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Cardio > Atrial arrhythmias > Flashcards

Atrial arrhythmias Flashcards

1
Q

three general classifications for AF

A

paroxysmal, persistent, and permanent

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2
Q

paroxysmal AF

A
  • AF terminates spontaneously within 7 days of onset
  • most lasts less than 24 hours
  • may recur with variable frequency
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3
Q

persistent AF

A
  • continuous AF that is sustained for > 7 days and does not terminate on its own
  • electrical or pharmacological cardioversion does not change the classification
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4
Q

permanent AF

A

does not terminate with attempts at pharmacologic or electrical cardioversion OR joint decision between patient and clinician to cease further attempts to restore/maintain sinus rhythm

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5
Q

acute AF

A

onset within last 48 hours

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6
Q

recurrent AF

A

when a patient has had 2 or more episodes (either paroxysmal or persistent can be recurrent)

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7
Q

Lone AF

A

applies to younger individuals ( < 60 years of age) without evidence of underlying cardiopulmonary disease

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8
Q

average rate of stroke in AF patients with no coagulation therapy

A

5% per year

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9
Q

t/f AF is viewed as a cardio disease

A

false, but it causes poor clinical outcomes from other things (like strokes)

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10
Q

_____% of all strokes are due to AF

A

15 percent

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11
Q

risk of stroke is ______ greater than people without AF

A

five times

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12
Q

cardiovascular conditions associated with AF

A
  • heart failure
  • valvular heart disease
  • coronary artery disease
  • hypertension
  • diabetes
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13
Q

secondary AF or acute causes of AF

A
  • MI or cardiac surgery
  • hyperthyroidism
  • PE
  • pericarditis
  • alcohol intake
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14
Q

t/f AF more common in Caucasians than AA

A

true

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15
Q

definition of atrial fibrillation

A

supraventricular tachyarrhythmia characterized by uncoordinated atrial activation caused by re-entry arrhythmias with consequent deterioration of atrial mechanical function

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16
Q

AF is characterized by what atrial rate

A

400-600 bpm

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17
Q

in AF the atria usually displays

A

structural abnormalities beyond those caused by underlying diseases

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18
Q

mechanism of a fib

A

multiple atrial re-entrant loops

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19
Q

loss of atrial kick leads to

A

decreased CO and irregular ventricular response thus the rhythm becomes “irregularly irregular”

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20
Q

symptoms of PSVT

A
  • intermittent episodes of rapid HR/palpitations
  • abruptly start and stop without provocation
  • syncope, chest or neck pressure
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21
Q

treating severe symptoms of PSVT

A

extremely rapid HR ( > 200 bpm)

- treatment of choice is DCC/shock

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22
Q

treating mild-moderate symptoms

A
  • patients usually don’t need DCC

- use non drug measures

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23
Q

common symptoms in a fib patients

A
  • palpitations
  • rapid HR
  • worsening HF
  • fatigue
  • chest pain
  • syncope
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24
Q

a fib EKG

A
  • irregularly irregular supraventricular rhythm
  • no P waves
  • ventricular response usually 120 to 180 bpm
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25
Q

a flutter EKG

A
  • regular supraventricular rhythm
  • characteristic saw tooth flutter waves
  • ventricular rate depends on how many atrial depolarizations are conducted
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26
Q

non drug measures to treat PSVT

A
  • unilateral carotid massage
  • Valsalva maneuvers
  • induced retching
  • ice water facial immersion
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27
Q

adenosine moa

A

prolong conduction time in slow antegrade pathway of the reentrant loop to terminate PSVT

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28
Q

verapamil and diltiazem moa

A

prolong conduction time in slow antegrade pathway of the reentrant loop to terminate PSVT

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29
Q

drug interactions for non dhp ccbs

A

3a4 inhibitors - careful with statins, hiv meds, and benzos

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30
Q

non dhp ccb clinical pearls

A
  • 2nd line agent: SLOW IV push

- can switch to po therapy if needed long term

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31
Q

first line treatment for automatic atrial tachycardia

A

verapamil and diltiazem

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32
Q

second line treatment for automatic atrial tachycardia

A

IV magnesium (high doses)

