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1- foundation year cardiovascular > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What are the 5 classes of anti-arrhythmic drugs?

A

~class I- Membrane stabilising drugs
~class II- beta-blocker
~class III- K+ channel blockers
~class IV- calcium channel blockers (rate limiting)
~others

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2
Q

What are the class I anti-arrhythmic drugs known as membrane stabilising drugs? 4 main drugs

A

disopyramide
lidocaine
flecainide/propafenone (contraindicated in asthma/severe COPD avoid in structural /ischeamic heart disease)

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3
Q

What are the class II anti-arrhythmic drugs known as beta-blockers?

A

propranolol, esmolol

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4
Q

What are the class III anti-arrhythmic drugs known as K+ channel blockers?

A

-amiodarone (4 weeks before &12 months after electrical cardioversion to increase success)
-sotalol
-dronedarone

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5
Q

What are the class IV anti-arrhythmic drugs known as CCB (rate limiting)?

A

-verapamil
-diltiazem (unlicensed)

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6
Q

What other anti-arrhythmic drugs are there?

A

-adenosine
-digoxin (effective in sedentary patients with non-paroxysmal AF and in patients with associative congestive HR)

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7
Q

What is atrial fibrillation?

A

abnormal, disorganised electrical signals fired cause the atria to quiver or fibrillate= rapid and irregular heart beat

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8
Q

what are some symptoms for AF?

A

-heart palpation’s
-dizziness
-shortness of breath
-tiredness

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9
Q

what can be some complications (other diseases-related) for AF?

A

stroke and heart failure

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10
Q

what the different types of AF? 3 types

A

-paroxysmal AF: EPISODES STOP WITHIN 48 HOURS WITHOUT TREATMENT
-persistent AF: episodes last >7 days
-permanent AF: present all the time

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11
Q

what are the 2 first steps for treatment in AF?

A

1) RATE CONTROL
2) RHYTHM CONTROL

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12
Q

what is reason for rate control in AF treatment?

A

controls ventricular rate

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13
Q

what is reason for rhythm control in AF treatment?

A

restore and maintain sinus rhythm

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14
Q

what is the treatment for rhythm control in AF?

A
  • electrical cardioversion or with pharmacological treatment (amiodarone/ flecainide
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15
Q

what is the preferred treatment for rhythm control and what are the additional notes for the use of a cardioversion?

A

-electrical preferred if >48 hours.
` due to risk of clotting have to wait until fully anticoagulated for 3 weeks before cardioversion and continue 4 weeks after
-if hemodynamically unstable =electrical cardioversion; give parenteral anticoagulant and rule out left atrial thrombus immediately before procedure

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16
Q

what drugs can be used as rhythm control after cardioversion if needed?

A

standard beta blocker
or
Sotalol, propafenone, amiodarone (can be started 4 weeks before and continued for 12 months after procedure to help success rate) of flecainide SPAF

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17
Q

What is THE TREATMENT FOR acute new-onset presentations for AF treatment in life threatening and non-life threatening scenarios?

A

-life threatening haemodynamic instability: electrical conversion
-without life threatening haemodynamic instability: <48 hours= rate and rhythm control (electrical or amiodarone/flecainide)
>48 hours=rate control (verapamil, betablocker)

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18
Q

what are the maintenance drugs treatment for AF?

A

first line= RATE CONTROL
-betablocker (not sotalol), rate limiting CCB, digoxin

second line=RHYTHM CONTROL
-beta-blocker or oral anti-arrhythmic drug (sotalol, amiodarone, flecainide, propafenone, dronedarone) (also given if rhythm control is still required post-cardioversion)

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19
Q

what is the treatment for paroxysmal and symptomatic AF? or they persist

A

-ventricular or rhythm control= standard beta blocker or oral anti-arrthmic drug
-if symptoms persist: SPAF drugs
-“PILL IN POCKET” if infrequent episodes- self treatment= flecainide or propafenone

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20
Q

What is the treatment for atrial flutter?

