Cardio 1 Flashcards
What is systole?
contraction (pumping)
What is diastole?
relaxation
Does systole change with heart rate?
no
Does diastole change with heart rate?
yes
What are normal heart sounds? (s1/s2/s3/s4)
s1 and s2
What heart sounds are heard in heart failure? (s1/s2/s3/s4)
s3
What heart sounds are heard in hypertrophied/stiff hearts? (s1/s2/s3/s4)
s4
S3 heart sounds are due to __
increased ventricular filling/dilation
S4 heart sounds are due to __
increased pressure
A ventricular gallop (S3) is correlated with __
Ken Tuc KY
early diastole
An atrial gallop (S4) is correlated with __
TE Nuh See
Late diastole
Arteries are __ vessels
conduit
Arterioles are __ vessels
resistance
Capillaries are __ vessels
exchange
Venules/Veins are __ vessels
capacitance
What are examples of organs that recondition blood?
Lungs
Kidneys
Skin
What are examples of organs that are supplied only for metabolic needs?
Brain
Heart
Skeletal muscle
Flow only occurs when there is a __
pressure difference
Heart need to keep pressure __>__ to maintain flow
arteries>veins
What is stroke volume?
fraction of blood that is pumped from the left ventricle during ventricular systole
What is stroke volume used for?
to calculate ejection fraction
What is left ventricular end diastolic volume (LVEDV)?
total amount of volume in the left ventricle at the end of diastole (before it is ejected
What is systemic vascular resistance (SVR)?
resistance exerted by the vascular bed impeding blood flow
What is low/narrow pulse pressure usually due to?
low stroke volume
(heart failure, trauma/blood loss, aortic stenosis)
What is high/wide pulse pressure usually due to?
increase in stroke volume/decrease in SVR
(temporary due to exercise)
(chronic due to anemia, atherosclerosis, aortic regurgitation)
Contraction is triggered by an __
action potential
Rate of change of transmembrane voltage IS/IS NOT proportional to the net current across membranes
IS
Current is influenced by movement of __
ions
What are three ions for cardiac transmembrane potentials?
NA, Ca, K
In order for effective pumping, what must be true? (5)
not arrhythmic
not stenotic
not regurgitant
not weak
not stiff
B1 receptors are in the __
heart
B2 receptors are in the __
lungs
M1,35 are excitatory/inhibitory
excitatory
increase heart rate/constriction
M2,4 are excitatory/inhibitory
inhibitory
decrease heart rate, produces vasodilation
nicotinic receptors are excitatory/inhibitory
can be either
several subsets
What does a cardio exam consist of?
jugular venous pressure
waveform
blood pressure
arterial pulse
palpitation of the heart
cardiac auscultation
jugular venous pressure (JVP) is an __
estimation of volume status
Central venous pressure is estimated by measuring __
the vertical distance from the top of the jugular venous pulsation to the sternal inflection point or clavicle
Elevated JVP is suggestive of __
right-sided heart failure
constructive pericarditis
pericardial effusion
What is an A wave?
right Atrial contraction
What is a C wave?
beginning of right ventricular Contraction as the triCuspid Closes, interrupts the x descent
What is the x descent?
fall in right atrial pressure (relaXation)
What is a V wave?
atrial diastole (Venous filling) and Ventricular Contraction
What is the Y descent?
emptYing of atrium into ventricle (ventricular diastole, tricuspid open)
What is the waveform abnormality in atrial fibrillation?
no a wave present
What is the waveform abnormality in pulmonary hypertension?
large a wave
What is the waveform abnormality in heart block/ventricular arrhythmias?
cannon a wave
What is the waveform abnormality in tricuspid regurgitation?
large v wave
What is the waveform abnormality in pericardial tamponade/tricuspid stenosis?
prolonged or blunted y descent
Too small of a cuff can result in an over/under estimation of BP
over
Too large of a cuff can result in an over/under estimation of BP
under
Measurement differences >10mmHg in arms may suggest __
atherosclerosis
aortic dissection
subclavian artery disease
Large leg-arm differences are seen in __
PAD
severe AR
Very low DBP may suggest __
severe AR
large AV fistula
Visible left anterior chest heave indicates __
enlarge RV
Visible right upper parasternal pulsation indicates __
aortic disease
A sternal lift indicates __
volume overload
Leftward/downward displacement of apex beat indicates __
enlarged LV
What is thrill and what is it from?
vibratory sensation felt over skin
due to a murmur
A systolic click indicates __
mitral valve prolapse
Friction rub is due to __
pericarditis
What is bruit and what is it from?
murmur
due to blood flow through vascular abnormality (narrowing)
Class I agents block __ channels, inhibit phase __ of action potential, and __ rate of depolarization WITH/WITHOUT changing the resting potential
sodium
0
decrease
without
Class I agents can interact with Na channels via what 3 routes?
-external hydrophilic route
-internal hydrophobic-hydrophilic route
-direct membrane spanning route
To cross the membrane and reach the sodium channels, the drugs must be in the __ form
neutral (uncharged)
Quinidine has which two rings?
quinoline
quinuclidine
Quinidine is BASIC/ACIDIC at physiological pH
basic
Quinidine IS/IS NOT protonated at physiological pH.
is protonated
Procainamide is a bio-iostere of __. The ester group was replaced with an __. This makes it more resistant to __, less __, and fewer __ effects.
procaine
amide
hydrolysis
lipophilic
CNS
The acetylated metabolite of procainamide IS/IS NOT active as an anti arrhythmic.
IS active
Disopyramide is a unique molecule with a chiral carbon directly linked to __
a pyridine ring, a phenyl ring, an amide, and an alkyl diisopropyl amine (tertiary amine)
Disopyramide’s tertiary amine is converted into salts such as phosphate to improve __
water solubility
Lidocaine is used for __ arrhythmias
ventricular
Lidocaine has a __ amine and is weakly BASIC/ACIDIC
tertiary
basic
Lidocaine has a RAPID/SLOW onset with administered parenterally
rapid
The amide bond of lidocaine is replaced with an ether to make __ more resistant to __
Mexiletine
hydrolysis
Mexiletine is weakly BASIC/ACIDIC
basic
Mexiletine primarily exits in the __ form in the stomach and in ___ form in the intestine
ionized (hydrophilic)
unionized (lipophilic)
Mexiletine undergoes EXTENSIVE/MINIMAL first pass metabolism
minimal
Mexiletine is used to slow down rapid __ rates on IV administration
ventricular (V-FIB)
Flecainide is a __ derivative and sold as an __ salt
bis-trifluoroethoxy benzamide
acetate
Flecainide is used to slow down rapid __ rates on IV administration
ventricular (V-FIB)
(after MI)
Propafenone has a __ and is sold as a __
chiral center
racemic mixture
The __ isomer of propafenone is mainly responsible for Beta1 blocking properties
S-(+)
Propafenone has a __ group and contains a weakly __ secondary amine group
phenyloxypropanolamine
basic
Beta2 agonists are used in the treatment of __
asthma and COPD
Beta1 antagonists are in the treatment of __
cardiovascular disorders
Beta-blockers INCREASE/DECREASE sympathetic stimulation of adrenergic receptors in both peripheral and central nervous system by __
decrease
norepinephrine
First generation beta blockers are __
nonselective
Second generation beta blockers are __
more selective for Beta1
Beta agonists have an __ structure, while beta antagonists have an __ structure
arylethanolamine
aryloxypropanolamine
Beta selectivity INCREASES/DECREASES with size of R group
increases
What are examples of first generation beta blockers?
