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Therapeutics III > Tisdale Arrhythmia > Flashcards

Tisdale Arrhythmia Flashcards

1
Q

What is torsades de pointes?

A

-When the QTc interval is 500 ms or more, there is an increased risk
-Torsades de pointes can cause sudden cardiac death

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2
Q

Types of supraventricular arrhythmias

A

-Sinus bradycardia
-Atrioventricular (AV) block
-Sinus tachycardia
-Atrial fibrillation
-Supraventricular tachycardia

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3
Q

Types of ventricular arrhythmias

A

-Premature ventricular complexes (PVCs)
-Ventricular tachycardia
-Ventricular fibrillation

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4
Q

What is sinus bradycardia?

A

-Heart rate less than 60 beats per minute
-Impulses originating in sinoatrial node
-Decreased automaticity of the SA node

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5
Q

Sinus bradycardia risk factors

A

-Myocardial infarction or ischemia
-Abnormal sympathetic or parasympathetic tone
-Hyperkalemia
-Hypermagnesemia
-Beta blockers
-CCBs
-Amiodarone
-Idiopathic

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6
Q

Symptoms of sinus bradycardia

A

-Hypotension
-Dizziness
-Syncope

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7
Q

Treatment of sinus bradycardia

A

-Only if patient is symptomatic
-Atropine 0.5-1 mg IV, repeat every 5 minutes
-Maximum dose 3 mg

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8
Q

What to do if patient is unresponsive to atropine

A

-Transcutaneous pacing (pacemaker on the skin)
-Dopamine 5-20 mcg/kg/min
-Epinephrine 2-10 mcg/min or 0.1-0.5 mcg/kg/min
-Isoproterenol 20-60 mcg IV bolus followed by doses of 10-20 mcg or infusion of 1-20 mcg/min

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9
Q

Adverse effects of atropine

A

-Tachycardia
-Urinary retention
-Blurred vision
-Dry mouth
-Mydriasis

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10
Q

Treatment of sinus bradycardia after heart transplant or spinal cord injury

A

-Aminophylline 6 mg/kg IV over 20-30 minutes
-Theophylline heart transplant: 300 mg IV followed by oral dose of 5-10 mg/kg/day titrated to effect
-Theophylline spinal cord injury: oral dose of 5-10 mg/kg/day titrated to effect

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11
Q

Long term treatment of sinus bradycardia

A

-Some patients may require a pacemaker
-For patients unwilling to undergo implantation of a permanent pacemaker: theophylline oral 5-10 mg/kg/day titrated to effect

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12
Q

Features of atrial fibrillation

A

-Atrial activity: chaotic and disorganized - no atrial depolarizations
-Ventricular rate: 120-180 bpm
-Rhythm: irregularly irregular
-P waves: Absent

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13
Q

Stage 1 atrial fibrillation

A

Presence of modifiable and nonmodifiable risk factors associated with AF

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14
Q

Stage 2 atrial fibrillation

A

-Pre-atrial fibrillation
-Evidence of structural or electrical findings that further predispose patients to AF (Atrial enlargement, frequent atrial premature beats, atrial flutter)

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15
Q

Stage 3A atrial fibrillation

A

Paroxysmal AF: AF that is intermittent and terminates within 7 days of onset

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16
Q

Stage 3B atrial fibrillation

A

Persistent AF: AF that is continuous and sustains for more than 7 days and requires intervention

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17
Q

Stage 3C atrial fibrillation

A

Long-standing persistent AF: AF that is continuous for more than 12 months in duration

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18
Q

Stage 3D atrial fibrillation

A

Successful AF ablation: freedom from AF after percutaneous or surgical intervention to eliminate AF

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19
Q

Stage 4 atrial fibrillation

A

Permanent trial fibrillation: no further attempts at rhythm control after discussion between the patient and clinician

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20
Q

Mechanisms of atrial fibrillation

A

-Abnormal atrial/pulmonary vein automaticity
-Atrial reentry

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21
Q

Atrial fibrillation risk factors

A

-Advancing age
-Cigarette smoking
-Sedentary lifestyle
-Alcohol
-Obesity
-Hypertension
-Diabetes mellitus
-Coronary artery disease
-Heart failure
-Obstructive sleep apnea
-Valvular heart disease
-Chronic kidney disease
-Genetic
-Idiopathic

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22
Q

Etiologies of reversible atrial fibrillation

A

-Hyperthyroidism
-Thoracic surgery (coronary artery bypass graft, lung resection, esophagectomy)
-Sepsis

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23
Q

Atrial fibrillation symptoms

A

-May be asymptomatic
-Palpitations
-Dizziness
-Fatigue
-Lightheadedness
-Shortness of breath
-Hypotension
-Syncope
-Angina (in patients with coronary artery disease)
-Exacerbation of heart failure symptoms

