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Pharmacy Pre-Reg 2020/2021 > Chaper 2: Cardiovascular - Arrythmia > Flashcards

Chaper 2: Cardiovascular - Arrythmia Flashcards

1
Q

What is an arrhythmia?

A

A problem with the rate or the rhythm of the heartbeat

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2
Q

What are the general symptoms of an arrhythmia?

A 
Palpitations
SOB
Dizziness
Fainting
Chest pain
Fatigue
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3
Q

What are the three types of supraventricular arrhythmias?

A

Atrial fibrillation
Atrial flutter
Paroxysmal supraventricular arrhythmia

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4
Q

What are the two types of ventricular arrhythmia

A 
Ventricular tachycardia (e.g. torsades de pointes)
Ventricular fibrillation
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5
Q

What are ectopic beats and how are they managed?

A

They are extra heartbeats that occur just before a regular heartbeat

They usually don’t require treatment

But if they are troublesome beta-blockers may help

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6
Q

What is atrial fibrillation?

A

An abnormally fast rhythm arising from or above the AV node

It is triggered by rapidly firing electrical impulses

When the AV node receives more impulses that it can conduct, an irregular ventricular rhythm results

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7
Q

What are the causes of atrial fibrillation?

A

Cardiovascular: CHF

Non-cardiovascular: infection, cancer, PE

Lifestyle: alcohol abuse, obesity

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8
Q

What is the main complication of atrial fibrillation and how is this managed?

A

Stroke
Managed using anticoagulants
E.g. warfarin, apixaban, rivaroxaban, dabigatran, edoxaban

But before initiating consider a patients risk of stroke vs risk of bleeding
Assessment tools can help with this

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9
Q

What are the three broad categories for managing atrial fibrillation?

A

Cardioversion

Rate control

Rhythm control

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10
Q

What is the first-line treatment for reversible atrial fibrillation?

A

Cardioversion

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11
Q

What drugs are used for pharmaceutical cardioversion?

A

Oral or IV amiodarone (preferred if there is structural heart disease)

Oral or IV flecainide

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12
Q

When is electrical cardioversion preferred?

A

When atrial fibrillation has been present for more than 48 hours

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13
Q

Anticoagulation and electrical cardioversion?

A

Patients should be anticoagulated for at least 3 weeks before electrical cardioversion

If this is not possible, use parenteral anticoagulation before cardioversion, then oral anticoagulation for at least 4 weeks afterwards

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14
Q

What are the two types of electrical cardioversion?

A

Direct current

Cardiac pacing

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15
Q

What drugs can be used for rate control?

A

Beta-blocker (not sotolol)

Rate-limiting CCB e.g. diltiazem, verapamil

Digoxin

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16
Q

When can digoxin be used in atrial fibrillation?

A

When the patient is predominantly sedentary (it is only effective when at controlling the ventricular rate when the heart is at rest)

For non-paroxysmal atrial fibrillation

For atrial fibrillation and heart failure

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17
Q

In atrial fibrillation, when mono therapy with one of the rate control drugs fails to control the ventricular rate, what do you do?

A

Consider cardioversion

Or use a combination of 2 drugs (beta-blocker, diltiazem or digoxin)

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18
Q

In atrial fibrillation, how to you select which beta-blocker to use

A

First choice is atenolol (cheapest)

Acebutolol, metoprolol, nadolol, oxprendolol and propranolol are also indicated in AF

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19
Q

In atrial fibrillation, when is rhythm control used

A

Post-cardioversion

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20
Q

In atrial fibrillation, what drugs can be used for rhythm control?

A

First line - standard beta-blocker

Other options include anti-arrhythmics e.g. amiodarone, flecainide, sotolol, propane ones

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21
Q

What do you do in the acute presentation of atrial fibrillation?

A

Life-threatening haemodynamic instability:
Electrical cardioversion

Non-life-threatening haemodynamic instability:

Consider cardioversion (remember to anticoagulate the patient for 3 weeks, prior to cardioversion offer rate control)

Less than 48 hours - rate or rhythm control

Over 48 hours - rhythm control

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22
Q

What is paroxysmal atrial fibrillation and how is it managed?