propranolol
carteolol
nadolol
penbutolol
S-timolol
What are examples of second generation beta blockers?
atenolol
metoprolol
acebutolol
betaxolol
bisoprolol
Esmolol has a very SHORT/LONG half life
short
What beta blocker has intrinsic sympathomimetic activity?
acebutolol
Beta blockers that prevent norepinephrine from binding to the receptor are __
antagonists
Beta blockers with intrinsic sympathomimetic activity stimulate the Beta receptors and are __
partial agonists
Stimulation of beta receptors by norepinephrine is responsible for increased __ and __
heart contraction
heart rate
Propranolol:
has a __ group
LIKELY/NOT LIKELY to pass the BBB
hydrocarbon naphthyl
likely
Atenolol:
has a __ group
LIKELY/NOT LIKELY to pass the BBB
a lower dose may be required in patients with __ impairment
polar acetamide
not likely
renal
Metoprolol:
is more HYDROPHILIC/LIPOPHILIC
a lower dose may be required in patients with __ impairment
lipophilic
hepatic
Class III agents block __ channels
Phase __ of action potential
INCREASE/DECREASE duration of action potential
potassium
3
increase
Amiodarone:
a __ derivative
highly HYRDOPHILIC/LIPOPHILIC
weakly BASIC/ACIDIC
diionated benzofuran
lipophilic
basic
Dronedarone:
a __ analogue of amiodarone
lack of __ and addition of __ group makes it more hydrophilic
Decreases risk of __
Reduced __ side effects
SHORTENS/LENGTHENS half-life
non-iodine containing benzofuran
iodine
methanesulfonyl
neurotoxicity
non-cardiovascular
shortens
Ibutilide:
Structurally similar to __
Contains __ and __ side chains
Has good __ solubility
Sold as a __
Sotalol
hydroxybutyl
heptyl
water
racemic mixture
A methanesulfonamide
Dofetilide:
Highly selective ___ blocker compared to amiodarone
POORLY/WELL absorbed
potassium channel
well
a bis-methanesulfonamide
What are Class I anti-arrhythmic agents?
Na channel blockers
What are Class II anti-arrhythmic agents?
beta-adrenergic blockers
What are Class III anti-arrhythmic agents?
K channel blockers
What are Class IV anti-arrhythmic agents?
Ca channel blockers
What are misc anti-arrhythmic agents?
Digoxin
Adenosine
What is the MOA of Class IV anti-arrhythmic agents?
inhibit SA nidal firing and decrease AV conduction because Ca involved in depolarization of nodal cells
What medications are Class IV anti-arrhythmic agents?
Verapamil
Diltiazem
What is the MOA of Digoxin?
Inhibits the Na/K ATPase which in turn serves to increase the calcium concentration inside heart cells
Increases the force of contraction
If adenosine is given IV It causes __
transient heart block in the AV node
What is the MOA of adenosine?
Binds to A1 receptor in cardiac tissue
inhibits adenylate cyclase, decreased cAMP, increased outward K flux, hyperpolarization
What are the 3 main components of adenosine’s SAR?
N at 3 and 7 position required
Ribose required for agonist activity
Substitution at N6 increases affinity for A1
Cardiac glycosides inhibit the __
Na/K ATPase pump
Positive intropic agents are used for __
heart failure
Negative chronotropic agents are used for __
arrhythmia
Cardiac glycosides are found in __ and __
plants
poisonous frogs
Glycosides contain both a __ and a __
sugar part
non-sugar part
The R group on the steroid ring of the glycoside differs depending on __
the origin of the glycoside
Aglycone:
CIS or TRANS fused?
-A/B
-C/D
-B/C
Has a characteristic __ shape
-Cis
-Cis
-Trans
U shape
R group at C-17 in aglycone is an __
lactone ring
The sugar part of cardiac glycosides are mono or polysaccharides with __ linkages and can be __
beta-1,4-glycosidic
acetylated
Lipophilicity of cardiac glycosides depends on __ and __
the number of sugar molecules
the number of -OH groups on aglycone
C/D trans fusion leads to __ aglycone
inactive
A/B trans leads to __ aglycone
decreased activity
What is the sugar attachment point on the cardiac glycoside?
C3-OH
The __ is important for receptor binding and __ is very important. (Cardiac glycosides)
lactone ring
C=C
If __ or __ are OH the duration of action of the cardiac glycoside is effected.
C12
C16
Which drug has a longer half-life: Digoxin or Digitoxin?
Digitoxin
Calculate the cardiac output for a 46 year old male with a heart rate of 78 beats per minute and a stroke volume of 70 mL.
a. 5.5 L/min
b. 5,460 L/min
c. 1.1 L/min
d. 897 L/min
5.5 L/min
Activation of the sympathetic nervous system would cause:
a. Decrease in heart rate
b. Increase in heart rate
c. Decrease in norepinephrine
d. Increase in acetylcholine
Increase in heart rate
During atrial systole, what is occurring?
a. The atria are contracting and allowing blood movement into the lungs and systemic circulation
b. The atria are relaxing and allowing blood to fill within each atria
c. Blood is moving from the atria to the ventricles via the pulmonary and aortic valves
d. Blood is moving from the atria to the ventricles via the tricuspid and mitral valves
Blood is moving from the atria to the ventricles via the tricuspid and mitral valves
Which of the following accurately describes phase 0 of the action potential?
a. depolarization due to a rapid influx of Na
b. repolarization due to a rapid efflux of K
c. depolarization due to a rapid efflux of Na
d. repolarization due to a rapid influx of K
depolarization due to a rapid influx of Na
Which of the following anchors actin to myosin and allows for contraction of the myofibril?
a. Troponin T
b. Troponin I
c. Troponin A
d. Troponin C
Troponin I
Which valve allows blood to move from the left atrium to the left ventricle?
