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Geriatrics > Atrial Fibrilation, HF, QTc Prolongation > Flashcards

Atrial Fibrilation, HF, QTc Prolongation Flashcards

1
Q

AFib is caused by…

A

Abnormal electrical conduction in atria, resulting in chaotic, uncoordinated contraction of atrial chambers

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2
Q

Patients with AFib may experience…

A

SOB, fatigue, palpitations
Chest discomfort
Anxiety, sweating

Or may be asymptomatic - patients can flip in + out of AFib

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3
Q

Two key clinical issues with AFib are…

A

Significant increased risk of ischemic stroke
Increased heart rate increases risk of heart failure

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4
Q

Stroke risk in AFib is managed via…

A

Anticoagulation with warfarin or DOAC’s

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5
Q

The dilemna of age with AFib and anticoagulation is…

A

Incidence of AFib increases with age, but advanced age increases risk for both stroke + major bleeds

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6
Q

Advanced age is a deterrent to anticoagulation due to…

A

Bleed risk
Adherence/INR monitoring with warfarin
Underestimation of benefit

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7
Q

Evidence for anticoagulation in Afib was shown via…

A

BAFTA trial - warfarin vs. ASA; anticoagulation significantly reduced strokes with no significant difference in major bleed rates

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8
Q

If individuals with AFib are unsuitable for anticoagulation, we could try…

A

ASA + clopidogrel to decrease stroke risk

However, did increase risk of major bleeding

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9
Q

Advantages of DOAC’s over warfarin include…

A

Equal/superior efficacy
Less ICH
No INR monitoring, fewer drug/food interactions

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10
Q

Disadvantages of DOAC’s over warfarin include…

A

More GI bleeds
Less long-term safety data
Caution in renal impairment/CI in severe renal impairment
Not indicated with mechanical heart valves

Some are $$$

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11
Q

Warfarin may be preferable over a DOAC when…

A

Someone has labile INR’s
Severe renal dysfunction

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12
Q

Unique points of dabigatran include…

A

Most GI upsetting
Most highly renally eliminated
BID dosing

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13
Q

Unique points of rivaroxaban include…

A

Needs to be taken with food for adequate absorption
OD dosing

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14
Q

Unique points of edoxaban include…

A

Has more DI’s
OD dosing

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14
Q

Unique points of apixaban include…

A

Best safety data so far
Shows superior efficacy compared to warfarin
BID dosing

Best choice when renal function is borderline

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15
Q

To determine risk of bleeding, we can use…

A

HAS-BLED criteria
Caution if score is 3+

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16
Q

Does anticoagulation contribute to fall risk?

A

Overall benefit with stroke prevention heavily outweighs risk of falls

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17
Q

Anticoagulation + ASA may be warranted for…

A

Post-PCI with high risk features for thrombotic CV events

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18
Q

Adherence with DOAC’s is important due to…

A

Rapid onset/offset - unreliable adherence will cause periods of no anticoagulation

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19
Q

Warfarin should be avoided in individuals with cognitive impairment, due to…

A

Frequent INR monitoring - likely will not have ability to self-manage dosage adjustments

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20
Q

Factors to consider when deciding between rate vs. rhythm control include…

A

Duration of AFib
Bothersome AFib symptoms
Comorbid heart failure

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21
Q

Likelihood of successful rhythm control decreases as Afib duration increases. Therefore, with persistent Afib we would focus on…

A

Rate control

22
Q

A trial that explored rhythm control in patients with early AFib (<1 year) found that…

A

Risks > Benfits - serious AE’s related to antiarrhythmic treatment

23
Q

Abalation is often less desirable for older adults due to…

A

Increased risk of procedural AE’s, and increased likelihood of Afib recurrence post-ablation

24
Q

____ remains important whether a patient is rate/rhythm controlled.

A

Anticoagulation

25
Q

Amiodarone AE’s are quite severe and include…

A

Optic neuropathy, neuritis, photosensitivity
Pulmonary + hepatic toxicity
Thyroid issues
Blue-grey skin discoloration

