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Therapeutics > Exam 2 lecture 7 > Flashcards

Exam 2 lecture 7 Flashcards

1
Q

Risk factors for A fib

A

Age
Cigarette smoking
Alcohol
sedentary lifestyle
Obesity
HFrEF and HFpEF
CKD
genetic
idiopathic
DM
HTN

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2
Q

reversible A fib etiologies

A

Hyperthyroidism
Thoracis surgery
-CABG
-Lung resection

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3
Q

A fib symptoms

A

May be asymptomatic
palpitations
dizziness
fatigue
lightheadedness
SOB
Hypotension
Syncope
Angina (in pts with coronary artery disease)
exacerbation of HF

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4
Q

morbidity and mortality risks of A fib

A

Strokes/embolism- risk increases 5X
HF- risk increases 3X
dementia and mortality increase 2X

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5
Q

prevention of A fib

A

weightloss
physical fitness- target 210 mins of vigorous exercise each week
smoking cessation
minimize/eliminate alcohol
BP and glucose control

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6
Q

goals of therapy of A fib

A

prevention of stroke/embolism
maintain sinus rhythm
Convert A fib to normal sinus rhythm

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7
Q

CHADSVASC score calculation

A

Congestive HF-1
Hypertension- 1
Age> or = 75- 2
Diabetes- 1
Stroke- 2
vascular disease- 1
Age- >65
Sex (female)- 1

max score 9

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8
Q

What are vascular diseases for CHADSVASC

A

Prior MI
PAD
aortic plaque

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9
Q

When are oral antibiotics recommended for pts with A fib

A

CHADSVASC score > or = 1 in men

CHADSVAC score > or = 2 in women

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10
Q

when can Oral anticoags be OMITTED for pts with A fib

A

0 in men
0-1 in women

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11
Q

should most A fib pts be on DOAC or warfarin

A

DOAC

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12
Q

when is warfarin preferred over DOAC in A fib

A

Pts with mechanical heart valves
A fib associated with heart valve disease (moderate to severe mitral valve stenosis)

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13
Q

Target INR for warfarin in pts with A Fib and mechanical heart valve

A

2.5-3.5

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14
Q

target INR for warfarin in pts with A fib associated with heart valve disease (mitral valve stenosis)

A

INR- 2-3

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15
Q

which anticoags to use for pts with ESRD or CrCl<15 and hemodialysis

A

Warfarin or apixaban preferred

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16
Q

warfarin monitroing

A

measure INR weekly during therapy initiation
measure atleast monthly in all pts after INR is stable

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17
Q

What are DOAC drugs

A

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

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18
Q

Drugs for ventricular rate control

A

Diltiazem and verapamil
BB
digoxin
Amiodarone

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19
Q

How do diltiazem and verapamil affect AV nodal conduction

A

Inhibit AV nodal conduction

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20
Q

Do we administer diltiazem or verapamil to pts with ADHF?

A

Never

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21
Q

How to treat hemodynamically unstable A fib

A

No drugs, DCC shock

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22
Q

Hemodynamically unstable definition

A

SBP<90 mm/Hg
HR>150 BPM
Lost consciousness
are experiencing ischemic chest pain

if they have at least 1 of these, pt is hemodynamically unstable

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23
Q

If pt is hemodynamically stable and goal is acute ventricular rate control in A fib what is the next step?

A

we need to see if they have decompensated HF

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24
Q

If pt is hemodynamically stable and goal is acute ventricular rate control in A fib and they have decompensated HF what drug do we use?

A

Amiodarone

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25
Q

If pt is hemodynamically stable and goal is acute ventricular rate control in A fib and they do not have decompensated HF what drugs do we use?

A

IV BB
IV diltiazem
IV verapamil

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26
Q

What to do if pt is hemodynamically stabel and goal is acute ventricular rate control in A fib and they do not have decompensated HF and BB, verapamil and diltiazem do not work?

