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Flashcards in 40. Antiarrhythmics Deck (38):
1

Dronedarone carries boxed warning against use in which of the following types of patients: (Select ALL that apply.)

A. Class IV heart failure
B. Permanent atrial fibrillation
C. Recurrent atrial fibrillation
D. Paroxysmal atrial fibrillation
E. Peripheral arterial disease

A, B. Dronedarone has been shown to be associated with worse outcomes in patients with moderate-severe heart failure, and when used in patients with permanent atrial fibrillation.

dronedarone (Multaq): PO. with meals. Boxed warning: HF (NYHA Class IV or any with recent hospitalization) and in patients with permanent AFib. CI: 2nd/3rd degree heart block, symptomatic heart failure, HR<50, concomitant use of strong 3A4 inhbitors and drugs that prolong QT, QT≥500ms, PR interval>280ms, lung or liver toxicity, severe hepatic impairment, pregnancy (X), nursing mothers. Warning: hepatic failure, lung disease, marked increase in SCr, prerenal azotemia, heart failure and acute renal failure have been reported in setting of HF or hypovolemia, hypokalemia, hypomagnesemia, concomitant administration of K-depleting diuretics. SE: QT prolongation, increase SCr, nausea, vomiting, abdominal pain, diarrhea, bradycardia, dermatitis, asthenia

2

Jack is a 77 year-old male with heart failure who is receiving a new prescription for amiodarone. The pharmacist will counsel the patient on risks to these organs with amiodarone therapy:

A. Liver, kidney, and eyes
B. Liver, colon, and kidney
C. Kidney, gall bladder, and CNS
D. Thyroid, pancreas, and liver
E. Thyroid, liver, and lungs

E. The patient should receive baseline laboratory function tests of these organs.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

3

A patient is beginning digoxin 0.125 mg daily. The patient has mild renal insufficiency. After a few weeks, the patient develops an infection with nausea and vomiting. She is weak, dehydrated and bradycardic. The patient is admitted to the hospital. Which of the following statements are correct? (Select ALL that apply.)

A. Hyperkalemia may increase the risk of digoxin toxicity more than hypokalemia.
B. Digoxin is mainly eliminated by the kidney and decreased renal function can lead to supratherapeutic levels.
C. An elevated digoxin level can worsen nausea and vomiting.
D. Mental confusion and bradycardia can be caused by an elevated digoxin level.
E. Digoxin toxicity should be treated with beta-agonists.

B, C, D. Digoxin is renally eliminated; elevated levels can cause nausea/vomiting as well as mental confusion and bradycardia.

digoxin (Digox, Lanoxin): PO, IV. used for rate control but not first line. only reduces resting heart rate (not during exercise). inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR)therapeutic range for AFib = 0.8-2.0ng/mL. CI: ventricular fibrillation. Warning: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome with AFib. SE: dizziness, mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

4

What class of antiarrhythmic is amiodarone in according to the Vaughn Williams classification system?

A. Ia
B. Ib
C. Ic
D. III
E. IV

D.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

5

Which of the following drugs is used to control ventricular rate in a patient presenting in atrial fibrillation with a rapid ventricular response?

A. Quinidine
B. Digoxin
C. Sotalol
D. Procainamide
E. Mexiletine

B. Digoxin acts to slow AV nodal conduction through a vagal effect. Although not effective for preventing exercise induced increases in heart rate, it does decrease resting heart rate. Although sotalol has beta-blocking effects, it is used to maintain sinus rhythm (rhythm control agent), not as ventricular rate controlling agent.

digoxin (Digox, Lanoxin): PO, IV. used for rate control but not first line. only reduces resting heart rate (not during exercise). inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR)therapeutic range for AFib = 0.8-2.0ng/mL. CI: ventricular fibrillation. Warning: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome with AFib. SE: dizziness, mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

6

Conrad is a 60 year-old obese male whose total cholesterol measured 312 mg/dL several years ago. He believed that high cholesterol was his only medical condition because that is all the doctor had mentioned. He refused medicine because he felt fine. The only thing he takes is a daily aspirin and one or two fish oil capsules. Recently, Conrad cut off a finger by accident while working in his wood shop. When he arrived at the hospital, he was in atrial fibrillation and was started on digoxin.  Which of the following statements regarding digoxin is correct?