A

Similar treatment as AF

first line= RATE CONTROL
-betablocker (not sotalol), rate limiting CCB, digoxin

second line=RHYTHM CONTROL
-beta-blocker or oral anti-arrhythmic drug (sotalol, amiodarone, flecainide, propafenone, dronedarone) (also given if rhythm control is still required post-cardioversion)

BUT ABLATION MORE SUITABLE

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21
Q

What is the scoring system used for stroke prevention?

A

CHA2DS2VASC

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22
Q

what does CHA2DS2VASC stand for?

A

Congestive heart failure or Left ventricular dysfunction hypertension
age 75+ diabetes
stroke/TIA/venous thromboembolism history vascular disease
65-74 years sex category

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23
Q

when do you give anticoagulation when using CHA2DS2VASC score?

A

give anticoagulation if score is 2 or more

24
Q

what treatment can be given for diagnosed AF?

A

WARFARIN OR noac

25
Q

What are the different types of ventricular tachycardia?

A

-pulseless
-unstable
-stable
-non-sustained

26
Q

what is the treatment for pulseless?

A

immediate defibrillation + CPR; iv AMIODARONE IS GIVEN REFRACTORY TO DEFIBRILLATION

27
Q

what is the treatment for an unstable person in ventricular tachycardia?

A

direct current cardioversion. If this fails give IV amiodarone and repeat direct current

28
Q

what is the treatment for a stable person in ventricular tachycardia?

A

IV anti-arrhythmic drugs (amiodarone preferred)

29
Q

what is the treatment for a non-sustained ventricular tachycardia?

A

beta-blocker

30
Q

what is maintenance treatment for people at high risk of cardiac arrest?

A

-most patients= cardioverter defibrillator implant
-some patients also require a drug= sotalol, beta-blocker alone or beta-blocker with amiodarone

31
Q

what is the treatment for prolonged QT interval?

A

magnesium sulphate

32
Q

what can cause a prolonged QT interval?

A

sotalol, amiodarone, macrolides, haloperidol, SSRIs, TCAs, antifungals and drugs that cause hypOKalaemia and bradycardia

SAMSTAH=QT prolongation

33
Q

how do paroxysmal supraventricular tachycardia stop?

A

spontaneously or with reflex vagal nerve (immerse face in cold water, carotid sinus massage) stimulation

34
Q

what drugs can help treat paroxysmal supraventricular tachycardia stop?
cases for haemodynamically unstable or recurrent episodes?

A

IV adenosine (contraindicated in COPD/asthma)
therefore IV verapamil would work too

  • unstable= direct current cardioversion
    -recurrent episodes=catheter ablation OR drugs (verapamil, diltiaazem, beta-blocker
35
Q

what is amiodarone and the standard loading dosing for it?

A

-200mg TDS of 7 days
-200mg BD for 7 days and then
-200mg OD as maintenance

36
Q

when should amiodarone be avoided in?

A

bradycardia and heart block
as it slows heart rate

37
Q

what is amiodarone common eye side effects for it?

A

-corneal micro-deposits= can be reversed when stopped
-optic neuropathy/neuritis
(blindness)

38
Q

what is the counselling points for corneal micro-deposits and optic neuropathy/neuritis?

A

-corneal micro-deposits= night-time glares when driving
-optic neuropathy /neuritis= stop if impaired vision

39
Q

what is amiodarone common skin side effects for it?

A

-phototoxicity (burning, erythema)
-slate-grey skin on light-exposed areas

40
Q

what is the counselling points for phytotoxicity and slat-grey skin?

A

shield skin from light during treatment. Use wide-spectrum, high SPF sunscreen for months after stopping due to long half life

41
Q

what other upper body condition can amiodarone cause?

A

thyroid issues- can cause hypo or hyper due to iodine content

42
Q

what is amiodarone common nerve side effects?

A

peripheral neuropathy

43
Q

what is the counselling points for peripheral neuropathy?