a. mitral valve
b. aortic valve
c. tricuspid valve
d. pulmonary valve
mitral valve
Which of the following would cause an increase in blood pressure?
a. decrease in heart rate
b. increase in LVEDV
c. decrease in stroke volume
d. increase in systemic vascular resistance
increase in systemic vascular resistance
What is occurring in the heart during S1?
a. Tricuspid and mitral valve closes, ventricular systole
b. Aortic and pulmonic valves open, ventricular diastole
c. Aortic and pulmonic valves close, ventricular systole
d. Tricuspid and mitral valves close, ventricular diastole
Tricuspid and mitral valve closes, ventricular systole
Cardiac index corrects the cardiac output based on:
a. heart rate
b. body surface area
c. weight
d. blood pressure
body surface area
What purpose does the pericardial fluid within the pericardium serve?
a. Speeds up the action potential to allow for increased conduction
b. The fluid does not have a specific purpose but increases the risk of pericardial effusion
c. Serves as a barrier to protect the heart from trauma
d. Acts as a lubricant to allow the heart to move freely during contraction and relaxation
Acts as a lubricant to allow the heart to move freely during contraction and relaxation
What three factors determine O2 delivery to tissues?
a. body surface area
b. ejection fraction
c. weight
d. oxygen saturation
e. hemoglobin
f. cardiac output
d. oxygen saturation
e. hemoglobin
f. cardiac output
Which of the following is a normal ejection fraction?
a. 20-25%
b. 90-95%
c. 60-65%
d. 40-45%
60-65%
The influx of which cation into the myocardium is most critical in inducing myocardial contraction?
a. Mg
b. K
c. Na
d. Ca
Ca
Which of the following is the primary neurotransmitter of the parasympathetic nervous system?
a. vasopressin
b. acetylcholine
c. epinephrine
d. norepinephrine
acetylcholine
What vessel supplies blood to the LAD and Circumflex?
a. Diagnol artery
b. Right coronary artery
c. Left main artery
d. Aorta
Left main artery
As an antiarrhythmic agent, procainamide has fewer CNS side effects than procaine because:
a. Procainamide has a greater ability to cross cell membranes compared to procaine
b. Procainamide is more susceptible to metabolic hydrolysis than procaine
c. Conversion of the ester to an amide makes the molecule less lipophilic
d. The metabolic hydrolysis of procainamide gives p-aminobenzoic acid
Conversion of the ester to an amide makes the molecule less lipophilic
The most basic nitrogen atom in the following molecule is:
a. 3
b. 4
c. 2
d. 1
4
Which two of the following statements best describe why Mexiletine can be taken orally whereas Lidocaine is administered IV?
a. Mexiletine has a chiral center but not lidocaine
b. Conversion of the amide function of lidocaine to an ether function in mexiletine makes it metabolically more stable
c. Being more lipophilic mexiletine is almost completely absorbed with a bioavailability of 80-90%
d. Mexiletine is a primary amine whereas lidocaine is a tertiary amine
b. Conversion of the amide function of lidocaine to an ether function in mexiletine makes it metabolically more stable
c. Being more lipophilic mexiletine is almost completely absorbed with a bioavailability of 80-90%
The absence of the two iodine atoms and the introduction of a methane sulfonamide group in dronedarone compared to amiodarone result in:
Select ALL that apply.
a. An increase in the ability to cross cell membranes
b. Reduction in the ability to form salts with acids
c. A decrease in the lipophilicity of the molecule
d. A decrease in neurotoxicity
c. A decrease in the lipophilicity of the molecule
d. A decrease in neurotoxicity
Which of the following molecules is likely to be the most selective b1 antagonist with shortest duration of action?
a. A
b. B
c. C
d. D
e. E
D
What happens in phase 4?
resting membran potential
What happens in phase 0?
opening of fast Na channels
rapid influx of Na
What happens in phase 1?
Opening of transient K channels
K efflux
What happens in phase 2?
Plateau is a phase of maintained depolarization
Ca enters the cell by opening L-type Ca channels
K leaves cell by opening transient K channels
What happens in phase 3?
opening of K channels
K efflux
Antiarrhythmic drugs suppress arrhythmias by blocking flow through __ or by __
specific ion channels
altering autonomic function
Antiarrhythmic drugs can cause __
arrhythmias
What medications are Class 1A anti arrhythmic drugs?
Disopyramide
Procainamide
Quinidine
What medications are Class 1B anti arrhythmic drugs?
Lidocaine
Mexiletine
Phenytoin
What medications are Class 1C anti arrhythmic drugs?
Flecainide
Propafenone
Class 1 anti- arrhythmic drugs have no effect in __ cells
pacemaker
What is the mechanism of action of class 1 anti arrhythmic agents?
Blockage of fast sodium channels
Decrease phase 4 diastolic Na currents
Increase threshold
For blockers, most useful drugs bind readily to RESTING/ACTIVE/INACTIVE channels
active or inactive
Dissociation occurs during the RESTING/ACTIVE/INACTIVE stage.
resting
Recovery time from Na block is expressed as __
Recovery Time Constant (Trec)
If there is a rapid binding/dissociation Trec is SMALL/LARGE
small
If there is a slow binding/dissociation Trec is SMALL/LARGE
large
Drugs with a SLOW/FAST recovery rate have a greater effect
slow
Class 1A anti arrhythmic drugs have a greater affinity for the OPEN/INACTIVE state and have a SLOW/INTERMEDIATE/FAST recovery
open
intermediate
Class 1B anti arrhythmic drugs have a greater affinity for the OPEN/INACTIVE state and have a SLOW/INTERMEDIATE/FAST recovery
inactive
fast
Class 1C anti arrhythmic drugs have a greater affinity for the OPEN/INACTIVE state and have a SLOW/INTERMEDIATE/FAST recovery
open
slow
There are fast and slow acetylators of __
prcainamide
What are adverse effects of Disopiramide?
Anticholinergic activity
(dry mouth, constipation, urinary retention)
Lidocaine is not effective for __ arrhythmias
atrial
Which class 1 subclass is associated with Torsades de pointes?
Class 1A
What are some common ADRs for Procainamide?
GI problems
hypotension
fatal bone marrow aplasia
lupus syndrome
risk of Torsades
What are some common ADRs for Quinidine?
GI irritating
Cinchonism
Thrombocytopenia
Risk of Torsades
What are some common ADRs for Lidocaine?
CNS effects
Convulsions
Nystagmus
What are some common ADRs for Mexiletine?
Very GI irritating
CNS effects
What are some common ADRs for Flecainide?
