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Cardio > Pharmacotherapy of Dysrhythmias > Flashcards

Pharmacotherapy of Dysrhythmias Flashcards

1
Q

symptoms of dysrhythmias

A

palpitations, chest pain, fatigue, dyspnea, lightheadedness, syncope, CHF exacerbation, embolic complication

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2
Q

types of supraventricular arrhythmias

A

AFib, AFL, atrial tachycardia, AVNRT/SVT

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3
Q

pathophysiology of AFib

A

multiple small reentrant atrial circuits, automaticity, atrial remodeling, irregularly irregular HR/rhythm, loss of atrial contribution to ventricular filling

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4
Q

risk factors for AFib

A

drugs (caffeine, stimulants), alcohol, smoking, obesity, MI, diabetes, HTN, age, etc etc etc

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5
Q

complications of AFib

A

stroke, heart failure, mortality

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6
Q

_____ AFib terminates spontaneously of with intervention within 7 days of onset

A

paroxysmal

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7
Q

____ AFib is continuous AFib sustained > 7 days

A

persistent

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8
Q

______ AFib lasts greater than 12 months

A

long-standing persistant

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9
Q

____ AFib involves a joint decision btwn patient and clinician to stop further attempts to restore/maintain normal sinus rhythm

A

permanent

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10
Q

_____ AFib is AFib in the absence of rheumatic mitral stenosis, mechanical or biprosthetic heart valve, mitral valve repair

A

non-valvular

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11
Q

AFib treatment goals

A

prevent thromboembolism, control ventricular rate, convert to and maintain NSR

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12
Q

how do you consider rate vs rhythm control

A

consider patient-specific factors: age, activity level, severity of symptoms: if AFib identified early, pursue rhythm control

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13
Q

consider rhythm control when…

A

patient preference, HFrEF, recent AFib diagnosis, high burden AFib, younger, failed rate control, worsening HF symptoms with AFib

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14
Q

consider rate control when…

A

patient preference, longstanding AFib, low burden AFib, severe LA dilation, NYHA III-IV, failed previous rhythm control

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15
Q

is there a difference in outcome between lenient and strict rate control

A

no

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16
Q

when to use lenient rate goal

A

asymptomatic or LVEF >40%

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17
Q

what is the lenient rate goal

A

<110 bpm

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18
Q

when to use strict rate goal

A

symptomatic or LVEF<40%

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19
Q

what is the strict rate goal

A

<80 bpm

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20
Q

agents to use for rate control

A

beta blockers/ verapamil/ diltiazem preferred, digoxin, amio (caution potential for cardioversion, stroke risk if pt is not anticoagulated)

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21
Q

when would digoxin or amio be preferred for rate control

A

in decompensated heart failure (LVEF <40%)

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22
Q

metoprolol dosing for rate control

A

2.5-5 mg IV bolus, up to 3 doses

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23
Q

diltiazem dosing for rate control

A

0.25 mg/kg IV bolus, 5-15 mg/hr infusion

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24
Q

amio dosing for rate control

A

150 mg IV bolus, 0.5-1 mg/kg infusion

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25
Q

what is DCCV

A

direct current cardioversion

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26
Q

meds used to enhance success of conversion by shock, and prevent immediate recurrence

A

flecainide, propafenone, amiodarone, ibutilide, dofetilide

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27
Q

echo-guided cardioversion

A

ensure no clot !!! can’t pursue rhythm control until you know there’s no clot–> clots can embolize if you shock and do rhythm control

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28
Q

pharmacologic agents for cardioversion

A

flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide

29
Q

flecainide dosing for cardioversion

A

200-300 mg PO

30
Q

propafenone dosing for cardioversion

A

600 mg PO

31
Q

amio dosing for cardioversion

A

IV bolus 150 mg over 1 hr. then cont infusion @ 1 mg/min x 6 hours. then infusion of 0.5 mg/min x 18 hours. then convert to PO: 400 mg bid or tid (7-10 days) until total loading dose of 10 grams reached

32
Q

what agents are used for the “pill in the pocket” method

A

flecainide, propafenone

33
Q

pearls for “pill in the pocket” method

A

low-access, rural areas, clearly symptomatic AFib, must be trialed in monitored setting first

34
Q

pharmacologic agents for maintenance of NSR

A

flecainide, propafenone, amiodarone, sotalol, dronedarone, dofetilide

35
Q

amio dosing for maintenance of NSR

A

200 mg daily

36
Q

dronedarone dosing for maintenance of NSR

A

400 mg bid

37
Q

dofetilide dosing for maintenance of NSR

A

125-500 mcg bid

38
Q

flecainide dosing for maintenance of NSR

A

50-150 mg bid

39
Q

propafenone dosing for maintenance of NSR

A

150-300 mg tid or 225-425 mg bid

40
Q

sotalol dosing for maintenance of NSR

A

80-160 mg bid

41
Q

general monitoring for antiarrhythmics

A

proarrhythmias (any antiarrhythmic can be proarrhythmic), QTc (class IA, III), potassium, magnesium, kidney function (sotalol, dofetilide, DOACs), left ventricular function

