Dysrhythmia (Week-12 $ Workshop-36)

Question 1

Dysrhythmia vs AF?

Answer 1

Dysrhythmia or AF both, Any of these may cause the heart to skip a beat, beat too fast, or beat too slow.

Atrial fibrillation (AF) is a form of arrhythmia, or irregular heartbeat, in which the atria (the two small upper chambers of the heart) quiver instead of beating effectively.

Question 2

What are the risk factors Peter has for Atrial Fibrillation?

Answer 2

Increasing age
Hypertension
Alcohol Consumption
Family history of CVD - father died from acute myocardial infarction at age 70

Question 3

How you determine paroxysmal Persistent and permanent AF?

Answer 3

Paroxysmal AF – recurrent episodes of AF which last less than seven days.(Rhythm control)

Persistent AF – episodes of AF Which last more than seven days and that has not spontaneously resolved within this time. (Rate and rhythm control)

Permanent AF – AF that has been present for more than one year and cardioversion has failed or not been attempted. (Rate control)

We cannot be sure because we don’t have enough information for his diagnosis. WE have to do ECG required.

Question 4

test to identify Dysarythemia ?

Answer 4

ECG EKG

Question 5

Epideomiology of Arterial fibrilation?

Answer 5

5% of all age 65 in nz suffer

Question 6

What is the mechanism of Dysrhythmia?

Answer 6

Abnormal impulse by increased automaticity
Electrical instability
Abnormal conduction like conduction delay

Question 7

Types of Dysrhythmia?

Answer 7

Tachycardia (>100 bpm)
Bradycardia (<60 bpm)
Supraventricular dysrhythmias (e.g. atrial fibrillation)
Ventricular dysrhythmias (e.g. ventricular fibrillation)
Bradyarrhythmias

Question 8

Treatment options of dysarhythmia?

Answer 8

Beta blockers (slow impulse generation in SA node)
Non-dihydropyridine calcium channel blockers (slow conduction in SA/AV node)

Question 9

Causes/risk factors of dysrhythmia?

Answer 9

Coronary artery disease
High blood pressure
Cardiomyopathy (changes in heart muscle)
Valve disorders
Electrolyte imbalances
Injury (i.e. myocardial infarction)
Healing process after heart surgery
Drugs

Question 10

Signs and symptoms of dysrhythmia

Answer 10

Asymptomatic
Palpitations / “racing heart”
Feeling of pause
Anxiety
Shortness of breath
Dizziness, loss of consciousness
Cardiac arrest

Question 11

Atrial Fibrillation - Classification?

Answer 11

First detected
Only one diagnosed episode

Paroxysmal
Recurrent episodes that stop on their own < 7 days

Persistent
Recurrent episodes that last > 7 days

Permanent
Ongoing long-term episode

Question 12

Ris factors for Arterial Fibrilation?

Answer 12

Age. The older you are, the greater your risk of developing atrial fibrillation
Heart disease
High blood pressure
Other chronic conditions
Drinking alcohol
Obesity
Family history

Question 13

Cmopare when we need to control HR and when we control Rhythm Control?

Answer 13

Rate control: Persistent arrythmia, less symtomatic, age below 65, No heart failure, Hypertension

Rhythm control: Paroxysmal arrythmia, On going symptoms show dispite rate control, Age above 65, Heart failure

Question 14

Please design a treatment plan for Peter. Please consider pharmacist-specific goals of therapy, options, and a recommendation.
Pharmacist goals

Answer 14

To alleviate symptoms of arrhythmia (i.e. heart racing, feeling lightheaded and anxious, etc) by controlling heart rate (<110 bpm) & restoring sinus rhythm
To prevent complications associated with arrhythmias, e.g. stroke
To prevent mortality
To normalise signs (target HR < 110bpm)

Question 15

Treatment option for arterial fibrilation to control rate?

Answer 15

First Line:Beta blocker 2nd Line: CCB
Metoprolol succinate MR 95 - 190mg OD - better evidence base
Monitoring:
Aim for HR < 110bpm
Side effects, e.g. fatigue, nightmares, cold toe and finger
Bisoprolol [dose dependent on the degree of heart rate elevation, NZF] - usual dose 1.25-10mg OD
Carvedilol

CCB:
Diltiazem IR 60mg TDS
Verapamil IR 40mg TDS or verapamil CR 120 - 480mg (CCB; BPAC)

Question 16

Treatment option for arterial fibrilation to control Rhythm?

Answer 16

Amiodarone 200mg TDS for 1 weeks, and then titrate dose

Flecainide 50mg BD and then titrate dose

Sotalol 80mg OD or 40mg BD

Nothing
Electrical conversion maybe considered (if presenting within 48 hrs of symptom onset)

Question 17

Non-pharmacological therapy for arterial fibrilation:

Answer 17

Reduce alcohol intake
Regular physical exercise - recommended 30 minutes per day for at least 5 days per week (total of 150 minutes)
Manage stress
Healthy, balanced diet - reduce sodium and saturated fat intake
Aim for a healthy weight. Currently, his BMI is under 25, but should ensure he maintains a BMI below 25.

Question 18

When we have to change or modify patients antithrombotic medication and why or why not?

Answer 18

By assessing CHADA VASc score and HASBLED score

give Dabigatran
Patient complience no need INR test
No dose adjustment required

Question 19

HASBLED (risk of bleeding) score

Answer 19

Hypertension
Abnormal LIver/Renal 
Stroke
Bleeding
Labile INR
ELderly over 65
Drug or Alcohol

Question 20

What medication is recommended if HASBLED score is high ?

Answer 20

1) Warfarin 3mg OD (Adjust with INR result (Chenck INR every week) warferin takes 7-10 days or 3 weeks to reach steady state INR
2) Dabigatran 150 BD

Question 21

What do you need to monitor during Dabigatran use?

Answer 21

Signs of bleeding or anemia
Monitor or Assess renal function

AE: Abdominal pain Anaemia nausea diarrhoea

Question 22

“Peter is in the hospital with a stomach bleed. Why didn’t you tell him not to take aspirin along with his other medications?” You respond, “I’m sorry to hear this but Peter never mentioned he was taking aspirin.” She replies, “Did you ask? He bought it here after he read about it online”.
List one or two strategies you could implement as a community pharmacist to prevent this situation from happening again. Try to think about it from the perspective of the ‘system’, rather than the ‘individual’.

Answer 22

attach DDI alerts to their customer rewards card

ask when they’re buying aspirin or nsaids if they take any other medications, counsel on appropriate use - this works best if they are only buying from your pharmacy.

Ask if there have been any medication changes when collecting prescriptions and repeats on high risk medications (Anticoagulants).

Teach everyone (including shop staff) to ask about their current medication

Ask patients about any side effects they may have noticed from their medicines

Make sure the patient knows what to watch out for (warning signs of bleeds ect) and ask them everytime you see them if there have been any changes, if he is taking anything OTC and double check about all his meds.

Mandatory counselling for any patients on anticoagulants & ask if they’ve had any new meds, OTCs, supplements, etc.

Attach a sign with the aspirin, saying that if you have these conditions/taking these medications etc, talk to pharmacist