A

Intermittent AF - it begins suddenly and stops on its own within 7 days

Manage with a standard beta-blocker

Or consider an oral anti-arrhythmic e.g. amiodarone, flecainide, sotolol, dronedarone, propafenone

In some patients, the ‘pill in pocket’ approach may be considered

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23
Q

What is the pill in pocket approach and when can it be used in atrial fibrillation?

A

It is when patients can self-treat when an episode occurs

It can be used in paroxysmal atrial fibrillation, where there are infrequent episodes

Drug options include oral flecainide or propafenone

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24
Q

What are the risk factors for stroke in atrial fibrillation?

A

Prior ischaemic stroke, TIA or thromboembolic events

Other heart conditions e.g. HF, LVSD

Other CV conditions e.g. diabetes, hypertension

Patient factors e.g. over the age of 65, female

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25
What are the signs of haemodynamic instability?
``` Rapid pulse (>150 beats per minimum) Low blood pressure (systolic BP <90mmHg Ongoing chest pain Increasing breathlessness Severe dizziness ```
26
Describe the two screening tools to determine whether anticoagulation should be initiated in atrial fibrillation
``` CHADSVAS - stroke risk C - CHF/LVSD (1) H - Hypertension (1) A - Age >75 (2) D - Diabetes (1) S - Stroke/TIA/systemic arterial embolism (2) V - Vascular disease (precious MI, aortic plague (1) A - Age 65-74 (1) S - Sex, male 0, female 1 ``` ``` HASBLED H -Hypertension (1) A - Abnormal liver function (1) A - Abnormal renal function (1) S - Stroke (1) (Major) Bleeding history (1) L - Labile INR E - Elderly (>65) Drugs and alcohol (Drugs includes anticoagulants and NSAIDS (1), alcohol abuse (1)) ```
27
What oral anticoagulants can be used for stroke prevention in atrial fibrillation?
Vitamin K antagonists: Warfarin Apixaban, rivaroxaban, edoxaban, dabigatran
28
What is atrial flutter and how does this differ from atrial fibrillation?
Atrial flutter is when the atria beat faster than the ventricles, causing for the heart rhythm to be out of sync In atrial fibrillation, the atria beat irregularly. In atrial flutter that beat regularly but faster than usual and more often than the ventricles
29
How is atrial flutter managed?
First, rate control Beta-blockers, rate-limiting CCB, digoxin Note, IV is preferred if a rapid rate control is required Then conversion of sinus rhythm by: Electrical cardioversion (preferred if the atrial flutter has been present for more than 48 hours) Pharmacological cardioversion Catheter ablation Remember, fully anticoagulate for 3 weeks prior to cardioversion
30
How do you manage paroxysmal supraventricular tachycardia?
First, reflex vagal stimulation If this is not adequate or if symptoms are severe, use IV adenosine IV verapamil is an alternative to IV adenosine, but avoid in patients recently treated with beta-blockers In patients who are haemodynamically unstable or do not respond to either of the above do electrical cardioversion Prophylaxis can include verapamil, diltiazem, beta-blockers, flecainide, propafenone
31
What can be used to treat an arrhythmia after an MI?
Lidocaine Disopyramide
32
How do you manage ventricular tachycardias?
Pulseless patients: Defibrillation ``` Sustained ventricular tachycardia and haemodynamically unstable: Electrical cardioversion (direct current) ``` Sustained ventricular tachycardia and haemodynamically stable: IV anti-arrhythmics e.g. amiodarone Non-sustained ventricular tachycardia and haemodynamically stable: Beta-blocker Most patients will require maintenance therapy, e.g. beta-blocker, or beta-blocker and amiodarone
33
What is torsades de pointes?
A form of ventricular tachycardia that is associated with a long QT interval syndrome
34
How is torsades de pointes managed?
IV magnesium sulfate Beta-blocker Avoid anti-arrhythmics as these also prolong the QT interval and so can worsen the condition
35
Which drugs can be used to manage which types of arrhythmia s?
