Therapeutics - Anti Arrhythmic Drugs Flashcards
1
Q
what is normal sinus rhythm?
A
60-100 bpm
2
Q
what is the pathway of normal sinus rhythm
A
starts with electrical impulses generated at the SA
SA located at the right atrium
spreads to atria to AV node
travels down bundle of HIs
further spreads to bundle branches
reaches the purkinje fibers which stimulate ventricle contraction
3
Q
what is an arrhythmia
A
an irregular heartbeat
occurs when electrical signals that control the heart rhythm do not work properly
heart beats too fast or too slow or irregular pattern (fibrillation)
4
Q
p wave controls what action of the heart
A
activation of the atria
5
Q
the qrs wave controls which action of the heart
A
activation of the ventricles
6
Q
what does the t wave control
A
recovery wave, repolarization of the ventricles
7
Q
Supraventricular arrhythmias occur where in the heart
A
above the bundle of his
8
Q
where does normal sinus node originate
A
SA node
9
Q
normal sinus rhythm transmits through the _____ to the his purkinje system
A
AV node
10
Q
how to measure rhythm of the heart
A
EKG
11
Q
What are the supraventricular arrhythmias
A
sinus brady, sinus tachy, paroxysmal supraventricular tachy, atrial flutter, atrial fib, WPW, premature atrial contractions
12
Q
T or F supraventricular arrhthymias are characterized by normal QRS complexes
A
T
13
Q
T or F ventricular arrhythmias are considered emergent and life threatening
A
T
14
Q
What are the ventricular arrhythmias
A
premature ventricular contractions, ventricular tachy, ventricular fib, pulseless electrial activity, asystole
15
Q
what types of conduction blocks are there
A
first, second, third AV block
left or right bundle branch block
16
Q
sinus brady is ____ bpm
A
less than 60
17
Q
what are some causes of sinus brady?
A
increased vagal tone - parasympathetic effects
inferior wall MI
medications such as beta blockers, verapamil
18
Q
what are the symptoms of sinus brady?
A
from none to
organ hypoperfusion
hypotension, altered mental status, shock, ischemia
19
Q
what is the first step to treat sinus brady?
A
find the causes and correct causes
20
Q
what is the first line treatment of sinus brady?
A
atropine 1 mg IV repeat every 3-5 minutes
21
Q
what is the maximum dose of atropine
A
3 mg
22
Q
what to use for sinus brady if atropine fails?
A
transcutaneous pacing, dopamine and epinephrine
23
Q
how many bpm is sinus tachy
A
greater than 100 bpm
24
Q
what are the causes of sinus tachy
A
body attempting to maintain CO and BP, can be physiologic
medications - sympathetic (epinephrine), caffeine, nicotine, cocaine, anything blocking parasympathetic (atropine)
25
what are the symptoms of sinus tachy?
none to
palpitations, irregular pulse, fatigue, syncope, and other signs of organ hypo-perfusion
26
what is the non pharmacologic treatment for sinus tachy
vagal maneuvers - valsalva, carotid massage to decrease sympathetic tone which increases vagal tone
27
what is the pharmacologic treatment of sinus tachy?
adenosine is the first line of treatment
6 mg IV bolus, can repeat with 12 mg IV bolus q2 minutes
max 30 mg
glush line following bolus
28
what are some symptoms a patient with sinus tachy treated with adenosine may experience
chest heaviness
flushing
anxiety
wheezy or sob In asthma pts
29
if adenosine does not work for sinus tachy, what other drugs can be used?
beta blocker or non DHP CCB
30
what is seen for afib on an ekg
irregularly irregular ventricular rate with NO P WAVES
unreadable because 350 - 450 bpm
ventricular rate ranges from normal to RVR up to 160 bpm
31
atrial fibrillation can be paroxysmal which means it lasts _____ days
less than 7
32
atrial fibrillation that last more than 7 days is called
persistent afib
33
can afib be permanent
yes
34
what are some risk factors for afib?
age
smoking
sedentary
alcohol
increased weight
taller
htn
db
cvd
ckd
osa
hyperthyroidism
sepsis
more education
more income
white
male
35
what are the symptoms of afib
none to symptoms of tachycardia
palpitations, irregular pulse, fatigue, syncope, and other signs of organ hypo-perfusion
36
how can afib be managed?