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24
Q

Atrial fibrillation morbidity/mortality risks

A

-Stroke/systemic embolism - risk increased 5x
-Heart failure - risk increased 3x
-Dementia - risk increased 2x
-Mortality - risk increased 2x

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25
Q

How to prevent atrial fibrillation

A

-Lifestyle and risk factor modification
-Physical fitness
-Smoking cessation
-Minimize or eliminate alcohol consumption
-Blood pressure control in patients with hypertension
-Optimal glucose and A1C management in patients with diabetes

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26
Q

Atrial fibrillation goals of therapy

A

-Prevent stroke/systemic embolism
-Slow ventricular response by inhibiting conduction of impulses to ventricles
-Convert atrial fibrillation to normal sinus rhythm
-Maintain sinus rhythm (reduce frequency of episodes)

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27
Q

When are oral anticoagulants recommended for patients with atrial fibrillation?

A

-CHADSVASc score of 2 or more in men
-CHADSVASc score of 3 or more in women

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28
Q

When can oral anticoagulants be omitted in patients with atrial fibrillation?

A

-CHADSVASc score of 0 in men
-CHADSVASc score of 0-1 in women

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29
Q

What anticoagulant is preferred in atrial fibrillation?

A

-DOACs are preferred
-Warfarin is preferred over DOACs in patients with a mechanical heart valve and patients with atrial fibrillation associated with heart valve disease
-Warfarin or apixaban are preferred in patients with end-stage kidney disease and/or on hemodialysis

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30
Q

Drugs for ventricular rate control

A

-Diltiazem
-Verapamil
-Esmolol
-Propranolol
-Metoprolol
-Digoxin
-Amiodarone

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31
Q

How to define hemodynamically unstable

A

One of the following is true:
-Systolic less than 90
-BPM over 150
-Loss of consciousness
-Ischemic chest pain

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32
Q

How do you treat acute ventricular rate control (AFIB) if the patient is not hemodynamically stable?

A

Direct current cardioversion

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33
Q

How do you treat acute ventricular rate control (AFIB) if the patient is hemodynamically stable and has decompensated heart failure

A

Amiodarone

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34
Q

How do you treat acute ventricular rate control (AFIB) if the patient is hemodynamically stable and does not have decompensated heart failure?

A

-Beta-blocker, diltiazem, or verapamil
-Digoxin
-Amiodarone

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35
Q

How do you treat long-term ventricular rate control (AFIB) if the LVEF is 40% or less?

A

-Beta-blocker
-Digoxin

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36
Q

How do you treat long-term ventricular rate control (AFIB) if the LVEF is over 40%?

A

-Beta-blocker, diltiazem, or verapamil
-Digoxin

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37
Q

When is it safe to convert to sinus rhythm?

A

-If AF has been present for 48 hours or less, conversion to sinus rhythm is safe
-If AF has been present for more than 48 hours, conversion to sinus rhythm should not be preformed until patient has been anticoagulated for 3 weeks, or unless a transesophageal echocardiogram (TEE) has been performed to rule out a clot in the atrium

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38
Q

How do you convert hemodynamically stable atrial fibrillation patients to sinus rhythm who have normal LV function?

A

IV amiodarone, ibutilide

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39
Q

How do you convert hemodynamically stable atrial fibrillation patients to sinus rhythm who have HFrEF (LVEF 40% or less)?

A

IV amiodarone

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40
Q

How do you convert hemodynamically stable atrial fibrillation patients to sinus rhythm who are not in the hospital and have normal LV function?

A

Flecainide, propafenone

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41
Q

Oral amiodarone adverse effects

A

-Blue-grey skin discoloration
-Photosensitivity
-Corneal microdeposits
-Pulmonary fibrosis
-Hepatotoxicity
-Bradycardia
-Hype/hyperthyroidism

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42
Q

Dofetilide adverse effects

A

Torsades de pointes

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43
Q

How do you dose dofetilide when the creatinine clearance is over 60?

A

500 mcg orally twice daily

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44
Q

How do you dose dofetilide when the creatinine clearance is 40-60?

A

250 mcg orally twice daily

45
Q

How do you dose dofetilide when the creatinine clearance is 20-39?

A

125 mcg orally twice daily

46
Q

How do you dose dofetilide when the creatinine clearance is less than 20?

A

Contraindicated

47
Q

Amiodarone recommended monitoring

A

-Hypo- or hyperthyroidism: TSH (T3 and T4 if TSH abnormal)
-Hepatotoxicity: liver function tests (ALT, AST)
-QT interval prolongation: ECG
-Pulmonary fibrosis: chest X-ray

48
Q

What to give for maintenance therapy of sinus rhythm following conversion to SR or for paroxysmal AF when the patient has normal LV function, and has no history of a prior MI or significant heart disease

A

-Dofetilide, dronedarone, flecainide, propafenone
-Amiodarone
-Sotalol

49
Q

What to give for maintenance therapy of sinus rhythm following conversion to SR or for paroxysmal AF when the patient has a history of prior MI or significant structural heart disease, including HFrEF (LVEF 40% or less)

A

-Amiodarone, dronedarone, dofetilide
-Sotalol

50
Q

What is dronedarone contraindicated in?

