Exam 2 - Tisdale (arrhythmia) Flashcards
1
Q
what is a normal QT interval
A
380 - 460 ms
2
Q
what is a normal QTc in men
A
360 - 470 ms
3
Q
what is a normal QTc in women
A
360 - 480 ms
4
Q
Torsades de pointes is not good because?
A
it can cause sudden cardiac death….
5
Q
what value for QTc interval is to cause risk for Torsades de Pointes
A
> /= to 500 ms
6
Q
QT interval is measuring ________ time
A
ventricular repolarization
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
8
Q
what types of antimicrobials can lead to torsades de pointes
A
macrolides and fluroquinolones
9
Q
what are the macrolide antibiotics
A
azithromycin, clarithromycin, erythromycin
10
Q
what are the fluroquinolone antibiotics
A
levofloxacin, moxifloxacin, ciprofloxacin
11
Q
what are the two main groups of arrhythmias
A
SUPRAventricular
or
Ventricular
12
Q
what are the types of SUPRAventricular arrhythmias
A
- sinus bradycardia
- AV block
- Sinus tachycardia
- Atrial Fibrilation
- Paroxysmal Supraventricular Tachycardia
13
Q
what are the types of Ventricular arrhythmias
A
PVCs (Premarture ventricular complexes)
Ventricular tachycardia
Ventricular fibrilation
14
Q
Sinus Bradycardia:
HR < _____
Impulses originating in ______
A
< 60 BPM
originating in SA node
15
Q
Mechanism of Sinus bradycardia?
A
decreased automaticity of SA node
16
Q
Main Etiologies/Risk Factors for Sinus Bradycardia
A
MI/Ischemia Abnormal Sympathetic/Parasympathetic tone Electrolyte Abnormalities Drugs Idiopathic
17
Q
what electrolyte abnormalities can cause sinus bradycardia
A
hyperkalemia
hypermagnersemia
18
Q
what drugs can cause sinus bradycardia
A
beta blockers digoxin CCBs (diltiazem, verapamil) Amiodarone Dronedarone Ivabradine
19
Q
Sxs of Sinus Bradycardia
A
- hypotension
- dizziness
- syncope
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)
21
Q
ADEs of Atropine
A
- Tachycardia
- urinary retention
- blurred vision
- dry mouth
- mydriasis
22
Q
how to treat sinus bradycardia long term
A
patients require a pacemaker
23
Q
“Features” of Atrial Fibrillation
Atrial Activity: ?
A
chaotic/disorganized – no atrial depolarizations
24
Q
“Features” of Atrial Fibrillation
Ventricular Rate: ?
A
~ 120 - 180 BPM
25
"Features" of Atrial Fibrillation
| Rhythm?
Irregularly Irregular
26
"Features" of Atrial Fibrillation
| P waves?
Absent
27
Types of A.Fib
Paroxysmal
Persistent
Long-Standing Persistent
Permanent
28
What is Paroxysmal A. Fib
Intermittent episodes of A.Fib
| start and stop suddenly and spontaneously; can last for minutes to hours
29
What is persistent A.Fib
continuous episode of A.Fib that does NOT terminate spontaneously
May last > 7 days
30
What is long standing A.Fib
continuous A.fib for > 12 months in duration
31
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
32
2 mechanisms that cause A.Fib
abnormal atrial PULMONARY VEIN automaticity
+
atrial reentry
33
Main Risk Factors/Etiologies for A.Fib
- HTN
- CAD
- HF
- Valvular Heart Disease
34
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)
35
Etiologies of REVERSIBLE A.Fib
- hyperthyroidism
- Pulmonary embolism
- Thoracic surgery
- alcohol use/binge drinking (1 - 2 drinks even..)
36
Sx of A.Fib
- Palpitations
- Dizziness/Fatigue/Lightheadedness/Hypotension
- Syncompe
- SOB
- Syncope
- Angina
- Exacerbation of HF sx
37
Morbidity and mortality of A.Fib
- Stroke
- HF
- Dementia
- Mortality
38
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...
