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PHARMACY: Pre registration > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

What is a complication of AF?

A

Stroke

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2
Q

What are the two types of ‘control’ we can target AF management with?

A

Rate control or rhythm control

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3
Q

How would you react to an acute presentation of AF if New-onset, life threatening AF?

A

New-onset, life threatening AF should undergo emergency electrical cardio version without delaying achieve anti-coagulation

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4
Q

How would you react to an acute presentation of AF but NOT new-onset, life threatening AF?

A

Offer rate or rhythm control if less than 48 hours.

If more than 48 hours, rate control is preferred.

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5
Q

Give examples of pharmacological cardio version drugs:

A
  • IV amiodarone
    or
    flecainide

(amiodarone is preferred if there is structural disease)

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6
Q

What can you give if urgent rate control is required?

A

IV beta blocker or verapamil

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7
Q

What is the purpose of a cardio version?

A

To restore sinus rhythm - it can be either electrical or pharmacological

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8
Q

In a patient presenting with AF for over 48 hours, what type of cardio version is preferred?

A

Electrical cardioversion - not to be attempted until patient has been fully anti coagulated for at least 3 weeks

If this is not possible, a left atrial thrombus should be ruled out and parenteral anticoagulation (heparin) commenced immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks

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9
Q

What medication is used to control ventricular rate?

A

Standard beta blocker (not sotalol) or a rate limiting calcium channel blocker such as diltiazem or verapamil

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10
Q

When is digoxin effective in rate control?

A

Controlling ventricular rate at REST and should only be used as monotherapy in predominantly sedentary patients with non paroxysmal AF

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11
Q

Rate control is first line for AF, when would you consider adding in rhythm control?

A

If the dual combination of either a beta blocker, digoxin or diltiazem doesn’t control ventricular rate, you would then consider a rhythm control strategy

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12
Q

Is digoxin used when AF is accompanied by congestive heart failure?

A

Yes

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13
Q

What drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion?

A

consider a standard beta-blocker (not sotalol hydrochloride) as first-line treatment.

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14
Q

If a beta blocker is not appropriate or is ineffective in maintaining sinus rhythm (‘rhythm control’) post-cardioversion, what would you consider?

A

an alternative anti-arrhythmic drug such as;
- amiodarone hydrochloride, - flecainide acetate,
- propafenone hydrochloride,
or sotalol hydrochloride)

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15
Q

In what patients would you avoid flecainide and propafenone?

A

In patients with known ischaemic or structural heart disease and, for patients with left ventricular impairment or heart failure

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16
Q

When would you consider dronedarone for AF?

A

ay be considered as a second-line treatment option in patients with persistent or paroxysmal atrial fibrillation

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17
Q

What is the “pill in the pocket” approach and who is it for?

A

Selected patients with infrequent episodes of symptomatic paroxysmal atrial fibrillation, sinus rhythm.
It involves the patient taking an oral anti-arrhythmic drug to self-treat an episode of atrial fibrillation when it occurs.

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18
Q

What should all patients with atrial fibrillation (including those with continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm or catheter ablation) should be assessed for?

A

Their risk of stroke and the need for thromboprophylaxis; this needs to be balanced with the patient’s risk of bleeding

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19
Q

How do we assess stroke risk?

A

The CHA2DS2-VASc risk tool and bleeding risk using the ORBIT bleeding risk tool

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20
Q

What are the risk factors for stroke taken into account by CHA2DS2-VASc?

A

age, sex, and prior history of congestive heart failure, hypertension, stroke, transient ischaemic attacks (TIA), thromboembolic events, vascular disease, or diabetes mellitus

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21
Q

Based on the CHA2DS2-VASc, when would anti-coagulation be offered?

A

all patients with a CHA2DS2-VASc score of 2 or above, and be considered in men with a CHA2DS2-VASc score of 1; these scores should be reviewed at least annually

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22
Q

When would you give parenteral anti-coagulation to patients with new onset AF?

A

Those who are receiving subtherapeutic or no anticoagulation therapy, until assessment is made and appropriate anticoagulation is started

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23
Q

When would you offer oral anticoagulation to a patient with AF?