A

NYHA class III or IV or recent decompensated HF

51
Q

When would you adjust dofetilide dose?

A

Adjust 2-3 hours after first dose - check QTc interval

52
Q

How do you adjust dofetilide dose if QTc increases by 15% or less?

A

Continue current dose

53
Q

How do you adjust dofetilide dose if QTc increases by more than 15% or to greater than 500 ms?

A

Decrease dose by 50%

54
Q

How do you adjust dofetilide dose if QTc is over 500 ms after the second dose?

A

Discontinue dofetilide

55
Q

How do you initiate sotalol therapy?

A

Place patient on continuous ECG monitoring and proceed only if QTc is 450 ms or less

56
Q

How do you dose sotalol if the patient has CrCl over 60?

A

80 mg twice daily

57
Q

How do you dose sotalol if the patient has CrCl 40-60?

A

80 mg once daily

58
Q

When should you check QTc interval after each sotalol/dofetilide dose?

A

2-4 hours

59
Q

How do you dose sotalol if the patient has QTc less than 500 ms after 3 days?

A

-Patient can be discharged
-Dose can be increased to 120 mg twice daily and patient can be followed for 3 days on this dose

60
Q

How do you dose sotalol if the patient has QTc of 500 ms or more?

A

Discontinue sotalol

61
Q

When should catheter ablation be used for rhythm control in atrial fibrillation?

A

In patients whom antiarrhythmic drugs have been ineffective, contraindicated, not tolerated or not preferred

62
Q

When can catheter ablation be used as first-line therapy?

A

In selected patients (generally younger and with fewer comorbidities) with symptomatic paroxysmal atrial fibrillation

63
Q

What is supraventricular tachycardia?

A

-Regular rhythm
-Narrow QRS complex
-Heart rate 110 - >250 beats per minute
-Spontaneous initiation and termination
-Prevalence: 225 per 100,000
-Incidence: 35 cases per 100,000 persons per year

64
Q

What is paroxysmal SVT?

A

-A subset of SVT
-Intermittent episodes of SVT
-Episodes start suddenly and spontaneously, last for minutes to hours, and terminate suddenly and spontaneously

65
Q

Risk factors

A

-Women have 2x higher risk than men
-Age over 65 years have a 5x greater risk than younger people
-Often occurs in individuals with no underlying CVD

66
Q

Symptoms of supraventricular tachycardia

A

-“Neck-pounding”
-Palpitations
-Dizziness
-Weakness
-Lightheadedness
-Near-syncope
-Syncope
-Polyuria

67
Q

How do you treat patients to terminate hemodynamically stable SVT?

A

-Vagal maneuvers and/or IV adenosine
-If ineffective or not feasible then give IV beta-blockers or IV diltiazem or IV verapamil
-If ineffective or not feasible then give synchronized DCC

68
Q

How do you treat patients for the prevention of recurrence of SVT when the patient is asymptomatic or minimally symptomatic?

A

Clinical follow-up without treatment

69
Q

How do you treat patients for the prevention of recurrence of SVT when the patient is symptomatic and is a candidate for catheter ablation?

A

Catheter ablation

70
Q

How do you treat patients for the prevention of recurrence of SVT when the patient is symptomatic, is not a candidate for catheter ablation, and does not have HFrEF?

A

-Beta-blockers, diltiazem, verapamil
-Flecainide, propafenone (CI in CAD)
-Catheter ablation if all else fails

71
Q

How do you treat patients for the prevention of recurrence of SVT when the patient is symptomatic, is not a candidate for catheter ablation, and has HFrEF (LVEF less than 40%)?

A

-Amiodarone, digoxin, dofetilide, sotalol
-Catheter ablation if all else fails

72
Q

What are the different types of ventricular arrhythmias?

A

-Premature ventricular complexes (PVCs)
-Ventricular tachycardia
-Ventricular fibrillation

73
Q

What are premature ventricular complexes?

A

-Wide QRS complexes
-Low prevalence in healthy population
-Prevalence increases with advancing age

74
Q

What are simple premature ventricular complexes?

A

Isolated single PVCs

75
Q

What are paired premature ventricular complexes?

A

Couplets, two in a row

76
Q

What are bigeminy PVCs?

A

Every second beat

77
Q

What are trigeminy PVCs?

A

Every third beat

78
Q

What are quadrigeminy PVCs?

