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c/r > Atrial Fibrillation TReatment > Flashcards

Atrial Fibrillation TReatment Flashcards

1
Q

What is it?

A

What is it?

Disorganized and irregular atrial electrical activity
“quivering”
occurs when atrial tissue is modified due to abnormalities in structure or function

Atrial Rate: 600-800 bpm
Ventricular rate: 100-180 bpm
or pt could have a somewhat normal heart rate

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2
Q

Arrythmia etiologies

A

Arrythmia etiologies

  1. causes of scarring or fibrotic tissue like..
    a. Ischemic heart disease
    b. cardiomyopathy
    c. fibrotic diseases
  2. changes to cardiac action potential like…
    a. electrolyte abnormalities
    b. drugs
  3. other..
    a. genetic diseases
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3
Q

Pathogenesis

A

Pathogenesis

Triggered by rapidly firing ectopic beats in the atria. ectopic beats can occur due to previously discussed etiologies of arryhtmias

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4
Q

Types of A fib

A

Types of A fib

Paraoxysmal: Terminates within 7 days of onset

Persistent: Last >7 days

Long standing: Last greater than 12 months

Permanent: pt and clinician have decided that there will be no more effort to restore or maintain sinus rhythm

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5
Q

Clinical Manifestations

A

Clinical Manifestations

Fatigue
SOB
palpitations
hypotension
Dizziness, lightheadedness
syncope

many pts are asymptomatic and may not know they have A fib.

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6
Q

At increased risk for ..

A

At increased risk for ..

  1. stroke (5 fold increase)
  2. heart failure: 3 fold increase
  3. dementia: 2-fold increase
  4. hospitalization: 2 fold increase
  5. mortality: 2 fold increase in risk
  6. cost
    a. pts have an increased cost of $87,000/ year
    b. costs health care system $27 B annually
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7
Q

3 categories of treatment for Afib

A
  1. anticoagulation
  2. rate control
  3. rhythm control
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8
Q

Why Anticoagulate

A

Why Anticoagulant?

Strokes in pts with a fib are more detrimental than pts ho had strokes without A fib

clot can form in left atrial appendage due to pooling of blood in that area

anticoagulation can prevent clot from forming

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9
Q

CHA2DS2VASc Score

What is it used for

A

determine person with a fibs risk of stroke

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10
Q

CHA2DS2VASc Score

categories

A

Determine Risk of Stroke

CHA2DS2VASc Score

Congestive Heart Failure .                                                1 point
Hypertension:                                                                       1point
Age > 75:                                                                               2
Diabetes Mellitus:                                                                 1 
Stroke/ tia/ systemic embolism:                                        2 points
Vascular Disease (PAD, CAD, coratid vascular disease   1 point
Age 65-74                                                                             1 point
Sc: Sex category (female)                                                   1 point

Anticoagulant:

  1. Males with CHA2DS2VASc Score >/= 2
  2. Females with with CHA2DS2VASc Score >/= 3
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11
Q

HAS BLED SCORE

A

Determine Risk of Bleeding if we were to anticoagulate a pt with A fib

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12
Q

chronic anticoagulation for afib

A

oral anticoagulants

  1. DOACS > warfarin
    unless patient has mitral stenosis or mechanical heart valves, then warfarin preferred

apixaban

rivaroxaban

edoxaban

dabigatran

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13
Q

acute anticoagulation for afib

A

Heparin
LWMH
Fondaparinux (arixtra)
IV direct thrombin inhibitors

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14
Q

Why do rate control?

A

Why do rate control?

to regulate the ventricular heart rate during A fib, reduce or eliminate symptoms, improve hemodynamics, prevent HF, and reduce risk of adverse CV outcomes

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15
Q

Acute Vs Chronic Rate Control

A

Acute Vs Chronic Rate Control

Acute: generally use IV (bolus +IV)
and transition to oral (generally avoid BB +non DHP CCB but sometimes used if pt is monitored closely)

chronic: oral agents
may require multiple agents (generally avoid BB +non DHP CCB but sometimes used if pt is monitored closely)

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16
Q

Types of Rate control

A

Types of Rate control

  1. Lenient: Goal is HR <110 bpm
    for patients who..
    asymptomatic pts. AND EF> 40%
  2. Strict rate control: Goal is HR < 80 bpm
    for patient who are..
    Symptomatic OR have EF<40%
17
Q

Rate control Algorithm

A

if have no CV disease

first line: BB, Verapamil, diltiazem
second line: amiodarone

if HTN, or HFpEF
first line: BB, Verapamil, diltiazem
second line: amiodarone

if have LV dysfunction or HF
first line: BB (with mortality beenfit), Digoxin
second line: amiodarone

if have COPD
first line: BB, Verapamil, diltiazem
second line: NONE.