39
Goals of therapy for EVERY A.Fib pt
- ventricular rate control
| - Prevention of stroke/systemic embolism
40
what "specific" goal of therapy is for Persistent A.Fib ONLY
Conversion to sinus rhythm
41
what "specific" goal of therapy is for Paroxysmal A.Fib ONLY
maintenance of sinus rhythm
42
what drugs are used for Ventricular Rate Control in A.Fib
```
diltiazem
Verapamil
Beta-Blockers
Digoxin
Amiodarone
```
43
what are the side effects of Diltiazem and Verapamil
- Hypotension (mainly IV)
- Bradycardia
- HF exacerbation
- AV block
44
Diltiazem and Verapamil have a MOA that is direct ______ inhibition
AV Node
45
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
46
Digoxin ADEs
N/V
Anorexia
Ventricular Arrhythmias
47
Drug interactions for digoxin
Amiodarone and Verapamil inhibit digoxin inhibition
48
MOA for Amiodarone
CCB and Beta Blocker
49
MOA for Digoxin
Vagal Stimulation
and
Direct AV node inhibition
50
(extensive) ADEs of Amiodarone
- Hypotension/Bradycardia
- Blue-grey skin discoloration
- Photosensitivity
- Corneal Microdeposits
- PULMONARY FIBROSIS
- Hepatoxicity
- Hypothyroidism/Hyperthyroidism
51
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
52
if a PT has A.Fib AND HTN - what drugs should they use for Ventricular Rate control?
beta-blocker
diltiazem
verapamil
amiodarone --- 2nd line
53
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
54
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)
55
what other disease states are considered for ventricular rate control in A.Fib pts
HTN, HF/LV dysfunction, or COPD
56
For A.Fib pts what is the goal BPM
< 110 BPM
| buuuut if pt has HFrEF goal is < 80 BPM
57
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
58
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)
59
what drugs can be used for A.Fib --- converting to Sinus Rhythm
- DCC
- Amiodarone
- Dofetilide
- Ibutilide
- Propafenone
- Flecanide
60
For A.Fib ---- Can't use _______ when patient is Hemodynamically unstable, therefore use ______
can't use DRUGS; use electricity
61
for A.Fib ---- can't use drugs to get patient back to sinus rhythm if patient is _________
hemodynamically unstable
62
what criteria is for hemodynamically unstable
- Systolic BP < 90 mmHG
- HR > 150 BPM
- Ischemic chest pain
- Pt has lost/is losing consciousness
63
Oral dosing for amiodarone
200 mg QD
64
which drug for conversion to sinus rhythm for A.Fib has dosing based off of kidney function
CrCl is used for DOFETILIDE dosing
65
which drugs used for conversion to sinus rhythm for A.Fib may take 3 - 8 hrs to take effect
Propafenone
| Flecanide
66
which drugs used for conversion to sinus rhythm for A.Fib are known as "pocket pills"
Propafenone
| Flecanide
67
dosing for propafenone
450 - 600 mg single oral dose
68
dosing for flecanide
200 - 300 mg single oral dose
69
Kidney dosing for Dofetilide:
| if CrCl > 60 mL/min
500 mcg BID
70
Kidney dosing for Dofetilide:
| if CrCl 40 - 60
250 mcg BID
71
Kidney dosing for Dofetilide:
| if CrCl 20 - 39
125 mcg BID
72
Kidney dosing for Dofetilide:
| if CrCl < 20
contraindicated
73
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
74
for A.Fib what drugs can be used for MAINTENANCE of Sinus Rhythm
```
amiodarone
dofetilide
dronedarone
sotalol
propafenone
flecanide
```
75
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
76
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
77
what CHADSVASc score warrants oral anticoag
> or = 2
78
when is Warfarin the anti-coag of choice
Valvular AF
Hemodialysis
ESRD but not on dialysis (CrCl < 15 mL/min)
79
antidote for dabigatran
idarucizumab
80
what is the normal desired INR for warfarin
2 - 3
81
which DOAC should NOT be used if CrCl is > 95 mL/min
Edoxaban
82
dosing for Dabigatran (renal dosing!!)
150 mg BID (CrCl > 30 mL/min)
| 75 mg BID (15 - 30 mL/min)
83
dosing for Rivaroxaban (renal dosing!!)
20 mg QPM with meal (CrCl > 50 mL/min)
| 15 mg QPM with meal(CrCl 15 - 50 mL/min)
84
dosing for Apixaban (renal dosing!!)
5 or 2.5 mg BID
85
dosing for Edoxaban (renal dosing!!)
