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Year 3: Cardiology > Cardiology: Cardiac Arrhythmia - AF II > Flashcards

Cardiology: Cardiac Arrhythmia - AF II Flashcards

1
Q

What is meant by a ‘holiday heart’? [1]

A

Holiday heart syndrome typically refers to atrial fibrillation induced by binge alcohol consumption, frequently observed during long weekends, vacations, and holidays.

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2
Q

Describe the principles of managment of AF [2]

A

Rate or rhythm control

Anticoagulation to prevent strokes

TOM TIP: The following details on rate and rhythm control get quite detailed and complex. Most patients will end up on a beta blocker for rate control, often bisoprolol, plus a DOAC for anticoagulation. If you remember one thing about the treatment of atrial fibrillation, remember this combination.

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3
Q

Describe the overall process for the acute management of AF

A
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4
Q

In patients presenting acutely with AF, it is first important to perform a clinical assessment (e.g. ABCDE) and determine haemodynamic stability.

If a patient is haemodynamically unstable - what is the treatment? [1]

A

Electrical cardioversion

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5
Q

In patients presenting acutely with AF, it is first important to perform a clinical assessment (e.g. ABCDE) and determine haemodynamic stability.

If a patient is haemodynamically stable - describe the next stages of treatment

A

If AF has started within 48hrs of presentation
- Immediate pharmalogical cardioversion

If AF has started in more than 48hrs of presentation:
- Delayed, electrical cardioversion

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6
Q

Why is assessment of the cardiac function with echocardiography is required when cardioversion is being considered? [1]

A

Assessment of the cardiac function with echocardiography is required because flecainide (type I antiarrhythmic) is dangerous in structural heart disease (pro-arrhythmic and increased risk of sudden cardiac death)

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7
Q

Describe the treatment used for rhythm control for AF (electrical and pharmological) [3]

A

DC Cardioversion
- electrical stimulation to restore sinus rhythm

Amiodarone
- antiarrhythmic drug which can restore sinus rhythm on its own. It is suitable in most patients

Flecainide
- an antiarrhythmic drug that can be used in some patients to restore sinus rhythm, but is contraindicated in those with possible structural or ischaemic heart disease

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8
Q

Describe the medication used for rate control in the treatment of AF [3]

A

Rate control aims to get the heart rate below 100 and extend the time during diastole for the ventricles to fill with blood.

Beta blocker:
- atenolol or bisoprolol

CCB:
- Diltiazem or verapamil

Digoxin

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9
Q

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except in which four instances? [4]

A

NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except with:

  • A reversible cause for their AF
  • New onset atrial fibrillation (within the last 48 hours)
  • Heart failure caused by atrial fibrillation
  • Symptoms despite being effectively rate controlled
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10
Q

Describe the different types of Cardioversion for AF rhythm control [4]

A

For cardioversion, there is a choice between:
- Immediate cardioversion
- Delayed cardioversion

There are two options for immediate cardioversion:
* Pharmacological cardioversion
* Electrical cardioversion (recommended)
Electrical cardioversion aims to shock the heart back into sinus rhythm. It involves using a cardiac defibrillator machine to deliver controlled shocks. This is usually done with sedation or general anaesthesia.

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11
Q

Immediate cardioversion is used to treat AF in which instances? [2]

A
  • AF present for less than 48 hours
  • Causing life-threatening haemodynamic instability
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12
Q

Which drug is usually considered before & after electrical cardioversion to prevent AF from recurring? [1]

A

Amiodarone may be considered before and after electrical cardioversion to prevent AF from recurring.

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13
Q

Long-term AF rhythm control is with which drugs? [3]

A

Beta blockers first-line

Dronedarone second-line for maintaining normal rhythm where patients have had successful cardioversion

Amiodarone is useful in patients with heart failure or left ventricular dysfunction

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14
Q

Describe the Management of Paroxysmal Atrial Fibrillation [1]

Which drug is used? [1]

What other medication should still be continued? [1]

A

“pill-in-the-pocket” approach.:
- they take a pill to terminate their atrial fibrillation only when they feel the symptoms starting.

Flecainide is the usual treatment for a pill-in-the-pocket approach.

Patients with paroxysmal atrial fibrillation should still be anticoagulated based on their CHA2DS2-VASc score, similar to permanent atrial fibrillation.