GI problems
Blurred vision
What drugs elevate concentrations of Procainamide?
Amiodarone
Cimetidine
Quinidine elevates concentrations of what drugs?
Digoxin
Warfarin
Quinidine decreases metabolism of __ into __
codeine into morphine
What drug elevates concentrations of quinidine?
amiodarone
What drugs decrease lidocaine metabolism?
beta blockers
cimetidine
Melixetine reduce clearance of what medication?
theophylline
What increases concentrations of Flecainide?
amiodarone
Class 1A anti arrhythmic are indicated for __
atrial and ventricular arrhythmias
Class 1B anti arrhythmic are indicated for __
local anesthesia
ventricular arrhythmias
Class 1C anti arrhythmic are indicated for __
atrial and ventricular arrhythmias
Class 1C anti arrhythmic drugs have a high risk of __ in patients with CHF and CAD
proarrhythmias
What drug specifically inhibits slow Na channels in pacemaker cells?
Ivabradine (Corlanor)
Ivabradine is FDA approved for and used off label for __ and __
CHF (increased ejection fraction)
angina
tachycardia
What are adverse effects caused by ivabradine?
Bradycardia
risk of increased QT
AV block
vision changes
Beta blockers are used to treat __
hypertension
ischemic heart disease
heart failure
arrhythmias cause by increased sympathetic tone
Which beta blockers are nonselective?
nanodol
propranolol
timolol
sotalol
Which beta blockers are selective?
acebutolol
atenolol
esmolol
metoprolol
pindolol
penbutolol
Which beta blockers have vasodilation effects?
carvedilol
betaxolol
What is the primary effect of beta blockers?
in the pacemaker cells:
decreases automaticity in SA node
decrease slope of phase 4
Decrease heart rate
Decrease Na and Ca currents
What is a secondary effect of beta blockers?
in Cardiomyocytes:
Decrease heart rate
decrease force of contraction
decrease activity of Ca channels
What are therapeutic uses for beta blockers?
SA node increase automaticity
Supraventricular tachycardia
DADs and EADs
To terminate AV and AV nodal reentry or to prevent such arrhythmias
Controlling ventricular response in AF or Aflutter
Physical or emotional stress induced-arryhtmias
Prophylaxis for post MI arrhythmias
Cocaine induced arrhythmias
Angina, HF, HTN
What are non-cardiovascular uses for beta blockers?
thyrotoxicosis
anxiety
essential tremors
What are common adverse effects of beta blockers?
hypotension
bradycardia
dizziness
fatigue
lethargy
What are severe ADRs of beta blockers?
heart block
Aggravation of heart failure in susceptible individuals
Bronchosonstriction (nonselective)
Can induce DAD and EAD mediated arrhythmias
What are drugs that enhance AV nodal inhibition of beta blockers?
amidoarone
clonidine
digoxin
diltiazem
dronedarone
verapamil
Beta blockers may mask the symptoms of __
hypoglycemia
What are contraindications for beta blockers?
sinus bradycardia
cariogenic shock
second or third degree heart block
What are typical class III anti arrhythmic drugs?
Dofetilide (Tikosyn)
Ibuteilide (Corvert) (IV)
What are drugs that are mainly class II anti arrhythmic but also part of other classes?
Amiodarone (Cordarone, Pacerone)
Dronedarone (Multaq)
Sotalol (Betapace)
What are common uses of K channel blockers?
Atrial fibrillation/flutter
Anatomic reentry
DAD-mediated VT
Class II anti arryhtmics delay rectifier ___ in phase __ in __
K channels
phase 3
cardiomyocytes
K channel blocker have no effect on K channels in phase __ or __ transient K channels
phase 4
T1
What are effects of K channel blockers?
prolonged or increased action potential duration (Increased QT)
Increased refractory period
What are adverse effects of K channel blockers?
Increased risk of EAD
Increased risk of Tornadoes de pointes
What is an oral class III anti arrhythmic?
dofetilide
What is an IV class III anti arrhythmic?
Ibutilide
What are common adverse effects of dofetilide?
CNS
GI problems
Bradycardia
Torsades
What are rare adverse effects of dofetilide?
hepatotoxicity
angioedema
AV block
What are rare adverse effects of Dofetilide?
hepatotoxicity
angioedema
AV block
What are common adverse effects of ibutilide?
Headache
Nausea
Bradycardia
Torsades
What are contraindications of dofetilide?
Increased baseline QT
hypersensitivity
Hepatic or renal impairment
Hypokalemia
What are contraindications of ibutilide?
Increased baseline QT
Hypersensitivity
What medications increase Dofetilide effects?
loop and thiazide diuretics
What medications increase Dofetilide concentrations?
Cimetidine
Verapamil
Antifungals
Ibutilide may increase concentrations of __
lidocaine
__ may increase the arrhythmogenic effect of ibutilide
propafenone
Amiodarone has a SHORT/LONG half-life
long
35-110 days
What is the mechanism of action of amiodarone?
Blocks inactivated Na channels
Blocks K channels
Blocks Ca channels
Blocks beta receptors
Blockas alpha1 receptors
What are the effects of amiodarone?
Impairs SA nodal function
Modifies automaticity
Decrease AV conduction
Increase refractoriness
Increase APD
What is the mechanism of action of sotalol?
Blockes adrenergic receptor
Blocks K channels
What are the effects of sotalol?
Effects of beta blockers
Effects of K channel blockers
Increase action potential duration
Increase refractory period
Decrease adrenergic response
Decrease SA pacemaker rate
Decrease AV conduction rate
What are common adverse effects of amiodarone?
hypothyroidism
hyperthyroidism
hypotension
CNS
GI disturbances
Eye problems
Blue-gray pigmentation
Bradycardia
Torsades
What are effects that happen at toxic rates of amiodarone?
pulmonary toxicity
hepatotoxicity
What are adverse effects of dronedarone?
GI distubrances
Skin rash
Muscle weakness
Torsades
Hepatotoxicity
Renal and lung toxicity
What are contraindications of amiodarone?
Increased QT interval
iodine hypersensitivity
AV block
Thyroid disease
What are contraindications of dronederone?
Increased baseline QT
Heart failure
What are common adverse effects of sotalol?
CNS
bradycardia
dyspnea
What are less common adverse effects of sotalol?
bronchospasm
hypotension
Torsades
What are contraindications of sotalol?
Increased baseline QT
heart block
heart failure
bronchial asthma
Amiodarone increases the level of which drugs?
statins
warfarin
digoxin
quinidine
procainamide
phenytoin
flecainide
cyclosporine
What drug decreases amiodarone metabolism?
cimetidine
What medication decreases amiodarone concentration?
rifampicin
What medications reduce absorption of sotalol?
antacids
What medications increase bradycardia effect of sotalol?
