Exam 2 - Tisdale (arrhythmia) Flashcards
what is a normal QT interval
380 - 460 ms
what is a normal QTc in men
360 - 470 ms
what is a normal QTc in women
360 - 480 ms
Torsades de pointes is not good because?
it can cause sudden cardiac death….
what value for QTc interval is to cause risk for Torsades de Pointes
> /= to 500 ms
QT interval is measuring ________ time
ventricular repolarization
what are some drug classes that may cause torsades de pointes
antiarrhythmic drugs antimicrobials antidepressants antipsychotics Anticancer (drugs that end in "nib") Opioids
what types of antimicrobials can lead to torsades de pointes
macrolides and fluroquinolones
what are the macrolide antibiotics
azithromycin, clarithromycin, erythromycin
what are the fluroquinolone antibiotics
levofloxacin, moxifloxacin, ciprofloxacin
what are the two main groups of arrhythmias
SUPRAventricular
or
Ventricular
what are the types of SUPRAventricular arrhythmias
- sinus bradycardia
- AV block
- Sinus tachycardia
- Atrial Fibrilation
- Paroxysmal Supraventricular Tachycardia
what are the types of Ventricular arrhythmias
PVCs (Premarture ventricular complexes)
Ventricular tachycardia
Ventricular fibrilation
Sinus Bradycardia:
HR < _____
Impulses originating in ______
< 60 BPM
originating in SA node
Mechanism of Sinus bradycardia?
decreased automaticity of SA node
Main Etiologies/Risk Factors for Sinus Bradycardia
MI/Ischemia Abnormal Sympathetic/Parasympathetic tone Electrolyte Abnormalities Drugs Idiopathic
what electrolyte abnormalities can cause sinus bradycardia
hyperkalemia
hypermagnersemia
what drugs can cause sinus bradycardia
beta blockers digoxin CCBs (diltiazem, verapamil) Amiodarone Dronedarone Ivabradine
Sxs of Sinus Bradycardia
- hypotension
- dizziness
- syncope
Tx (immediate) of Sinus Bradycardia
- ONLY TX IF PT IS SYMPTOMATIC
- Atropine 0.5 mg IV Q 5 mins
MAX DOSE: 3 mg
If unresponsive to Atropine:
Dopamine
Epinephrine
Transcutaneous Pacing (electrodes on skin)
ADEs of Atropine
- Tachycardia
- urinary retention
- blurred vision
- dry mouth
- mydriasis
how to treat sinus bradycardia long term
patients require a pacemaker
“Features” of Atrial Fibrillation
Atrial Activity: ?
chaotic/disorganized – no atrial depolarizations
“Features” of Atrial Fibrillation
Ventricular Rate: ?
~ 120 - 180 BPM
“Features” of Atrial Fibrillation
Rhythm?
Irregularly Irregular
“Features” of Atrial Fibrillation
P waves?
Absent
Types of A.Fib
Paroxysmal
Persistent
Long-Standing Persistent
Permanent
What is Paroxysmal A. Fib
Intermittent episodes of A.Fib
start and stop suddenly and spontaneously; can last for minutes to hours
What is persistent A.Fib
continuous episode of A.Fib that does NOT terminate spontaneously
May last > 7 days
What is long standing A.Fib
continuous A.fib for > 12 months in duration
what is Permanent A.Fib
always present – pt never again to be in sinus rhythm
A.Fib cannot be terminated
Accepting fact that can get back to sinus rhythm
2 mechanisms that cause A.Fib
abnormal atrial PULMONARY VEIN automaticity
+
atrial reentry
Main Risk Factors/Etiologies for A.Fib
- HTN
- CAD
- HF
- Valvular Heart Disease
HTN, CAD, and HF all lead to _________ which is why then can all lead to A.Fib….
lead to LV hypertrophy –> LA hypertrophy (heart is working supa hard)
Etiologies of REVERSIBLE A.Fib
- hyperthyroidism
- Pulmonary embolism
- Thoracic surgery
- alcohol use/binge drinking (1 - 2 drinks even..)
