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Cardiology 1 > Clin Med - AFib > Flashcards

Clin Med - AFib Flashcards

1
Q

Atrial fibrillation overview

A
  • Most common chronic arrhythmia
  • Irregularly irregular rhythm
  • Patient often feels palpitations with acute onset
  • Fatigue with acute and chronic A-Fib
  • Erratic atrial activity on EKG
  • Common cause of CVA due to thromboembolism
  • More common in elderly
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2
Q

Causes of A-Fib

A
  • Diabetes
  • AGE-Risk factor
  • Valvular heart disease-including rheumatic
  • Dilated cardiomyopathy
  • Atrial septal defect (ASD)
  • Hypertension
  • Coronary Heart disease
  • Thyrotoxicosis
  • Can be with no apparent cause or heart disease
  • Stimulants-meds, etc.
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3
Q

Normal heart and A-Fib causes

A
  • Pericarditis
  • Chest trauma
  • Obstructive sleep apnea
  • Thoracic or cardiac surgery
  • Pulmonary disease
  • Medication such as Theophylline or Beta Adrenergic agonists
  • Acute alcohol excess or alcohol withdrawal
  • Stimulants-medications, caffeine, street drugs
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4
Q

A-Fib S&S

A
  • Fatigue**Most c/o this even if no other sx
  • Palpitations**Can be very uncomfortable
  • Usually tachycardic but can range from slow to rapid
  • Pulse is irregular**Can usually hear it when auscultated and feel it when manually checking pulse
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5
Q

A-Fib findings on EKG

A
  • Irregularly irregular
  • Atrial activity may be fine or course***can be mistaken for atrial flutter if course
  • QRS complexes-irregular pattern but normal appearance
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6
Q

A-Fib in the hemodynamically unstable

A
  • shock
  • severe hypotension
  • pulmonary edema
  • ongoing Myocardial infarction
  • cardiac ischemia
  • usually due to rapid ventricular rate
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7
Q

A-Fib in the hemodynamically stable (primary A-Fib)

A
  • Paroxysmal
  • Persistant
  • Permanent
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8
Q

A-Fib in the hemodynamically stable (secondary A-Fib)

A
  • Acute MI
  • Cardiac or Thoracic Surgery
  • Hypertension
  • Pericarditis
  • Myocarditis
  • Hyperthyroidism
  • Acute pulmonary disease
  • Diabetes
  • Stimulants
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9
Q

What treatment is preferred in the hemodynamically unstable?

A

Electrocardioversion preferred in unstable patients

  • -Shock 100-200J synchronized with R-wave
  • -If not improved, 360J attempt
  • -If not restored load with Ibutilide (1mg over 10 minutes) then 360J shock, may repeat after 10 minutes
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10
Q

What tx is preferred in the hemodynamically stable?

A
  • H&P
  • EKG
  • Transthoracic echocardiogram
  • Blood tests
  • Any additional tests
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11
Q

A-Fib H&P

A
  • Symptoms**
  • Clinical type
  • -1st episode
  • Paroxysmal (what most people are, A-fib comes and goes
  • -Persistent (gone over a week without going back into normal rhythm)
  • -Permanent
  • Date of onset
  • Frequency, duration, precipitating factors
  • Response to any previous treatments
  • Presence of cardiac disease or other reversible conditions
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12
Q

A-Fib EKG

A
  • Verify the rhythm
  • Check for right ventricular hypertrophy**
  • Evaluation of the p-wave
  • Check for bundle branch block
  • Check for prior MI
  • To measure and follow R-R, QRS, QT intervals
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13
Q

TTE A-Fib

A 
TRANSTHORACIC ECHOCARDIOGRAM (TTE)
-Valvular heart disease
-LA and RA size
-LV size and function, check for hypertrophy
-Peak RV pressure** Pulmonary HTN
-Pericardial disease
Clots** low sensitivity compared to TEE
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14
Q

A-Fib Lab Tests

A
  • Thyroid
  • Renal function
  • Hepatic function
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15
Q

