual eye test
serum potassium before treatment [causes hypokalaemia]
thyroid function before treatment and annually
liver function before treatment and every 6 months
ECG and blood pressure
what is the patient and carer advice for amiodarone?
- shield skin from sunlight several months after treatment and during
- use wide spectrum suncream
- alert medical attention if any of these symptoms show [light headed, fainting, palpitations, chest pain]
what are the important interactions of amiodarone?
enzyme inhibitor
increases plasma conc of warfarin, digoxin, phenytoin, ciclosporin
interacts with lithium and increases its conc [causes arrythmia]
interacts with statins and increases its conc [causes Myopathy]
interacts with drugs that cause QT interval prolongation [anti abcdde]
what is the mechanism of action of digoxin?
increases force of contraction of heart and decreases heart rate by reducing conductivity in atrioventricular node
what are the indications of digoxin?
Atrial flutter
atrial fibrillation
heart failure
what is the dose of digoxin based on for management of Atrial fibrillation?
based on ventricular rate at rest which should not fall below 60 beats per min
which route is NOT recommended for digoxin?
IM route
does digoxin have a long half life or short half life?
how many times during the day is it normally taken?
sometimes it is taken twice daily - why?
long half life
once daily
due to nausea side effect
what is the digoxin maintenance dose for Atrial fibrillation or atrial flutter?
is a loading dose required with this?
how should the dose be altered in elderly?
125mcg -250mcg once daily
loading dose needed
reduce dose in elderly
what is the dose of digoxin for worsening/severe heart failure in sinus rhythm?
is a loading dose required?
62.5mcg - 125mcg once daily
no loading dose required
what is the digoxin dose for rapid digitalisation for atrial fibrillation or atrial flutter?
0.75mg - 1.5mg in divided doses, dose to be given over 24 hours
what is the digoxin dose for emergency loading dose for atrial fibrillation or atrial flutter?
by IV infusion: 0.75mg - 1mg loading dose to be given over at least 2 hours
is digoxin a narrow therapeutic drug?
yes
what is the therapeutic range for digoxin?
what is the toxicity range for digoxin?
therapeutic: 1-2mcg/L
toxicity: 1.5mcg/L - 3mcg/L
everything you need to know about digoxin is in the term 2kidneys.
explain this term
2 = therapeutic conc of 1mcg-2mcg/L. anything outside this conc is toxicity
K =monitor potassium levels. low potassium levels leads to digitalis toxicity
i = digoxin is positively inotropic and increases force of contraction of heart
D = decreasing potassium levels means digitalis toxicity
N = nausea common s/e
e = emesis/vomiting common s/e
y = yellow vision s/e
s = potassium sparing diuretic
kidneys = monitor renal function
what can you give to prevent hypokalaemia in people who take digoxin?
potassium sparing diuretics
potassium supplements
why must you reduce the dose of digoxin in the elderly?
they are at risk of digitalis toxicity
what must you do if digoxin toxicity occurs?
withdraw digoxin
if there is a life threatening overdose: reverse with digoxin specific antibody fragments
what are the side effects of digoxin? [8]
nausea, vomiting, yellow vision skin reactions dizziness diarrhoea cardiac conduction disorder arrythmias
what are the monitoring requirements of digoxin? [4]
plasma digoxin conc - should be taken 6 doses after dose
renal function
oxygen - hypoxia
serum electrolytes: potassium, calcium, magnesium
what are the important drug interactions with digoxin? [6]
crased
calcium channel blockers eg verapamil rifampicin amiodarone st johns wort erythromycin diuretics
what do antifibrinolytic drugs and haemostatics do?
stop bleeding
what is the dose of tranexamic acid for the management of menorrhagia?
1g three times a day for up to 4 days. start on day of period. max 4g daily
what is the dose of tranexamic acid of epistaxis [bleeding from nose]?
1g three times a day for 7 days
what is the side effects of tranexamic acid? [3]
diarrhoea
nausea
vomiting
what is the monitoring requirements of tranexamic acid?
regular liver function tests
what is there a risk of when taking tranexamic acid with contraceptive pill?
increased risk of DVT
what is the age requirement for menorrhagia otc?
18 and over
what are the red flags with using tranexamic acid?