18
Q

Why do Rhythm Control?

A

Why do Rhythm Control?

In studies, Rhythm control did not improve mortality compared to rate control, actually increased adverse events

but rhythm control is indicated in pts who…..

  1. Hemodynamically ustable
    2 Symptomatic despite rate control
    3.Inability to achieve rate control
19
Q

Which method of should be used to conversion to sinus rhythm?

A

Which method of should be used to conversion to sinus rhythm?

  1. hemodynamically unstable
    a. immediate cardio version
  2. symptomatic despite rate control
    - DCCV, chemical cardio version, or both
  3. Inability to achieve rate control
    - DCCV, chemical cardio version, or both
20
Q

What is techniques are used for rhythm control

A

What is techniques are used for rhythm control

Two methods
1. Chemical cardio version
a. utilizes antiarryhthmic drugs to convert to sinus rhythm.
works 20-70% of the time

  1. Direct current cardioversion (DCCV)
    a. utilizes a defribillator to shock the patients heart into normal sinus rhythm.
    b. works almost 100% of the time, the trick is KEEPING them in sinus rhythm
21
Q

acute rhythm control if it has been more than 48

A
  1. Delayed cardioversion with anticoag x3 week, then DCCV.
    if pt is really sompotmatic and cant wait, do TEE to look for clot in left appendage of heart. if no clot, then can do DCCV, if there is, they have no choice to do delayed cardioversion
22
Q

Acute rhythm control if < 48 hours

A

consider DCCV

if DCCV is unfeasible, undesireable, or unsuccessful,
if EF>40, use aiodarone, dofetilide, flecainide, ibutilide, propafenone

if EF<40%: amiodaarone, dofetilide
ibutilide

23
Q

acute chemical csrdioversion drugs

A

Class I (sodium channel blockers): flecainide, propafenone

Class III potassium channel blockade. Amiodarone, dofetilide, ibutilide

24
Q

chronic chemical cardioversion antiarrythmic drugs

A

Clas 1 sodium channel blockers: flecainide, propafenone

clas III. sotalol, dofetilide, dronedarone

25
Q

in general what are the four classes of chemical cardioversion

A

class !: sodium channel blockade
class @: Beta blockers
Class III. potassium channel blockade
CLass Iv: calcium channel blockers, Verapamil, diltiazem

26
Q

Class 1C Antiarrhythmics

Examples: Flecainide, Propafenone

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Dosing:

Adverse Effects:

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI:

Renal Adjustments:–

Monitoring Parameters: ‘–

A

Class 1C Antiarrhythmics

Examples: Flecainide, Propafenone

Class: Class I antiarryhtmic, Sodium Channel Blocker

Indication: A fib

Mechanism of Action: mebrane stabilizers. decrease excitability of cardiac tissue by

Effects of mechanism of Action: slows conduction in cardiac tissue

Dosing: Flecainide: 50 mg twice daily (MDD=300 mg)
Propafenone: IR-150 mg q8h (MDD=300 mg)
ER: 225 mg twice daily (MDD=850 mg

Adverse Effects: Propafenone: metallic taste

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI: Metabolized by CYP2D6

Renal Adjustments:–

Monitoring Parameters: ‘–
Pearls:
Class 1C have the highest potency so they can cardiovert

27
Q

Class 3 Antiarrhythmics

Examples: Dofetilide (Tikosyn)

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action: prolongs action potential duration

Dosing: normal:

Adverse Effects:

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI:

Renal Adjustments:

Monitoring Parameters:

Pearls: –

A

Class 3 Antiarrhythmics

Examples: Dofetilide (Tikosyn)

Class: Class III antiarryhtmic, Potassium channel blocker

Indication: A fib

Mechanism of Action: extends refractory period of cardiac action potential

Effects of mechanism of Action: prolongs action potential duration

Dosing: normal: 500 mcp PO twice daily. has renal adjustments

Adverse Effects: QT prolongation

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI: VErapamil: increases absorption of dofetilide in the gut increase risk of QT prolongation (must titrate pt off of verapamil to dofetilide)
HCTZ: effects clearance and electrolytes
MEtformin and Trimethoprim: active tubular secretion
additive QT prolongation with other medications