A

Every fourth beat

79
Q

Mechanism of PVCs

A

Increased automaticity of ventricular muscle cells/Purkinje fibers

80
Q

Risk factors for PVC

A

-Ischemic heart disease
-Myocardial infarction
-Anemia
-Hypoxia
-Cardiac surgery

81
Q

Symptoms of PVC

A

-Usually asymptomatic
-Frequent/repetitive PVCs can result in palpitations, dizziness, lightheadedness

82
Q

How to treat asymptomatic PVCs

A

Asymptomatic PVCs should not be treated

83
Q

How to treat symptomatic PVCs in patients who do not have CAD or HF

A

-Beta-blockers, diltiazem, or verapamil
-If unresponsive - antiarrhythmic drugs

84
Q

How to treat frequent symptomatic PVCs (>15% of beats) in patients who are unresponsive to beta-blockers, CCBs or antiarrhythmic drugs

A

Catheter ablation

85
Q

How to treat symptomatic PVCs in patients who have CAD

A

-Beta-blockers, diltiazem, or verapamil
-If unresponsive - antiarrhythmic drugs

86
Q

How to treat symptomatic PVCs in patients who have HF

A

Beta-blockers

87
Q

What is ventricular tachycardia?

A

-Regular rhythm
-Wide QRS complexes
-Defined as a series of 3 or more consecutive PVCs at a rate of over 100 bpm

88
Q

Types of ventricular tachycardia

A

-Nonsustained
-Sustained

89
Q

What is nonsustained ventricular tachycardia?

A

3 or more consecutive VPDs, terminates spontaneously

90
Q

What is sustained ventricular tachycardia?

A

-VT lasting more than 30 seconds
-Requires termination because of hemodynamic instability in less than 30 seconds

91
Q

What is sustained monomorphic VT in patients with no structural heart disease known as?

A

Idiopathic VT

92
Q

What is idiopathic VT sometimes responsive to?

A

Verapamil

93
Q

Ventricular tachycardia mechanism

A

-Increased ventricular automaticity
-Reentry

94
Q

Risk factors of ventricular tachycardia

A

-Coronary artery disease
-Myocardial infarction
-HFrEF
-Electrolyte abnormalities (hypokalemia, hypomagnesemia)
-Flecainide
-Propafenone
-Digoxin

95
Q

Symptoms of ventricular tachycardia

A

-May be asymptomatic (nonsustained VT)
-Palpitations
-Hypotension
-Dizziness
-Lightheadedness
-Syncope
-Angina

96
Q

What is the class 1 treatment to terminate VT in a patient with structural heart disease?

A

DCC

97
Q

What is the class 2a treatment to terminate VT in a patient with structural heart disease?

A

IV procainamide

98
Q

What is the class 2b treatment to terminate VT in a patient with structural heart disease?

A

IV amiodarone or IV sotalol

99
Q

What do you do when VT is terminated after the first treatment in a patient with structural heart disease?

A

Give therapy to prevent recurrence guided by underlying heart disease

100
Q

What do you do when VT is not terminated after the first treatment in a patient with structural heart disease?

A

DCC

101
Q

How do you treat verapamil-sensitive VT in a patient who does not have structural heart disease?

A

Verapamil

102
Q

How do you treat outflow tract VT in a patient who does not have structural heart disease?

A

beta-blocker

103
Q

What do you do when VT is terminated after the first treatment in a patient without structural heart disease?

A

Therapy to prevent recurrence

104
Q

What do you do when VT is not terminated after the first treatment in a patient without structural heart disease?

A

DCC

105
Q

What therapy is used to prevent recurrence of VT and sudden cardiac death?

A

-Implantable cardioverter-defibrillator
-Amiodarone
-Sotalol
-Catheter ablation

106
Q

What is ventricular fibrillation

A

-Irregular, disorganized, chaotic electrical activity
-No recognizable QRS complexes

107
Q

Risk factors of ventricular fibrillation

A

-Myocardial infarction
-HFrEF
-Coronary artery disease

108
Q

Symptoms of ventricular fibrillation

A

Syndrome of sudden cardiac death

109
Q

How do you terminate VT (or VT with no pulse)

A

-CPR for 2 minutes and obtain IV/IO access
-Defibrillation shock
-CPR for 2 minutes
-Epinephrine 1 mg IV/IO
-Defibrillation shock
-CPR for 2 minutes
-Amiodarone 300 mg IV/IO or lidocaine 1-1.5 mg/kg IV/IO
-After first dose of amio/lidocaine, every subsequent dose should be halved
-CPR should be occurring throughout the entire duration
-Continue pattern of defibrillation, shock, then CPR for 2 minutes, then epinephrine 1 mg IV every 3-5 minutes until patient is resuscitated or resuscitation attempt is terminated

Therapeutics III (42 decks)

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