Ca channel blockers
Sotalol in combination with __ increase risk of heart block
digoxin
What are effects of calcium channel blockers on the heart?
Increase vasodilation
decrease contractility
Decrease heart rate
decrease SA conduction
decrease AV conduction
What are the major effects on pacemaker cells that calcium channel blockers do?
Increase the threshold and slow depolarization
Block Ca channels in later phase 4 and in phase 0 - decrease heart rate
Decrease SA rate
Decrease AV conduction - increase refractory period
Decrease reentrant arrhythmias involving AV node
What are common adverse effects of calcium channel blockers?
bradycardia
GI irritating
Constipation
Dizziness/lightheadedness
Headache
Hypotension
Peripheral edema
What are rare/severe adverse effects of calcium channels blockers?
Worsening of heart failure
AV block
Increase hepatic enzymes
What are contraindications of calcium channel blockers?
Heart failure
Cardiogenic shocl
Second or third degree AV block
What are calcium channel blockers used for?
reentrant arrhythmias involving AV node
PSVT, Afib, Aflutter
Ventricular rate control
What drugs increase the risk of bradycardia if taken with verapamil?
amiodarone
beta blcokers
What drug increases the effects of verapamil?
fluconazole
Verapamil increase concentrations of what drugs?
statins
digoxin
dofetilide
theophilline
cyclosporine
What drugs increase effects of diltiazem?
CYP3A4 inhibitors
What drugs increase hypotensive effects of diltiazem?
sildenafil
azole antifungals
antihypertensive drugs
What drugs decrease hypotensive effects of diltiazem?
Rifampin
erythromycin
If diltiazem is taken with which drugs it can increase risk of bradycardia?
amiodarone
beta blockers
What is the mechanism of action of adenosine?
G protein-coupled adenosine receptors
Activates ACh-sensitive K channels-hyperpolarization
Decrease Ca current
What is adensoine used for?
PSVT
Inhibition of DADs elicited by sympathetic stimualtion
What are adverse effects of adenosine?
short lived
flushing
chest tightness
dizziness
syncope
transient SA/AV block
transient asystole
What drugs potentiate the effects of adenosine?
carbamazepine
dipyridamole
What medication diminishes the effects of adenosine?
theophylline
Digoxin has a LOW/HIGH therapeutic index
low
Andmistration of __ increases risk of toxicity of dogoxin
antibiotics that destroy intestinal microflora
What is the site of action for digoxin?
Atrium SA and AV nodes for arrhythmias
What is the mechanism of action for arrhythmias of digoxin?
Increases vagal tone - activation of ACh sensitive K channels in atrium - shortening APD
Decrease Ca currents in AV node - suppresses the AV node
What is digoxin used for?
terminating re-entrant arrhythmias involving atrium and AV node
Controlling ventricular rate response in afib
What are common ADRs of digoxin?
GI
Dizziness
headache
blurred or yellow vision
What are less common ADRs of digoxin?
atrial tachycardia
AV block
ventricular arryhtmias
hyperkalemia
What is an antidote for Digoxin toxicity?
Digibind
What disease states can enhance digoxin toxicity?
hypothyroidism
hypokalemia
hypomagnesemia
hypercalcemia
What is the potential mechanism of action of magnesium sulfate for arryhtmias?
Competes with Ca at ion channel transport site
What is Magnesium Sulfate used for?
Prevention/treatment of Torsades
Arryhtmias due to digoxin/digitalis toxicity
What are adverse effects of magnesium sulfate?
hypotension
breathing difficulties
You are developing a drug that will affect phase 4 in SA node cells. Which main characteristic should the drug have to produce a specific effect only in these cells?
a. It should inhibit rectifier potassium channels
b. It should inhibit L-type calcium channels
c. It should inhibit T-type potassium channels
d. It should inhibit slow sodium channels
It should inhibit slow sodium channels
Which drug can cause arrhythmias by affecting K+ channels?
a. Dofetilide
b. Atenolol
c. Flecainide
d. Lidocaine
Dofetilide
Beta blockers are used to treat arrhythmias because________.
a. They decrease the AV refractory period
b. They increase automaticity
c. They increase AV conduction time
d. They increase phase 4
They increase AV conduction time
In a patient diagnosed with arrhythmia caused by an AV reentry mechanism, you most likely use ________because it________?
a. Flecainade; blocks sodium channels
b. Verapamil; blocks calcium channels
c. Quinidine; blocks potassium channels
d. Lidocaine; blocks sodium channels
Verapamil; blocks calcium channels
__________ is used in a patient with a ventricular tachycardia produced by an ectopic focus because it inhibits________ and __________.
a. Procanamide; fast sodium channels; reduces phase 4
b. Adenosine; ACh-sensitive K+ channels; hyperpolarizes cardiomyocytes
c. Propanolol; beta receptors; increases calcium current
d. Phenytoin; slow sodium channels; increases APD
Procanamide; fast sodium channels; reduces phase 4
Which class I drug has significant cholinergic adverse effects producing dry mouth and constipation?
a. Disopyramide (norpace)
b. Lidocaine (xylocaine)
c. Flecainide (tambocor)
d. Procainamide (procan SR)
Disopyramide (norpace)
Which drug classes cause both effects: a reduction in the heart contraction force, and a slowing of the AV node conduction?
a. Class I and Class II
b. Class I and Class III
c. Class II and Class III
d. Class II and Class IV
e. Class III and Class IV
Class II and Class IV
Which of the following electrolyte abnormalities is assocaited with Tosades de Pointes?
Hyperkalemia
Hyponatremia
Hypercalcemia
Hypermagnesemia
Hyperkalemia
RJ’s rhythm strip shows 5 large boxes between the top of his QRS complexes. What is RJ’s heart rate?
60 beats/min
75 beats/min
90 beats/min
80 beats/min
60 beats/min
Identify the abnormal aspect of this EKG:
a. Wide QRS complex
b. Prolonged PR interval
c. Delta wave
d. ST segment depression
Prolonged PR interval
Identify the dysrhythmia that is occuring in this EKG:
a. Atrial fibrillation
b. Ventricular tachycardia
c. Atrial flutter
d. Ventricular fibrillation
Atrial fibrillation
The rapid influx of sodium in Phase 0 of the action potential correlates to which section of the rhythm strip?
P
S
T
Q
Q
Which of the following best describes the path of electricity within the heart?
