CARDIOVASCULAR SYSTEM-Arrythmia, AF Flashcards
1
Q
What are 7 modifiable risk factors of CVD?
A
o High blood pressure
o Physical inactivity
o Smoking
o Diet and weight
o Diabetes
o Cholesterol
o Stress
2
Q
What are 3 non-modifiable risk factors?
A
Age/sex
Family History
Race/ethnic background
3
Q
What are some lifestyle choices to prevent CVD?
A
Moderate alcohol
Stop smoking
Sleep well
4
Q
6 types of CVD?
A
o Coronary Heart Disease (CHD) = disease of the blood vessels supplying the heart muscle.
o Cerebrovascular disease = disease of the blood vessels supplying the brain.
o Peripheral arterial disease = disease of blood vessels supplying the arms and legs.
o Rheumatic heart disease = damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria.
o Congenital heart disease = malformations of heart structure existing at birth.
o Deep vein thrombosis + pulmonary embolism = blood clots in the leg veins, which can dislodge and move to the heart and lungs.
5
Q
What is Coronary Heart disease?
A
disease of the blood vessels supplying the heart muscle
6
Q
What is cerebrovascular disease?
A
disease of the blood vessels supplying the brain.
7
Q
Peripheral arterial disease?
A
disease of blood vessels supplying the arms and legs
8
Q
What is rheumatic heart disease?
A
damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria.
9
Q
What is congenital heart disease?
A
malformations of heart structure existing at birth.
10
Q
DVT and PE?
A
blood clots in the leg veins, which can dislodge and move to the heart and lungs.
11
Q
What 3 drug types can cause secondary HT?
A
Anti-inflammatory corticosteroids (e.g. prednisone)
Birth control pills (esp. containing estrogen)
Cold medicines (e.g. containing pseudoephedrine, phenylephrine)
12
Q
What is clinic BP target?
A
<140/90mmHg
13
Q
What is 1st line treatment for hypertension in patients under 55 and not afro-carribbean?
A
ACEi or ARB
14
Q
What is 1st line HT treatment for patient over 55 years or afro-caribbean?
A
CCB
15
Q
What is ectopic heartbeat?
A
Type of arrhythmia- irregular HB.
16
Q
What are 2 aims of atrial fibrillation management?
A
Rate control
Rhythm control
17
Q
What are 3 symptoms of atrial fibrillation?
A
PALPITATIONS
dizzy
Dyspnoea - difficulty breathing
18
Q
What are the 3 meds used as rate control for atrial fibrillation?
A
-Beta Blocker
-Rate limiting CCB
-Digoxin
19
Q
Why is Sotalol not used to treat AF?
A
Increases QT interval
20
Q
What 2 CCBs used for AF?
A
Diltizem and verapamil
21
Q
What 3 drugs help treat rhythm control?
A
Anti-arrythmic drug= Amiodarone , flecainide and propafenone
22
Q
What 2 anti-arrhythmic drugs to avoid in Ishaemic Heart disease?
A
Flecainide and propafenone - can cause cardiac toxicity
23
Q
How is Atrial flutter treated?
A
Similar to AF
24
Q
What should we do if treatment does not work to control symptoms of AF?
A
cardioversion and ablation
25
What is CHADSVASC and what score requires anti-coagulation?
Risk of having stroke.
score of 2+ = needs anticoagulant.
2 in females
1 in males
26
What beta blocker is NOT used to treat AF/arrhythmias?
Sotalol
27
What specific group of patients are treated with digoxin for AF?
Sedentary patients and non -paroxysmal AF
28
What 1st line drug is used to treat rhythm control post- cardioversion?
Beta blocker
29
What does CHADSVAS stand for?
C= Chronic HF or LVSD
H= Hypertension
A= age 75 and + (+2 points)
D= DM
S = Stroke/ TIA / VTE (+2 points)
V= Vascular disease
A = 65-74 years
S = Sex, female
30
What does ORBIT stand for?
O = Older than 75 years
R = reduced haemoglobin/ haematocrit or anaemia (2)
B = bleeding hx (2)
I= insufficient kidney function
T = treatment with anti-platelet
31
What is paroxysmal supraventricular tachycardia?
Fast HR that occurs in atria.
32
How do we treat Paroxysmal supraventricular Tachycardia?
Reflex vagal nerve stimulation.
e.g. Face in ice cold water
33
What 2 drugs can be used to treat Paroxysmal supraventricular Tachycardia If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms?
IV adenosine
or
Verapamil
reflex vagal stimulation -1st line
34
When is IV adenosine contraindicated for treatment of Paroxysmal supraventricular Tachycardia?
Not for COPD, asthma patients
35
What drug/treatment can be used to treat RECURRENT episodes of Paroxysmal supra-ventricular Tachycardia?
Catheter ablation or anti-arrhythmic drugs (e.g. verapamil, diltiazem)
36
What is a ventricular arrhythmia?
Fast heart rate which happens in ventricles
37
What is the treatment for Ventricular arrhythmia if a patient is pulseless?
CPR/defibrillator
38
What is the treatment for Ventricular arrhythmia if a patient is at high risk of cardiac arrest?