A

Use Digoxin

27
Q

What is digoxin, BB, diltiazem and verapamil do not work in hemodynamically stable pt with A fib without decompensated HF what drug do we use

A

Amiodarone

28
Q

goal HR for a fib pts

A

<100-110 BPM

29
Q

longterm ventricular rate control for A fib pts

A

Is LVEF>40 or <40

30
Q

long term ventricular rate control if LVEF< 40 in a fib pts

A

BB

31
Q

long term ventricular rate control in pts with LVEF<40 in a fib pts and BB does not work

A

digoxin

32
Q

longterm ventricular rate control if LVEF>40 % in A fib pts

A

BB, diltiazem, verapamil

33
Q

Longterm ventricular rate control in LVEF>40% in a fib pts and BB, diltiazem and verapamil do not work

A

Digoxin

34
Q

Can we administer veraamil and diltiazem if LVEF < 40%

A

no

35
Q

can we use verapamil and digoxin together

A

no

36
Q

WHat to do if pt is on verapamil and digoxin

A

switch verapamil to diltiazem and alter digoxin dose

37
Q

What are some rules before converting to sinus rhythm in a fib pts

A

If AF has been present <48 hrs, conversion to sinus rhythm is safe
If AF has been present>48 hrs conversion to sinus rhythm should not be performed

38
Q

What to do if AF has been present >48 hrs and we want to convert to sinus rhythm

A

Sinus rhythm should not be performed until pt has been anticoagulated for 3 weeks or unless TEE has been performed to rule out clot in atrium

39
Q

What are some drugs to convert to sinus rhythm

A

DCC (non pcol)

Amiodarone
Ibutillide IV drugs
Procainamide

Flecainide
Propafenne oral drugs

40
Q

amiodarone adverse effects

A

Hypotension, bradycardia, QT prolongation

41
Q

Ibutillide adverse effects

A

Torsades de pointes

42
Q

Procainamide adverse effects

A

QT prolongation
torsades de pointes, hypotension, HFrEF exacerbation

43
Q

Flecainide and propafenone adverse effects

A

Dizziness
Blurred vision
HFrEF exacerbation

44
Q

What do we have to be concerned about when doing DCC

A

Do not administer shock on T wave

45
Q

hemodynamically stable AF to sinus rhythm treatment parameters

A

Normal LV function
LV function<40
AF occuring outside hospital in pt with normal LV function

46
Q

hemodynamically stable AF to sinus rhythm with normal LV function treatment

A

IV amiodarone
Ibutilide

47
Q

what to do in hemodynamically stable AF to sinus rhythm in normal LV when IV amiodarone and Ibutilide do not work

A

use Procainamide

48
Q

Hemodynamically stable AF to sinus rhtyhtm in HFrEF (LVEF<40%) treatment

A

IV amiodarone

49
Q

Hemodynamically stable AF to sinus rhythm treatment in AF occuring outside the hospital in pt with normal LV function

A

Felcainide/propafenone (pill in the pocket)

50
Q

When should we not administer procainamide

A

If pt has already received amiodarone or ibutilide

51
Q

Why should we not give procainamide if pt has already received amiodarone or ibutilide

A

Due to risk of excessive QT prolongation and torsades de pointes

52
Q

Flecainide and propafenone should not be given in patients with

A

HFrEF

53
Q

Drugs for maintainence of sinus rhythm and prevention of recurrence

A

Amiodarone
Dofetillide
Dronedarone
Sotalol
Propafenone
Flecainide

54
Q

How long does it take amiodarone to reach steady state? what is its half life?

A

It takes 10 months to get to steady state
2 month half life

55
Q

What is a notable thing to know about amiodarone for the exam

A

Inhibits metabolism of warfarin

56
Q

What to do if someone is on amiodarone and we add warfarin

A

We need to reduce warfarin dose by 1/3 and monitor INR until steady state

57
Q

What to do if patient is on Digoxin and we add amiodarone

A

Put pt on half of digoxins dose (0.125 mg/day)

58
Q

What is the most feared adverse effect of amiodarone

A

Pulmonary fibrosis

59
Q

Dofetilide dosing

A

Crcl>60- 500 mcg po BID
CrCl 40-60- 250 mcg po BID
CrCl- 20-39- 125 mcg po BID

60
Q

When is dofetilide contraindicated

A

CrCl<20

61
Q

Adverse effect of dofetilide

A

torsades de pointes

62
Q

Amiodarone monitoring

A

hypo/hyperthyroid baseline testing before therapy and monitor TSH.
initial follow up 3-6 months
additional follow up 6 months

hepatotoxicity- ALT,AST baseline test and initial follow up 3-6 months, additional follow up 6 months

QT prolongation- Baseline ECG
follow up annually

Pulmonary fibrosis- Baseline initial chest x ray

63
Q
A

Therapeutics (38 decks)

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