SA node, AV node, Bundle of His, Purkinje fibers
Purkinje fibers, Bundle of His, AV node, SA node
Bundle of His, SA node, Purkinje fibers, AV node
AV node, Purkinje Fibers, SA node, Bundle of His
SA node, AV node, Bundle of His, Purkinje fibers
The characteristic of an EKG that can lead to torsades de pointe is:
a. Widened QRS complex
b. Prolonged QT interval
c. ST segment elevation
d. Prolonged PR interval
Prolonged QT interval
Calculate the heart rate of this rhythm on the EKG strip.
a. Less than 60 BPM
b. Within 60-80 BPM
c. Within 80-100 BPM
d. Over 100 BPM
Within 60-80 BPM
Which of the following electrolytes is not directly involved with action potential electrophysiology?
Sodium
Potassium
Calcium
Bicarbonate
Bicarbonate
Which of the following leads are formed by voltage triangles, otherwise known as Einthoven’s triange?
Leads I, II, III
Leads V1, V2, V3
Leads aVR, aVL, aFV
Leads V1, aVR, V3
Leads I, II, III
Atrium action potential has a more narrow phase __ and more gradual phase __
phase 2
phase 3
What happens during the p wave?
atria contraction
What happens during the QRS complex?
ventricle contraction
What happens during the t wave?
ventricular repolarization
Absolute refractory period is when there is __ to any stimulus, and is in phase(s) __
no reaction from cells
phases 1 and 2
Effect refractory period is when there is __ to any stimulus and is in phase(s) __
a lock, weak response
phase 3
Relative refractory period is when __ and happens in phase(s) __
large stimulus may propogate a response, but slower than normal
phase 4
How many positive electrodes are used for an EKG?
one
The EKG tracing is based on the sensing of the __
positive electrode
An electrical wavefront approaching a positive electrode causes a __
positive deflection
An electrical wavefront moving away from a positive electrode creates a __
negative deflection
An electrical wavefront moving perpendicular to a positive electrode causes an __
isoelectric deflection
A 12 lead EKG includes:
I, II, III, aVF, aVL, and aVR
An average PR interval is __ or __ small squares
0.12-0.2 seconds
<5
An average QRS interval is __ or __ small squares
0.008-0.1 seconds
<2.5
An average QTc interval is __ for males or __ for females
<0.46 seconds
<0.47 seconds
An average ST interval is __ or __ small squares
0.08-0.12 seconds
<3
If Q wave is >1 small box or amplitude is 1/3 of the QRS indication of __
past MI
Increased PR interval may indicate __
1st degree AV block
Prolonged QTc (>0.48s) puts patients at risk of __
Torsades
Elevation or depression of ST segment may indicate __
an acute MI
QT has to be corrected for heart rate using __
Bazett’s formula
What information can be obtained from the EKG?
rate
rhythm
axis
hypertrophy
infarction
What structure normally starts electric conduction in the heart?
SA node
What is the most accurate way to determine rate on an EKG?
60/(# of small boxes x 0.04)
What are the steps to determining rhythm on an EKG?
Is there a p wave in front of every QRS complex?
Is there a QRS complex after each p wave?
Is the rhythm regular?
Is the heart rate 60-100bpm?
Is the PR interval prolonged or QRS complex wide?
Is there a delta wave?
What is enhanced automaticity?
non-pacemaker myocardial tissue fires on its own instead of waiting to be stimulated by a neighboring cell
What are causes of enhanced automaticity?
Ischemia
Electrolyte imbalances
Acidemia
Medications
What is the proposed underlying mechanism of triggered activity causing dysrhythmias?
spontaneous depolarization during phases 2-4 of the action potential
leads to sustained triggering of action potentials
What is EAD?
early afterdepolarization
during phase 2/3
factors that prolong the QTc or increase intracellular Na
What is DAD?
delayed afterdepolarization
during phase 3/4
factors that increase intracellular Ca
What are the 3 conduction requirements for re-entry to occur?
At least two pathways for impulse conduction
One area with unidirectional block in one pathway
Slowed conduction in the other pathway
Accessory pathways are __ dependent
NA
What is a conduction block?
occurs when conduction tissue is unexcitable
Cannot communicate the impulse to the next area
can be permanent or transient?
What are causes of conduction block?
ischemia
trauma
scarring
fibrosis
medications
Describe Sinus tachycardia
regular rhythm
rate >100 bpm
always has an underlying cause
Most common: overactivation of SNS
Infection/fever, exercise, pain, stress
Describe Sinus Bradycardia
regular rhythm
rate <60 bpm
Due to decreased SNS or increased PNS activity
Common causes: hypothyroidism, hypertension, medications, vagal nerve stimulation
Describe Premature Ventricular Contractions
Single abnormal beat earlier than expected
originates in the ventricle
QRS is wider, taller, and early
Cause: electrolyte abnormalities, exercise, ischemia, heart failure
Describe Ventricular Tachycardia
originates in the ventricles, wide complex
Don’t see p wave
>140-260 bpm
Requires at least 3 beats Sustained >30s or requires intervention, Nonsustained <30 seconds
Monomorphic or polymorphic
Common causes are CAD and heart fialure
Describe Torsades de Pointes
type of polymorphic VT, but with changes in direction of the complex
If not treated, can lead to vfib quickly
Cause: prolonged QTc, drugs, hypokalemia
Describe Ventricular Fibrillation
chaotic electrical discharge that does not effectively depolarize ventricles
Wide QRS complex, usually >300 bpm
Fatal if not rapidly terminated
Causes: AMI, HF, hypokalemia
Describe Asystole
total absence of electrical activity
heart is unable to generate a single QRS complex
Myocardium is functionally dead
Describe PEA
no pulse, but some electrical activity
heart is unable to generate a single QRS complex
Myocardium is functionally dead
Describe Premature Atrial Contractions
premature ectopic beat
still a visible P wave before the PAC
Causes: increased SNS, decreased PNS, stimulants, alcohol
Describe Atrial Fibrillation
no organized atrial contraction or normal P waves
Atria beating at 400-600 bpm
Normal contracting ventricles but beating fast >100-200 bpm
Causes: advanced age, valvular heart disease, HF, COPD
Describe Atrial Flutter
presence of flutter waves with atrial rate of 200-300 bpm
rhythm is regular
sawtooth appearance
Cause: HF, valvular heart disease, COPD
Describe Supraventricular Tachycardia
regular rhythm
rate 160-260 bom
P wave looks different than normal
Cause: increased SNS activation
Describe Wolff Parkinson White Syndrome
type of SVT
preexcitation syndrome
accessary pathway leading to tachyarrhythmia
congenital heart defect
delta wave
Describe 1st degree AV block
abnormally long delay in transmission of the atrial impulse through the AV node
prolonged PR interval
Causes: medications, sick sinus syndrome
Describe 2nd degree AV block Mobitz Type I
Wenckebach
progressive prolonging of PR interval
Suddent QRS drop
Cause: disease of AV node (medications, inferior MI)
Describe 2nd degree AV block Mobitz Type II
PR intervals are consistent, sudden drop of QRS complex
Due to disease of the His bundle or Purkinje fibers
Cause: anteroseptal MI, HF, sarcoidosis
Describe 3rd degree AV block
No association between P wave and QRS complex due to AV dissociation
Two pacemakers, one in atria and one In ventricles
Length of PR intervals may vary, no pattern
Cause: advanced age, infarction, medications
Which of the following cannot be detected from the ECG?
