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Therapeutics 3 Kappa Epsilon > Exam 2 - Tisdale (arrhythmia) > Flashcards

Exam 2 - Tisdale (arrhythmia) Flashcards

1
Q

what is a normal QT interval

A

380 - 460 ms

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2
Q

what is a normal QTc in men

A

360 - 470 ms

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3
Q

what is a normal QTc in women

A

360 - 480 ms

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4
Q

Torsades de pointes is not good because?

A

it can cause sudden cardiac death….

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5
Q

what value for QTc interval is to cause risk for Torsades de Pointes

A

> /= to 500 ms

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6
Q

QT interval is measuring ________ time

A

ventricular repolarization

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7
Q

what are some drug classes that may cause torsades de pointes

A 
antiarrhythmic drugs
antimicrobials
antidepressants
antipsychotics
Anticancer (drugs that end in "nib")
Opioids
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8
Q

what types of antimicrobials can lead to torsades de pointes

A

macrolides and fluroquinolones

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9
Q

what are the macrolide antibiotics

A

azithromycin, clarithromycin, erythromycin

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10
Q

what are the fluroquinolone antibiotics

A

levofloxacin, moxifloxacin, ciprofloxacin

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11
Q

what are the two main groups of arrhythmias

A

SUPRAventricular
or
Ventricular

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12
Q

what are the types of SUPRAventricular arrhythmias

A
  • sinus bradycardia
  • AV block
  • Sinus tachycardia
  • Atrial Fibrilation
  • Paroxysmal Supraventricular Tachycardia
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13
Q

what are the types of Ventricular arrhythmias

A

PVCs (Premarture ventricular complexes)
Ventricular tachycardia
Ventricular fibrilation

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14
Q

Sinus Bradycardia:
HR < _____
Impulses originating in ______

A

< 60 BPM

originating in SA node

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15
Q

Mechanism of Sinus bradycardia?

A

decreased automaticity of SA node

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16
Q

Main Etiologies/Risk Factors for Sinus Bradycardia

A 
MI/Ischemia
Abnormal Sympathetic/Parasympathetic tone
Electrolyte Abnormalities
Drugs
Idiopathic
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17
Q

what electrolyte abnormalities can cause sinus bradycardia

A

hyperkalemia

hypermagnersemia

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18
Q

what drugs can cause sinus bradycardia

A 
beta blockers
digoxin
CCBs (diltiazem, verapamil)
Amiodarone
Dronedarone
Ivabradine
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19
Q

Sxs of Sinus Bradycardia

A
  • hypotension
  • dizziness
  • syncope
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20
Q

Tx (immediate) of Sinus Bradycardia

A
  • 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)

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21
Q

ADEs of Atropine

A
  • Tachycardia
  • urinary retention
  • blurred vision
  • dry mouth
  • mydriasis
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22
Q

how to treat sinus bradycardia long term

A

patients require a pacemaker

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23
Q

“Features” of Atrial Fibrillation

Atrial Activity: ?

A

chaotic/disorganized – no atrial depolarizations

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24
Q

“Features” of Atrial Fibrillation

Ventricular Rate: ?

A

~ 120 - 180 BPM

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25
Q

“Features” of Atrial Fibrillation

Rhythm?

A

Irregularly Irregular

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26
Q

“Features” of Atrial Fibrillation

P waves?

A

Absent

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27
Q

Types of A.Fib

A

Paroxysmal
Persistent
Long-Standing Persistent
Permanent

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28
Q

What is Paroxysmal A. Fib

A

Intermittent episodes of A.Fib

start and stop suddenly and spontaneously; can last for minutes to hours

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29
Q

What is persistent A.Fib

A

continuous episode of A.Fib that does NOT terminate spontaneously
May last > 7 days

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30
Q

What is long standing A.Fib

A

continuous A.fib for > 12 months in duration

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31
Q

what is Permanent A.Fib

A

always present – pt never again to be in sinus rhythm
A.Fib cannot be terminated
Accepting fact that can get back to sinus rhythm

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32
Q

2 mechanisms that cause A.Fib

A

abnormal atrial PULMONARY VEIN automaticity
+
atrial reentry

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33
Q

Main Risk Factors/Etiologies for A.Fib

A
  • HTN
  • CAD
  • HF
  • Valvular Heart Disease
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34
Q

HTN, CAD, and HF all lead to _________ which is why then can all lead to A.Fib….