Renal Adjustments:

CRCl 40-60 mL/mim : 250 mcg PO twice daily
CrCl 20-40 mL/min: 125 mcg PO twice daily
CRcl< 20: contraindicated

Monitoring Parameters:
1. ,ust stay in hospital for 3 days to monitor for QT prolongation

Pearls: –

28
Q

Class 3 Antiarrhythmics

Examples: Amiodarone

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Dosing: normal:

Adverse Effects:

Absolute Contraindications: –.

Half life:

Pregnancy: –

Warning/ Precautions:–

DDI: imedications

Renal Adjustments: –

Monitoring Parameters:

Pearls:

A

Class 3 Antiarrhythmics

Examples: Amiodarone
Class: Class III antiarryhtmic, Potassium channel blocker + Beta Blocker

Indication: A fib

Mechanism of Action: exhibits properties of all the classes of antiarryhtmics

Effects of mechanism of Action: prolongs action potential duration

Dosing: normal: multiple dosing schemes, initial loading dose goal 8-10 g over 2-4 weeks. maintenance: 100-200 mg daily oral

Adverse Effects: QT prolongation, bradycardia, pulmonary fibrosis, thyroid dysfunction, corneal deposits, hepatotoxicity, blue/gray skin color

Absolute Contraindications: –.

Half life: 50 days

Pregnancy: –

Warning/ Precautions:–

DDI: inhibits, CYP3A4, CYP2D6, CYP2C9, PGP
additive QT prolongation with other medications

Renal Adjustments: –

Monitoring Parameters:
1. ,ECG at baseline and every 3- 6 months
thyroid function tests at baseline and every 6 months
Liver function tests at baseline and every 6 months
Chest x-ray at baseline and every 12 months
pulmonary function tests at baseline and every 12 months

Pearls:
1. most effective antiarryhtmic
usually asverse effects occur in long term use (10 years)

29
Q

Class 3 Antiarrhythmics

Examples: Sotalol (Betapace)

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI:

Renal Adjustments:

Monitoring Parameters:

Pearls: –

A

Class 3 Antiarrhythmics

Examples: Sotalol (Betapace)

Class: Class III antiarryhtmic, Potassium channel blocker + Beta Blocker

Indication: A fib

Mechanism of Action: extends refractory period of cardiac action potential + beta blocker

Effects of mechanism of Action: prolongs action potential duration

Dosing: normal: 40-120 mg depending on QT prolongation PO twice daily. Start =80 mg. has renal adjustments

Adverse Effects: QT prolongation

Absolute Contraindications: –.

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI: VErapamil: increases absorption of dofetilide in the gut increase risk of QT prolongation (must titrate pt off of verapamil to dofetilide)
HCTZ: effects clearance and electrolytes
MEtformin and Trimethoprim: active tubular secretion
additive QT prolongation with other medications

Renal Adjustments: FRequency of dosing dependent on renal function
CRCl >60 mL/min: q 12 hours
CRCl 40-60 mL/mim : q24 hours
CRcl <40: contraindicated

Monitoring Parameters:
1. ,ust stay in hospital for 3 days to monitor for QT prolongation

Pearls: –

30
Q

Class 3 Antiarrhythmics

Examples: Dronedarone (Multaq)

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Dosing: normal:

Adverse Effects:

Absolute Contraindications:

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI:

Renal Adjustments:–

Monitoring Parameters: –

Pearls: –

A

Class 3 Antiarrhythmics

Examples: Dronedarone (Multaq)

Class: Class III antiarryhtmic,

Indication: A fib

Mechanism of Action: structural analof of amiodarone (without iondine. exhibits properties of al the classes of antiarrythmics

Effects of mechanism of Action: prolongs action potential duration

Dosing: normal:400 mg q12 hours (oral only)

Adverse Effects: QT prolongation, bradycardia, hepatotoxicity0

Absolute Contraindications: patients with HF and permanenet A fib

Half life: –

Pregnancy: –

Warning/ Precautions:–

DDI: inhibits CYP3A4, CYP2D6, PGP
additive qt prolongation with other medications

Renal Adjustments:–

Monitoring Parameters: –

Pearls: –

c/r (12 decks)

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