a. heart rate
b. an abnormal heart rhythm
c. prior MI
d. ejection fraction
ejection fraction
A patient presents to ED with a pulse of 30 bpm. You overhear the ED physician reading the ECG and they state there is no association between the P wave and the QRS complex. What kind of arrhythmia is this?
complete heart block
What arrhythmia is fatal if not treated immediately?
ventricular fibrillation
Name the arrhythmia.
Sinus tachycarida
Name the arrhythmia.
Sinus bradycardia
Name the arrhythmia.
Premature Ventricular Contractions
Name the arrhythmia.
Ventricular tachycardia
Name the arrhythmia.
Torsades de Pointes
Name the arrhythmia.
Ventricular Fibrillation
Name the arrhythmia.
Top Asystole
Bottom PEA
Name the arrhythmia.
Premature Atrial COntractions
Name the arrhythmia.
Atrial Fibrillation
Name the arrhythmia.
Atrial Flutter
Name the arrhythmia.
Supraventricular Tachycardias
Name the arrhythmia.
Wolff Parkinson White Syndrome
Name the arrhythmia.
1st degree AV block
Name the arrhythmia.
2nd degree AV block Mobitz Type I
Wenckebach
Name the arrhythmia.
2nd degree AV block Mobitz Type II
Name the arrhythmia.
3rd degree AV block
What is the acronym for antiarrhythmic drugs?
South - Class 1 Na Channel Blockers
Beach - Class 2 Beta Blockers
Pol - Class 3 Potassium blockers
ka - Class 4 calcium channel blockers
What is the mechanism of each class of antiarrhythmic drugs?
Class 1: phase 0 (odd)
Class 2: phase 4 (opposite)
Class 3: phase 3 (=)
Class 4: phase 2 (opposite)
What is the acronym for class I AADs?
Double Quarter Pounder
(1A: Disopyramide, Quinidine, Procainamide)
Lettuce Mayo
(1B: Lidocaine, Mexiletine)
Fries Please
(1C: Flecainide, Propafenone)
Which class 1 subtype has the strongest Na blockade?
Class 1c
Which class 1 subtype has the weakest Na blockade?
Class 1b
Which class 1 subtype has moderate Na blockade ability?
Class 1a
What is the acronym for class 3 AADs?
DAD IS
(Dronedarone, Amiodarone, Dofetilide, Ibutilide, Sotalol))
Which of the following best describes the primary ion channel inhibited by sotalol, the corresponding action potential phase affected, and its effects on the ECG?
a. Na, phase 4 causing prolongation of QTc
b. Na, phase 1 causing widening of the QRS
c. K, phase 2 causing a widening of the QRS
d. K, phase 3 causing a prolongation of the QTc
d. K, phase 3 causing a prolongation of the QTc
What are examples of atrial arrhythmias?
PACs
SVT
WPWS
Afib
Aflutter
What is pharmacological therapy for PAC?
typically do not require medication
if symptomatic or clinically indicated can do low dose metoprolol
What is nonpharm treatment for atrial arrhythmias?
minimize alcohol intake
avoid smoking
minimize caffeine intake
stress
What are symptoms of SVT?
palpatations
dizziness
syncope
weakness
polyuria
Chronic oral anticoagulation IS/IS NOT recommended for SVT
IS NOT
If patients present acutely with symptoms or rapid ventricular rate with SVT can medicate with __
Vagal maneuvers
IV adenosine
IV beta blocker
IV non-DHP CCB
IV amiodarone
If recurrent/refractory symptoms of SVT can do oral maintenance therapy with __
beta blockers
non-DHP CCB
catheter ablation
What is the Valsalva maneuver?
lay patient supine
blow through syringe or obstructed straw for 10-15 seconds
What is the diving reflex?
Take multiple deep breaths
hold breath
then immersing face in a basin of water
What is bearing down?
bearing down as if making a bowel movement
What is a carotid sinus massage?
should be done by a provider
applying pressure with fingertips to carotid sinus areas on face
Adenosine administration is useful if patients do not respond to __
vagal maneuvers
Can adenosine be repeated?
yes
What is the half-life of adenosine?
10 seconds
What are contraindications of adenosine therapy?
heart transplant
SVT with an accessory pathway
What are types of catheter ablations?
radiofrequency ablations
cryofrequency ablations
AV node ablation
epicardial ablation
maze ablation
What are the treatment options for WPWS?
IV procainamide
IV ibutilide
Direct current cardioversion
Catheter ablation preferred if patients are symptomatic and known accessory pathway
What medications are contraindicated in WPWS?
IV amiodarone
adenosine
digoxin
non-DHP CCBs
lidocaine
use caution with beta blockers
Once WPWS accessory pathway has been eliminated do the CI agents still need to be avoided?
no
Stop bolus IV Procainamide if __
QRS widens >50% original width
hypotension occurs
or max was given
IV procainamide should be reduced by __ in renal/hepatic impairments
50%
IV procainamide is contraindicated in patients with __
recent MI (6 days - 2 years)
Discontinue IV ibutilide as soon as __
arrhytmia terminates
VT occurs
prolongation of QTc
Can IV ibutilide be repeated?
yes
When is IV ibutilide contrainidicated?
chronic AF
electrolyte imbalance
requires continuous ECG monitoring
ejection fraction <40% (HF)
What are risk factors for AFib?
CAD
heart failure
older age
diabetes mellitus
obesity
obstructive sleep apnea
cardiothoracic surgery
hyperthyroidism
alcohol use
What is the most common arrhythmia in clinical practice?
atrial fibrillation
What are signs/symptoms of AFib?
fatigue
palpitations
shortness of breath
syncope
angina
Afib poses an increased risk of __
SSE
heart failure
dementia
hospitalization
mortality
In a patient with Afib and LV dysfunction or HFrEF with medications should be used for rate control?
Beta blockers +/- digoxin
amiodarone
In a patient with afib without LV dysfunction or HFrEF which medications should be used for rate control?
beta blockers or non-dhp CCB
amiodarone
Which beta blocker are given IV push?