Always check for DI’s - common ones include warfarin, digoxin, BB/Non-DHP CCB’s

26
Q

Medications for rate-control include…

A

Beta-blockers
Non-DHP CCB’s
Digoxin

27
Q

Beta-blockers are preferred for rate control with…

A

Concurrent CAD, Heart failure

If asthma/COPD, aim for cardioselective BB

28
Q

Non-DHP CCB’s are preferred for rate control with…

A

Severe/poorly controlled asthma or COPD, sensitive to BB’s
Add on to BB’s if rate control not achieved

29
Q

Digoxin is usually used as ____ therapy because…

A

Add-on - less effective, does not control HR during exercise

30
Q

Digoxin may be benefician with…

A

Concurrent, symptomatic HF

31
Q

Target heart rate in AFib is…

A

Below 100 bpm at rest

32
Q

Digoxin efficacy is monitored via…

A

Target HR

NOT serum digoxin levels

33
Q

Digoxin toxicity is monitored via…

A

Serum levels - ideally maintain trough level below 1 nmol/L

34
Q

Digoxin AE’s often manifest as…

A

GI issues (N/V/D, decreased appetite), then develops into cognitive issues + vision (delirium, blurred vision, ocular haloes)

CAUTION with renal impairment

35
Q

Severity of heart failure symptoms can be classified by…

A

NYHA functional capacity; class 1 (no limitation) to class 4 (inability to carry on any physical activity without discomfort)

36
Q

The 4 standard drug therapies for HFrEF include…

A

ARNI (or ACEI/ARB)
Beta-blocker
MRA
SGLT2 inhibitor

37
Q

This can be used to relieve symptoms in heart failure

A

Diuretics - furosemide
Help manage SOB, fluid retention, increased weight

Titrated to minimum effective dose, to maintain euvolemia

38
Q

Which drug classes should be initiated first for HFrEF treatment?

A

Based on clinical characteristics of patient, such as…

Hemodynamic status
Renal function, BP
AE/tolerability
Cost + Adherence

39
Q

Evidence of ARNI vs. ACEI for HFrEF showed that…

A

ARNI showed a decrease in CV mortality and HF hospitalizations - however, increase in symptomatic hypotension

40
Q

Switching from ACEI to ARNI requires…

A

A 36 hour washout period - risk of angioedema

41
Q

With ACEI/ARB/ARNI’s, we should monitor…

A

SCr + Electrolytes within 1-2 weeks of initiation or titration
Sitting + standing BP

Frail older adults more susceptible to hypotension with ARNI

42
Q

Monitoring with beta-blockers includes…

A

HR, BP, fatigue

43
Q

Monitoring with MRA’s includes…

A

Electrolytes - potassium
Avoid if CrCl is low

44
Q

SGLT2 inhibitors in HF demonstrated…

A

Benefit in reducing hospitalizations or CV death

45
Q

Notable monitoring with SGLT2 inhibitors include…

A

Decrease in GFR ~15% upon initiation
May cause hypovolemia
Sick day management - SADMANS

46
Q

Tolerability of SGLT2 inhibitors…

A

Fairly well tolerated. May see increased risk of yeast infection, UTI, diabetic ketoacidosis

47
Q

Digoxin could be used in heart failure if…

A

Symptoms despite optimized 1st + 2nd line medications

Remember that blood levels are only used to measure toxicity

48
Q

Regarding dosing of quadruple HF therapy, we should try to…

A

Titrate to target doses as tolerated
Can space doses if orthostatic hypotension/low BP is limiting titration

49
Q

Dosing of furosemide should be…

A

The lowest effective dose to mainatain euvolemia

50
Q

This could be used for HFpEF…

A

Empagliflozin - showed a decrease in HF hospitalizations.

51
Q

QT prolongation may lead to ____, which is dangerous because…

A

Torsades de Pointes (TdP) - arrythmia may lead to sudden cardiac death

52
Q

Risks of TdP include…

A

Older, female
Electrolyte abnormalities
Chronic diseases - liver, kidney, HTN
Smoking
Drugs

53
Q

Pharmacist role in QT prolongation + TdP involves…

A

Identifying risk factors (RISQ-PATH score) - if high risk, can try alternative medication, or recommend baseline + follow-up ECG

Watch for drug interactions

Geriatrics (12 decks)

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