A. Digoxin decreases vagal tone which reduces the resting heart rate.
B. Digoxin dose should be decreased by 25% when switching from oral to IV
C. Digoxin blocks the K+/H+ ATPase pump
D. Digoxin is pregnancy category X.
E. Digoxin has a short half-live of 2 hours.

B. Digoxin enhances vagal tone, blocks the Na+/H+ ATPase pump, has a ~24-48 hour half-life and is pregnancy category C.

digoxin (Digox, Lanoxin): PO, IV. used for rate control but not first line. only reduces resting heart rate (not during exercise). inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR)therapeutic range for AFib = 0.8-2.0ng/mL. CI: ventricular fibrillation. Warning: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome with AFib. SE: dizziness, mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

7

What class of antiarrhythmic is verapamil in according to the Vaughn Williams classification system?

A. Ia
B. Ib
C. Ic
D. III
E. IV

E.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

8

A patient presents with a supraventricular tachycardia. The rhythm is terminated with adenosine. Which of the following correctly describes adenosine's pharmacology?

A. Beta-1 receptor agonist
B. Calcium channel antagonist
C. Potassium channel agonist
D. Sodium channel antagonist
E. Adenosine receptor agonist

E. Adenosine works by activating A1 receptors in the AV node, causing transient AV block which can terminate re-entrant arrhythmias involving the AV node.

adenosine (Adenocard): IV. activates adenosine-1 receptors to slow conduction through AV node. used in paroxysmal supraventricular tachycardia. 2nd/3rd degree heart block, sick sinus syndrome, symptomatic bradycardia, bronchospastic lung disease. SE: transient new arrhythmia, facial flushing, chest pain/pressure, neck discomfort, dizziness, headache, GI distress, transient decrease in blood pressure, dyspnea

9

Jack has been using amiodarone for nine months. Long-term therapy with amiodarone can cause the following thyroid problems: (Select ALL that apply.)

A. Hypothyroidism, as demonstrated by a high TSH and low FT4
B. Hypothyroidism, as demonstrated by a low TSH and high FT4
C. Hyperthyroidism, as demonstrated by a low TSH and high FT4
D. Hyperthyroidism, as demonstrated by a high TSH and low FT4
E. Amiodarone does not affect the thyroid

A, C. The incidence of amiodarone-induced thyroid dysfunction is about 4% of patients. The effects range from abnormal thyroid function test findings to overt thyroid dysfunction, which can manifest as either hyperthyroidism or hypothyroidism. All patients using amiodarone should have the thyroid function monitored (by the primary parameters FT4 and TSH), along with symptoms.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

10

Sotalol is classified in which Vaughan Williams class?

A. Ia
B. Ib
C. Ic
D. II
E. III

E. Although sotalol has beta-blocking effects, it is a potent potassium channel blocker and is classified as a class III antiarrhythmic.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

11

Which Vaughan Williams classification represents agents that bind to Na+ channels for a prolonged period of time (long-acting)?

A. Ia
B. Ib
C. Ic
D. II
E. III

C.

Primary Ion Channels

Class Ia – intermediate DoA: Na blocker

Class Ib – fast DoA: Na blocker

Class Ic – long DoA: Na blocker

Class II: beta blockers (indirect calcium channel blockers)

Class III: potassium channel blockers

Class IV: calcium channel blockers (direct)

"Some block potassium channels" = sodium blocker, beta blocker, potassium blocker, calcium blocker

Class I and III are rhythm control: convert/maintain normal sinus rhythm

Class II and IV are rate control

12

Multaq has a warning against use with any of the following medications: voriconazole, ritonavir, telithromycin, ketoconazole, itraconazole, clarithromycin, cyclosporine and grapefruit. Which statement correctly describes the risk if Multaq is administered with any of these medications?