A

be aware of numbness, tingling hands and feet and tremors

44
Q

what is amiodarone common lungs side effects?

A

pneumonitis, pulmonary fibrosis

45
Q

what is the counselling points for lung side effects?

A

be aware of shortness, dry cough

46
Q

what is amiodarone common liver side effects?

A

hepatotoxicity

47
Q

what is the counselling points for liver side effects?

A

jaundice, nausea, vomiting, malaise, itching, dark urine bruising, abdominal pain, 3x liver transaminase

48
Q

what is amiodarone common thyroid dysfunction side effects?

A

-hyperthyroidism (weight loss, heat intolerance, tachycardia)
=give carbimazole if necessary withdraw amiodarone
-hypothyroidism (weight gain, cold intolerance, bradycardia)
=start levothyroxine withdrawing amiodarone if essential

49
Q

what are some monitoring needed for amiodarone?

A

-annual eye test: annually
-chest x ray before treatment
-LFT every 6 months
-blood pressure and ECG
-serum potassium: before treatment
-thyroid function test: 6 monthly

-ECG and live transaminase if using IV

50
Q

what are some interactions with amiodarone?

A

-it has a extremely long T1/2- 50 days. there can be a danger of interactions several months after stopping

-increased plasma amiodarone conc=grapefruit
-amiodarone is an enzyme inhibitor= would interact with warfarin, phenytoin digoxin( so use half dose of digoxin) as they are CYP450 enzyme substrates
-drugs that cause hypokalemia
-increased risk of myopathy=statins
-bradycardia, AV block and myocardial depression=beta-blocker, rate limiting CCBs
-qt prolongation, increased risk of ventricular arrhythmia= quinolones, macrocodes, TCAS,SSRIs, lithium
quinine, hydroxchlotoquine, anti-malarias, antipsychotics
-its a

51
Q

what is the therapeutic levels of digoxin? when to measure levels? toxicity levels increase from when?

A

0.7-2ng/ml (check conc 6-12 hours after dose)
regular monitoring is not required during maintenance treatment unless toxicity suspected OR in renal impairment (really cleared)
-toxicity levels increase from 1.5-3ng/ml

52
Q

what is the doses for digoxin?

A

-loading doses required due to long T1/2
-maintenance once daily:
=atrial flutter and non-paroxysmal AF in sedentary patients 125-250mcg
=worsening or severe HF (in sinus rhythm) 62.5-125mcg
-different dosage frommes have different bioavailabilities
Elixir=75% tablets=90% IV 100%

53
Q

what are some of the signs of toxicity in digoxin?

A

-bradycardia/heart block
-nausea, vomiting and diarrhoea, abdominal pain
-blurred or yellow vision
-confusion, delirium
-rash
-depression

54
Q

what is treatment for signs of toxicity for digoxin?

A

withdrawal- correct electrolyte imbalances
Digoxin-specific antibody for life-threatening ventricular arrhythmias unresponsive to atropine

55
Q

what are some interactions for digoxin?

A

-hypOKalaemia predisposes to digoxin toxicity= diuretics (loop/thiazide), B2 agonist, steroids, theophylline (if K+ <4.5mmol/l give K+ supplements OR K+ sparing diuretics
-increased plasma digoxin conc when using with CYP450 ENZYME INHIBITORS means toxicity= amiodarone (half digoxin dose), rate limiting CCB, macrocodes, cyclosporin (enzyme inhibitors)
-decreased plasma digoxin conc using with CYP450 ENZYME inducers means sub-therapeutic= st johns wort, rifampicin
-Reduced renal excretion meaning toxicity= NSAIDs, ACE inhibitors/ARBs
-TCAs- can induce arrhythmias
-beta blockers-increase risk of AV block and increase plasma conc

56
Q

what is the acronyms for remembering the digoxin interactions?

A

CRASED
-CCB
-RIFAMPICIN
-AMIODARONE
-ST JOHNS WORT
-ERYTHOMYCIN
-DIURETICS

1- foundation year cardiovascular (7 decks)

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