60 mg QD (CrCl 50 - 95 mL/min)
| 30 mg QD (CrCl 15 - 50 mL/min)
86
what antiarrhythymic drugs may cause torsades de pointes
(SADDIP) "Remember SAD DIP in health status???"
```
Sotalol
amiodarone
Dronedarone
Dofetilide
Ibutilide
Procaindamide
```
87
what drugs inhibit digoxin elimination
amiodarone
| verapamil
88
PST arrhythymia stands for?
Paroxysmal Supraventricular Tachycardia
89
PST Arrhythmia:
| has HR: ____ - _____ BPM
110 - 250
90
PST Arrhythmia:
| has (regular or irregular) rhythm
REGULAR
91
PST Arrhythmia:
| has _______ initiation and termination
spontaneous
92
what is the most common pathway for PST Arrhythmia
Reentry through AV Node
93
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
94
Sx of PST
```
POLYURIA (?)
Neck-Pounding
Palpitations
Dizziness/Weakness/Lightheadedness
Near-Syncope/Syncope
```
95
T or F: PST has associated risk for increase mortality/morbidity
false!! no increase risk for stroke or mortality
96
Adenosine is used to _________
terminate PST
97
Goals of Therapy for PST
Terminate PSVT
Restore Sinus Rhythm
Prevent Recurrences
(mainly treat symptoms for patients)
98
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
```
99
ADEs of Adenosine
```
chest pain!! (not MI)
flushing
SOB
Sinus pauses
bronchospasms
```
100
dosing for Adenosine
```
6 mg IV rapid bolus
1 -2 minutes....
do 12 mg
1 - 2 minutes
do 12 mg AGAIN
and thats it
```
101
what drugs can be used to terminate PSVT
```
ADENOSINE!!
Beta blockers
verapamil
diltiazem
Amiodarone
```
102
how to tx asymptomatic PSVT
do nerfin'
103
PSVT ECG findings?
NARROW QRS complexes
104
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
105
PVC ECG findings
wide QRS complexes
106
what types of PVCs
```
Simple (isolated single PVC)
Pair (couplets)
Bigeminy (every 2nd beat)
Trigeminy
Quadrigeminy
or Frequent (> 30 PVCs per hour)
```
107
what is the mechanism for PVC
increased automaticity of ventricular muscle cells/purkinje fibers
108
Eiologies/Risk factors for PVCs
MI and Ischemic heart disease!!!!!
also Anemia
Hypoxia
Cardiac surgery
109
Sx of PVC
usuallllly Asymptomatic
Frequent PVCs can lead to palpitations/dizziness/lightheadedness
110
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
111
how to treat asymptomatic PVC
do not treat!!
112
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
113
ECG of ventricular tachycardia
wide QRS complexes
| regular rhythm
114
Ventricular Tachycardia is defined as a series of ________
3 consecutive VPDs (aka PVCs) at a rate > 100 BPM
115
what are the two types of ventricular tachycardia
nonsustained
and
sustained
116
Etiologies/Risk factors for Ventricular tachycardia
```
CAD
MI
HFrEF
Electrolyte abnormalities
Drugs (flecanide, propefenone, digoxin)
```
117
what electrolyte abnormalities can cause ventricular tachycardia
Hypokalemia and HYPOmagnesemia
118
what drugs can cause ventricular tachycardia
flecainide
propafenone
digoxin
119
Sxs of ventricular tachycardias
```
palpitations
hypotension/dizziness/lightheadedness
syncope
angina
(can be asymptomatic aka nonsustained VT)
```
120
sustained VT may progress to what?
ventricular Fibrilation (life threatnening arrhythmia)
121
what drugs can be used to terminate ventricular tachycardia
```
Procainamide
Amiodarone
Sotalol
Verapamil
Beta-Blockers
```
122
what are the idiopathic VTs
verapamil sensitive VT
or
Outflow tract VT
123
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
124
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)
125
for VT: how do you prevent recurrence/sudden cardiac death?
ICD (implantable cardioverter defibrillator)
Amiodarone
Sotalol
Catheter Ablation
126
ECG of ventricular fibrilation
no recognizable QRS complexes
127
Risk factors for V.Fib
MI
HFrEF
CAD
128
the only effective tx for V.Fib is???
defibrilation
129
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!!