Sx of A.Fib
- Palpitations
- Dizziness/Fatigue/Lightheadedness/Hypotension
- Syncompe
- SOB
- Syncope
- Angina
- Exacerbation of HF sx
Morbidity and mortality of A.Fib
- Stroke
- HF
- Dementia
- Mortality
T or F: A.Fib patients are at risk for stroke/systemic embolism
hella TRUE — atria no contracting (just quivering) and blood starts to pool and clots form…
Goals of therapy for EVERY A.Fib pt
- ventricular rate control
- Prevention of stroke/systemic embolism
what “specific” goal of therapy is for Persistent A.Fib ONLY
Conversion to sinus rhythm
what “specific” goal of therapy is for Paroxysmal A.Fib ONLY
maintenance of sinus rhythm
what drugs are used for Ventricular Rate Control in A.Fib
diltiazem Verapamil Beta-Blockers Digoxin Amiodarone
what are the side effects of Diltiazem and Verapamil
- Hypotension (mainly IV)
- Bradycardia
- HF exacerbation
- AV block
Diltiazem and Verapamil have a MOA that is direct ______ inhibition
AV Node
T or F: Do NOT use Diltiazem or Verapamil in HF pts
TRUE!! They are both negative ionotropes — do not use in HF pts at allllll
Digoxin ADEs
N/V
Anorexia
Ventricular Arrhythmias
Drug interactions for digoxin
Amiodarone and Verapamil inhibit digoxin inhibition
MOA for Amiodarone
CCB and Beta Blocker
MOA for Digoxin
Vagal Stimulation
and
Direct AV node inhibition
(extensive) ADEs of Amiodarone
- Hypotension/Bradycardia
- Blue-grey skin discoloration
- Photosensitivity
- Corneal Microdeposits
- PULMONARY FIBROSIS
- Hepatoxicity
- Hypothyroidism/Hyperthyroidism
if a PT has A.Fib but no other CV - what drugs should they use for Ventricular Rate control?
beta-blocker
diltiazem
verapamil
amiodarone — 2nd line
if a PT has A.Fib AND HTN - what drugs should they use for Ventricular Rate control?
beta-blocker
diltiazem
verapamil
amiodarone — 2nd line
if a PT has A.Fib AND LV Dysfunction or HF - what drugs should they use for Ventricular Rate control?
beta blockers
digoxin
amiodarone — 2nd line
if a PT has A.Fib AND COPD - what drugs should they use for Ventricular Rate control?
beta-blocker
diltiazem
verapamil
(NO amiodarone 2nd line - bc pulmonary fibrosis)
what other disease states are considered for ventricular rate control in A.Fib pts
HTN, HF/LV dysfunction, or COPD
For A.Fib pts what is the goal BPM
< 110 BPM
buuuut if pt has HFrEF goal is < 80 BPM
A.Fib – converting to sinus rhythm its safe to do when?
if A.Fib has been prsent for < 48 hours
OR
if greater than 48 hrs and TEE has been done to ensure no clot is in the atrium
converting to sinus rhythm — if greater than 48 hrs since onset of Sx? what do ya do?