Other A-Fib tests

A
  • 6 minute walk (check rate control)
  • Exercise tolerance test **check rate control if in question
  • Trans esophageal echocardiogram (TEE) ** more sensitive for LV thrombus, can guide cardioversion
  • Electrophysiology
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16
Q

A-Fib Classification - 1st episode

A
  • The first time it’s been known to happen

- Can be paroxysmal (where it comes and goes) or persistent (started and didn’t stop)

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17
Q

A-Fib Classification - Paroxysmal

A
  • Where it comes and goes
  • AF that terminates spontaneously or with intervention within 7 days of onset
  • Episodes may be recurrent
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18
Q

A-Fib Classification - Persistent

A
  • Continuous AF that is sustained longer than 7 days

- Long standing persistent- continuous AF over 12 months duration

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19
Q

A-Fib Classification - Permanent

A
  • Chronic AF
  • Term used when a joint decision between the patient and the clinician is made to stop further attempts to restore or maintain sinus rhythm
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20
Q

A-Fib Classification - Non-Valvular

A

AF in absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair

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21
Q

3 objectives of A-Fib management

A
  1. PREVENTING THROMBOEMBOLISM
  2. RATE CONTROL
  3. CORRECTING RHYTHM DISTURBANCE
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22
Q

CHA₂DS₂-VASс SCORE-for NONVALVULAR AF

A
  • Congestive heart failure
  • Hypertension
  • Age (75 or greater, 2 points)
  • Diabetes
  • Stroke (prior episode or TIA, 2 points)
  • Vascular disease
  • Age (age 65-74)
  • Sex category (female)
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23
Q

What does CHA₂ represent?

A

C-ongestive heart failure
Signs/symptoms of heart failure confirmed with objective evidence of cardiac dysfunction

H-ypertension
Resting BP >140/90 mmHg on at least 2 occasions or current antihypertensive pharmacologic treatment

A-ge 75 or greater, notice the ₂, worth 2 points

24
Q

What does DS₂ represent?

A

D-iabetes
Fasting glucose >125mg/dl or treatment with oral hypoglycemic agent and/or insulin

S-troke, TIA or TE**Thromboembolism
Includes any history of cerebral ischemia
Notice the ₂-worth 2 points

25
Q

What does VASс represent?

A

V-ascular disease
Prior MI, peripheral artery disease, or aortic plaque

A-ge (65 to 74)

S-ex category (not a yes or no question) *Female gender confers higher risk

26
Q

Selection of antithrombotic therapy based on risk of thromboembolism

A
  1. CHA₂DS₂-VASс score to assess stroke risk
  2. Re-evaluate the need for oral anticoagulants at periodic intervals (the patient may not need them forever if you get them rate/rhythm controlled).
  3. With nonvalvular AF and CHADS-CAS score of 0-1, it is reasonable to omit anticoagulant therapy
27
Q

The CHA₂DS₂-VASс score - what to do???

A

SCORE 0

  • May consider no antithrombotic therapy
  • Healthy lifestyle may be all that’s needed

SCORE 1
-Consider oral anticoagulation for therapy *if point is for female gender alone-may consider no anticoagulant therapy and just healthy lifestyle

SCORE 2
-Consider oral anticoagulation for therapy (most are anticoagulated at scores of 2 and above)

SCORE 3 and up
-Oral anticoagulation therapy is recommended

28
Q

Preventing Thromboembolism

A

-Aspirin (antiplatelet) ** how to check w/lab-platelets: check their platelets and insure they’re not too low
-Warfarin
-Other anticoagulants
dabigatran, rivaroxaban, apixaban, edoxaban

29
Q

Aspirin use in A-Fib

A

-For nonvalvular AF and CHADS-VAS score of 0-1

ANTIPLATELET

  • -Increased bleeding risk
  • -No monitoring
30
Q

A-Fib anticoagulants

A

WARFARIN

  • -Increased bleeding risk
  • -Requires monitoring

Dabigatran

  • -Direct thrombin inhibitor
  • -No monitoring required (generally yearly renal function evaluation-more often if necessary)

Rivaroxaban, apixaban and edoxaban

  • -Factor Xa inhibitors
  • -No monitoring required
31
Q

What A-Fib is warfarin recommended for?

