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BNF/Pre-Reg 2017-2018 > CV: Arrhythmias > Flashcards

CV: Arrhythmias Flashcards

1
Q

If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, what treatment should be used?

A

If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, beta-blockers are sometimes effective and may be safer than other suppressant drugs.

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2
Q

Atrial fibrillation can be managed by either controlling the ventricular rate (‘r______ control’) or by attempting to restore and maintain sinus rhythm (‘______ control’).

A

Atrial fibrillation can be managed by either controlling the ventricular rate (‘rate control’) or by attempting to restore and maintain sinus rhythm (‘rhythm control’).

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3
Q

All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo what without delaying to achieve anticoagulation?

A

All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo emergency electrical cardioversion without delaying to achieve anticoagulation.

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4
Q

In patients presenting acutely but without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than __ hours; _____ control is preferred if onset is more than __ hours or uncertain.

A

In patients presenting acutely but without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than 48 hours; rate control is preferred if onset is more than 48 hours or uncertain.

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5
Q

If pharmacological cardioversion has been agreed, intravenous _____________, or alternatively _______ acetate, can be used (_______ hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

A

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

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6
Q

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease).

If urgent rate control is required, a ________ or ___________can be given intravenously.

A

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

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7
Q

If atrial fibrillation has been present for more than 48 hours, _________ cardioversion is preferred and should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced.

A

If atrial fibrillation has been present for more than 48 hours, electrical cardioversion is preferred and should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced, an

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8
Q

What is the preferred first-line drug treatment strategy for atrial fibrillation except in patients with new-onset AF, heart failure secondary to AF AF suitable for ablation therapy or with a rerversible cause?

A

Rate control is the preferred first-line drug treatment strategy for atrial fibrillation except in patients with new-onset atrial fibrillation, heart failure secondary to atrial fibrillation, atrial flutter suitable for an ablation strategy, atrial fibrillation with a reversible cause, or if rhythm control is more suitable based on clinical judgement.

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9
Q

Ventricular rate can be controlled with what? (2)

A
  1. Standard beta-blocker (NOT sotalol)

2. A rate-limiting CCB such as diltiazem or verapamil monotherapy.

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10
Q

Digoxin should be used only in what AF patients?

A

Digoxin is only effective at controlling the ventricular rate at rest, and should only be used as monotherapy predominantly in patients who are sedentary with non-paroxysmal atrial fibrillation.

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11
Q

If rate control monotherapy of AF fails what can be done?

A

When a single drug fails to adequately control the ventricular rate, a combination of two drugs including a beta-blocker, digoxin, or diltiazem hydrochloride can be used.

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12
Q

If rate control dual therapy of AF fails what can be done?

A

If symptoms are not controlled with a combination of two drugs, a rhythm-control strategy should be considered. If ventricular function is diminished, the combination of a beta-blocker (that is licensed for use in heart failure) and digoxin is preferred. Digoxin is also used when atrial fibrillation is accompanied by congestive heart failure.

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13
Q

In AF, if ventricular function is diminished, the combination of a beta-blocker licensed for use in heart failure and what is preffered?

A

If symptoms are not controlled with a combination of two drugs, a rhythm-control strategy should be considered. If ventricular function is diminished, the combination of a beta-blocker (that is licensed for use in heart failure) and digoxin is preferred. Digoxin is also used when atrial fibrillation is accompanied by congestive heart failure.

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14
Q

If drug treatment is required to maintain sinus rhythm (rhythm control) post-cardioversion, what should be used?

A

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

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15
Q

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective what should be considered?

A

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

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16
Q

Dronedarone may be considered in what AF?

A

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

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17
Q

If necessary, amiodarone can be started how long before and continued for how long after electrical cardioversion to increase the success of the procedure, and to maintain sinus rhythm?

A

4 weeks before and for 12 months after

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18
Q

Flecaine acetate or propagenone hydrochloride should not be given in what circumstances?

A

If there is known ischaemic or structural heart disease.