- legs/arms painful or swollen
- anaphylactic reaction
- coughing/coughing up blood
- colour vision/vision impairment
what are the contraindications of tranexamic acid?
- epilepsy
- dvt
- PE eg shortness of breath
- irregular periods
- renal problems
- pregnancy
what are the 2 types of venous thromboembolism?
1 - pulmonary embolism: clot in artery in lung
2 - deep vein thromboembolism: clot in body usually legs
give examples of antiplatelets, anticoagulants and thrombolytics.
which is the strongest one that causes highest risk of bleeds?
antiplatelets: clopidogrel, aspirin, dipyridamole
anticoagulants: warfarin, doacs
thrombolytics: highest bleed risk eg alteplase
which patients have the highest risk of venous thromboembolism? [9]
pt over 60 pt with blood disorder pt with history of VTE pt who are obese/overweight pt with reduced motility pt with malignant disease eg cancer dehydration pt taking hrt/combined hormonal contraception pregnancy and postpartum periods
what are the 2 methods of thromboprophylaxis?
mechanical prophylaxis
pharmacological prophylaxis
what is mechanical prophylaxis of VTE?
anti-embolism stockings to be worn for pt due for surgery
worn all the time until pt is mobile again
who must not be offered anti-embolism stockings?
pt with acute stroke, peripheral arterial disease, neuropathy and leg oedema
in which patients should pharmacological prophylaxis of VTE be initiated?
when should this be initiated?
in pt undergoing surgery where the risk of VTE is higher than the risk of bleeding.
as soon as possible or within 14 hours of admission
what are the 2 types of heparins and which ones are preferred?
low molecular weight heparins - preferred
unfractionated heparins
give examples of low molecular weight heparins
enoxaparin, dalteparin, tinzaparin
in which patients are unfractionated heparins preferred?
those with renal impairment or risk of overdose
what should be given to patients undergoing hip or knee replacement surgery, hip fracture surgery, day surgery or GI bariatric surgery?
fondaparinux sodium
how long should pharmacological prophylaxis in general surgery continue for?
at least 7 days post surgery or until pt is mobile again
in which surgery is low molecular weight heparins suitable for?
all
in which surgery/pt type are unfractionated heparins suitable for?
ppl with renal impairment 15-50
or pt with higher risk of bleeding/overdose
in which surgery are DOACS suitable for?
elective knee/hip replacement surgery after LMWH or low dose aspirin
what is first line for treatment of VTE or PE?
rivaroxaban or apixaban
what is 2nd line treatment for confirmed VTE or PE?
if rivaroxaban or apixaban unsuitable:
- give LMWH for at least 5 days then dabigatran or edoxaban OR
- give LMWH together with vitamin K antagonist for at least 5 days or until INR is 2 for 2 consectutive readings followed by vitamin K antagonist on its own
what are the 4 treatment options of confirmed VTE or PE in renally impaired patients?
- offer apixaban
- offer rivaroxaban
- offer LMWH for at least 5 days followed by either dabigatran [if estimated crcl is 30ml/min] or edoxaban
- LMWH or unfractionated heparin together with vitamin K antagonist for 5 days or until iNR is 2 for 2 consecutive readings then vitamin K antagonist on its own
how is VTE treated in pregnancy>
LMWH or unfractionated heparins used bc they do not cross the placenta
which heparins are preferred in treatment of VTE in pregnancy and why?
LMWH bc lower risk of osteoporosis and heparin induced thrombocytopenia
what is the common side effect of heparin and how is it reversed?
haemorrhage
withdraw heparin and give protamine sulphate as an antidote to reverse effects
what is proximal deep vein thrombosis?
what is isolated deep vein thrombosis?
proximal: clot in femoral thigh
isolated: clot below knee confined in calf veins
what is the anticoagulant treatment duration for someone who has confirmed proximal DVT or PE?
what is the duration for someone with active cancer in addition?
3 months
3-6 months for active cancer?
what is the anticoagulant treatment duration for someone with provoked DVT or PE?
provoked by pregnancy, HRT eg
what if they have active cancer?
3 months
3-6 months for active cancer
what is the anticoagulant treatment duration for unprovoked DVT or PE?
what if they have active cancer
beyond 3 months
beyond 6 months for active cancer