A

Valvular and Nonvalvular AF

32
Q

What are NOAC’s? Give examples.

A

Dabigatran, rivaroxaban, apixaban or edoxaban (NOAC’s: Non-vitamin K Oral AntiCoagulants)

33
Q

What A-Fib are NOAC’s for?

A

Only non-valvular

34
Q

When do you use dabigatran?

A

With prior stroke, TIA, or CHADS-VAS score ≥ 2

35
Q

Why is dabigatran preferred over warfarin?

A

they have lower mortality rates and lower risk of intracranial hemorrhage or hemorrhagic stroke than warfarin

36
Q

Atrial fibrillation goal HR

A

GOAL resting heart rate < 80bpm, lenient goal of rhr < 110 may be reasonable if patients remain asymptomatic and LV systolic function is preserved

37
Q

A-fib medications

A
  • Beta blockers-used to slow heart rate
  • Calcium channel blockers-have multiple effects on the heart, slow the rate and reduce the strength of the muscle cell’s contraction.
  • Digoxin-slows the rate at which electrical currents are conducted from the atria to the ventricle (has lots of side effects and medication interactions and can build up toxic levels in the body)
38
Q

ATRIAL FIBRILLATION-RATE CONTROL Outpatient

A
  1. Beta blockers or nondihydropyridine calcium channel antagonist for paroxysmal, persistent, or permanent AF
  2. Oral amiodarone may be useful for ventricular rate control when other measures are contraindicated or unsuccessful
  3. Digoxin - if others contraindicated or failed
  4. Assess rate control during exertion and adjust treatment as necessary
  5. AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological therapy is inadequate and rhythm control is not achievable
39
Q

ATRIAL FIBRILLATION-RATE CONTROL Acute Setting

A
  • IV beta blocker or nondihydropyridine calcium channel blocker to slow ventricular heart rate in patients without pre-excitation.
  • IV amiodarone can be used for rate control in critically ill patient without pre-excitation
40
Q

ATRIAL FIBRILLATION-RATE CONTROL - what not to use/do

A
  • Nondihydropyridine calcium channel blockers should not be used in decompensated HF
  • Pre-excitation and AF-do not use digoxin, nondihydropyridine calcium channel blockers or amiodarone** may increase ventricular response and results in ventricular fibrillation
  • Dronedarone should not be used to control ventricular rate with permanent AF
41
Q

A-Fib rhythm control measures (5)

A
  1. Electrical and/or Pharmacological Cardioversion
  2. MUST PREVENT CLOTS!!
  3. Catheter Ablation
  4. MAZE Procedure
  5. Pacemaker
42
Q

When is direct current cardioversion recommended?

A

Recommended for AF or Flutter:

  • to restore sinus rhythm.
  • with RVR that does not respond to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension or HF
  • and pre-excitation with hemodynamic instability
43
Q

PHARMACOLOGICAL CARDIOVERSION

A
  • Flecainaide, dofetilide, propafenone, and IV ibutilide for cardioverison of AF or Flutter, given no contraindications to the medications
  • Amiodarone is also a reasonable choice
  • Propafenone or flecainide to terminate AF in outpatient environment in a safe monitored setting
44
Q

Which pharm cardioversion drug should not be given outpatient?