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19
Q

In symptomatic paroxysmal atrial fibrillation, ventricular rhythm is controlled with a standard beta-blocker. Alternatively, if symptoms persist or a standard beta-blocker is not appropriate, what can be given? (5)

A

Alternatively, if symptoms persist or a standard beta-blocker is not appropriate, an oral anti-arrhythmic drug such as dronedarone (see NICE guidance), sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride can be given.

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20
Q

In selected paroxysmal atrial fibrillation patients with infrequent episodes, what approach can be taken?

A

Sinus rhythm can be restored using the ‘pill-in-the-pocket’ approach; this involves the patient taking oral flecainde or propafenone hydrochloride to self-treat an episode of AF when it occurs.

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21
Q

Oral anticoagulation should be offered to patients with confirmed diagnosis of atrial fibrillation with what risk factors?

A
  1. Sinus rhythm not successfully restored within 48 hours of onset.
  2. high risk of recurrence of AF such as those with structural heart disease, prolonged history of AF (>12 mths), a history of failed attempts at cardioversion.
  3. Patients whom the risk of stroke outweighs the risk of bleeding.
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22
Q

Why should aspitin not be offered as monotherapy soley for stroke prevention in AF?

A

Aspirin is less effective than warfarin sodium at preventing emboli; the modest benefit is offset by the risk of bleeding, and aspirin should not be offered as monotherapy solely for stroke prevention in atrial fibrillation.

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23
Q

In what types of AF can oral anticoagulation be acheived with apixaban, dabigatran, edoxaban or rivaroxaban?

A

Non-valvular AF

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24
Q

Like atrial fibrillation, treatment options for atrial flutter involve either controlling the ventricular rate or attempting to restore and maintain sinus rhythm. However, atrial flutter generally responds less well what?

A

Like atrial fibrillation, treatment options for atrial flutter involve either controlling the ventricular rate or attempting to restore and maintain sinus rhythm. However, atrial flutter generally responds less well to drug treatment than atrial fibrillation.

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25
Q

If the duration of atrial flutter is unknown, or it has lasted for over 48 hours, cardioversion should not be attempted until the patient has been fully anticoagulated for at least __ weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.

A

If the duration of atrial flutter is unknown, or it has lasted for over 48 hours, cardioversion should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.

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26
Q

What are the non-drug treatment options for paroxysmal supraventricular tachycardia? (3)

A
  1. Reflex vagal stimulation such as the Valsalva manoeuvre.
  2. immersing the face in ice-cold water
  3. Carotid sinus massage
27
Q

In PSVT, if the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, what should be given?

A

IV adenosine.

28
Q

If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, intravenous adenosine should be given. If adenosine is ineffective or contra-indicated, what is an alternative?

A

If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, intravenous adenosine should be given. If adenosine is ineffective or contra-indicated, intravenous verapamil hydrochloride is an alternative, but it should be avoided in patients recently treated with beta-blockers.

29
Q

In the management of arrhythmias after myocardial infarction, Bradycardia, particularly if complicated by hypotension should be treated how?

A

Bradycardia, particularly if complicated by hypotension, should be treated with an intravenous dose of atropine sulfate the dose may be repeated if necessary.

30
Q

What is torsade de pointes?

A

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome (usually drug-induced, but other factors including hypokalaemia, severe bradycardia, and genetic predisposition are also implicated). Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness. If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death. Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered. Anti-arrhythmics can further prolong the QT interval, thus worsening the condition.

31
Q

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome which is usually drug induced, what other factors can cause it/are implicated? (3)

A
  1. hypokalaemia
  2. Severe bradycardia
  3. Genetic predisposition
32
Q

Intravenous infusion of what is usually effective in the treatment of Torsade de pointes?

A

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome (usually drug-induced, but other factors including hypokalaemia, severe bradycardia, and genetic predisposition are also implicated). Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness. If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death. Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered. Anti-arrhythmics can further prolong the QT interval, thus worsening the condition.