Supraventricular arrhythmia: Digoxin, adenosine, verapamil Ventricular arrhythmia: Lidocaine Both: Everything else
36
What are the class I anti-arrhythmics?
Lidocaine (IA) Disopyramide (IB) Flecainide (IC) Propafenone (IC)
37
What are the class II anti-arrhythmics?
Beta-blockers
38
What are the class III anti-arrhythmics?
Amiodarone Dronedarone
39
What are the class IV anti-arrhythmics?
CCBs e.g. verapamil
40
What is a side-effect of most anti-arrhythmic drugs?
Arrhythmia Hypokalaemia can enhance this effect
41
What is lidocaine indicated for and how is it administered?
Arrhythmia in MI IV
42
What should you do if both flecainide and amiodarone are given?
Reduce the flecainide dose by half
43
Which is preferred in pregnancy/breastfeeding out of amiodarone and flecainide for arrhythmia?
Flecainide
44
Should propafenone be taken with or without food?
With food
45
What is the dose of amiodarone in arrhythmias?
Oral 200mg TDS for 1 week, then 200mg BD for 1 week, then a maintenance dose of 200mg OD IV 5mg/kg, to be given over 20-120 minutes Maximum 1.2g
46
What is the dose of amiodarone for ventricular fibrillation, or pulseless ventricular tachycardia refractory to defibrillation?
Only considered after the administration of adrenaline IV injection 300mg in a pre-filled syringe or 20ml glucose Then 150mg if required IV infusion 900mg over 24hours
47
What are the contraindications of amiodarone?
Thyroid dysfunction Iodine sensitivity Sinus node disease Sino-atrial block Sinus bradycardia Severe conduction disturbances With IV use Severe arterial hypotension, severe respiratory failure Bolus - CHF, cardiomyopathy
48
What should you consider if you see an amiodarone prescription in the elderly?
STOPP criteria
49
What should you consider with regards to amiodarone and it’s interactions?
It’s long half life There is a potential for drug interactions for weeks/months after amiodarone has been stopped
50
What are 10 side effects of amiodarone
``` Hyperthyroidism Hypothyroidism Nausea Vomiting Hepatic disorders Corneal deposits Bronchospasm Respiratory disorders Arrythmia Skin reactions Delirium Pancreatitis Photosensitivity reactions Headache Erectile dysfunction Constipation Sleep disorders Altered smell or taste Thrombocytopenia, neutropenia, agranulocytosis ```
51
Can amiodarone be given in pregnancy or breastfeeding?
Avoid in pregnancy unless essential Avoid in breastfeeding
52
What are the monitoring requirements of amiodarone?
Before treatment: Chest X-ray Serum potassium concentration 6 monthly During treatment T4 and TSH LFT
53
Patient counselling with amiodarone?
Phototoxocity - during and after treatment May affect driving and skilled tasks
54
What is the risk of the concurrent use of amiodarone and sofobusir, and what symptoms should patients look out for?
Heart block and severe bradycardia ``` Symptoms include: SOB light-headedness Palpitations Fainting Fatigue Chest pain ```
55
Can amiodarone be given to patients with Wolff-Parkinson-White syndrome?
Yes
56
What is the indication for adenosine?
Paroxysmal supraventricular arrhythmia For rapid conversion to sinus rhythm (including those associated with accessory conducting pathways e.g. Wolff-Parkinson-White syndrome)
57
What is the indication of sotalol?
Maintenance of sinus rhythm following cardioversion of atrial fibrillation or atrial flutter Treatment of non-sustained ventricular Arrythmia Prophylaxis of paroxysmal atrial fibrillation Life-threatening arrhythmias ``` It is no longer indicated in Angina Hypertension Thyrotoxicosis Secondary prevention after an MI ```
58
What is the dose of sotalol?
Initially 80mg daily in 1-2 divided doses Increased gradually to 160-320mg daily in 2 divided doses
59
What effect does sotalol have on the QT interval?
QT interval prolongation
60
What are the symptoms of digoxin toxicity?
Nausea, vomiting Neurological symptoms e.g. confusion Increased heartbeat Reduced appetite
61
How do you manage digoxin toxicity?
Withdraw digoxin and correct electrolyte abnormalities Administer digoxin-specific antibody fragments
62
What should the ventricular rate at rest be above whilst on digoxin?
60 beats per minute
63