A

To patients with a confirmed diagnosis of atrial fibrillation in whom a stable sinus rhythm has not been successfully restored within 48 hours of onset; or where their risk of stroke outweighs their risk of bleeding; or who have had, or are at high risk of, recurrence of atrial fibrillation such as those with structural heart disease, a prolonged history of atrial fibrillation (more than 12 months), or a history of failed attempts at cardioversion.

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24
Q

Would you give a DOAC to someone with valvular AF?

A

Oral anticoagulation with a direct-acting oral anticoagulant such as apixaban, dabigatran etexilate, edoxaban, or rivaroxaban, is recommended in non-valvular atrial fibrillation.

If direct-acting oral anticoagulants are contra-indicated or unsuitable, offer a vitamin K antagonist such as warfarin sodium.

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25
Q

Is aspirin monotherapy used solely for stroke prevention?

A

No - this is not recommended

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26
Q

What is the purpose of atrial flutter treatment?

A

Controlling the ventricular rate or attempting to restore and maintain sinus rhythm. However, atrial flutter generally responds less well to drug treatment than atrial fibrillation.

27
Q

Ventricular rate can be controlled by administration of:

A
  • A beta-blocker, diltiazem hydrochloride [unlicensed indication], or verapamil hydrochloride; an intravenous beta-blocker or verapamil hydrochloride is preferred for rapid control.
  • Digoxin can be added if rate control remains inadequate, and may be particularly useful in those with heart failure.
28
Q

What is the best treatment for atrial flutter if it has been more than 48 hours?

A

Cardioversion - should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.

29
Q

How to relieve paroxysmal supraventricular tachycardia?

A

Vagal stimulation such as a Valsalva manoeuvre, immersing the face in ice-cold water, or carotid sinus massage;

such manoeuvres should be performed with ECG monitoring.

30
Q

If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, what should be given?

A

Intravenous adenosine should be given. If adenosine is ineffective or contra-indicated, intravenous verapamil hydrochloride is an alternative, but it should be avoided in patients recently treated with beta-blockers.

31
Q

Recurrent episodes of paroxysmal supraventricular tachycardia can be treated by catheter ablation, or prevented with drugs such as:

A
  • diltiazem hydrochloride
  • verapamil hydrochloride
  • beta-blockers including sotalol hydrochloride, flecainide acetate or propafenone hydrochloride.
32
Q

Bradycardia, particularly if complicated by hypotension, should be treated with:

A

An intravenous dose of atropine sulfate the dose may be repeated if necessary. If there is a risk of asystole, or if the patient is unstable and has failed to respond to atropine sulfate, adrenaline/epinephrine should be given by intravenous infusion, and the dose adjusted according to response.

33
Q

What should patients with unstable sustained ventricular tachycardia, who continue to deteriorate with signs of hypotension or reduced cardiac output receive?

A

direct current cardioversion to restore sinus rhythm. If this fails, intravenous amiodarone hydrochloride should be administered and direct current cardioversion repeated.

34
Q

What is Torsade de pointes?

A

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome (usually drug-induced, but other factors including hypokalaemia, severe bradycardia, and genetic predisposition are also implicated)

35
Q

How is torsade de pointes treated?

A

If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death.

Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered.

Anti-arrhythmics can further prolong the QT interval, thus worsening the condition.

36
Q

What are the four classes of anti arrhythmic drugs with examples:

A

Class I: membrane stabilising drugs (e.g. lidocaine, flecainide)

Class II: beta-blockers
Class III: amiodarone; sotalol (also Class II)
Class IV: calcium-channel blockers (includes verapamil but not dihydropyridines)

37
Q

What determines anti arrhythmic drug class?

A

Anti-arrhythmic drugs can be classified clinically into those that act on supraventricular arrhythmias (e.g. verapamil hydrochloride),
those that act on both supraventricular and ventricular arrhythmias (e.g. amiodarone hydrochloride),
and those that act on ventricular arrhythmias (e.g. lidocaine hydrochloride).