33
Q

Anti-arrhytmic drugs can be classified how? (3)

A

Into:

1) Those that act on supraventicular arrhythmias such as verapamil.
2) those that act on both supraventricular and ventricular arrhythmias such as amiodarone.
3) Those that act on ventricular arrhythmias only: Lidocaine

34
Q

Most drugs that are effective in countering arrhythmias can also provoke them, moreover what electrolyte imbalance can enhance the arrhythmogenic (pro-arrhythmic) effect of many drugs?

A

HYPOKALAEMIA

35
Q

What is usually the drug of choice in terminating paroxysmal supraventricular tachycardia?

A

Adenosine: feeling of dread.

36
Q

Adenosine has a very short duration of action (half-life 8-10s) so its side effects are short lived. What drug prolongs the half-life of adenosine?

A

The antiplatelet dipyridamole

37
Q

In terminating paroxysmal supraventricular tachycardia, why may verapamil be preferable to adenosine?

A

In Asthma.

38
Q

Unlike verapamil, adenosine can be used after what?

A

a beta blocker.

39
Q

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in arrhytmias associated with what?

A

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in supraventricular arrhythmias associated with accessory conducting pathways (e.g. Wolff- Parkinson-White syndrome).

40
Q

Cardiac glycosides are contra-indicated in SV arrhythmias associated with what syndrome?

A

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in supraventricular arrhythmias associated with accessory conducting pathways (e.g. Wolff- Parkinson-White syndrome).

41
Q

Verapamil hydrochloride is usually effective for supraventricular tachycardias. An initial intravenous dose (important: serious beta-blocker interaction hazard) may be followed by oral treatment; what may occur with large doses?

A

Verapamil hydrochloride is usually effective for supraventricular tachycardias. An initial intravenous dose (important: serious beta-blocker interaction hazard) may be followed by oral treatment; hypotension may occur with large doses.

42
Q

Intravenous administration of a what can achieve rapid control of the ventricular rate in supraventricular arrhythmias?

A

A beta-blocker: propranolol or esmolol.

43
Q

What are the drugs used for both supraventricular and ventricular arrhythmias?

A

Amiodarone, propranolol, disopyramide, flecainamide and propafenone.

44
Q

Amiodarone hydrochloride may be given by IV infusion as well as by mouth, and has the advantage of causing little or no what?

A

myocardial depression

45
Q

How long is the half-life of amiodarone?

A

Extends to several weeks. Only needs to be given once daily.

Many weeks or months may be required to achieve steady-state plasma-amiodarone concentration.

46
Q

Beta-blockers act as anti-arrhythmic drugs principally by attentuating what?

A

The effects of the sympathetic system on automaticity and conductivity within the heart.

Sotalol has a role in the management of ventricular arrhythmias.

47
Q

What can and what can’t the beta-blocker sotalol be used for?

A

Can:
Management of ventricular arrhythmias.

Can’t:
Control ventricular rate.
Be used in the management of torsade de pointes.

48
Q

Disopyramide can be given by intravenous injection to control arrhythmias after myocardial infarction (including those not responding to lidocaine hydrochloride) but it impairs what?

A

Cardiac contracility.

It also has an antimuscarinic effect which limits its use in patients suceptible to angle-closure glaucoma or with prostatic hyperplasia.

49
Q

What are the risks of flecainide use?

A

It can precipitate serious arrhythmias in a small minority of patients (including those with otherwise normal hearts).

50
Q

Why is propafenone hydrochloride cautioned for use in patients with obstructive airway disease?

A

Propafenone hydrochloride is used for the prophylaxis and treatment of ventricular arrhythmias and also for some supraventricular arrhythmias. It has complex mechanisms of action, including weak beta-blocking activity (therefore caution is needed in obstructive airways disease—contra- indicated if severe).

51
Q

Drugs for ventricular arrhythmias include what? (3)

A
  1. Adenosine
  2. Cardiac glycosides
  3. Verapamil
52
Q

Broadly speaking, arrhythmias are split according to two things, what are they?

A

The site and the heart rate.

53
Q

Broadly speaking, arrhythmias are split according to two things: site and heart rate.