reduce stroke risk
optimize risk factors
symptom management to control rhythm and rate
37
what are the different risk factors and what are the reccomendations for management
overweight - loss greater than 10%
inactive -210 minutes per week of moderate to vigorous
smoke cigarettes - quit
alcohol - minimize or eliminate
caffeine - only as needed to avoid triggers
HTN - reach BP goals
38
what are the randomized controlled trials comparing rate control versus rhythm control
AFFIRM, RACE, AF CHF
39
all the patients in AFFIRM, RACE, AF CHF received
oral antioagulation
40
what were the results of AFFIRM
overall mortality and strokes equivalent, less hospitalizations and AE with rate control
41
what were the results of the RACE study
cardiovascular death and morbidity equivalent
42
what were the results of the AF CHF
cardiovascular death equivalent
43
what did the EAST ADNET4 study reveal
early rhytm control led to fewer composite outcomes
44
what are the goals of rate control?
to reduce symptoms and have resting HR between 100-110 bpm
45
what are the pharmacologic options for rate control?
beta blockers
calcium channel blockers
digoxin
46
why are beta blockers a good option for rate control>
inexpensive and generic
47
what is the loading dose and maintenance dose of metroprolol for rate control for afib?
loading dose - 5 mg IV over 5 minutes for acute rate control
maintenance - 25-100 mg po bid
48
when are beta blockers controindicated?
in 2nd or 3rd degree heart block, sick sinus syndrome and severe bradycardia
49
in which pts should beta blockers be avoided
if the pt has an hyperactive airway, hypoglycemia in db pts
50
what are the only kind of calcium channel blockers can be used to control rate
nondihydropyridines - many formulations
51
what is the loading and maintenance dose of diltiazem for control rate in afib patients
loading dose - 0.25 mg/kg IV over 2 minutes, repeat 0.35 mg/kg in 15 mins, then 5-15 mg/hr IV infusion for acute
maintenance dose 60-90 mg tid or 4x day po for long acting
52
what is the loading and maintenance dose for control rate for afib using verapamil
loading dose - 5-10 mg IV ocer 2 minutes, can repeat 10 mg in 15-30 m then 5-10 mg/hr IV for acute
maintenance 40-120 mg tid po for long acting
53
calcium channel blockers should be avoided in
HFrEF
54
what kind of DDI should we be aware of for calcium channel blockers
CYP450 and CYP3A4
55
afib rate controlled with digoxin needs adjustment for ___ impaired patients
renally
56
which is more effective digoxin or BB/CCBs
BB/CCBs
57
what is the po dosage for digoxin
125 or 250 mcg tablets
58
what is the iv dosage of digoxin
100 mcg/ml
59
What are some drug interactions that one should be aware of when administering digoxin?
verapamil
quinidine
propafenone
flecainide
amiodarone
pgq inhibitors
60
what is the goal of rhythm control?
to reach nsm and reduce symptoms
61
what is acute transition to NSR called
cardioversion
62
how can one treat rhythm control "cardioversion"
medications like ibutilide, amiodarone, flecainide, propafenone "pill in the pocket?
or can do electrical cardioversion
63
how to maintain rhythm of atrial fib?
dofetilide, dronedarone, flecainide, propafenone, amiodarone, sotalol
limited by comorbidities such as MI, HF or structural heart disease
64
if a pt needs to maintain afib rhythm, but has HF, MI or other structural heart disease, what medication can they take?
sotalol
amiodarone
65
When should we choose to control rhythm in afib pts
if atrial fibrillation is less than a year, and if HF symptoms persist on rate control, hemo instability
short duration, concurrent HF, persistent symptoms, hemodynamically unstable
66
what variables impact whether we control rate or rhythm for afib>
patient choice
age
antecedent history of af
symptom burden
rate control in af
la size
lv function in af
av regurgitation in af
67
if the patient is younger, what is preferred, rate or rhythm control?
rhythm
68
patients with a longer history of afib, should control their
rate
69
patients with more symptoms, treatment of afib faors
rhythm control
70
what is the daily dose of flecainide for rhythm control
200-300 mg po daily
71
what is the daily dose of propafenone for rhythm control
450-900 mg daily
72
what is the dosage of flecainide and propafenone?
