Therapeutics 3 Flashcards
What would an ECG for atrial flutter show
- impulses travel in circular course in atria
- rapid flutter waves, ventricular response irregular
What can atrial flutter be caused by
Ischaemic heart disease, caffeine, alcohol and stress
Where does atrial flutter originate
originates from single atria focus (RA)
How can atrial flutter be treated
- adenosine (identification of flutter waves)
- anti-arrhythmic (1A, 1C, III)
3.Anticoagulation - ablation
what would an ECG of AF show
- impulses have chaotic, random pathways in atria
- baseline irregular, ventricular response irregular
Describe the prevalence of AF with age
AF increases with age
what can AF lead to
reduced atrial contraction, therefore risk of thrombus/embolic event
What is usually the cause of AF in young patients
young patients with no underlying structural heart disease often have an acute identifiable precipitant for their AF
- eg alcohol
What is AF complicated by
heart failure, ischaemic stroke
Is rate control superior to rhythm control
rate control non inferior to rhythm control
- no significant difference between groups
- trend favoured rate control
What should be recommended for all patients with AF
Anticoagulation to reduce stroke risk
outline the guidelines of when to offer rate control
offer as first line strategy in patients with AF, except in people:
- whose AF has a reversible cause
- who have heart failure thought to be caused by AF
- with new onset AF
- with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
- for whom a rhythm control strategy would be more suitable based on clinical judgement
How is a patient treated using rate control
Monotherapy:
- Beta blocker (not sotalol)
- rate limiting calcium channel blocker
- digoxin (sedentary)
if uncontrolled, combine 2 of the above
how is a patient treated using rhythm control
if rate controlled but symptoms continue or rate uncontrolled
- DCCV
- dronedarone (post DCCV)
- beta blocker
- class 1C (not in structural heart disease/ischaemic heart disease)
- amiodarone
- pill in pocket (Paroxysmal/cause known)
how does the risk of stroke increase in patients with AF
Risk of stroke increases five fold for people with AF
What can be used to calculate the AF stroke risk
CHADSVASc score
Outline the criteria of the CHADSVASc score
C- congestive heart failure/LV dysfunction (1)
H- hypertension (1)
A- age greater than/equal to 75 years (2)
D- diabetes mellitus (1)
S- stroke (2)
V- vascular disease (1)
A- age 65-74 years (1)
S- sex female (1)
What would the scores of the CHADSVASc score mean
- offer anticoagulation to people with a CHADSVASc score of 2 or above, taking bleeding risk into account
- consider anticoagulation for men with a score of 1
- do not offer anticoagulation to people aged less than 65 with AF and no risk factors other than their sex
- do not offer aspirin (antiplatelet) monotherapy solely for stroke prevention to people with AF
What can be used to calculate bleeding risk in AF
HASBLED
Outline the criteria of HASBLED
H- hypertension (1)
A- abnormal renal and liver function (1 point each)
S- stroke (1)
B- bleeding (1)
L- label INRs(1)
E- elderly, aged greater than 65 (1)
D- drugs or alcohol (1 point each)
What would the scores of HASBLED mean
patients with a high bleeding risk (score greater or equal to 3) should undergo regular clinical review following the initiation of oral anticoagulation
What are the main classes of anticoagulants used
vitamin K antagonists and direct thrombin inhibitor/direct inhibitor of activated factor X (DOACS/NOACs)
Give an example of evidence of warfarin use in stroke prevention in AF
SPAF III:
- low fixed dose warfarin and aspirin vs adjusted standard dose warfarin
- in high risk AF patients, low fixed dose warfarin plus aspirin was inferior to adjusted standard dose warfarin in reducing stroke
- need to monitor INR
What is the target INR for stroke prevention in AF
2-3
