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PY365 AF > Therapeutics 3 > Flashcards

Therapeutics 3 Flashcards

1
Q

What would an ECG for atrial flutter show

A
  • impulses travel in circular course in atria
  • rapid flutter waves, ventricular response irregular
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2
Q

What can atrial flutter be caused by

A

Ischaemic heart disease, caffeine, alcohol and stress

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3
Q

Where does atrial flutter originate

A

originates from single atria focus (RA)

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4
Q

How can atrial flutter be treated

A
  1. adenosine (identification of flutter waves)
  2. anti-arrhythmic (1A, 1C, III)
    3.Anticoagulation
  3. ablation
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5
Q

what would an ECG of AF show

A
  • impulses have chaotic, random pathways in atria
  • baseline irregular, ventricular response irregular
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6
Q

Describe the prevalence of AF with age

A

AF increases with age

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7
Q

what can AF lead to

A

reduced atrial contraction, therefore risk of thrombus/embolic event

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8
Q

What is usually the cause of AF in young patients

A

young patients with no underlying structural heart disease often have an acute identifiable precipitant for their AF
- eg alcohol

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9
Q

What is AF complicated by

A

heart failure, ischaemic stroke

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10
Q

Is rate control superior to rhythm control

A

rate control non inferior to rhythm control
- no significant difference between groups
- trend favoured rate control

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11
Q

What should be recommended for all patients with AF

A

Anticoagulation to reduce stroke risk

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12
Q

outline the guidelines of when to offer rate control

A

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

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13
Q

How is a patient treated using rate control

A

Monotherapy:
- Beta blocker (not sotalol)
- rate limiting calcium channel blocker
- digoxin (sedentary)
if uncontrolled, combine 2 of the above

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14
Q

how is a patient treated using rhythm control

A

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)

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15
Q

how does the risk of stroke increase in patients with AF

A

Risk of stroke increases five fold for people with AF

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16
Q

What can be used to calculate the AF stroke risk

A

CHADSVASc score

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17
Q

Outline the criteria of the CHADSVASc score

A

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)

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18
Q

What would the scores of the CHADSVASc score mean

A
  1. offer anticoagulation to people with a CHADSVASc score of 2 or above, taking bleeding risk into account
  2. consider anticoagulation for men with a score of 1
  3. do not offer anticoagulation to people aged less than 65 with AF and no risk factors other than their sex
  4. do not offer aspirin (antiplatelet) monotherapy solely for stroke prevention to people with AF
19
Q

What can be used to calculate bleeding risk in AF

A

HASBLED

20
Q

Outline the criteria of HASBLED

A

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)

21
Q

What would the scores of HASBLED mean

A

patients with a high bleeding risk (score greater or equal to 3) should undergo regular clinical review following the initiation of oral anticoagulation

22
Q

What are the main classes of anticoagulants used

A

vitamin K antagonists and direct thrombin inhibitor/direct inhibitor of activated factor X (DOACS/NOACs)

23
Q

Give an example of evidence of warfarin use in stroke prevention in AF

A

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

24
Q

What is the target INR for stroke prevention in AF

A

2-3

25
Q

What factors should be considered with use of warfarin

A
  • risk of bleeding vs benefit to the patient
  • target and range INR
  • educate the patient: monitoring of INR, adverse effects, missed doses, drug interactions, adherence
26
Q

Give an example of a vitamin k antagonist

A

warfarin

27
Q

give an example of a direct thrombin inhibitor

A

dabigatran

28
Q

give an example of a direct inhibitor of activated factor X

A

apixaban, rivaroxaban, edoxaban

29
Q

What are the 4 DOACs licensed for stroke reduction in non valvular AF

A

Dabigatran, rivaroxaban, apixaban, edoxaban

30
Q

describe the ARISTOTLE study

A
  • apixaban 5mg bd vs warfarin
  • primary endpoint: ischaemic or haemorrhagic stroke or systemic embolism
  • results: apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding and lower mortality
  • GI bleeding similar between both groups
31
Q

What are the national guidelines on the use of anticoagulation

A

anticoagulation may be with apixaban, dabigatran, rivaroxaban or a vitamin K antagonist
- consider anticoagulation for men with CHADSVASc score of 1
- offer anticoagulation for people with CHADSVASc score of 2 or above

32
Q

What is the usual dose of apixaban

A

5mg bd

33
Q

what is the reduced dose of apixaban

A

2.5mg bd

34
Q

when would you use the reduced dose for apixaban

A

if 2 or more of:
- age greater than 80 years
- weight less than 60kg
- creati=anine greater than 133umol/l or CrCl 15-29ml/min

35
Q

what is the usual dose of dabigatran

A

150mg bd

36
Q

What is the reduced dose of dabigatran

A

110mg bd

37
Q

when would you use the reduced dose for dabigatran

A
  • age greater than 80 years
  • concomitant verapamil
  • consider if age greater than 75 years, GORD or gastritis, HASBLED is greater or equal to 3, or CrCl 30-49ml/min
38
Q

what is the usual dose of edoxaban

A

60mg od

39
Q

what is the reduced dose of edoxaban

A

30mg od

40
Q

when would you use the reduced dose for edoxaban

A
  • CrCl 15-50ml/min
  • weight less than 60kg
  • concomitant ciclosporin, dronedarone, erythromycin, ketoconazole
41
Q

what is the usual dose of rivaroxiban

A

20mg od

42
Q

what is the reduced dose of rivaroxaban

A

15mg od

43
Q

when would you use the reduced dose of rivaroxaban

A

CrCl 15-49ml/min

44
Q

what is the equation for calculating CrCl

A

CrCl= 1.23(male)/1.04(female x (140 - age) x weight (kg)/ serum creatinine (micro mol/l)

PY365 AF (19 decks)

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