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33
Q

hemodynamic instability

A

AF with severe hypotension, pulmonary edema, or in setting of acute MI

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34
Q

if pt has normal LV function what drug do you put them on initially

A
  1. IV b-blockers

2. IV diltiazem or IV verapamil

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35
Q

if pt has LV dysfunction what drug do you put them on initially

A
  1. IV digoxin

2. IV amiodarone

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36
Q

affirm trial

A
  • largest trial for rate v. rhythm control
  • no statistical difference
  • tendency towards increased mortality in rhythm control group
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37
Q

rate control is for

A

patients who are NOT symptomatic

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38
Q

rate control IV used in

A

acute setting, po can be used in non acute

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39
Q

drugs used in rate control

A
  • metoprolol
  • atenolol
  • diltiazem
  • verapamil
  • digoxin
40
Q

major side effects of metoprolol

A

hypotension, bradycardia, heart block, bronchospasm, heart failure

41
Q

clinical use of metoprolol

A

1st line for adrenergic state; avoid in asthma/COPD

42
Q

major side effects of atenolol

A

hypotension, bradycardia, heart block, bronchospasm, heart failure

43
Q

clinical use of atenolol

A

1st line for adrenergic state; avoid in asthma/COPD

44
Q

major side effects of diltiazem

A

hypotension, bradycardia, heart failure, heart block, constipation

45
Q

clinical use of diltiazem

A

use in caution in HF; preferred in asthma/COPD

46
Q

major side effects of verapamil

A

hypotension, bradycardia, heart failure, heart block, constipation

47
Q

clinical use of verapamil

A

use in caution in HF; preferred in asthma/COPD

48
Q

major side effects of digoxin

A

digitalis toxicity, heart block, bradycardia, use with caution in patients with renal failure

49
Q

clinical use of digoxin

A

preferred in HFrEF patients for acute VR control; long term may switch to BB for HFrEF therapy

50
Q

adequate maintenance rate control

A

resting heart rate of < 80 bpm and < 100 bpm during exercise

51
Q

advantages to cardioversion

A
  • relief of symptoms (palpitations fatigue, dyspnea)
  • prevention of thromboembolism
  • prevention of tachycardia induced myocardial remodeling and cardiomyopathy
52
Q

disadvantages to cardioversion

A
  • antiarrhythmic agents generally have more side effects and are not as safe as agents used to control heart rate
  • increases risk of thromboembolism
53
Q

AF duration > 48 hours and anticoagulants

A
  • increased risk of formation
  • anticoagulation > 3 weeks prior to conversion
  • continue anticoags for 4 weeks after cardioversion (possible lifelong treatment if stroke risk factors)
54
Q

AF duration < 48 hours and anticoagulants

A

anticoags prior to cardioversion not needed

55
Q

electrical cardioversion

A
  • most effective method

- disadvantage is that it requires anesthesia and sedation

56
Q

pharmacological cardioversion

A

less effective than DCC; tends to be more effective if AF onset < 7 days prior to cardioversion

57
Q

drugs for cardioversion

A
  • flecainide
  • propafenone
  • dofetilide
  • ibutilide
  • amiodarone
58
Q

flecainide clinical pearls

A

pt needs to be on av node blocker (BB or NonDHP ccb) to start; contraindicated in patients w CAD and HF

59
Q

propafenone clinical pearls

A

pt needs to be on av node blocker (BB or NonDHP ccb) to start; contraindicated in patients w CAD and HF

60
Q

dofetilide ae

A

qt prolongation; torsades de pointes

adjust doses based on renal function

61
Q

dofetilide contraindicated with

A
  • cimetidine
  • ketoconazole
  • prochlorperazine
  • trimethoprim
  • megesterol
  • verapamil
  • diltiazem
62
Q

ibutilide ae

A

qt prolongation, torsades de pointes

63
Q

ibutilide clinical pearls

A

contraindicated in pts w HF

64
Q

amiodarone loading therapy ae

A

hypotension, bradycardia, QT prolongation, GI upset

65
Q

rhythm maintenance drugs

A
  • amiodarone
  • dofetilide
  • flecainide
  • propafenone
  • sotalol
  • dronedarone
66
Q

sotalol ae

A

torsades de pointes, heart failure, exacerbation of bronchospastic disease, bradycardia

