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Pharm II Exam 3 > Anti-arrhythmic drugs: Vfib, Bradycardia, Cardiac arrest > Flashcards

Anti-arrhythmic drugs: Vfib, Bradycardia, Cardiac arrest Flashcards

1
Q

What is cardiac arrest?

A

Cessation of cardiac mechanical activity (pulseless, unresponsive, apneic)

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2
Q

Half of cardiac arrests happen where?

A

Outside of the hospital (in public, witnessed or non-witnessed)

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3
Q

Survival rates of cardiac arrest?

A

Low, higher w/ witnessed arrest (7-8%)

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4
Q

Hospital survival rates of cardiac arrest?

A

Higher due to rapid response, defibrillation, if shockable rhythm

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5
Q

What are the most common etiologies in adult arrest?

A

VFib and pulseless Vtach
(typically ischemic heart disease, blood is fully oxygenated at arrest)

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6
Q

What are the most common etiologies in pediatric arrest?

A

Pulseless electrical activity (PEA) and asystole
(typically acute respiratory failure, asphyxiation, patient is typically hypoxemic/hypotensive)

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7
Q

Which drugs affect phase 0 of the cardiac cycle (Na+ inward flow/depolarozation)?

A

Na+ channel blockers
Strong: Flecainide, Propafenone
Moderate: Quinidine, Procainimide, Mexiletine
Weak: Lidocaine, Phenytoin

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8
Q

Which drugs affect phase 2 of the cardiac cycle (Ca2+ inward flow, K+ outward flow, Plateau phase)?

A

CCBs: Verapamil, Diltiazem

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9
Q

Which drugs affect phase 3 of the cardiac cycle (K+ outward flow, Ca2+ starts to close, Rapid repolarization)?

A

K+ channel blockers: Amiodarone, Sotalol

Also Dofetilide, Dronedarone

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10
Q

Which drugs affect phase 4 of the cardiac cycle (resting potential)?

A

BBs: Propanolol, Metoprolol, Atenolol, Esmolol

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11
Q

What are relatively stable tachycardias?

A

Sinus tachy, AV-nodal re-entry SVT

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12
Q

Are relatively stable tachycardias easier to manage with rate control?

A

Yes

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13
Q

How to manage patient with symptomatic tachycardia that is unstable?

A

Synchronized cardioversion

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14
Q

How to manage patient with acute symptomatic tachycardia that is stable?

A

Determine if QRS is wide or narrow
If narrow: (<120) w/ regular ventricular rhythm –>Adenosine is drug of choice, if failure to respond –> BB (IV esmolol, PO metoprolol or atenolol) or CCB (Non-DHPs)

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15
Q

Avoid Adenosine in what kind of tachycardia?

A

Unstable (narrow or wide) or irregular

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16
Q

How to manage a stable patient with symptomatic tachycardia w/ narrow complex, A-fib, SVT, or sinus tachy w/ irregular ventricular rhythm (usually A-fib)?

A

General: focus on control of rapid ventricular rate (BB or CCB preferred), goal HR <110bpm

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17
Q

How to manage an unstable patient with symptomatic tachycardia w/ narrow complex (A-fib, SVT, or sinus tachy) w/ irregular ventricular rhythm?

A

Cardioversion preferred (can be electrical or pharmacologic)

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18
Q

If A-fib is present for more than 48 hours (time is takes for a clot to form), what is the patient at risk for?

A

Cardioembolic event, get TEE to rule out emboli

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19
Q

Which BBs are B-1 selective?

A

Esmolol, Metoprolol, Atenolol

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20
Q

What are beta-blocker blues?

A

Fatigue/depression that may occur as a result of BB therapy

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21
Q

What are the unstable tachycardias?

A

Wide-complex monomorphic VT, Torsades de pointes

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22
Q

How are unstable tachycardias managed?

A

Carefully managed w/ multiple agents including antiarrhythmetics

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23
Q

Symptomatic tachycardias with a wide complex (>120ms) are usually what?

A

Ventricular arrhythmias

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24
Q

Which medications can be used in V-tach with regular rhythm?

A

-Adenosine first line (ONLY IF REGULAR RATE), avoid if unstable/irregular!!!
-Procainamide, Amiodarone, or Sotalol (If QTc is <500)

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25
Q

Which is the risk of V-tach with irregular rhythm and QTc >500 ?

A

Usually can turn into Torsades

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26
Q

How to manage V-tach with irregular rhythm and unstable vitals?

A

Immediate defibrillation

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27
Q

Treatment of V-tach with irregular rhythm and QTc >500 that turns into Torsades?

A

Magnesium sulfate bolus (trying to correct electrolytes and stabilize action potential)

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28
Q

What meds should be withdrawn in V-tach w/ irregular rhythm if QTc >500?

A

Any QT-prolonging meds:
-Antiarrhythmics (class I & III) outside of Amiodarone
*assess for drugs that can increase conc. of antiarrhythmetics

-Antifungals: Fluconazole
-Macrolides: Erythromycin
-Quinolones: Levofloxacin
-Antipsychotics: Haldol, Ziprasidone
-Anti-nausea: Droperidol, Promethazine

29
Q

How can digoxin be dangerous?