A. This statement is incorrect; Multaq is preferred because it has few significant drug interactions.
B. These are strong CYP 3A4 inducers; Multaq is a 3A4 substrate and concurrent use would increase the concentration and could cause an arrhythmia and other adverse reactions.
C. These are strong CYP 3A4 inhibitors; Multaq is a 3A4 substrate and concurrent use would increase the concentration and could cause an arrhythmia and other adverse reactions.
D. If administered together, the patient is at high risk for hypersensitivity.
E. If administered together, the concentration of Multaq would decrease and the arrhythmia would not be treated.

C. Both dronedarone (Multaq) and amiodarone are CYP 3A4 substrates; do not use with 3A4 inhibitors.

dronedarone (Multaq): PO. with meals. Boxed warning: HF (NYHA Class IV or any with recent hospitalization) and in patients with permanent AFib. CI: 2nd/3rd degree heart block, symptomatic heart failure, HR<50, concomitant use of strong 3A4 inhbitors and drugs that prolong QT, QT≥500ms, PR interval>280ms, lung or liver toxicity, severe hepatic impairment, pregnancy (X), nursing mothers. Warning: hepatic failure, lung disease, marked increase in SCr, prerenal azotemia, heart failure and acute renal failure have been reported in setting of HF or hypovolemia, hypokalemia, hypomagnesemia, concomitant administration of K-depleting diuretics. SE: QT prolongation, increase SCr, nausea, vomiting, abdominal pain, diarrhea, bradycardia, dermatitis, asthenia

13

What phase of the cardiac action potential does propranolol mainly work?  

A. Phase 0
B. Phase 1
C. Phase 2
D. Phase 3
E. Phase 4

C. Propranolol works mainly on phase 2 of the cardiac action potential.

Phase 0 is depolarization (Na channels open, Na enters)

Phase 1 is peak (Na channels close)

Phase 2 is plateau (Ca channel opens, K channel opens, Ca enters, K exits)

Phase 3 is repolarization (Ca channel closes, K exits)

Phase 4 is automaticity (slow increase in potential)

14

What class of antiarrhythmic is mexiletine in according to the Vaughn Williams classification system?

A. Ia
B. Ib
C. Ic
D. III
E. IV

B.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

15

A patient was using furosemide 40 mg twice daily (at 8 am and 12 noon) for heart failure. The doctor forgot to call in a prescription for potassium when he called the pharmacy to order the furosemide. The patient’s other medications include carvedilol, digoxin and aspirin. The patient ran out of the potassium. The patient is at increased risk for:

A. Digoxin toxicity
B. Carvedilol toxicity
C. Aspirin toxicity
D. Furosemide toxicity
E. None of the above

A. Hypokalemia may increase the risk of digoxin toxicity. The potassium must be kept within the normal physiologic range when using digoxin.

digoxin (Digox, Lanoxin): PO, IV. used for rate control but not first line. only reduces resting heart rate (not during exercise). inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR)therapeutic range for AFib = 0.8-2.0ng/mL. CI: ventricular fibrillation. Warning: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome with AFib. SE: dizziness, mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

16

What phase of the cardiac action potential does quinidine mainly work?  

A. Phase 0
B. Phase 1
C. Phase 2
D. Phase 3
E. Phase 4

A. Quinidine works mainly on phase 0 of the cardiac action potential.

Phase 0 is depolarization (Na channels open, Na enters)

Phase 1 is peak (Na channels close)

Phase 2 is plateau (Ca channel opens, K channel opens, Ca enters, K exits)

Phase 3 is repolarization (Ca channel closes, K exits)

Phase 4 is automaticity (slow increase in potential)

17

What phase of the cardiac action potential does amiodarone mainly work?  

A. Phase 0
B. Phase 1
C. Phase 2
D. Phase 3
E. Phase 4

D. Amiodarone works mainly on phase 3 of the cardiac action potential.

Phase 0 is depolarization (Na channels open, Na enters)

Phase 1 is peak (Na channels close)

Phase 2 is plateau (Ca channel opens, K channel opens, Ca enters, K exits)

Phase 3 is repolarization (Ca channel closes, K exits)

Phase 4 is automaticity (slow increase in potential)

18

A patient who works in the fields of a farm is seen by his primary care physician for a blue-grey skin discoloration of the face and forearms. The patient states that he normally wears a hat, a short-sleeved shirt, and pants when working. Which antiarrhythmic is the patient likely receiving?

