E2: AF

Question 1

CHA2DS2VASC Score Risk Criteria and their points

Answer 1

C: CHF/Heart failure = 1 point
H: Hypertension = 1 point
A2: Age > or equal to 75 = 2 points!!!
D: Diabetes mellitus = 1 point
S2: Prior stroke or TIA = 2 points!!
V: Vascular disease (MI, PAD, aortic plaque) = 1 point
A: Age 65-74 yr
Sc: Sex (Female) = 1 point

Question 2

Determine stroke prevention in atrial fibrillation (based on CHA2DS2VASC score)

Answer 2

0 = omit therapy
1 if female = omit therapy

1 if male = consider oral anticoagulant
2 if female = consider oral anticoagulant

> or equal to 2 if male = oral anticoagulant
or equal to 3 if female = oral anticoagulant

Question 3

When is warfarin preferred over DOAC for stroke prevention in A. Fib? (3)

When is DOAC preferred over warfarin for stroke prevention in A. Fib? (3)

*both mention CrCl

Answer 3

Warfarin > DOAC
1. Valvular AF
2. Renal or hepatic disease
3. Cheap, DOC if patient can’t afford DOAC

DOAC > Warfarin
1. First line for most
2. Can switch if fluctuating INRs from warfarin, SE from warfarin, or lots of short-term warfarin interactions
3. Can use Apixaban in CrCl 15-30 but no CrCl requirement for warfarin

Question 4

When is one DOAC preferred over others
** MIGHT need to double-check this one

Answer 4

Apixaban preferred if >75 yr (Beer’s list

Question 5

Goal INR for warfarin in most
Goal INR for warfarin in special population

Answer 5

Normal: 2-3
Special population: AF and CAD who undergo PCI (stent)
Goal: 2-2.5

Question 6

Goal resting HR for A. Fib
Why

Answer 6

60-80 BPM
Maintain on lower end of normal HR just incase it goes up
Must maintain low HR to prevent ventricular arrythmias and cardiomyopathy

Question 7

Determine when BBL or CCB is preferred for rate control, especially in relation to comorbid conditions.

Answer 7

Beta-blockers: most effective rate control drug class (AFFIRM trial); preferred over CCBs in HFrEF

CCB: IV diltiazem preferred for hospital rate control; PO CCBs preferred over BBLs in asthma/COPD

Question 8

Compare and contrast amiodarone and dronedarone
Cost:
DI: Which has more
Elimination: Which is longer
CI

Answer 8

Cost: Dronedarone more expensive
DI: Amiodarone has more DI
Elimination: Amiodarone (14-75 days) vs Dronedarone (13-19 hr)

CI
Both have
-2nd/3rd degree heart bloc
-Bradycardia
-Prolonged QT interval
-Caution in liver disease or severe liver impairment
***Dronedarone also has
-concurrent strong 3A4 inhibitors
-NYHA Class II-IV HF (BBW)
-Permanent AF (BBW)

Question 9

Compare and contrast amiodarone and dronedarone
SE
Management of SE
Monitoring

Answer 9

Amiodarone:
SE
-Hepatic (BBW)
-Renal
-Arrythmias/torsades de pointes (BBW)
**Phototoxicity (blue-gray skin color)
-Nausea
**Thyroid
**Pulmonary (BBW)
**Ocular
**Polyneuropathy

Management
**Hypothyroidism: levothyroxine
**Hyperthyroidism: antithyroid meds or d/c
**Corneal microdeposits: nothing
**Optic neuritis: d/c
**pulmonary fibrosis: d/c
-Hepatotoxicity: lower dose or d/c if LE >2x ULN
-Bradycardia/heart block: lower dose or d/c
-Neuropathy: lower dose or d/c

Monitoring
-ECG
-Liver enzymes
-Chemistry panel/SCr
-Other proarrythmic drugs
**Thyroid function
**Chest X-ray, PFTs
**Eye exam

Dronedarone: anything listed with the “-“ above plus the following
SE:
_ Renal ↑ SCr by 0.1 mg/dL
_Phototoxicity (rash)
_N/V/D/Abdominal pain

Management:
_Bradycardia/heart block: D/C

Question 10

Distinguish between AV node and atrial ablation.

Answer 10

AV Node ablation: RATE CONTROL
-Prevents atrial impulses from getting to ventricles
-Creates need for permanent pacemaker and still requires anticoagulation because atria continue to fibrillate
-No mortality benefit, but ↓ hospitalizations and ↑ quality of life

Atrial ablation: RHYTHM CONTROL
-cauterization of cardiac tissue in atria that is responsible for triggering or maintain an arrhythmia (cauterizer areas of atria that are trying to start new and extra beats)