CVS - clinical management of AF

Question 1

What is arrhythmia?

Answer 1

Abnormal rate and/or rhythm of heartbeat
Too fast (TACHYcardia), too slow (BRADYcardia) or irregular

Question 2

What range is heart rate is arrhythmia:

Answer 2

60-100 bpm

Question 3

What are the common arrhythimas?

Answer 3

• Ectopic beats; electrical impulse can cancel the AV node and heart beat can skip a beat
• AF
• VT; venticular tachycardia
• VF; Ventricular fibrillation (life threatening)

Question 4

What are the different types of AF?

Answer 4

Paroxysmal AF - episodes come and go

Persistent AF - each episode lasts for longer than seven days

Long-standing persistent AF - continuous AF for a year or longer

Permanent AF - present all the time

Question 5

Symptoms of AF

Answer 5

Can be asymptomatic – especially in older people
Palpitations
Tiredness
Breathlessness/dyspnoea
Syncope/dizziness
Chest pain/discomfort

Question 6

Is AF more common in men or women?

Answer 6

7% of those over 65, more common in women

more likely in those with other conditions; hypertension, atherosclerosis, heart valve issues

Question 7

How does prognosis work?

Answer 7

not life threatening

Can cause heart failure as ventricles work too hard and enlarge > stroke

Question 8

What are the goals of management?

Answer 8

establish the diagnosis of atrial fibrillation

control and prevent symptoms (by controlling ventricular rate or atrial rhythm)

prevent stroke

Question 9

Treatment?

Answer 9

1. admit if necessary (stroke or HF)
2. rate control
3. rhythm control
4. stroke prevention

Question 10

Example of beta blockers;

Answer 10

atenolol
acebutolol
metoprolol
nadolol
bisoprolol

adverse effects, bronchospasm, cold extremites, sleep disturbance, fatigure, sexual dysfunction

Question 11

Rate-limiting calcium-channel blockers

Answer 11

verapamil and diltiazem

Question 12

Digoxin monotherapy

Answer 12

in people with non-paroxysmal AF who are sedentary

Question 13

Cardioversion - rhythm control

Answer 13

Recommended in some people with new-onset AF (within 48 hours of presentation), especially with reversible cause, in HF worsened by AF or with atrial flutter.

Carried out in specialist care

Pharmacological cardioversion

Electrical cardioversion (esp. if pt. has had AF for longer than 48 hours)

Surgical cardioversion

Question 14

Flecainide (class Ic antiarrhythmic) - hwo to administer and s.e?

Answer 14

IV loaded then oral dosing

asthenia, dizziness, dyspnoea, fatigue, fever, oedema, pro-arrhythmic effects, visual disturbances, lots of drug interactions

Question 15

Amiodarone (class III antiarrhythmic) DOSE?

Answer 15

200mg tds x7, bd x7, od

Adverse effects: bradycardia, hyperthyroidism, hypothyroidism, jaundice, nausea…

Question 16

Catheter ablation - surgery:

Answer 16

normally carried out via a vein in the groin (sometimes wrist)

• area of heart causing abnormal electrical discharges destroyed with radiofrequency energy or cryotherapy
• if this is at the AV node, a pacemaker will be used in advance to restore sinus rhythm (“ablate and pace”)

Question 17

stroke prevention; virchow’s triad

Answer 17

changes in vessel wall

changes in pattern of blood flow
changes in constituents of blood

Question 18

Risk of stroke increases:

Answer 18

5x in non-rheumatic AF
17x in rheumatic (valvular) AF

More than 20% of strokes in the UK are attributable to AF

Question 19

What do pharmacists do to score a risk of stroke?

Answer 19

stratification

Score 2 and above
Anticoagulation recommended

Score 1 and male
Consider anticoagulation

Score 0 (or 1 and female)
Anticoagulation not recommended

Do NOT offer antiplatelet drugs to anyone for stroke prevention in AF

Question 20

More risk to male or women stroke

Answer 20

score 1 point for being female

if female scores 1 point - anticoagulant will not be given

Question 21

e.g. score of 4

Answer 21

5.5% untreated&raquo_space;» 1.7% treated

Question 22

what is important to balance as well as stroke risk?

Answer 22

risk of bleeding (address reversible risk factors)

Question 23

ORBIT

Answer 23

used to show risk;

sez
hemoglobin
age
bleeding hsitroy
GFR
treatment with antiplatelet agents

Question 24

Direct-acting oral anticoagulants (DOACs)

Answer 24

Direct thrombin inhibitor – dabigatran
Direct factor Xa inhibitors – apixaban, edoxaban, rivaroxaban

Question 25

Vitamin K antagonists

Answer 25

warfarin, acenocoumarol, phenindione

Question 26

Which drug is more common to use than warfain now?

Answer 26

DOACs

standard dosing
No monitoring of INR req.

Number of interactiosn have been discovered - aware
Difficult to reverse effects

Question 27

Dosing DOAC

Answer 27

• apixaban
• dabigartran
  -edoxaban
• rivaroxaban

Question 28

Monitoring - patients taking DOAC

Answer 28

patients need to have bloods at least annually
All patients aged >75yrs (or if on dabigatran) need to be monitored 6-monthly.
Plus, patients need to be monitored according to CrCl:

Question 29

What needs to be incl in an anual review?

Answer 29

Patient counselling:
Adherence – short half life so very important

Specific dosing advice – keep dabigatran in packet, rivaroxaban take with food

Missed doses – daily preps (riv, edox) take within 12 hours, bd (apix, dab) take within 6 hours

Monitoring – inform of
frequency and arrange

Alcohol – stay within limits

Bleeding – advise on signs and symptoms and emergency advice

OTC - avoid aspirin/NSAIDs, St John’s wort

Warning card – carry it and show it when receiving medical care

Question 30

What is the most common adverse effect of wardarin?

Answer 30

bleeding

Question 31

are warfarin effects reversible?

Answer 31

yes when using vit K