Cardioverter defibrillator implant or anti-arrhythmic drug
39
What is the drug treatment for Ventricular tachycardia if a patient has haemodynamic instability?
If stable/sustained= IV anti-arrhythmic drug
Non-sustained = beta blocker/ sotalol
emergency direct current cardioversion- unstable sustained instability
40
What is torsade de pointes?
Life threatening type of ventricular tachycardia with long QT interval.
41
What are 3 main symptoms of torsade de pointes?
Syncope + seizures
Palpitations
Dyspnoea
42
What 3 things can cause torsade de pointes?
Drugs that prolong QT interval
HypOkalaemia
Severe bradycardia
43
What is 1st line drug treatment for torsade de pointes?
IV Magnesium sulfate
44
List 4 anti-arrhythmic drug classes?
Class 1 = Na+ channel blockers
Class 2 = Beta blockers
Class 3. = K+ channel blockers
Class 4 = rate limiting CCB
45
What is class 1 anti-arrythmic drug?
Na+ channel blockers
46
List some Na+ channel blockers
Lidocaine
Flecanide
Propafenone
Disopyramide
47
What class 1 anti-arrhythmic drug is CI in asthma/ copd/ IHD?
Propafenone
48
Give examples of class 3 - k+ channel blockers?
Amiodarone
Sotatolol
Dronedarone
49
What drug is a BB and also a class 3 k+ channel blocker too?
Sotalol
50
What class 3 k+ channel blocker can cause hepatotoxicity/ HF?
Dronedarone
51
What is MOA of Amiodarone?
Block K+ channel which causes repolarisation in phase 3 of cardiac Action potential
52
What indication is amiodarone for?
Arrhythmia + CPR
53
What is oral loading dose of Amiodarone?
200mg TDS - 1Week
then BD
then OD- maintenance
54
What is a key counselling point for amiodarone
Provide patient alert card
55
What is a MRHA 2022 alert for amiodarone?
Risk of serious SE which can last for 1 month after STOPPING.
Review regularly.
Monitor LFT/TFT.
CT scan if pulmonary toxicity
56
What are 8 SE of amiodarone?
1.Corneal micro deposits
2.Optic neuropathy
3.GREY skin/phototoxicity
4.Peripheral neuropathy (pins and needles)
5. thyroid dysfunction
6. hepatotoxicity
7. pulmonary toxicity
8. QT prolongation
57
What to monitor in amiodarone?
Eye tests, report impaired vision
Protect skin from UV.
Monitor K+- for hypOkalaemia. (Before)
CT scan for lungs (before))
LFTS + TFTS (6 months)
58
What mneumonic to remember amiodarone SE?
P = pulmonary toxic/ prolonged qt
H = hyper/hypothyroidism
O = optic neuritis
N = neuropathy limbs
E= eyes. corneal microdeposits
S = skin - sensitive to sunlight.
59
How can amiodarone levels rise? (2 things interact)
Interacts with grapefruit juice and cimetidine
60
What are grapefruit juice and cimetidine examples of
Enzyme inhibitor
61
What is enzyme inhibitor?
(prevent liver enzyme breaking down the drug so levels rise)
62
Is Amiodarone and enzyme inhibitor or inducer?
Inhibitor
63
How does amiodarone cause bradycardia?
Interacts with BB, CCB
64
What 2 CCB can cause cardio depression?
Diltiazem
Verapamil
65
What interacts with amiodarone to cause rhabdomyoloysis and myopathy?
Statin - adjust dose
66
What dose digoxin should be given with amiodarone?
1/2 dose
67
What 6 drugs can interact with amiodarone to cause peripheral neuropathy?
Cisplatin
Isoniazid
Metronidazole
Nitrofurantoin
Phenytoin
Vinca alkaloid
68
What drugs can interact with amiodarone?
TCA
SSRI
Macrolides
5 HT3 antagonist
Antipsychotics
Anti-arrhythmics
69
What is MOA of digoxin?
Reduces force of contraction, inhibits Na+/K+ ATPase in myocardium
Reduces HR + SA node automaticity
70
What is digoxin indication?
Atrial fibrillation + HF.
71
What is digoxin therapeutic index?
0.7- 2 ng/L
72
How to do therapeutic drug monitoring for digoxin?
Plasma conc. checked 6 hrs after dose.
NO reg monitoring needed unless RI/toxicity. Monitor electrolytes and renal function.
73
What is digoxin loading dose for rapid digitalisation?
0.75–1.5 mg in divided doses, dose to be given over 24 hours.
Reduce dose in elderly.
74
What is digoxin maintenance dose for Non-paroxysmal AF in sedentary patients
125-250 mcg OD
75
What is digoxin maintenance dose for worsening HF?
62.5- 125mcg OD
76
What is Tablet Digoxin bioavailability?
63%
77
What is digoxin elixir bioavailability?
75%
78
What formulation of digoxin has best bioavailability?
IV = 100%
79
What are signs of digoxin toxicity?
