Therapeutics - Arrhythmias Part 2 Flashcards
2 goals for rhythm control for afib
get to NSR
reduce patient’s symptoms
what is an “acute transition to NSR”
a cardioversion
2 general methods for rhythm control for afib
cardioversion or chronic meds
which 2 rhythm control drugs use the “pill in pocket” approach
flecainide, propafenone
the choice of anti arrhythmics for afib is severely limited by what
any heart disease
ONLY TWO antiarrhythmics that can be given to afib patients who also have MI, HF, or other structural heart disease
amiodarone, sotalol
general guideline on when to give anti ARRHYTHMICS for afib
if had afib for less than a year (if over a year – very hard to get back to normal sinus rhythm)
if the pt has concurrent heart failure
pt has persistent symptoms while on rate control
they are hemodynamically unstable
dose of flecainide/propafenone for pill in pocket approach
flecainide - 200-300mg once
propafenone - 450-900mg once
explain what the “pill in pocket” approach exactly is
patients self administered a dose when they feel symptoms
has been shown to reduce hospital admissions and costs - improved qol
HOWEVER, the patient must first be on an AV nodal blocking agent (otherwise, this approach can cause rapid av conduction and atrial flutter)
sotalol contraindication
in creatinine clearance less than 40ml!
important monitoring parameter for sotalol (anti-arrhytmic)
monitor QT!!!!! for initial 3 days, and then every 3-6 months
patient’s creatinine clearance is 40-60mL/min
what is sotalol dosing
once a day
if below 40 - contraindicated!
true or false
amiodarone is very effective at maintaining normal sinus rhythm
true
monitoring recommendations for amiodarone ADRs
baseline: chest xray, liver fxn test, EKG
repeat TSH and liver fxn every 6 months
repeat EKG and physical every year
loading and maintenance dosing amiodarone
loading - total - 6-10g (400-800mg daily in 2-4 doses) - big dose 1st so it starts working
maintenance is 200mg QD
haloperidol + amiodarone
risk torsada
methadone + amiodarone
risk torsada
dofetilide brand
tikosyn
concern with dofetilide
risk for serious ventricular arrhythmias!!!
contraindication to dofetlilide
creatinine clearance less than 20
explain when dofetilide should be initiated and the monitoring parameters
initiate inpatient for 3 days – monitor EKG! for QT!
then monitor EKG every 3-6 months
dronedarone brand name
multaq
multaq (dronedarone) dosing
500mcg BID (adjust for renal)
differentiate between dronedarone and amiodarone
dronedarone has a shorter half life, no iodine, and less noncardiac toxicities
HOWEVER, it is also less effective, increases serum creatinine, AND has an FDA warning of acute hepatic failure
dronederone contraindications
does this also apply to amiodarone
NHYA class II-III with recent decompensation HF or NHYA class IV.
OR permanent afib
amiodarone CAN be used in these cases
true or false
if hemodynamically unstable, CARDIOVERT
true
patient has dizziness, palpitations, blurry vision, and is in afib.
has RVR on the EKG (rapid ventricular rate)
BP 89/42
HR = 155bpm
O2 sat = 82%
medical team decides antiarrhythmic approach. what is best?
DIRECT CARDIOVERSION NOW
this patient is not hemodynamically stable. we dont have time to wait 3 weeks for them to be anticoagulated
however, we can anticoagulate AFTER the cardioversion
if the patient was stable, then we could anticoagulate 1st bc we have the time
patient with afib is being considered for amiodarone vs dronedarone
which would make dronedarone more desirable?
-history of class III HF with recent decompensation
-excellent kidney function
-history of liver disease
-pt desire to avoid serious ADR
-allergy to shellfish
i think it’s patient desire to avoid serious ADR
amiodarone doesnt need dose adjustment fir renal failoure
define “sudden cardiac arrest
sudden cessation of cardiac activity. victim is unresponsive with non breathing or signs of circulation
4 causes of sudden cardiac arrest
pulseless VT
VT
PEA (pulseless electrical activity)
asystole
true or false
VT (ventricular tachycardia) can occur either with or without a pulse
TRUE
if with a pulse, perfusion is still happening
what is PVC
“premature ventricular contractions”
there is an extra ventricular systolic beat
“3 PVCs + HR over 100”
ventricular tachycardia (VT)
“hallmark of long QTc
torsada
“flatline”
asystole
“chaotic asynchronous contraction”
ventricular fibrillation
4 cardiac emergency arrhythmias
VT
VF
PEA
asystole
“organized, electrical activity that fails to produce mechanical contraction to produce a pulse”
also called a non-perfusinf rhythm
PEA “pulseless electrical activitt”
what does defibrillation do
try to get to NSR (AKA cardioversion! only dif is that defibrillation is working with a non-life sustaining rhythm)
ONLY 2 cardiac emergencies that get defibrillation
for pulseless VT and VF
NOT FOR PEA OR ASYSTOLE
TRUE OR FALSE
never interupt CPR to place an IV or give drugs
TRUE - just focus on CPR
3 drugs that can potentially be used in cardiac arrest but do NOT increase survival
epinephrine
amiodarone
vasopressin (not rec in recent guidelines)
when is amiodarone appropriate for cardiac arrest patient
only if failed defibrillation 3x and epinephrine once
dose of epi for cardiac arrest
1mg IV/IO.repeat every 3-5 mins (no max)
ventilation rate
2 breaths/30 secs or 1 breath/8 secs (if advanced airway available)
asystole to vfib
have gone from a nonshockable rhythm to a shockable rhythm