38
Q

What is the Vaughan Williams classification:

A

Anti-arrhythmic drugs can also be classified according to their effects on the electrical behaviour of myocardial cells during activity (the Vaughan Williams classification) although this classification is of less clinical significance:

39
Q

What is the treatment of choice for terminating paroxysmal supraventricular tachycardia?

A

Adenosine

40
Q

Does adenosine have a long half life:

A

No - very short 8-10 seconds

41
Q

Can adenosine be used after a beta blocker?

A

Yes - unlike verapamil

42
Q

What type of drug is digoxin?

A

A cardiac glycoside

43
Q

How does digoxin work in arrthymias?

A

Oral administration of a cardiac glycoside slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate.

44
Q

Cardiac glycoside contraindications:

A

Supraventricular arrhythmias associated with accessory conducting pathways (e.g. Wolff- Parkinson-White syndrome).

45
Q

Can verapamil be used with beta blockers?

A

NO - serious interaction

46
Q

Is verapamil effective for supra ventricular tachycardias?

A

Usually - initial iv dose followed by oral treatment

47
Q

Risks with large doses of verapamil?

A

Hypotension

48
Q

Contraindications of verapamil:

A

In AF and atrial flutter

49
Q

What drugs can achieve rapid control of ventricular rate:

A

Intravenous administration of a beta-blocker such as esmolol hydrochloride or propranolol hydrochloride, can achieve rapid control of the ventricular rate.

50
Q

Drugs for both supraventricular and ventricular arrhythmias include:

A

Amiodarone hydrochloride, beta-blockers, disopyramide, flecainide acetate, procainamide (available from ‘special-order’ manufacturers or specialist importing companies), and propafenone hydrochloride.

51
Q

What is amiodarone used for?

A

Amiodarone hydrochloride is used in the treatment of arrhythmias, particularly when other drugs are ineffective or contraindicated. It can be used for paroxysmal supraventricular, nodal and ventricular tachycardias, atrial fibrillation and flutter, and ventricular fibrillation. It can also be used for tachyarrhythmias associated with Wolff-Parkinson-White syndrome.

52
Q

Is amiodarone given orally or IV?

A

Amiodarone hydrochloride may be given by intravenous infusion as well as by mouth,

53
Q

What is good about amiodarone?

A

has the advantage of causing little or no myocardial depression. Unlike oral amiodarone hydrochloride, intravenous amiodarone hydrochloride acts relatively rapidly.

54
Q

What is intravenous amiodarone given for?

A

in cardiopulmonary resuscitation for ventricular fibrillation or pulseless tachycardia refractory to defibrillation.

55
Q

Is the half life of amiodarone long:

A

has a very long half-life (extending to several weeks) and only needs to be given once daily (but high doses can cause nausea unless divided). Many weeks or months may be required to achieve steady-state plasma-amiodarone concentration; this is particularly important when drug interactions are likely.

56
Q

how do beta blockers work as anti-arrthymic drugs:

A

Beta-blockers act as anti-arrhythmic drugs principally by attenuating the effects of the sympathetic system on automaticity and conductivity within the heart

57
Q

What is disopyramide used for and how does it work?

A

Disopyramide can be given by intravenous injection to control arrhythmias after myocardial infarction (including those not responding to lidocaine hydrochloride), but it impairs cardiac contractility. Oral administration of disopyramide is useful, but it has an antimuscarinic effect which limits its use in patients susceptible to angle-closure glaucoma or with prostatic hyperplasia.

58
Q

Drugs for supraventricular arrhythmias include:

A

adenosine, cardiac glycosides, and verapamil hydrochloride.

59
Q

Drugs for ventricular arrhythmias include:

A

Lidocaine

60
Q

Drugs for both supraventricular and ventricular arrhythmias include

A

amiodarone hydrochloride, beta-blockers, disopyramide, flecainide acetate, procainamide (available from ‘special- order’ manufacturers or specialist importing companies), and propafenone hydrochloride.

61
Q

Is IV amiodarone fast acting?

A

Yes

62
Q

What patients are disopyramide not recommended in?

A

Patients susceptible to angle closure glaucoma or with prostatic hyperplasia.

63
Q

What class of anti-arrhythmic is lidocaine?

A

I B

PHARMACY: Pre registration (18 decks)

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