67
Q

dronedarone ae

A

torsades de pointes, heart failure, GI upset, liver failure, avoid 3A4 inhibitors

68
Q

highest risk factors for stroke in a fib patients

A
  • mitral valve stenosis
  • prosthetic heart valve
  • prior stroke or tia
69
Q

medium risk factors for stroke in a fib pts

A
  • age >75
  • hypertension
  • diabetes
  • CHF/LV dysfunction
70
Q

vascular disease =

A

prior MI, PAD, or aortic plaque

71
Q

chadsvasc score of 0 in men/ 1 in women

A

no anti-thrombotic therapy

72
Q

chadsvasc score of 1 in men/ 2 in women

A

oral anticoag can be considered. NOACs preferred

73
Q

chadsvasc score of 2 or more in men / 3 or more in women

A

treatment with NOAC preferred over warfarin

74
Q

pts with valvular a fib

A

warfarin is only recommendation

75
Q

dabigatran moa

A

direct oral thrombin inhibitor

76
Q

dabigatran dosing

A

normal: 150 bid
CrCl < 30 = 75 bid
CrCl < 15 = do not use

77
Q

drug interactions with dabigatran

A
  • avoid use with rifampin and carbamazepine

- use 75 mg in pts taking verapamil, ketoconazole, amiodarone, or dronedarone

78
Q

missed doses of dabigatran

A

if > 6 hours to next dose, take missed dose; if not, skip dose

79
Q

dabigatran clinical pearls

A
  • very sensitive to moisture

- gastritis common

80
Q

RE-LY trial

A
  • dabigatran 150 bid non inferior to unblinded warfarin, less number of strokes with more major bleeding
  • dabigatran 110 bid non inferior to warfarin with same number of strokes and less major bleeding
81
Q

rivaroxaban moa

A

factor 10a inhibitor

82
Q

rivaroxaban dosing

A

normal: 20 mg with dinner
CrCl < 15-50: 15 mg daily
do not use if crcl lower than 15

83
Q

drug interactions with xarelto

A
  • avoid in cyp3a4 inducers; phenytoin, carbamazepine, and rifampin
  • cyp3a4 inhibitors: ketoconazole, itraconazole, ritanovir, clarithromycin
84
Q

Xarelto missed doses

A

take missed dose ASAP on same day, resume next day on normal schedule

85
Q

Xarelto clinical pearls

A

any dose greater or equal to 15 = take with food

not recommended in lactose intolerant pts

86
Q

ROCKET AF trial

A

rivaroxaban non inferior to warfarin in stroke prevention with no significant difference in clinically major bleeding. ICH and fatal bleeding lower in xarelto

87
Q

apixaban moa

A

factor 10a inhibitor

88
Q

apixaban dosing

A 
normal : 5 mg bid
if:
- < 60 kg
- age > 80 
- SCr > 1.5
dosing is 2.5 mg bid
89
Q

apixaban drug interactions

A
  • use 2.5 mg bid when taking clarithromycin, ketoconazole, itraconazole, or ritanovir
  • avoid use w rifampin, carbamazepine, phenytoin, st. johns wort
90
Q

missed doses of apixaban

A

take asap and resume bid dosing, do not double up

91
Q

clinical pearls of eliquis

A

grapefruit juice may increase effects

92
Q

ARISTOTLE trial

A

apixaban non inferior and superior to warfarin for prevention of stroke with lower major clinical bleeding

93
Q

edoxaban moa

A

10a inhibitor

94
Q

edoxaban dosing

A

crcl >95 do not use
normal: 60 mg daily
crcl 15-50: 30 mg daily
crcl < 15 do not use

95
Q

edoxaban drug interactions

A
  • rifampin, carbamazepine

- 30 mg daily if pt taking verapamil, dronedarone, or quinidine

96
Q

edoxaban missed dose

A

take asap; resume next day schedule

97
Q

edoxaban clinical pearls

A

crcl > 95 with AF bad bc of increased risk of stroke as compared to warfarin

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