Is digoxin used for rapid control of heart rate?
No, it has a long half life. | Do electrical cardioversion
64
Can digoxin be administered orally, by IV, by IM and by SC?
Oral and IV - yes | IM and SC - no
65
Do patients with heart failure and are in sinus rhythm require a loading dose?
No - their levels will be satisfactory in about a week
66
How often is digoxin given?
Usually OD | Can sometimes be BD e.g. due to nausea
67
What concentration of digoxin is more likely to be toxic?
1.5-3mcg/L
68
What is the risk of hypokalaemia for patients on digoxin and how is this managed?
It predisposes the patient do digoxin toxicity Manage with a potassium sparing diuretic or potassium supplements
69
How do you give digoxin to a patient with thyroid disease?
Reduce the dose in hypothyroidism May need to increase the dose in hyperthyroidism Thyrotoxicosis Reduce the dose until it is in control
70
What are the indications and doses for digoxin
Maintenance of atrial fibrillation or atrial flutter 125-250mcg OD ``` Heart failure (for patients in sinus rhythm) 62.5-125mcg OD ``` Rapid digitalisation of atrial fibrillation or atrial flutter 0.75-1.5mg in divided doses Given over 24 hours Emergency loading dose for atrial fibrillation or atrial flutter 0.75-1.5mg in divided doses Given over at least 2 hours
71
When should the dose of digoxin be reduced?
Elderly Renal impairment Concurrent use of amiodarone, dronedarone, quinine (reduce by half) If another cardiac glycosides has been given in the preceding 2 weeks
72
When switching from IV digoxin to oral digoxin, how much should the dose be increased by in order to maintain the same digoxin-plasma concentration?
20-33%
73
What are the contraindications and cautions of digoxin?
Contraindications Ventricular tachycardia or fibrillation, heart block, myocarditis ``` Cautions Hypercalcaemia Hypokalaemia, hypomagnaesia Hypoxia Recent MI Elderly (STOPP criteria?) ```
74
What are 8 side-effects of digoxin?
``` Arrythmias Dizziness Diarrhoea Vomiting Skin reactions Vision changes (yellow vision) Thrombocytopenia Depression Nausea Increased appetite Confusion Malaise GI disorders Headache ```
75
What are the monitoring requirements for digoxin?
Monitor digoxin-plasma concentration and serum electrolytes in renal impairment Monitor digoxin-plasma if digoxin toxicity is suspected When doing a plasma-digoxin concentration assay, take blood 6 hours after a dose Heart rate (should be maintained over 60 beats per minute)
76
Which class of medication for atrial fibrillation does verapamil interact with, and what is the consequence?
Beta-blockers Increased risk of severe hypotension and bradycardia AVOID
77
What is a shared contraindication for digoxin and verapamil?
Arrythmia associated witch conduction pathways s.g. WPW syndrome
78
Which LFT in particular do we monitor to assess for amiodarone liver toxicity?
Transaminases
79
Which drugs are interact with amiodarone by increasing the risk of Tordades de pointes?
``` Sotalol Co-trimoxazole Erythromycin Chlorpromazine Haloperidol Amisulpride Amitripyline Anti-malarials ```
80
What is the rescue drug for severe bradycardia following IV amiodarone being administered too quickly?
Atropine
81
In which groups of patients should flecainide and propafenone not be used in?
Asthma COPD Structural/ischaemic heart disease
82
What can cause QT interval prolongation and therefore Torsades de Pointes?
Drugs Hypokalaemia Bradycardia
83
Does amiodarone cause hypo or hyperkalaemia? What is the problem with this?
Hypokalaemia This increases the pro-arrythmic effect of amiodarone
84
For paroxysmal supraventricular tachycardia, when might IV verapamil be preferred over IV adenosine?
Asthma or COPD
85
Why does hypokalaemia need to be corrected before starting soltolol?
Both hypokalaemia and sotolol can prolong the QT interval and increase the risk of arrhythmias
86
How can digoxin toxicity affect vision?
It can cause yellow vision
87
What is valvular AF?
AF + artificial heart valve Valvular AF - warfarin Non-valvular AF - warfarin or DOACs

Pharmacy Pre-Reg 2020/2021 (18 decks)

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