either put pt on anticoag for 3 weeks and have them come back before you can do DCC
OR
do TEE and see if clot or not (if clot — do 3 week anticoag; if no clot - go for DCC)
what drugs can be used for A.Fib — converting to Sinus Rhythm
- DCC
- Amiodarone
- Dofetilide
- Ibutilide
- Propafenone
- Flecanide
For A.Fib —- Can’t use _______ when patient is Hemodynamically unstable, therefore use ______
can’t use DRUGS; use electricity
for A.Fib —- can’t use drugs to get patient back to sinus rhythm if patient is _________
hemodynamically unstable
what criteria is for hemodynamically unstable
- Systolic BP < 90 mmHG
- HR > 150 BPM
- Ischemic chest pain
- Pt has lost/is losing consciousness
Oral dosing for amiodarone
200 mg QD
which drug for conversion to sinus rhythm for A.Fib has dosing based off of kidney function
CrCl is used for DOFETILIDE dosing
which drugs used for conversion to sinus rhythm for A.Fib may take 3 - 8 hrs to take effect
Propafenone
Flecanide
which drugs used for conversion to sinus rhythm for A.Fib are known as “pocket pills”
Propafenone
Flecanide
dosing for propafenone
450 - 600 mg single oral dose
dosing for flecanide
200 - 300 mg single oral dose
Kidney dosing for Dofetilide:
if CrCl > 60 mL/min
500 mcg BID
Kidney dosing for Dofetilide:
if CrCl 40 - 60
250 mcg BID
Kidney dosing for Dofetilide:
if CrCl 20 - 39
125 mcg BID
Kidney dosing for Dofetilide:
if CrCl < 20
contraindicated
when would you not do DCC to get pt back to sinus rhythym
if we afraid pt will aspirate (get food/acid into lungs) aka if pt has eaten in past 8 - 12 hours
for A.Fib what drugs can be used for MAINTENANCE of Sinus Rhythm
amiodarone dofetilide dronedarone sotalol propafenone flecanide
what are some monitoring parameters for Amiodarone
LFTs baseline and every 6 mos
Thyroid function tests
Chest X-ray - baseline and annually
pulmonary function tests
for A.Fib what drugs can be used for MAINTENANCE of Sinus Rhythm IF someone has Structural heart disease
NOOO Flecanide or Propafenone
if CAD: Dofetilide, Dronedarone, Sotalol
If HFrEF: Amiodarone; Dofetilide
or Catheter Ablation
what CHADSVASc score warrants oral anticoag
> or = 2
when is Warfarin the anti-coag of choice
Valvular AF
Hemodialysis
ESRD but not on dialysis (CrCl < 15 mL/min)
antidote for dabigatran
idarucizumab
what is the normal desired INR for warfarin
2 - 3
which DOAC should NOT be used if CrCl is > 95 mL/min
Edoxaban
dosing for Dabigatran (renal dosing!!)
150 mg BID (CrCl > 30 mL/min)
75 mg BID (15 - 30 mL/min)
dosing for Rivaroxaban (renal dosing!!)
20 mg QPM with meal (CrCl > 50 mL/min)
15 mg QPM with meal(CrCl 15 - 50 mL/min)
dosing for Apixaban (renal dosing!!)
5 or 2.5 mg BID
dosing for Edoxaban (renal dosing!!)
60 mg QD (CrCl 50 - 95 mL/min)
30 mg QD (CrCl 15 - 50 mL/min)
what antiarrhythymic drugs may cause torsades de pointes
(SADDIP) “Remember SAD DIP in health status???”
Sotalol amiodarone Dronedarone Dofetilide Ibutilide Procaindamide
what drugs inhibit digoxin elimination
amiodarone
verapamil
PST arrhythymia stands for?
Paroxysmal Supraventricular Tachycardia
PST Arrhythmia:
has HR: ____ - _____ BPM
110 - 250
PST Arrhythmia:
has (regular or irregular) rhythm
REGULAR
PST Arrhythmia:
has _______ initiation and termination
spontaneous
what is the most common pathway for PST Arrhythmia
Reentry through AV Node
Etiologies/Risk Factors for PST
Women more likely than men (2x)
over 65 y.o (5x greater risk)
usually in patients with NO underlying CVD
Sx of PST
POLYURIA (?) Neck-Pounding Palpitations Dizziness/Weakness/Lightheadedness Near-Syncope/Syncope
T or F: PST has associated risk for increase mortality/morbidity
false!! no increase risk for stroke or mortality
Adenosine is used to _________
terminate PST
Goals of Therapy for PST
Terminate PSVT
Restore Sinus Rhythm
Prevent Recurrences
(mainly treat symptoms for patients)
How to treat HEMODYNAMICALLY STABLE PSVT
Vagal Maneuvers and/or IV adenosine if doesn't work... do IV. Beta blocker, or verapamil, or diltizaem if the doesn't work.... do DCC
ADEs of Adenosine
chest pain!! (not MI) flushing SOB Sinus pauses bronchospasms
dosing for Adenosine
6 mg IV rapid bolus 1 -2 minutes.... do 12 mg 1 - 2 minutes do 12 mg AGAIN and thats it
what drugs can be used to terminate PSVT
ADENOSINE!! Beta blockers verapamil diltiazem Amiodarone
how to tx asymptomatic PSVT
do nerfin’
PSVT ECG findings?