prn , one dose
73
for flecainide or propafenone, a ____ agent is necessary
AV nodal blocking agent
74
what is the daily dose of sotalol for rhythm control in pts with afib
150-320 mg daily
75
what are the monitoring parameters of sotalol
monitor EKG - QTC interval for initial 3 days then 3-6 months
76
in what pts is sotalol contraindicated in
ClCr less than 40 ml/min
77
which drug is most effective in rhythm control in afib patients
amiodarone is highly effective
78
amiodarone is highly effective but why is it reserved only for patients who failed other therapies
because it has multiple toxicities
79
what is the half life of amiodarone
58 days - 15-143
80
T or F amiodarone has large volume distribution
T
81
what are the DDI of amiodarone
it inhibits CYP 1A2, 2D6, 2C9, 3A4, PGP
82
what is the loading dose of amiodarone
6-10 mg total
83
what is the maintenance dose of amiodarone
200 mg per day
84
what are the monitoring reccomendations for amiodarone
baseline - cxr, alt/ast, tsh, ekg
repeat every 6 months : tsh, alt/ast
repeat every year - ekg, physical (for skin and neuropathy)
others as clinicaly indicated - CXR, CT, opthalmic
85
what are drug that prolong the QTc interval and risk for torsades de pointes
type I and III antiarrhythmias
azithromycin
chlorpromazine and thioridiazine
citalopram
clarithromycin and erythromycin
haloperidol
methadone
86
what are the ADR of amiodarone
hypo and hyper thyroidism
hepatotoxicity
qt interval prolongation
interstitial lung disease
corneal microdepsots
blue gray skin - photosensitivity
neurological
87
what is the daily dose for dofetilide
500 mcg
88
does dofetilide need to be dose adjusted
yes for renal dysfunction
89
dofetilide is contraindicated in patients with
ClCr less than 20 ml/min
90
what are the risks of dofetilide
serious ventricular arrythmias
91
when should dofetilide be administered
initiate while inpatients x3 days
qtc prolonging risk
then EKG 3-6 months
92
what is the daily dose for dronedarone
400 mg bid
93
what are the benefits of dronedarone over amiodarone
has a shorter half life
there is no iodine
and less noncardiac toxicities
94
is dronedarone more or less effective than amiodarone
less effective
95
dronedarone is CI in pts
with permanent AF
NHYA class 2-3 with recent composition
NHYA class 4
96
dronedarone has an FDA warning for
hepatotoxicity
97
what causes cardiac emergencies
pulseless VT, VF, PEA, and asystole
98
extra ventricular systolic beat characterizes
PVC
99
what characterizes ventricular tachy
greater than 3 PVCs + HR greater than 100
100
TdP is characterized by
hall mark of long QTc
101
PEA is characterized by
organized electrical activity
102
flatline is also known as
asystole
103
T or F vtach can be with or without a pulse
T
104
if there is a pulse during Vtach this means that there is ____ happening
perfusion
105
TdP can be due to
congenital long QT syndrome but more likely drugs
106
by definition ventricular fibrillation is considered
hemodynamically unstable
107
key characteristic of VF on ECG is
no clear QRS complexes
108
a lack of pulse, cardiac output and blood pressure of VF can lead to
sudden cardiac death
109
what are the components of basic life support
basic recognition of SCA and activation of emergent responses
early performance of high quality CPR - CAB , hand only
rapid defibrillation for VF , pulseless VT only
110
what does ACLS stand for
advanced cardiac life support
111
defibrillation is only for
pulseless VT and VF
112
what ACLS intervention outcomes improve survival to hospital discharge
high quality CPR
defibrillation when appropriate
113
what ACLS intervention outcomes improve the return of spontaneous circulation but DO NOT improve survival to discharge
IV access placement, drug deliery, advanced airway placement
114
what are the treatable causes of sudden cardiac arrest
Hypoxia
hypovolemia
hydrogen ions - acidosis
hypo hyper kalemia
hypothermia
toxins
tamponade
tension pneumo
thrombosis pulm and coronary
115
what are the ACLS medications
epinephrine 1 mg IV/ IO every 3-5 m
amiodarone 300 mg IV IO once when defib x3 fails and epinephrine x1
vasopressin 40 units not recc
116
ventillation is
2 breaths per 30 s or 1 breath / 8 seconds if bag valve mask ambu bag self inflating bag
117