A

lead to LV hypertrophy –> LA hypertrophy (heart is working supa hard)

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35
Q

Etiologies of REVERSIBLE A.Fib

A
  • hyperthyroidism
  • Pulmonary embolism
  • Thoracic surgery
  • alcohol use/binge drinking (1 - 2 drinks even..)
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36
Q

Sx of A.Fib

A
  • Palpitations
  • Dizziness/Fatigue/Lightheadedness/Hypotension
  • Syncompe
  • SOB
  • Syncope
  • Angina
  • Exacerbation of HF sx
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37
Q

Morbidity and mortality of A.Fib

A
  • Stroke
  • HF
  • Dementia
  • Mortality
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38
Q

T or F: A.Fib patients are at risk for stroke/systemic embolism

A

hella TRUE — atria no contracting (just quivering) and blood starts to pool and clots form…

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39
Q

Goals of therapy for EVERY A.Fib pt

A
  • ventricular rate control

- Prevention of stroke/systemic embolism

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40
Q

what “specific” goal of therapy is for Persistent A.Fib ONLY

A

Conversion to sinus rhythm

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41
Q

what “specific” goal of therapy is for Paroxysmal A.Fib ONLY

A

maintenance of sinus rhythm

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42
Q

what drugs are used for Ventricular Rate Control in A.Fib

A 
diltiazem
Verapamil
Beta-Blockers
Digoxin
Amiodarone
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43
Q

what are the side effects of Diltiazem and Verapamil

A
  • Hypotension (mainly IV)
  • Bradycardia
  • HF exacerbation
  • AV block
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44
Q

Diltiazem and Verapamil have a MOA that is direct ______ inhibition

A

AV Node

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45
Q

T or F: Do NOT use Diltiazem or Verapamil in HF pts

A

TRUE!! They are both negative ionotropes — do not use in HF pts at allllll

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46
Q

Digoxin ADEs

A

N/V
Anorexia
Ventricular Arrhythmias

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47
Q

Drug interactions for digoxin

A

Amiodarone and Verapamil inhibit digoxin inhibition

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48
Q

MOA for Amiodarone

A

CCB and Beta Blocker

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49
Q

MOA for Digoxin

A

Vagal Stimulation
and
Direct AV node inhibition

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50
Q

(extensive) ADEs of Amiodarone

A
  • Hypotension/Bradycardia
  • Blue-grey skin discoloration
  • Photosensitivity
  • Corneal Microdeposits
  • PULMONARY FIBROSIS
  • Hepatoxicity
  • Hypothyroidism/Hyperthyroidism
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51
Q

if a PT has A.Fib but no other CV - what drugs should they use for Ventricular Rate control?

A

beta-blocker
diltiazem
verapamil

amiodarone — 2nd line

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52
Q

if a PT has A.Fib AND HTN - what drugs should they use for Ventricular Rate control?

A

beta-blocker
diltiazem
verapamil

amiodarone — 2nd line

53
Q

if a PT has A.Fib AND LV Dysfunction or HF - what drugs should they use for Ventricular Rate control?

A

beta blockers
digoxin

amiodarone — 2nd line

54
Q

if a PT has A.Fib AND COPD - what drugs should they use for Ventricular Rate control?

A

beta-blocker
diltiazem
verapamil

(NO amiodarone 2nd line - bc pulmonary fibrosis)

55
Q

what other disease states are considered for ventricular rate control in A.Fib pts

A

HTN, HF/LV dysfunction, or COPD

56
Q

For A.Fib pts what is the goal BPM

A

< 110 BPM

buuuut if pt has HFrEF goal is < 80 BPM

57
Q

A.Fib – converting to sinus rhythm its safe to do when?

A

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

58
Q

converting to sinus rhythm — if greater than 48 hrs since onset of Sx? what do ya do?