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15
Q

What are the options of AF treatment when rate or rhythm control is not tolerated / adequate?

A

Ablation:
- Left atrial ablation
- Atrioventricular node ablation and a permanent pacemaker

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16
Q

Describe the process of left atrial ablation [8]

A

Left atrial ablation is performed in a catheter laboratory, often called a “cath lab”.

Under general anaesthetic or sedation

A catheter is inserted into a femoral vein and fed through the venous system under x-ray guidance to the heart

The catheter punctures through the septum into the left atrium.

Once in the left atrium, it is placed against different areas to test the electrical signals.

The operator attempts to identify the location of any abnormal electrical pathways.

Once identified, radiofrequency ablation (heat) is applied to burn the abnormal area of electrical activity.

This leaves scar tissue that does not conduct electrical activity

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17
Q

Describe the process of AVN ablation to treat AF [3]

A

Atrioventricular node ablation involves destroying the connection between the atria and ventricles (the atrioventricular node)

After the procedure, the irregular electrical activity in the atria cannot pass through to the ventricles

A permanent pacemaker is required to control ventricular contraction

Anticoagulation is still needed to prevent strokes.

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18
Q

What are the anticoagulants that NICE guidelines (2021) recommend for AF? [2] :

A

Direct-acting oral anticoagulants (DOACs) first-line:
- Apixaban
- edoxaban
- rivaroxaban
- dabigatran

Warfarin second-line, if DOACs are contraindicated

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19
Q

Why are DOACs 1st line c.f. to warfarin with AF? [1]

A

Direct-acting oral anticoagulants (DOACs) are oral anticoagulants that do not require INR monitoring, unlike warfarin

20
Q

Describe the MoA of apixaban, edoxaban and rivaroxaban [1]

Describe the MoA of dabigatran [1]

A

Apixaban, edoxaban and rivaroxaban are direct factor Xa inhibitors.

Dabigatran is a direct thrombin inhibitor.

21
Q

Describe the dosing regimen of apixaban and dabigatran compared to edoxaban and rivaroxaban? [2]

A

Apixaban and dabigatran are taken twice daily

Edoxaban and rivaroxaban are taken once daily.

22
Q

What is the target INR for warfarin treatment in AF? [1]

A

The target INR for AF is 2 – 3.

23
Q

Describe what is meant by INR with regards to warfarin treatment [1]

A

The INR (international normalised ratio) is used to assess how anticoagulated the patient is by warfarin.

The INR calculates the patient’s prothrombin time (time to clot) compared with the prothrombin time of an average healthy adult.

An INR of 2 means the patient has a prothrombin time twice that of an average healthy adult (it takes them twice as long to form a blood clot).

24
Q

Describe what is meant by time in therapeutic range (TTR) with regards to warfarin treatment [1]

A

Time in therapeutic range (TTR) refers to the percentage of time that the INR is in the target range.

When the INR is too low, the patient is at increased risk of a stroke.

When the INR is too high, the patient is at increased risk of bleeding.

25
Q

Interactions with which other drug types may impact warfarin’s INR? [1]

Interactions with which food types may impact warfarin’s INR? [3]

A

Antibiotics: both warfarin and abx involve cytochrome P450 system for metabolism.

leafy green vegetables (contains vitamin K), and those that affect the P450 system, such as cranberry juice and alcohol.

26
Q

Which instances would you give vitamin K to a patient taking warfarin? [1]

A

Vitamin K can reverse the effects of warfarin in the event of a very high INR or significant bleeding.

27
Q

What is the risk of using flecainide for paroxysmal atrial fibrillation treatment? [1]

A

There is a risk of flecainide converting the atrial fibrillation into atrial flutter, with 1:1 AV conduction to the ventricles, causing a very fast ventricular rate.

28
Q

Describe what is meant by CHA2DS2-VASc [1]

A

Tool for assessing whether a patient with atrial fibrillation should start anticoagulation

The higher the score, the higher the risk of developing a stroke or TIA.