NARROW QRS complexes
tx for Symptomatic PSVT
- Catheter ablation
if they don’t want that
if HFrEF - do amiodarone, digoxin, dofetilide, or sotalol
if NO HFrEF - do Beta blockers/verapamil/diltizaem
or 2nd line do flecanide/propfeanone
if none of that drugs work… catheter ablation then
PVC ECG findings
wide QRS complexes
what types of PVCs
Simple (isolated single PVC) Pair (couplets) Bigeminy (every 2nd beat) Trigeminy Quadrigeminy or Frequent (> 30 PVCs per hour)
what is the mechanism for PVC
increased automaticity of ventricular muscle cells/purkinje fibers
Eiologies/Risk factors for PVCs
MI and Ischemic heart disease!!!!!
also Anemia
Hypoxia
Cardiac surgery
Sx of PVC
usuallllly Asymptomatic
Frequent PVCs can lead to palpitations/dizziness/lightheadedness
T or F: PVCs are NOT correlated to increased long term risk of CVD/mortality
FALSE!!! PVCs (ventricular problems are big dealio)
vs
PSVTs/PSTs are NOT associated with increased mortality
how to treat asymptomatic PVC
do not treat!!
how to treat symptomatic PVC
first does pt have HF?
if NO – do beta blocker, or verapamil, or diltiazem (antiarrhythmics if unresponsive)
if they DO have HF — use ONLY BETA BLOCKERS
Catheter Ablation if tx FREQUENT symptomatic PVC
ECG of ventricular tachycardia
wide QRS complexes
regular rhythm
Ventricular Tachycardia is defined as a series of ________
3 consecutive VPDs (aka PVCs) at a rate > 100 BPM
what are the two types of ventricular tachycardia
nonsustained
and
sustained
Etiologies/Risk factors for Ventricular tachycardia
CAD MI HFrEF Electrolyte abnormalities Drugs (flecanide, propefenone, digoxin)
what electrolyte abnormalities can cause ventricular tachycardia
Hypokalemia and HYPOmagnesemia
what drugs can cause ventricular tachycardia
flecainide
propafenone
digoxin
Sxs of ventricular tachycardias
palpitations hypotension/dizziness/lightheadedness syncope angina (can be asymptomatic aka nonsustained VT)
sustained VT may progress to what?
ventricular Fibrilation (life threatnening arrhythmia)
what drugs can be used to terminate ventricular tachycardia
Procainamide Amiodarone Sotalol Verapamil Beta-Blockers
what are the idiopathic VTs
verapamil sensitive VT
or
Outflow tract VT
how you terminate hemodynamically VT depends on if the patient has _______ or not
Structural heart disease (or not)
most people do have struc. heart disease
what are the 3 main options for terminating hemodynamically stable VT
DCC (best option)
IV procainamide (2nd best option)
IV amiodarone or IV Sotalol (3rd best option)
for VT: how do you prevent recurrence/sudden cardiac death?
ICD (implantable cardioverter defibrillator)
Amiodarone
Sotalol
Catheter Ablation
ECG of ventricular fibrilation
no recognizable QRS complexes
Risk factors for V.Fib
MI
HFrEF
CAD
the only effective tx for V.Fib is???
defibrilation
what drugs can be used ALONG SIDE defibrillation (not alone) for treating V.Fib
Epinephrine and Amiodarone
no drugs can be used alone for treating v.fib always need defibrilation!!