Metoprolol
propranolol
Which beta blockers are given by infusion?
esmolol
Non-DHP CCBs are given by IV PUSH/INFUSION
push
Which non-dhp CCB is preferred in patients with labile/low BP?
diltiazem
Dosing of Digoxin varies based on patient’s
weight
renal function
age
medications
heart failure diagnosis
Reduce loading dose of digoxin by 50% if __
renal dysfunction
elderly
drug interactions (amidoarone, dronedarone, verapamil)
What are signs of toxicity of digoxin?
bidirectional VT
blurred vision
heart block
Digoxin is a good option for a patient with afib and __
acute decompensated HF
What steady state should be chosen for digoxin dose calculation?
1
What CL NR should be used for non-heart failure or for only mild symptoms in digoxin calculations?
40 mL/min
What Cl NR should be used for severe heart failure in digoxin calculations?
20 mL/min
What is the Afib trough goal for digoxin?
0.8-2 ng/mL
What is the heart failure trough goal for digoxin?
0.5-0.9 ng/mL
Higher risk of death in trough levels of >__ of digoxin
1.2 ng/mL
If loading dose of digoxin is given, check level ___ after loading dose
12-24 hours
If no loading dose of digoxin is given, obtain trough __ after therapy
3-5 days
If changing maintenance dose of digoxin check trough in __
5-7 days
If renal function, check digoxin trough in __
15-20 days
1 vial of digoxin immune fab (Digifab) will bind __ digoxin
500mcg
In acute digoxin overdose, if dose is unknown, give __
10 vials
may repeat with another 10 vials
In acute digoxin overdose, if vial is known give __
number of vials = total body load (0.8*mg digoxin ingested) x2
In chronic digoxin toxicity, and serum concentration is unknown give __
6 vials
In chronic digoxin toxicity, and serum concentration is known, give __
number of vials = (serum conc (ng/mL) x body weight (kg) / 100
After giving Digifab, monitor __ hourly for 4-6 hours and then daily
potassium
Should you check digoxin level after giving digifab? why or why not?
no
bound in the blood, will be falsely high
Can amiodarone be used in heart failure?
yes
For rhythm control of afib first line therapy is __
cardio version
For afib rhythm control no HFrEF which medications can be used?
amiodarone
dofetilide
flecainide
ibutilide
propfenone
procainamide
For afib rhythm control with HFrEF with medications can be used?
amiodarone
dofetilide
What should be done before doing cardioversion?
anticoagulation
ensure no clot
Amiodarone has a higher dose for afib for RATE/RHYTHM control
rate
What FDA requirements are there for dofetilide?
hospitalization for first 3 days (5 doses)
baseline QTc and 2-3 hours after every dose
If >500 Etc discontinue
Monitor __ every 3 months on dofetilide
SCr
K
Mg
QTc
What medications CANNOT be taken with dofetilide?
hydrochlorothiazide
prochlorperazine
trimethoprim
verapamil
What medications can be taken as needed for afib?
flecainide
propafenone
Risk of __ with class 1C antiarrhythmics
1:1 AV node conduction
What medicatoin should be given with flecainide or propafenone bc of 1:1 AV node conduction?
beta blocker or non-dhp CCB
For afib maintenance therapy with CAD which medications can be used?
dofetilide
dronedarone
sotalol
amiodarone
For afib maintenance therapy with HF which medications can be used?
amiodarone
dofetilide
For afib maintenance therapy without structural heart disease (CAD/HF) which medications can be used?
dofetilide
dronedarone
flecainide
propafenone
sotalol
amiodarone
Dronedarone is contraindicated in patients with __
heart failure
Sotalol is contraindicated in CrCl <__, __ HF, EF </=__, or baseline QTc >__
CrCL <40
acute decomponsated HF
EF </=30%
baseline QTc >450
What drugs should have continuous ECG monitoring for 3 days upon initiation/dose adjustments?
Dofetilide
Sotalol
Flecainide or Propafenone? Renal dose adjustment
Flecainide
Flecainide or Propafenone? Hepatic dose adjustment
Propafenone
When is rate control preferred for Afib?
prefers rate control
older
longer history of AF
fewer symptoms
When is rhythm control preferred for Afib?
prefers rhythm control
younger (<60yo)
shorter history of AF
more symptoms
Most clots in patients with afib originate in the __
left atrial appendage
Nonvalvular AF excludes patients with __ or __
moderate/severe mitral stenosis
mechanical heart valves
Patients with VALVULAR/NON-VALVULAR Afib should be anticoagulated regardless of score
valvular
Patients with valvular afib SHOULD/SHOULD NOT be put on a DOAC
should not
What are the components of a CHA2DS-VASc Score?
(Congestive) heart failure
Hypertension
Age >/=75
Diabetes mellitus
Prior Stroke, TIA, or VTE
Vascular disease (prior MI, PAD, aortic plaque)
Age 65-74
Sex category (female)
A CHA2DS2-VASc score of __ or higher indicated high risk of thrombosis
2
DOACs are indicated in a CHA2DS2-VASc score of __ in men and __ in women
2
3
Is aspirin recommended for afib?
no
What are the components of a HAS-BLED score?
Hypertension SBP>160
Abnormal renal or hepatic function
History of stroke
History of Bleeding
Labile INRs
Older adults >65
Drugs or alcohol excess
What HAS-Bled score warrants more frequent monitoring?
3
What is considered abnormal renal function for HAS-BLED score?
chronic dialysis
renal transplant
SCr 2.26 or greater
What is considered abnormal liver function for HAS-BLED score?
chronic hepatic disease
bilirubin >2x UNL
Phos >3x UNL
Apixaban should be decreased to 2.5mg BID if what is true?
2/3 of the following:
80yo+
SCr 1.5+
60kg or less
A 75 YOM presents to the ED with palpatations, dizziness, and lightheadedness. PMH: moderate mitral valve stenosis. Has Afib. BP 110/72 HR 140. What is the most appropriate treatment?
Diltiazem
A 68YOF presents with AF. After her HR is controlled with metoprolol, she is asymptomatic. PMH: HTN, T2DM, osteoarthritis, and depression. Meds: metoprolol, lisinopril, tylenol, metformin, citalopram. HR 82 BP 130/88 SCr 0.8 CrCl 60 normal hepatic function. CHA2DS2-VASc and HAS-BLED scores?
4
1
What are types of ventricular arrhythmias?
PVC
vtach
vfib
torsades
asystole/PEA
If patient presents with PVC, is asymptomatic, but has CAD, what should be considered?
beta blockers
If patients presents with symptomatic PVC what should be considered?
beta blockers
non-DHP CCBs