A

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)

59
Q

what drugs can be used for A.Fib — converting to Sinus Rhythm

A
  • DCC
  • Amiodarone
  • Dofetilide
  • Ibutilide
  • Propafenone
  • Flecanide
60
Q

For A.Fib —- Can’t use _______ when patient is Hemodynamically unstable, therefore use ______

A

can’t use DRUGS; use electricity

61
Q

for A.Fib —- can’t use drugs to get patient back to sinus rhythm if patient is _________

A

hemodynamically unstable

62
Q

what criteria is for hemodynamically unstable

A
  • Systolic BP < 90 mmHG
  • HR > 150 BPM
  • Ischemic chest pain
  • Pt has lost/is losing consciousness
63
Q

Oral dosing for amiodarone

A

200 mg QD

64
Q

which drug for conversion to sinus rhythm for A.Fib has dosing based off of kidney function

A

CrCl is used for DOFETILIDE dosing

65
Q

which drugs used for conversion to sinus rhythm for A.Fib may take 3 - 8 hrs to take effect

A

Propafenone

Flecanide

66
Q

which drugs used for conversion to sinus rhythm for A.Fib are known as “pocket pills”

A

Propafenone

Flecanide

67
Q

dosing for propafenone

A

450 - 600 mg single oral dose

68
Q

dosing for flecanide

A

200 - 300 mg single oral dose

69
Q

Kidney dosing for Dofetilide:

if CrCl > 60 mL/min

A

500 mcg BID

70
Q

Kidney dosing for Dofetilide:

if CrCl 40 - 60

A

250 mcg BID

71
Q

Kidney dosing for Dofetilide:

if CrCl 20 - 39

A

125 mcg BID

72
Q

Kidney dosing for Dofetilide:

if CrCl < 20

A

contraindicated

73
Q

when would you not do DCC to get pt back to sinus rhythym

A

if we afraid pt will aspirate (get food/acid into lungs) aka if pt has eaten in past 8 - 12 hours

74
Q

for A.Fib what drugs can be used for MAINTENANCE of Sinus Rhythm

A 
amiodarone
dofetilide
dronedarone
sotalol
propafenone
flecanide
75
Q

what are some monitoring parameters for Amiodarone

A

LFTs baseline and every 6 mos
Thyroid function tests
Chest X-ray - baseline and annually
pulmonary function tests

76
Q

for A.Fib what drugs can be used for MAINTENANCE of Sinus Rhythm IF someone has Structural heart disease

A

NOOO Flecanide or Propafenone

if CAD: Dofetilide, Dronedarone, Sotalol

If HFrEF: Amiodarone; Dofetilide

or Catheter Ablation

77
Q

what CHADSVASc score warrants oral anticoag

A

> or = 2

78
Q

when is Warfarin the anti-coag of choice

A

Valvular AF
Hemodialysis
ESRD but not on dialysis (CrCl < 15 mL/min)

79
Q

antidote for dabigatran

A

idarucizumab

80
Q

what is the normal desired INR for warfarin

A

2 - 3

81
Q

which DOAC should NOT be used if CrCl is > 95 mL/min

A

Edoxaban

82
Q

dosing for Dabigatran (renal dosing!!)

A

150 mg BID (CrCl > 30 mL/min)

75 mg BID (15 - 30 mL/min)

83
Q

dosing for Rivaroxaban (renal dosing!!)

A

20 mg QPM with meal (CrCl > 50 mL/min)

15 mg QPM with meal(CrCl 15 - 50 mL/min)

84
Q

dosing for Apixaban (renal dosing!!)

A

5 or 2.5 mg BID

85
Q

dosing for Edoxaban (renal dosing!!)

A

60 mg QD (CrCl 50 - 95 mL/min)

30 mg QD (CrCl 15 - 50 mL/min)

86
Q

what antiarrhythymic drugs may cause torsades de pointes

A

(SADDIP) “Remember SAD DIP in health status???”

Sotalol
amiodarone
Dronedarone
Dofetilide
Ibutilide
Procaindamide
87
Q

what drugs inhibit digoxin elimination

A

amiodarone

verapamil

88
Q

PST arrhythymia stands for?

A

Paroxysmal Supraventricular Tachycardia

89
Q

PST Arrhythmia:

has HR: ____ - _____ BPM

A

110 - 250

90
Q

PST Arrhythmia:

has (regular or irregular) rhythm

A

REGULAR

91
Q

PST Arrhythmia:

has _______ initiation and termination

A

spontaneous

92
Q

what is the most common pathway for PST Arrhythmia

A

Reentry through AV Node

93
Q

Etiologies/Risk Factors for PST

A

Women more likely than men (2x)
over 65 y.o (5x greater risk)
usually in patients with NO underlying CVD

94
Q

Sx of PST

A 
POLYURIA  (?)
Neck-Pounding
Palpitations
Dizziness/Weakness/Lightheadedness
Near-Syncope/Syncope
95
Q

