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PHRM 845 > Exam 2: Arrhythmias > Flashcards

Exam 2: Arrhythmias Flashcards

1
Q

Class 1 Medications are _______ and act on phase _________

A

Sodium channel blockers, 0

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2
Q

Class 2 Medication are __________
and act on phase ________

A

propranolol and metoprolol, 4

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3
Q

Class 3 Medications are _______ and act on phase _________

A

Potassium channel blockers (amiodarone, sotalol), 3

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4
Q

Class 4 Medications are _______ and act on phase __________

A

Calcium channel blockers, 2

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5
Q

Electrical Conduction in the Heart Steps

A
  1. SA node fires
  2. Excitation spreads through atrial myocardium
  3. AV node fires
  4. Excitation spreads down AV bundle
    5: Purkinjie fibers distribute excitation though ventricular myocardium
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6
Q

What influences nodal firing?

A

Pacemakers have automaticity
+
input from SNS and PSNS

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7
Q

Important Ion Channels in the Heart

A

sodium channels
calcium channels
potassium channels
HCN channels
hERG channel

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8
Q

Significance of hERG channels

A

an important channel to avoid being targeted when developing new drugs

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9
Q

Membrane Potential Outside of Cell

A

0 mV

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10
Q

Electrolyte Concentrations Outside of Cell

A

K = 5 mM
Na = 142 mM
Ca= 5 mM
Cl = 103 mM

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11
Q

Membrane Potential Inside of Cell

A

-70 mV

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12
Q

Electrolyte Concentrations Inside of Cell

A

K = 148 mM
Na = 10 mM
Ca= < 1 uM
Cl = 4 mM

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13
Q

Concentration Gradient: Sodium

A

flows inside of cell (142 -> 10)

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14
Q

Electrical Gradient: Sodium

A

flows inside of cell (+ to -)

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15
Q

Concentration Gradient: Potassium

A

flows outside of cell (5 <- 148)

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16
Q

Electrical Gradient: Potassium

A

inside of cell (+ to -)

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17
Q

Pacemaker Cells

A

calcium dependent spikes
non contractile cells
depolarized
high automaticity

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18
Q

Ventricular Myocytes

A

sodium dependent spikes
contractile cells
hyperpolarized

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19
Q

Currents for pacemaker APs: iCa

A

carries AP upstroke (phase 0)

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20
Q

Currents for pacemaker APs: iK

A

repolarizing K+ current (phase 3)

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21
Q

Currents for pacemaker APs: if

A

diastolic pacemaker current (phase 4)
HCN channel

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22
Q

Currents for pacemaker APs: iK(ACh)

A

K+ current activated by vagus (phase 4)

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23
Q

Acetylcholine

A

decreased HCN and calcium current

hyper-polarization (GIRK)

Atrium and SA/AV nodes

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24
Q

Myocyte AP Currents: iNa

A

carries ap upstroke (phase 0)

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25
Q

Myocyte AP Currents: iKto

A

transient outward repolarizing current (phase 1)

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26
Q

Myocyte AP Currents: iCa(L)

A

plateau Ca2+ current critical for muscle contraction (phase 2)

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27
Q

Myocyte AP Currents: iK

A

repolarizing K+ current (phase 3)

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28
Q

Myocyte AP Currents: if

A

pacemaker current (phase 4, very minimal)

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29
Q

No _______ channel involved in myocytes

A

calcium channels

neuronal action potential

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30
Q

The Refractory Period

A

result of a 2nd stimulus on ability to elicit an AP is greater as you progress through the RRP (relative refractory period)

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31
Q

Re-entry requirements

A

multiple parallel pathways

unidirectional block

conduction time greater than ERP (effective refractory period)