A

Dofetilide should not be used outpatient**risk of excessive QT prolongation and can cause torsades

45
Q

MAINTENANCE OF SINUS RHYTHM-MEDS

A
  • AMIODARONE-use when other agents have failed or are contraindicated and take consideration of risk
  • DOFETILIDE
  • DRONENDARONE
  • FLECAINIDE
  • PROPAFENONE
  • SOTALOL (Beta-blocker: used for cardioversion and rate control, both. Make sure the patient’s rhythm isn’t too slow using this drug)
  • DISOPYRAMIDE
  • QUINIDINE
46
Q

ANTIARRYTHMIC THERAPY

A
  • Should NOT be continued when AF becomes permanent
  • Ace inhibitor or ARB may be considered for PRIMARY prevention if HTN is causative reason for AF not beneficial without h/o cardiovascular disease
  • Statin therapy may be reasonable for primary prevention of new-onset AF after coronary artery surgery
47
Q

CATHETER ABLATION

A
  • WITH OR WITHOUT STRUCTURAL HEART DAMAGE
  • Useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic med when rhythm-control strategy is desired
  • CONSIDER THE RISK AND BENEFIT FOR THE PATIENT
  • Reasonable initial rhythm-control strategy in patients with recurrent symptomatic paroxysmal AF-weigh risks against pharmacological therapy
  • Should NOT be performed in patients who cannot be anticoagulated during and after the procedure
48
Q

MAZE PROCEDURE

A
  • Small cuts are made to the heart tissue then stitches or burned to form scar tissue disrupting the pathway of the aberrant electrical activity
  • Use in highly symptomatic patients failing other means of control
49
Q

PACEMAKER

A

USED WHEN OTHER MEANS FAIL AND PATIENT IS SYMPTOMATIC

-WITH AF OR FLUTTER ≥ 48 hours or unknown duration and no anticoagulation for preceding 3 weeks, it is reasonable to perform TEE before cardioversion and then cardiovert if no LA thrombus is identified provided anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks

50
Q

ATRIAL FLUTTER

A
  • Usually REGULAR heart rhythm
  • Tachycardic **100-150bpm
  • Palpitations and/or fatigue common
  • Sawtooth pattern on ECG, leads II, III, AVF
  • Usually seen with structural heart disease or COPD/emphysema
  • Less common than A-Fib
  • Lower risk of thromboemboli due to continued contractile function of the atria
51
Q

ATRIAL FLUTTER TREATMENT GOALS

A

VENTRICULAR RATE CONTROL

  • -USE SAME AGENTS AS A-FIB
  • -MORE DIFFICULT TO CONTROL

If HEMODYNAMIC INSTABILITY-ADMIT AND FOLLOW A-FIB GUIDELINES

52
Q

Atrial Flutter Treatment

A

MEDS-SAME AS A-FIB, IBUTILIDE MOST SUCESSFUL

CARDIOVERSION-VERY EFFECTIVE, ALMOST 90% CONVERT AT LOW JOULE SYNCHRONIZED CARDIOVERSION (No anticoagulation needed if converted within 48 hours of onset)

CATHETER ABLATION IN CHRONIC A-FLUTTER

53
Q

CHRONIC ATRIAL FLUTTER

A

MUST ANTICOAGULATE WITH SAME AGENTS AS ATRIAL FIBRILLATION

RATE CONTROL (AMIODARONE AND DOFETILIDE AR THE DRUGS OF CHOICE PLUS OR MINUS AN AV NODAL BLOCKER)

CATHETER ABLATION-HIGHLY SUCCESSFUL

54
Q

ATRIAL FIBRILLATION Symptoms

A

SYMPTOMS-palpitations, dizziness, fatigue, weakness, sob, angina, syncope, asymptomatic

55
Q

A-Fib Work-Up

A

H&P, CXR, EKG, TSH, Cardiac enzymes, Echo, Hepatic & Renal Function

56
Q

A-Fib Treatment

A
  • Rate control
  • Rhythm control
  • Prevent Clots
57
Q

ATRIAL FIBRILLATION-THE RUNDOWN

A
  • DC Cardioversion for hemodynamically unstable
  • -Safe if AF <48hrs
  • -Coagulate if AF>48hours and r/o LV clot

-Follow guidelines for anticoagulation medications- CHA₂DS₂-VASс

Cardiology 1 (11 decks)

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