A

Narrow therapeutic window, can cause toxicity easily

30
Q

Which BBs are non-specific, and can be dangerous with athsma?

A

Natolol, Propanolol

31
Q

What is QTc prolongation?

A

Delayed repolarization of the ventricles, heart takes longer to contract/relax

32
Q

Goal of Adenosine bolus?

A

Trying to get patient back to NSR

33
Q

Usually an irregular ventricular rhythm w/ a narrow complex is caused by what?

A

A-fib

34
Q

Usually an irregular ventricular rhythm w/ a narrow complex is caused by what?

A

A-fib

35
Q

Procainamide is what class of antiarrhythmetic?

A

Class Ia

36
Q

MOA of Procainamide?

A

Includes blockade of Na+ channels of the heart muscle

37
Q

Procainamide adjustment for geriatric population?

A

None, use adult dosing

38
Q

Renal and Hepatic adjustments for Procainamide?

A

None

39
Q

ROA of Procainamide?

A

IV bolus over 30-60 min

40
Q

Side effects of Procainamide?

A

Diarrhea, loss of strength/energy, vomiting, hypotension, dizziness, fatigue

41
Q

Every antiarrhythmetic can cause QTc prolongation, with the exception of what medication?

A

Amiodarone

42
Q

How does amiodarone bring the body back to NSR?

A

Extending the next repolarization

43
Q

Can Sotalol be used in acute renal failure?

A

NO

44
Q

VFib and Pulseless VT have a better survival and less comorbidity with what?

A

Early CPR and defibrillation

45
Q

During AED preparation for Vfib and pulseless VTach, what should be ongoing?

A

CPR

46
Q

After 2 minutes of compressions in Vfib and pulseless Vtach, check what?

A

Rhythm and pulse

47
Q

What can improve survival of out-of-hospital VF and pulseless VT?

A

AED

48
Q

Can an airway be established without interrupting compressions in VFib/Pulseless Vtach?

A

Yes

49
Q

1st line pharmacotherapy for VF/Pulseless VT?

A

Epinephrine IV (after CPR/defibrillation shock 1 and 2 and CPR)

50
Q

MOA of Epinephrine?

A

Potent alpha-1 & beta-1 agonist

51
Q

What is a second agent that can be added to a shockable rhythm after the administration of cpr/defib/epi if needed?

A

Amiodarone IV

52
Q

What is bradycardia?

A

Symptomatic patient with HR <50bpm

53
Q

How to manage bradycardia?

A

Treat underlying cause, establish airway, IV access
-identify hypotension, mental status changes, cardiovascular collapse

54
Q

Medication for bradycardia?

A

Treat w/ Atropine
(if ineffective, then administer dopamine or epinephrine)

55
Q

MOA of Atropine?

A

Antagonist, muscarinic R blocker (blocks parasympathetic pathway which is inhibitory)
causes excitatory event –> raises HR

56
Q

MOA of Dopamine?

A

Mixed alpha/beta agonist w/ D1 R agonist
*stimulates HR and force of contraction (has some vasoconstriction)

57
Q

Usually an irregular ventricular rhythm w/ a narrow complex is caused by what?

A

A-fib

58
Q

Most common drug that induces bradycardia?

A

Beta blockers

59
Q

If the patient has v-tach with regular rhythm and a QTc >500 what is the drug of choice?

A

Amiodarone (risk of torsades is low w this drug)

60
Q

Treatment for chronic nonsustained (intermittent) VT that is asymptomatic?

A

No tx required (unless post-MI or rHF - give BB)

61
Q

1st treatment for chronic nonsustained (intermittent) VT that is symptomatic?

A

Beta Blocker

62
Q

2nd line treatment for chronic nonsustained (intermittent) VT that is symptomatic (if BB does not work)?

A

Non-dihydropyridine CCB
**ONLY IF NO STRUCTURAL HEART DZ (MI or rHF)

63
Q

What to add to therapy for chronic nonsustained (intermittent) VT that is symptomatic despite BB or Non-DHP CCB?

A

Antiarrhythmetic therapy
MC: Amiodarone, Flecainide, Propafenone, Sotalol

64
Q

If the patient has HFrEF, what is the preferred antiarrhythmetic for VT?

A

Amiodarone
(in addition to standard HFrEF therapy)

65
Q

If the patient has Chronic kidney disease, what med do we have to be cautious with ?

A

Sotalol: dosing must be reduced

66
Q

If the patient has QTc prolongation, which meds should be avoided?

A

Avoid antiarrhythmetics in QTc >500ms
**EXCEPT FOR AMIODARONE

67
Q

If an antiarrhythmetic is added to an ACS event, what may happen?

A

Can have poor outcomes (increase mortality)
If HAVE TO USE antiarrhythmetic: use amiodarone

68
Q

Although most antiarrhythmetics can be used for ventricular and atrial arrhythmias, which two drugs are used for A-fib ONLY?

A

Dofetilide, Dronedarone
**NOT TO BE USED IN VENTRICULAR ARRHYTHMIAS

Pharm II Exam 3 (6 decks)

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