What may the site of abnormality be?

A

Supraventricular
OR
Ventricular

54
Q

Broadly speaking, arrhythmias are split according to two things: site and heart rate.

What may the heart rate be?

A

Tachyarrhythmias

bradyarrhythmias

55
Q

The two big supraventricular tachyarrhythmias are what?

A

Atrial flutter
Atrial fibrillation

Also includes Wolff-Parkinson-White syndrome and also Re-entry supraventricular tachycardia where a second electrical connection between atria and ventricles exist.

56
Q

Ventricular tachyarrhythmias are essentially split into narrow complex tachycardia, or broad complex tachycardia which consists of: (3)

A

Ventricular fibrillation
Ventricular tachycardia
Torsades de Pointes

57
Q

Bradyarrhythmias are essentially due to a blockage of the hearts conduction system. What are the different types?

A

Heart block - problems of the atrioventricular node.

Bundle branch block - problem of the purkinje fibres

58
Q

Non-dihydropyridine Calcium Channel Blockers should not be used for Afib in patients with heart failure. Why?

A

Dilt and Verap

They cause decreased force of heart contraction - they have negative inotropic effects, which can further reduce someones ejection fraction.

59
Q

Both diltiazem and verapamil are moderate inhibitors of what CYP enzyme?

A

CYP 3A4

60
Q

What side effect can verapamil cause that also phenytoin can?

A

Gingival hyperplasia.

61
Q

In the acute setting, if BB and CCB are out for patients with heart failure + Afib what does that leave?

A

Digoxin or amiodarone.

62
Q

Digoxin is what type of inotrope? How does this compare with diltiazem/verapamil?

A

Digoxin is a positive inotrope so will not depress the ejection fraction whereas both verpamil and diltiazem are negative inotropes = caution in HF.

63
Q

A 76-year old man is found to have AF: he is asymptomatic. He has PMH of hypertension, hypercholesterolmia and HF (NYHA II). He takes: furosemide, ramipril and simvastatin. Allergies: NKDA. Heart rate: 120 bpm with irregular rhythm.

What is the most appropriate drug for ventricular rate control?
Amiodarone
Bisoprolol
Digoxin
Doxazosin
Verapamil.
A

Bisoprolol.
There are two basic approaches to managing chronic atrial fibrililation. Rhythm control: restore normal sinus rhythm via electrical cardioversion or pharmacological cardioversion or both. Rate control: abnormal heart rhythm is accepted as permanent and efforts are focused simply on preventing ventricular rate from running too fast.

In most cases, both are equally effective and rate control considerably simpler.

The ideal agent for ventricular rate contol in AF is either a BB (bisopolol) or a non-dihydropyridine CCB (verapamil or dilitiazem). In practice, a BB is used in most patients.

Bisoprolol would be an appropriate choice for this patients due to his history of heart failure: beta blockers are indicated in heart failure to improve prognosis, whereas verapamil and diltiazem should be avoided.

Digoxin can be used for rate control in AF, but, on its own is only successful at controlling the rate at rest and should be used in sedentary patients only.

Amiodarone is effective for both rate and rhythm but is too toxic for first-line use.

Doxasoxin is an alpha blocker used in hypertension and BPH: no role in AF.

64
Q

A man with SVT is treated with metoprolol in an attempt to terminate the arrhythmia.
What is the receptor target of metoprolol?

Alpha1-adrenoceptor
Alpha2-adrenoceptor
Beta1-adrenoceptor
Beta2-adrenoceptor
Beta3-adrenoceptor
A

Metoprolol is a BB that is relatively selective for the B1-adrenoceptor, blockade of this receptor reduces the force of myocardial contraction and decreases the speed of electrical conduction in the heart.

By prolonging the refractory period of the atrioventricular node and slowing conduction in the atria, it can terminate some SVTs and reduce the ventricular rate in AF.

B2-adrenoceptors are found in smooth muscle, such as the bronchial tree; B3 are found in adipose tissue.

BNF/Pre-Reg 2017-2018 (144 decks)

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