T or F: PST has associated risk for increase mortality/morbidity

A

false!! no increase risk for stroke or mortality

96
Q

Adenosine is used to _________

A

terminate PST

97
Q

Goals of Therapy for PST

A

Terminate PSVT
Restore Sinus Rhythm
Prevent Recurrences
(mainly treat symptoms for patients)

98
Q

How to treat HEMODYNAMICALLY STABLE PSVT

A 
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
99
Q

ADEs of Adenosine

A 
chest pain!! (not MI)
flushing
SOB
Sinus pauses
bronchospasms
100
Q

dosing for Adenosine

A 
6 mg IV rapid bolus
1 -2 minutes....
do 12 mg
1 - 2 minutes
do 12 mg AGAIN
and thats it
101
Q

what drugs can be used to terminate PSVT

A 
ADENOSINE!!
Beta blockers
verapamil
diltiazem
Amiodarone
102
Q

how to tx asymptomatic PSVT

A

do nerfin’

103
Q

PSVT ECG findings?

A

NARROW QRS complexes

104
Q

tx for Symptomatic PSVT

A
  • 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

105
Q

PVC ECG findings

A

wide QRS complexes

106
Q

what types of PVCs

A 
Simple (isolated single PVC)
Pair (couplets)
Bigeminy (every 2nd beat)
Trigeminy
Quadrigeminy 
or Frequent (> 30 PVCs per hour)
107
Q

what is the mechanism for PVC

A

increased automaticity of ventricular muscle cells/purkinje fibers

108
Q

Eiologies/Risk factors for PVCs

A

MI and Ischemic heart disease!!!!!
also Anemia
Hypoxia
Cardiac surgery

109
Q

Sx of PVC

A

usuallllly Asymptomatic

Frequent PVCs can lead to palpitations/dizziness/lightheadedness

110
Q

T or F: PVCs are NOT correlated to increased long term risk of CVD/mortality

A

FALSE!!! PVCs (ventricular problems are big dealio)
vs
PSVTs/PSTs are NOT associated with increased mortality

111
Q

how to treat asymptomatic PVC

A

do not treat!!

112
Q

how to treat symptomatic PVC

A

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

113
Q

ECG of ventricular tachycardia

A

wide QRS complexes

regular rhythm

114
Q

Ventricular Tachycardia is defined as a series of ________

A

3 consecutive VPDs (aka PVCs) at a rate > 100 BPM

115
Q

what are the two types of ventricular tachycardia

A

nonsustained
and
sustained

116
Q

Etiologies/Risk factors for Ventricular tachycardia

A 
CAD
MI
HFrEF
Electrolyte abnormalities
Drugs (flecanide, propefenone, digoxin)
117
Q

what electrolyte abnormalities can cause ventricular tachycardia

A

Hypokalemia and HYPOmagnesemia

118
Q

what drugs can cause ventricular tachycardia

A

flecainide
propafenone
digoxin

119
Q

Sxs of ventricular tachycardias

A 
palpitations
hypotension/dizziness/lightheadedness
syncope
angina
(can be asymptomatic aka nonsustained VT)
120
Q

sustained VT may progress to what?

A

ventricular Fibrilation (life threatnening arrhythmia)

121
Q

what drugs can be used to terminate ventricular tachycardia

A 
Procainamide
Amiodarone
Sotalol
Verapamil
Beta-Blockers
122
Q

what are the idiopathic VTs

A

verapamil sensitive VT
or
Outflow tract VT

123
Q

how you terminate hemodynamically VT depends on if the patient has _______ or not

A

Structural heart disease (or not)

most people do have struc. heart disease

124
Q

what are the 3 main options for terminating hemodynamically stable VT

A

DCC (best option)
IV procainamide (2nd best option)
IV amiodarone or IV Sotalol (3rd best option)

125
Q

for VT: how do you prevent recurrence/sudden cardiac death?

A

ICD (implantable cardioverter defibrillator)
Amiodarone
Sotalol
Catheter Ablation

126
Q

ECG of ventricular fibrilation

A

no recognizable QRS complexes

127
Q

Risk factors for V.Fib

A

MI
HFrEF
CAD

128
Q

the only effective tx for V.Fib is???

A

defibrilation

129
Q

what drugs can be used ALONG SIDE defibrillation (not alone) for treating V.Fib

A

Epinephrine and Amiodarone

no drugs can be used alone for treating v.fib always need defibrilation!!

Therapeutics 3 Kappa Epsilon (20 decks)

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