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32
Q

Class 2 Drugs

A

beta AR blockade

shifts the timing of the peak

HCN channel slows down the pacemaker cell, longer phase 4

useful for arrhythmias involving catecholamines (epi, norepi, etc)

increases refractoriness of SA, AV node

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33
Q

Class 4 Drugs

A

calcium channel blockades

lower the mV of the peak

frequency dependent block

protect ventricular rate from atrial tachycardia

increases refractoriness of AV node and PR interval

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34
Q

Class 2 Change in EKG

A

increases PR interval

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35
Q

beta blockers used in antiarrhythmics: esmolol

A

cardioselective B1

very short half life ~9 min due to plasma esterase hydrolysis

given iv

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36
Q

beta blockers used in antiarrhythmics: acebutolol

A

cardioselective

weak partial agonist at B1AR (sympathomimetic)

weak sodium channel blockade

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37
Q

beta blockers used in antiarrhythmics: propranolol

A

non selective

weak sodium channel blockade

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38
Q

clinical uses of bAR blockers

A

arrhythmias involving catecholamines

atrial arrhythmias

post mi prevention of ventricular arrhythmias

prophylaxis in long QT syndrome

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39
Q

Calcium channel blockers in arrhythmias: MOA

A

frequency dependent block of calcium channels

selective block for channels opening more frequently

accumulation of blockade in rapidly depolarizing tissue

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40
Q

clinical uses of CCBs in arrhythmias

A

block re-entrant involving AV node

protect ventricular rate in aflutter and afib

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41
Q

Class 1A effect on AP

A

prolonged qt interval

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42
Q

Class 1B effect on AP

A

no clinically significant effect on ECG

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43
Q

Class 1C effect on AP

A

strong sodium channel block

widens QRS

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44
Q

Class 1A Drug

A

quinidine

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45
Q

Class 1B Drug

A

lidocaine
mexiletine

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46
Q

Class 1C

A

flecainide

ventricular and supra-ventricular

orally available

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47
Q

Class 3 MOA

A

block IKr

prolong action potential duration and QT interval

increases effective refractory period

increased ERP above conduction time around circuit will terminate re-entry

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48
Q

Class 3 Drugs

A

Amiodarone

blocks IKr the most

top choice prevention of afib

suppresses emergency ventricular and atrial arrhythmias

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49
Q

Adverse Effects: Amiodarone

A

hypothyroidism

pulmonary fibrosis

photosensitization

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50
Q

Digoxin

A

inhibition of AV node

also increase intropy, used for CHF

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51
Q

Adenosine

A

leads a brief but potent slowing of the heart

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52
Q

Questions to ask when looking at an EKG?

A

P wave in front of every QRS?

QRS after P wave?

Intervals are the same?

What is the rate?

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53
Q

PR interval normal

A

0.12-0.20 seconds (120-200 ms)

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54
Q

QTc interval in men

A

360-450 ms

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55
Q

QTc interval in women

A

360-460 ms

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56
Q

Torsades de Pointes

A

QTc interval ≥ 500 ms, there is an increased risk of the drug-induced arrhythmia known as TDP

can cause sudden cardiac death

57
Q

Sinus bradycardia

A

heart rate < 60 bpm

58
Q

sinus bradycardia moa

A

decreased automaticity of the SA node

59
Q

drugs that cause sinus bradycardia

A

digoxin
beta blockers
ccbs
amiodarone!
dronedarone
ivabrandine

60
Q

symptoms of bradycaria

A

hypotension
dizziness
syncope

61
Q

treatment of sinus bradycardia is only necessary when________

A

if patient is symptomatic

62
Q

first line treatment of sinus bradycardia

A

atropine 0.5-1mg IV, repeat every 5 minutes

max: 3 mg

63
Q

if unresponsive to first line sinus bradycardia treatment

A

transcutaneous pacing
dopamine
epi
isoproterenol

64
Q

atropine adverse effects

A

tachycardia
urinary retention
blurred vision
dry mouth
mydriasis

65
Q

treatment of sinus bradycardia after heart transplant or spinal cord injury

A

Aminophylline

IV then oral of theophylline in HT

Oral of theophylline in SCI

66
Q

Long term treatment of Sinus Bradycardia

A

permanent pacemaker

if unwilling to have pacemaker, theophylline oral

67
Q

afib: atrial activity

A

chaotic and disorganized, no atrial depolarizations

68
Q

afib: ventricular rate

A

120-180 bpm

69
Q

afib: rhythm

A

irregularly irregular

70
Q

afib: p waves

71
Q

stage 1 afib

A

presence of modifiable and nonmodifiable risk factors associated with AF

72
Q

stage 2 afib

A

pre-atrial fibrillation

evidence of structural or electrical findings that further predispose patients to AF

