Dysrhythmias part 2 Flashcards
what are Ectopic Atrial Arrhythmias
- Results from an ectopic atrial focus creates an AP at a rate faster > sinus rate, therefore becoming the pacemaker
- Atrial rate can range between 50 and 180 bpm
causes of ectopic atrial arrhythmias
-
benign/normal hearts
- Causes short nonsustained bursts
- 2–6% of young healthy adults on Holter monitors
- common in elderly patients -
Structural heart disease – causes sustained atrial tachycardia
- CAD, MI, valvular disease, congenital heart disease, or cardiomyopathies -
Other clinical scenarios may result in transient atrial tachycardia
- lyte disturbances (esp hypokalemia)
- chronic lung disease or pulm infection
- acutealcingestion
- hypoxia
- cardiac stimulants (theophylline,cocaine)
management for ectopic atrial arrhythmias
- Treat any underlying conditions
- Only treat if sustained and symptomatic
- 1st line - BB & non-dihydropyridine CCBs
- Refractory AT - Class IC / III AAD
- Radiofrequency ablations are effective
RF/causes of afib
- CHF
- HTN
- Advanced age
- CAD
- Valvular heart disease
Other Associated causes: alc, Thyroid disease, Lung disease, OSA, Family hx, Cardiac surgery, Pericarditis
presentation of afib
- asx
- Palpitations, heart racing sensation, SOB, chest pain, fatigue, dizziness, near syncope
- hypotension, esp if underlying heart disease and HR elevated
- Persistent tachycardia may lead to cardiomyopathy
- thromboembolic event – CVA, acute limb arterial occlusion
- Irregularly irregular rhythm
- signs of CHF
- Distal pulses may be difficult to obtain, esp if vent. rate is rapid
diagnostic evaluation for suspected afib
- Echo - r/o structural heart disease
- Ischemic evaluation if sx/RF present
- Stress test w/ nuclear imaging or cardiac cath - Labs:
- BMP - r/o electrolyte abnormalities
- TSH
- Other testing, if any, would be related to suspected causes
general management for afib
Three-Fold
- Rate control
- Rhythm control
- Thromboembolic event prevention
how to manage rate control in afib
- CCBs
- BB
- Digoxin
- AVN ablation and permanent pacemaker implantation
how to control rhythm in afib
Dependent on comorbidities
- Hemodynamically unstable - immediately cardioverted mechanically
-
Elective (non-emergent) Cardioversion
- Mechanical (Electricity) / Chemical (Ibutilide) - Needs AC x 4 wks following CV
Elective (non-emergent) Cardioversion
indications for
- < 48 hrs duration, or
- confirmed no thrombus with TEE, or
- 3 wks of therapeutic anticoagulation
how to determine if an afib pt needs an anticoag?
CHADS2 - VASc Score
- CHF - 1
- HTN (>140/90) - 1
- Age >=75 - 2
- DM - 1
- Prior TIA or Stroke - 2
- Vascular disease (MI, aortic plaque) - 1
- Age 65-74 - 1
- Sex category (female = 1 pt) - 1
Pt has a CHA2DS2-VASc score = 0
what is their management?
no anticoag
pt has a CHA2DS2-VASc score = 1
what is their management?
Start oral anticoagulation or antiplatelet therapy (ASA 81 mg)
preferably oral anticoagulation
pt has a CHA2DS2-VASc score = 2
what is their management
recommend oral anticoagulation
Initial anticoagulation options while determining long-term treatment option in afib
LMWH (1 mg/kg subQ Q12 hours)
Heparin (full dose sliding scale protocol)
long-term anticoags for afib
- Warfarin – INR goal 2.0 to 3.0
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
- Edoxaban (Savaysa)
which anticoags have:
Less intracranial bleeding
Higher incidence of GI bleeding
than warfarin?
Dabigatran
Rivaroxaban
which anticoags have
lower risk of major bleeding
Less intracranial bleeding
than warfarin?
Apixaban > Edoxaban
maintanence and pt ed for afib
- Maintenance
- May go between rate and rhythm control arms
- CBC and BMP Q6-12 months, depends on AAD used
- Outpt ambulatory monitoring to eval tx response - Patient Education
- Avoid alcohol
- Control underlying risk factors
- Monitor for signs of bleeding if on A/C
tx for atrial flutter
- Higher rate of cure with cath-based radiofrequency ablation, so should consider first-line
- Antiarrhythmics, Cardioversion, and rate control options same as AF
- AC same as AFib - Only needs AC x 4 wks post ablation, then no more!
pt with afib is in need for maintenance of sinus rhythm. They have no heart disease present, what would be the indicated management?
flow chart
- dronedarone, flecainide, propafenone, sotalol
- amiodarone, doftilide
- cath ablation
pt with afib is in need for maintenance of sinus rhythm. it is noted that the patient has HTN and substantial LVH, what would be the indicated management?
flow chart
amiodarone
cath ablation
pt with afib is in need for maintenance of sinus rhythm. it is noted that the patient has HTN but has no substantial LVH, what would be the indicated management?
flow chart
- dronedarone, flecainide, propafenone, sotalol
- amiodarone, dofetilide
- cath ablation
pt with afib is in need for maintenance of sinus rhythm. it is noted that the patient has CAD, what would be the indicated management?
flow chart
- dofetilide, dronedarone, sotalol
- amiodarone
- cath ablation
pt with afib is in need for maintenance of sinus rhythm. it is noted that the patient has HF, what would be the indicated management?
flow chart
- amiodarone, dofetilide
- cath ablation
