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CV arrythmias Flashcards

1
Q

ectopic beats compared to AF are often spontanoeous and resolve on their own

if tx is needed what drug class used?

A

beta blocker

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2
Q

AF tx aims to do what 2?

A

reduce symptoms and prevent complications, especially stroke

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3
Q

what is a stroke

A

blood doesn’t fully eject –> clot

blood pools in valve/ chambers -> clot and stroke risk

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4
Q

af managed through what 2?

A

ventricular rate control or sinus rhythm control

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5
Q

2 types of pts who may have AF acute

A

pt with or without life-threatening haemodynamic instability

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6
Q

treatment for pt with life-threatening haemodynamic instability caused by AF?

A

Emergency electrical cardioversion without delay to achieve anticoagulation!

prevents clotting

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7
Q

treatment for patients without life-threatening haemodynamic instability
Onset of AF <48 hours?
Onset of AF >48 hours?

A

Onset of AF <48 hours? Rate or Rhythm control

Onset of AF >48 hours? Rate control

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8
Q

what is meant by
rate control
rhythm control

A

rate: via medication
rhythm: cardioversion

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9
Q

2 Types of (Cardioversion) Rhythm Control to restore sinus rhythm?

A

Pharmacological
Electrical

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10
Q

pharmacological rhythm control examples 2

A

flecainide or amiodarone

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11
Q

electrical rhythm control examples?

A

start IV anticoagulation (heparin) and rule out a left atrial thrombus

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12
Q

3 Types of (ventricular) Rate Control Monotherapy?
this is preferred first line for AF except in pts with new onset

A

beta-blocker (not sotalol)
Rate-limiting CCB- verapamil/diltiazem
Digoxin (mainly sedentary patients with non-paroxysmal AF)

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13
Q

Choice of drug should be based on what?

A

individual symptoms
HR
comorbidities
patient preference

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14
Q

if monotherapy to control ventricular rate fails, what to do?

A

dual therapy:
combine any 2: beta blocker/digoxin/diltiazem

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15
Q

if symptoms not controlled w dual therapy, consider rhythm control and if LVEF < 40%, combine what 2 drugs?

A

bb and digoxin

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16
Q

AF maintenance,

if AF present > 48hrs, pt must be fully anticoaged for min 3 weeks and continue oral anticoag at least X after cardioversion

A

4 weeks

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17
Q

drugs tx usign what may be required post cardioversion?

A

standard bb
if symptoms persist or bb not appropriate: SPAF: sotalol, propadenone, amiodarone, or flecainide

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18
Q

whats paroxysmal AF?

A

paroxysmal: sudden attack/ increase insymptoms of diease
AF: irregular heart rhythm sudden and goes on its own

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19
Q

pill in pocket approach used to restore sinus rhythm what is this

A

take a tablet: flecainide or propadenone on onset of AF episode

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20
Q

ALL pts with AF should be assessed for stroke risk and thromboprophylaxis need balanced with risk of bleeding

using what tools?

A

stroke: CHA2DS2-VASc
bleeding risk: ORBIT

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21
Q

what does CHA2DS2-VASc consider?

A

Congestive HF
Hypertension
Age 75+ (2)
Diabetic
Stroke/TIA (2)
Vascular disease- DVT, aneurysm, etc
Age 65-74
Sex- female

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22
Q

When is thromboprophylaxis NOT needed? chadsvasc

A

Men= 0
Women= 1

needed if men: 1 and women: 2

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23
Q

thromboprophylaxis done with what 2 drugs?