  • atrial enlargement
  • frequent atrial premature beats
  • atrial flutter
73
Q

Stage 3a afib

A

paroxysmal AF

AF that is intermittent and terminates within ≤ 7 days of onset

74
Q

Stage 3b afib

A

persistent AF

af that is continuous and sustains for > 7 days and requires intervention

75
Q

stage 3c afib

A

long standing persistent AF

af that is is continuous for > 12 months in duration

76
Q

stage 3d afib

A

successful af ablation

freedom form af after percutaneous or surgical intervention to eliminate AF

77
Q

stage 4 afib

A

permanent trial fibrillation

no further attempts at rhythm control after discussion between the patient and clinician

78
Q

mechanisms of afib

A

abnormal atrial/pulmonary vein automaticity

atrial reentry

79
Q

Risk factors/etiologies of AFib

A

socioeconomic status
thoracic surgery
hyperthyroidism
alcohol
heart failure
idiopathic

80
Q

symptoms of afib

A

may be asymptomatic
palpitations
dizziness
fatigue
lightheadedness
sob
hypotension
syncope
angina
exacerbation of hf symptoms

81
Q

CHADSVAsc

A

CH x 1
HTN x1
Age ≥ 75 x 2
DM x1
Stroke x 2
Vascular Disease (PAD,aortic plaque, MI) x 2
Age 65-74 x1

82
Q

Oral AC recommended for pts with afib and ______

A

chadsvasc score

≥ 2 in men
≥ 3 in women

83
Q

oral ac reasonable for pts with afib and _______

A

chadsvasc score
1 in men
2 in women

84
Q

prevention of stroke/systemic embolism treatments

A

doacs preferred overwarfarin in most patients

85
Q

warfarin preferred over doacs

A

Mechanical Heart Valve (INR 2.5-3.5)

Heart Valve Disease (iNR 2.0-3.0)

86
Q

warfarin or apixaban preferred

A

ESCD (CrCl < 15 mL/min)
hemodialysis

87
Q

antidote for dabigatran

A

idarucizumaba

88
Q

antidote for xa factors

A

adexanet alfa

89
Q

drugs for ventricular rate control

A

diltiazem
verapamil
esmolol
propranolol
metoprolol
digoxin
amiodarone

90
Q

adverse effects: nonDHP CCBs

A

hypotension
bradycardia
HF exacerbation
AV block

91
Q

adverse effects: BBs

A

hypotension
bradycardia
HF exacerbation (if dose too high or increased too aggressively)
AV block

92
Q

adverse effects: digoxin

A

nausea
vomiting
ventricular arrhythmias

93
Q

adverse effects: amiodarone

A

hypotension (IV)
bradycardia
blue-grey skin
photosensitivity
corneal microdepositis
pulmonary fibrosis
hepatotoxicity
hypothyroidism
hyperthyroidism
qt prolongation

94
Q

conversion to sinus rhythm is safe when

A

if af has been present for ≤ 48 hours

95
Q

if af has been present for > 48 hours

A

conversion to SR should not be preformed

until

pt AC’d for 3 weeks or TEE has been preformed to rule out clot in atrium

96
Q

DCC risks

A

general anesthesia (aspiration)

97
Q

ibutilide mechanism

98
Q

ibutilide aes

A

torsades de pointes

99
Q

procainamide class

100
Q

procainamide aes

A

qt prolongation
torsades de pointes
hypotension
HFrEF exacerbation
agranulocytosis
neutropenia