29
Q

Which factors contribute to the CHA2DS2-VASc score? [8]

A

CHA2DS2-VASc is a mnemonic for the factors that score a point:

C – Congestive heart failure
H – Hypertension
A2 – Age above 75 (scores 2)
D – Diabetes
S2 – Stroke or TIA previously (scores 2)
V – Vascular disease
A – Age 65 – 74
S – Sex (female)

30
Q

What CHA2DS2-VASc indicates anticoagulation treatment for AF? [3]
(NICE, 2021)

A

0 – no anticoagulation

1 – consider anticoagulation in men (women automatically score 1)

2+ – offer anticoagulation

NB: Aspirin alone is NOT used for stroke prevention in atrial fibrillation (using aspirin was an option years ago).

31
Q

The NICE guidelines recommend using the [] score for assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation.

A

The NICE guidelines recommend using the ORBIT score for assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation.

32
Q

What factors contribute to ORBIT score? [5]

A

O – Older age (age 75 or above)

R – Renal impairment (GFR less than 60)

B – Bleeding previously (history of gastrointestinal or intracranial bleeding)

I – Iron (low haemoglobin or haematocrit)

T – Taking antiplatelet medication

33
Q

Explain the treatment that can be used as an option for those with contraindications to anticoagulation and a high stroke risk [1]

A

Left atrial appendage occlusion:

  • The left atrial appendage is a small pouch in the wall of the left atrium. It is the most common site for a thrombus to form.
  • Left atrial appendage occlusion involves inserting a catheter into the femoral vein, feeding that through the venous system to the right atrium and puncturing the septum between the atria to access the left atrium. Then, a plug is placed in the left atrial appendage, preventing blood from entering that area.
34
Q

What is the difference in when digoxin and CCBs such as verapamil and diltiazem are effective? [2]

A

Digoxin: only works when at rest (therefore less preferable)
Verapamil and Diltiazem: work at rest and during exercise

35
Q

Name five side effect of amiodarone use [5]

A
  • Pneumonitis
  • Bradycardia and Heart Block
  • Hepatitis
  • Photosensitivty and grey discolouration
  • Thyroid abnormalties (hyper & hypo): amIODarone - iodine in the drug
36
Q

Amiodarone is which type of anti-arrhythmic?

Class I
Class II
Class III
Class IV

A

Amiodarone is which type of anti-arrhythmic?

Class I
Class II
Class III
Class IV

37
Q

Flecainide is which type of anti-arrhythmic?

Class I
Class II
Class III
Class IV

A

Flecainide is which type of anti-arrhythmic?

Class I
Class II
Class III
Class IV

38
Q

Amiodarone works at which part of the cardiac action potential?

A
B
C
D
E

A

Amiodarone works at which part of the cardiac action potential?

A
B
C
D
E

39
Q

Descrbe the MoA of digoxin? [2]

How does it specifically work to treat AF or atrial flutter [2]

A

Negatively chronotropic (decreases HR); but positively inotropic (increases contraction)

In AF & atrial flutter: causes increased vagal (parasympathetic tone) - reducing conduction at the AVN

(In HR: inhibits Na/K ATP pumps, causing Na to accumulate in the cells; causing increased Ca2+ intracellularly too - increasing contraction)

40
Q

State 4 side effects of digoxin use [4]

A

Bradycardia
GI upset
Rash
Dizziness
Visual disturbance

41
Q

Digoxin is contraindicated in which conditions [2]

A
  • Second degree heart block
  • Ventricular arrhythmias
42
Q

Which drug classes can increase digoxin toxicity? [2]

A

Thiazide and loop diuretics (by causing hypokalaemia)

43
Q

Following cardioversion for acute AF, anticoagulation is commonly given for a minimum of [] weeks, even in patients at low-risk because of the risk of thromboembolism from [] Long-term continuation is then guided by usual risk stratification (i.e. CHADS-VASc).

A

Following cardioversion, anticoagulation is commonly given for a minimum of 4 weeks, even in patients at low-risk because of the risk of thromboembolism from atrial stunning post-restoration of sinus rhythm. Long-term continuation is then guided by usual risk stratification (i.e. CHADS-VASc).

44
Q

A patient has asthma and AF. What is their first line management? [1]

A

Diltiazem

Beta-blockers are contraindicated in patients with asthma when managing atrial fibrillation

45
Q

What’s the difference between what the ORBIT and CHAD2S2VASc scores are used for? [2]

A

ORBIT:
- bleeding risk from AF

CHAD2S2VASc:
- Risk of stroke from aF

Year 3: Cardiology (26 decks)

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