A

Warfarin (vit K antagonist)
OR DOACs in non-valvular AF

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24
Q

name of condition described:
abnormal heart rhythm occurring in upper chambers of heart (atria). rapid, regular heartbeat

A

atrial flutter

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25
Atrial flutter tx options same as af but responds better to which: electrical cardioversion or drug tx?
electrical
26
rate control of atrial flutter is normally temporary until sinus rhythm restored name 2 possible classes of rate control drugs used
bb or RL CCBs
27
t/f paroxysmal supraventricular tachycardia usually goes away on tis own without tx
true
28
if paroxysmal supraventricular tachycardia requires tx, reflex vagal stimulation may be needed which involves what procedures?
stimulate vagus nerve: - Valsalva manoeuvre, immerse face in ice-cold water, or carotid sinus massage
29
vagus nerve stim procedures should be performed with what monitoring?
ECG monitoring
30
if reflex vagal stim doesnt work, how is paroxysmal supraventricular tachycardia treated
a. iv adenosine b. ineffective, give iv verapamil
31
Recurrent episodes of paroxysmal supraventricular tachycardia can be treated by what
catheter ablation, or prevented with BBs or RL CCBS: diltiazem, verapamil, sotalol, flecainide, propafenone
32
Arrhythmias after myocardial infarction: how is bradycardia treated?
particularly if complicated by hypotension, IV atropine
33
Pulseless ventricular tachycardia or ventricular fibrillation require what?
very bad arrhythmias... resuscitation
34
pts with UNSTABLE or STABLE ventricular tachyardia tx with: direct current cardioversion if fails, iv amiodarone repeat current cardioversion
unstable
35
pts with UNSTABLE or STABLE ventricular tachyardia tx with: iv amiodarone direct current cardioversion non-sustained ventricular tachycardia can be treated with bb
stable
36
pts at high risk of cardiac arrest need maintenance therapy through what
- implantable cardioverter defibrillator - can add bb/ amiodarone (in combo with standard bb)
37
what is Torsade de pointes
form of ventricular tachycardia associated with a long QT syndrome
38
long QT syndrome/ torsade can be drug induced OR caused by what 3 factors
hypokalaemia, severe bradycardia, and genetic predisposition
39
what drugs can cause hypOkalaemia
amiodarone sotalol macrolides haloperidol ssris tcas antifungals
40
torsade usually self limiting but can be recurrent leading to what
impaired consciousness if torsade not controlled -> ventricular fibrillation --> death
41
torsade treated how
iv magnesium sulphate bb NOT sotalol and atrial/ ventricular pacing may be considered
42
why should Anti-arrhythmics NOT be used in torsade?
can prolong QT interval more -> worsen condition
43
Anti-arrhythmic drugs can be classified clinically into those that act on - supraventricular arrhythmias (e.g. A), - ventricular arrhythmias (e.g. B) - both supraventricular and ventricular arrhythmias (e.g. C)
A. verapamil B. lidocaine C. amiodarone
44
Anti-arrhythmic drugs can also be classified by effects on electrical behaviour of myocardial cells during activity (the Vaughan Williams classification) less important
Class I: membrane stabilising drugs (e.g. lidocaine, flecainide) Class II: beta-blockers Class III: amiodarone; sotalol (also Class II) Class IV: calcium-channel blockers (includes verapamil but not dihydropyridines)
45
hypokalaemia enhances the arrhythmogenic (X) effect of many drugs.
pro-arrhythmic due caution
46
amiodarone is a high risk drug with very long half life should be avoided in what 2 circumstances
bradycardia and heart block bc as a side effect it can slow down HR
47
6 main SEs of amiodarone TCP PHD
thyroid disorders corneal microdeposits photosensitivity reaction pulmonary tox hepatotoxicity driving and skilled tasks
48
what is meant by corneal microdeposits as a SE of amiodarone
pt dazzled by headlights of oncoming traffic reversible when tx ends if vision impaired: STOP
49
amiodarone contains iodine so affects what function?
thyroid can cause hypo or hyeprthyroidism treated w levothyroxine
50
how to treat photosensitivity reaction as SE of amiodarone
avoid sunlight use sunscreen for months after tx end
51
what other drugs cause photosensitivity reaction? SAN LIGHT