42
Q

special considerations for dofetilide

A

must be initiated in-patient: monitor QTc, kidney function (CrCL), adjust dose accordingly, monitor for minimum of 3 days

43
Q

dofetilide drug interactions

A

CYP3A4: verapamil, ketoconazole, trimethoprim, HCTZ

44
Q

contraindications with dofetilide

A

CrCL <20 mL/min, QTc > 440 msec

45
Q

what to monitor with amio

A

chest xray, pulmonary function, liver function, thyroid function (T4, TSH), opthalmologic, ECG

46
Q

drug interactions with amiodarone and dronedarone

A

digoxin and warfarin (cut dose in half), other anti-dysrhythmics, beta blockers, calcium channel blockers, statins (dose cap w/ simva and lova), QTc prolonging drugs, CYP3A substrates/inhibitors/inducers

47
Q

special considerations for digoxin

A

not first line, narrow therapeutic window, risk of toxicity (age, frailty, renal insufficiency), monitor serum drug concentrations

48
Q

therapeutic anticoagulation is required for ___ before and ___ after cardioversion

A

3 weeks before and 4 weeks after. exception: can perform cardioversion sooner if echo is performed to rule out presence of clot

49
Q

left atrial occlusion device

A

for patients with contraindications to anticoagulation (traps the clot so it can’t escape)

50
Q

ventricular dysrhythmias originate from where

A

below bundle of His

51
Q

ventricular dysrhythmias are characterized by ___

A

abnormal QRS, abnormal QT interval

52
Q

non-sustained ventricular tachycardia

A

less than 3 beats, terminates spontaneously

53
Q

sustained ventricular tachycardia

A

30 s or requiring termination in < 30 s due to hemodynamic compromise

54
Q

monomorphic ventricular tachycardia

A

stable, single QRS morphology with each beat

55
Q

polymorphic ventricular tachycardia

A

changing/multiform QRS morphology with each beat

56
Q

clinical presentation of PVCs

A

non life-threatening, typically asymptomatic, associated w/ increased risk of mortality

57
Q

clinical presentation of VT

A

symptoms vary from asymptomatic to pulseless + hemodynamic collapse. faster HR, longer duration, LV dysfunction= more symptoms

58
Q

clinical presentation of VF

A

hemodynamic collapse, syncope, cardiac arrest

59
Q

how do you know it’s torsades

A

polymorphic ventricular tachycardia characterized by prolongation of QT interval

60
Q

risk factors for drug-induced torsades

A

bradycardia, using >1 QT prolonging drug, digoxin therapy, female, heart failure, high drug levels, hypokalemia, impaired hepatic drug metabolism, left ventricular hypertrophy, rapid infusion by IV, recent conversion from AFib, QTc > 500 msec, severe hypomagnesemia, treatment w/ diuretics

61
Q

drugs that may cause TdP

A

antiarrhythmics: quinidine, procainamide, disopyramide, sotalol, dofetilide, ibutilide. anti-infectives (clarithromycin), antiemetics (droperidol), antipsychotics (haloperidol), antidepressants (sertraline), methadone

62
Q

what agents to use for monomorphic VT with no structural heart disease

A

verapamil or beta blocker

63
Q

what agents to use for monomorphic VT with structural heart disease

A

procainamide, sotalol, amiodarone

64
Q

what agents to use for polymorphic VT with normal QTc

A

amiodarone, beta blockers, lidocaine

65
Q

what agents to use for polymorphic VT with long QTc

A

d/c offending agents, correct lytes, magnesium, lidocaine, pacing, isoproterenol

66
Q

amio dosing for VT

A

150 mg IV, then infusion (1 mg/min for 6 hours, then 0.5 mg/min for 18 hours), monitor for hypotension/bradycardia/AV block

67
Q

lidocaine dosing for VT

A

1-1.5 mg/kg IV load, repeat 5-10 min later with 0.5-0.75 mg/kg then maintenance infusion of 1-4 mg/min. monitor for bradycardia and CNS changes

68
Q

procainamide dosing for VT

A

10-17 mg/kg IV load given as continuous infusion (20 mg/min) then maintenance infusion of 1-4 mg/min. monitor for QRS widening > 50%

69
Q

magnesium sulfate dosing for VT

A

1-2 gm IV over 15 min, may repeat as needed, may follow w/ infusion of 0.5-1 gm/hr. monitor for hypotension, vasodilation

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