101
Q

flecainide class

102
Q

propafenone class

103
Q

flecainaide and propafenone aes

A

dizziness
blurred vision
HFrEF exacerbation

104
Q

Drugs for Conversion to SR

A

DCC
Amiodarone
Ibutilide
Procainamide
Flecainide
Propafenone

105
Q

Drugs for Maintenance of SR

A

amiodarone
dofetilide
dronedarone
sotalol
propafenone
flecainide

106
Q

dofetilide aes

A

torsades de pointes

107
Q

dronedarone aes

A

bradycardia
diarrhea
nausea
asthenia
rash

108
Q

sotalol aes

A

beta blockade
torsades de pointes

109
Q

Dofetilide dose

A

CrCl based
> 60: 500 mcg orally bid
40-60: 250 mcg orally bid
20-39: 125 mcg orally bid
< 20: CI

110
Q

proceed for dofetilide use if QTc is

111
Q

proceed with sotalol use if QTC is

112
Q

catheter ablation place in therapy

A

antiarrhythmic drugs have been ineffective, contraindicated, not tolerated or not preferred

can be 1st line

113
Q

supraventricular tachycardia

A

regular rhythm
narrow QRS
HR 110 to >250 bpm
spontaneous initiation and termination

114
Q

paroxysmal SVT

A

intermittent episodes of SVT that start sudddenly and spontaneously, lasts for minutes to hours, and terminate suddenly and spontaneously

115
Q

mechanism of SVT

A

premature impulses

116
Q

symptoms of SVT

A

neck pounding
palpitations
dizziness
weakness
lightheadedness
near syncope
syncope
polyuria

117
Q

goals of svt

A

terminate SVT, restore sinus rhythm
prevent recurrence

118
Q

drugs for termination of SVT

A

adenosine
BBlockers
Diltiazem
Verapamil

119
Q

adenosine aes

A

chest pain
flushing
shortness of breath
sinus pauses
bronchospasm

120
Q

adenosine dosing

A

6 mg IV rapid bolus

if no response in 1-2 minutes, 12 mg IV rapid bolus

can repeat the 12 mg IV dose once

121
Q

contraindicated in pts with cad

A

flecainide
propafenone

122
Q

frequent PVC

A

at least one PVC on a 12 lead ECG

> 30 PVCs per hour

123
Q

mechanism of premature ventricular complexes

A

increased automaticity of ventricular muscle cells/purkinje fibers

124
Q

symptoms of PVCs

A

usually asymptomatic
palpitations
dizziness
lightheadedness

125
Q

treatment of PVCs not appropriate when

A

if asymptomatic

126
Q

treatment of PVCs in pts who do not have CAD OR HF or have CAD

A

BB, non DHP CCBs
if unresponsive, antiarrhythmic

127
Q

treatment of frequent symptomatic PVCs unresponsive to BB, non DHP CCBs or antiarrhythmic

A

catheter ablation

128
Q

treatment of symptomatic PVCs in pts who have HF

A

beta blockers

129
Q

ventricular tachycardia

A

regular rhythms
wide qrs complexes
≥ 3 consequtive VPDs at a rate of > 100 bpm

130
Q

non-sustained VT

A

≥ 3 consecutive VPDs, terminates spontaneously

131
Q

sustained

A

VT lasting > 30 seconds
requires termiantion because of hemodynamic instability in < 30 seconds

132
Q

sustained monomorphic VT in pts with no structural heat disease is known as

A

idiopathic vt

133
Q

mechanisms of vtach

A

increased ventricular automaticity
reentry

134
Q

drugs that cause vtach

A

flecainide
propafenone
digoxin

135
Q

symptoms of vtach

A

may be asymptomatic (nonsustained)
palpitations
hypotension
dizziness
lightheadedness
syncope
angina

136
Q

goals of therapy: vtach

A

terminate VT, restore SR
prevent recurrence of VT
reduce the risk of sudden Cardiac death

137
Q

Drugs for termiantion of ventricular tachycardia

A

procainamide
amiodarone
sotalol
verapamil
beta blockers (es,meto,prop)

138
Q

prevention of recurrence and sudden cardiac death

A

icd
amiodarone
sotalol
catheter ablation

139
Q

treatment of ventricular fibrillation

A

defibriillation
epinephrine
amiodarone
lidocaine

PHRM 845 (14 decks)

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