sulfonamides amiodarone nsaids loop diuretics isotretinoin griseofulvin hydro--terzole tetracycline
52
amiodarone loading dose
200mg TDS 7 days 200mg BD 7 days 200mg OD maintenance
53
how may SE pulmonary tox be observed w amiodarone use
report new/ progressive SOB or cough
54
hepatotox SE of amiodarone. stop if pt develops liver disease, how may this be noticed?
dark urine jaundice abdominal pain nausea vom light colour stools pruritis
55
why should you HALVE dose of digoxin when using amiodarone alongside it?
amiodarone: enzyme inhibitor
56
why could effects and interactions of amiodarone last for several weeks/ months
very long t1/2
57
what 4 main types of drugs can amiodarone interact with
- drugs causing hypokalaemia bc amiodarone does too - drugs causing QT prolongation - cyp450 enzyme substrates - drugs causing bradycardia
58
what drugs may cause QT prolongation thus interact with amiodarone
macrolides quinolones ssris antipsychotics ondansetron
59
emiodarone is cyp450 inhibitor so other enzyme inhibitors and inducers affect it too eg
inhib grapefruit warfarin contraceptives statin inducer phenytoin, phenobarb
60
what drugs can cause bradycardia thus interact w amiodarone
bb rl ccbs digoxin
61
what to monitor with amiodarone use? TLP-XE
thyroid function liver function Potassium chest XRay annual Eye exam
62
how often to do thyroid and liver func tests with amiodarone
before tx then every 6 months
63
when to do serum potassium and chest x ray w amiodarone tx
once before tx
64
why are potassium and chest x ray done on amiodarone tx
causes hypokalaemia due to pulmonary effects, rule out existing lung conditions
65
what to monitor with IV amiodarone?
ecg and liver transaminases
66
MHRA warning pts who have stopped amiodarone in last few months and need to start sofosbuvir and daclatasvir, simeprevir and sofosbuvir, or sofosbuvir and ledipasvir should be monitored why?
risk of severe heart blokc - fatal!
67
digoxin therapeutic range?
0.7-2.0 ng/mL
68
when is there a toxicity risk in dogoxin conc and how is this treated?
Increased from 1.5-3.0 ng/mL. Treated with digoxin-specific antibody
69
signs of digoxin tox? SICK AND SLOW
D&V SA/AV block+bradycardia Dizziness/confusion/depression Blurred/yellow vision
70
when do you take blood samples with digoxin
6-12 hrs after a dose
71
what 2 to monitor with digoxin
serum elecs and renal function
72
digoxin interactions? BTHC
bb TCA hypokalaemia drugs - risk of dig tox cyp450 enz inducers/ inhibitors
73
why do bb interact w digoxin
increase AV block risk and increases plasma concs
74
why do TCAs interact w digoxin
can induce arrhythmias if we're treating arrythmias no point giving drug than induces them!
75
how do cyp450 enz inducers and inhibitors each affect digoxin plasma conc?
inducer: reduces conc inhibitor: increases conc
76
which following SEs is least associated with amiodarone? hyperthyroidism renal failure pulmonary tox photosensitivity blurred vision
renal failure
77
adenosine used for terminating paroxysmal supraventricular arryhmias and SEs short lived why
short duration of action t1/2 only 8-10 secs but prolonged in px taking dipyridamole
78
unlike X, adenosine can be used after a bb but X may be better than adenosine in asthma
verapamil
79
digoxin belongs to class X and slows ventricular response in AF and flutter
cardiac glycoside
80
what may occur with large doses of verapamil
hypotension
81
iv verapamil may be followed by oral tx but whats a serious DDI with iv verapamil?
bb
82
iv bb eg X or Y can be used for rapid control of ventricular rate
emolol or propamolol
83
Supraventricular arrhythmias 4 main drugs
adneosin digoxin verapamil bbs
84
Drugs for both supraventricular and ventricular arrhythmias include what?
amiodarone, beta-blockers, disopyramide, flecainide acetate, procainamide (available from ‘special-order’ manufacturers or specialist importing companies), propafenone hydrochloride.
85
how do bb act an anti-arrhythmic drugs?
attenuating the effects of the sympathetic system on automaticity and conductivity within the heart.
86
what drug can be used for life threatening ventricular arrythmias? and which is normally used?
normally: lidocaine IV but no longer first choice serious: mexiletine

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