G= GI - Nausea/vom, abdo pain
Rash
Arrhythmia
CNS = confusion
Eyes - blurred vision, YELLOW HALO
80
What are signs of digoxin toxicity related to eyes?
Yellow halos
81
What 3 electrolyte imbalances can digoxin toxicity cause?
RI
HypOkalaemia
HypOmagnesia
HypERcalcaemia
82
What can hypOkalaemia cause for patients taking digoxin?
Digoxin toxicity
83
What 4 drug classes can cause hypOkalaemia?
B2 agonist
Corticosteroids
Diuretics - loop + thiazide
Theophyline
84
What 4 drugs/classes can increase digoxin levels?
Amiodarone
Rate-limiting CCB
Macrolides
Itraconazole/ ketaconazole
85
What ----------- inhibitors cause increased digoxin levels/toxicity
p-glycoprotein
86
What to do when giving (amiodarone/quinine/dronedarone) with digoxin?
REDUCE dose to 1/2 of digoxin
87
What ------ can reduce digoxin levels and stop it from working?
P-glycoprotein inducers
88
What are 3 =-glycoprotein inducers which reduce digoxin levels?
Phenytoin
St john's wart
Rifampicin
89
What are 4 examples of P-glycoprotein Inhibitors?
Amiodarone
CCB
Macrolides
Itraconazole/ ketaconazole
90
What 2 drug classes reduce renal excretion of digoxin?
ACEi/ARB
NSAIDs
91
What 2 drug classes increase bradycardia when given with digoxin?
BB
CCB rate limiting
92
What drugs can cause hypercalcaemia causing digoxin toxicity?
Vit D supplement
93
What is half-life of amiodarone?
50 days
94
Does digoxin cause hyper or Hypo calcaemia?
Hypercalcaemia
95
What phrase is used to describe digoxin toxicity?
Slow and sick
96
What is the mnemonic for enzyme inhibitors? - increasing drug levels to toxicity
SICK FACES
97
What does enzyme inhbitor- SICK FACES stand for?
Sodium valproate
Izoniziad
Cimetidine
Ketaconazole
Fluconazole
Alcohol + grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
98
If left ventricular ejection fraction (LVEF) is ≥40% what CCB is given?
verapamil hydrochloride
99
If urgent rate control is needed, what 2 drugs needed>
BB IV
Verapamil
100
In patients with suspected concomitant acute decompensated heart failure, what should be AVOIDED?
CCB
101
Patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation, what is done?
Emergency electrical cardioversion, without delaying to achieve anticoagulation.
102
When is rate or rhythm control offered in acute presenting AF?
offered if the onset of arrhythmia is less than 48 hours
103
If AF has been present for more than 48 hours, what type of cardioversion better?
Electrical cardioversion - delay it until patient has been fully anti-coagulated for at least 3 weeks.
104
Why is rapid IV administration of digoxin avoided?
Risk of hypertension and reduced coronary flow.
105
What drug acts on supraventricular and ventricular arrhythmias?
amiodarone hydrochloride
106
What drug acts on supra-ventricular arrhythmia only?
Verapamil
107
What drug acts on ventricular arrhythmia only?
lidocaine
108
What is 'pill in pocket' approach for Arrhythmia?
patient taking an oral anti-arrhythmic drug to self-treat an episode of atrial fibrillation when it occurs
propefenone + flecanide
109
What is ORBIT score out of?
7
110
What does the ORBIT scoring mean- low, medium, high?
0-2 Low
3 Medium
4-7 High
111
For amiodarone what 2 types of patients need close monitoring?
Patients at high risk of bradycardia should be monitored continuously for 48 hours.
Concomitant use of amiodarone with sofosbuvir and daclatasvir, simeprevir and sofosbuvir, or sofosbuvir and ledipasvir.
112
What symptoms should patients look out for if using amiodarone with concurrent sofosbuvir-containing regimens?
bradycardia and heart block
e.g. SOB, light-headedness, palpitations, fainting, unusual tiredness, chest pain
113
What condition is contraindicated in digoxin?
Hypoxia
114
Amiodarone and digoxin?
Increase risk of bradycardia
115
What 6 drug CLASSES cause QT prolongation? (ABCDE)
A - antiArrhythmics (amiodarone, sotalol, Flecainide)
B - antiBiotics (quinolones, macrolides, aminoglycosides)
C - antipsyChotics (Haloperidol, quetiapine, risperidone)
D - antiDepressants (SSRIs, TCAs)
Diuretics
E - antiEmetics (ondansetron)
116
What is max HB for patients on digoxin to avoid bradycardia?
maintenance dose – HR should not decrease below 60 bpm.
117
What drugs interact with digoxin? CRASED
CRASED (Calcium channel blockers - verapamil, Rifampicin, Amiodarone, SJW, Erythromycin, Diuretics except potassium spearing)
118
What 5 situations to not give rate control first line?
New onset AF
Atrial flutter suitable for an ablation strategy
AF with reversible cause (MI, hyperthyroidism, PE, excess caffeine & alchol)
HF primarily caused by AH
If rhythm control is more suitable
119
What is interaction between BB + verapamil
increases the risk of cardiovascular adverse effects.
120