A. Procainamide
B. Lidocaine
C. Ibutilide
D. Sotalol
E. Amiodarone

E. Amiodarone is known to be associated with photosensitivity which results in a blue-grey skin discoloration in regions of the skin exposed to sunlight. Patients should be counseled to minimize direct exposure to sunlight, to utilize a sunblock when outside, and to wear full-length sleeved shirts and pants and hat to reduce the risk.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

19

Which of the following are commonly cited side effects of amiodarone therapy? (Select ALL that apply.)

A. Hemolytic anemia
B. Taste perversions
C. Hypothyroidism
D. Microdeposits in the cornea
E. Photosensitivity

C, D, E.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

20

A patient has a long QT interval. She is at risk for fatal arrhythmias. Which of the following medications carries the lowest risk of further QT prolongation?

A. Quinidine
B. Procainamide
C. Dofetilide
D. Diltiazem
E. Amiodarone

D. The most potent prolongers of the QT interval are two subsets of the anti-arrhythmic drugs: the class Ia and the class III agents.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

21

Which of the following statements regarding amiodarone is correct?

A. Long intravenous infusions should be administered in a non-PVC containing bag.
B. Amiodarone is available as an oral tablet, oral solution and intravenous injection.
C. Amiodarone is pregnancy category X.
D. Amiodarone is safe to use in cardiogenic shock since it has no effect on blood pressure.
E. Amiodarone is a Class Ia antiarrhythmic.

A.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

22

What class of antiarrhythmic does disopyramide belong to according to the Vaughn Williams classification system?

A. Ia
B. Ib
C. Ic
D. III
E. IV

A.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

23

Jack is a 77 year-old male with heart failure. His current medications include Digox 0.25 mg daily, Lasix 40 mg daily, Coreg CR 20 mg daily, Mevacor 80 mg with dinner and lisinopril 40 mg daily. Jack has a diagnosis of NYHA Class III heart failure, dyslipidemia and hypertension. He smokes ½ pack of cigarettes daily. Current labs: K+ = 3.2 mEq/L, SCr = 1.4 mg/dL, BUN 43 mg/dL. The pharmacist has received a faxed prescription for Cordarone. Before the prescription for Cordarone is filled, the pharmacist should call the doctor to decrease the dose of which of the following medications? (Select ALL that apply.)

AMevacor
BLisinopril
CCoreg CR
DDigox
ELasix

A, D. Cordarone is an inhibitor of CYP 2C9, 2D6, 3A4 and p-glycoprotein. When starting Cordarone, the Digox dose must be decreased by 30-50%. Mevacor should not exceed a maximum daily dose of 40 mg in patients on Cordarone.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life.(40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

24

Jack has been using amiodarone for fifteen months and developed hypothyroidism. His doctor switches him to Multaq to try and alleviate the problem. The doctor has read that Multaq is not quite as effective as amiodarone, but may have less pulmonary, vision and thyroid toxicities. The correct generic name for Multaq is:

A. Tocainide
B. Flecainide
C. Dofetilide
D. Mexilitine
E. Dronedarone

E. The generic name of Multaq is dronedarone.

dronedarone (Multaq): PO. with meals. Boxed warning: HF (NYHA Class IV or any with recent hospitalization) and in patients with permanent AFib. CI: 2nd/3rd degree heart block, symptomatic heart failure, HR<50, concomitant use of strong 3A4 inhbitors and drugs that prolong QT, QT≥500ms, PR interval>280ms, lung or liver toxicity, severe hepatic impairment, pregnancy (X), nursing mothers. Warning: hepatic failure, lung disease, marked increase in SCr, prerenal azotemia, heart failure and acute renal failure have been reported in setting of HF or hypovolemia, hypokalemia, hypomagnesemia, concomitant administration of K-depleting diuretics. SE: QT prolongation, increase SCr, nausea, vomiting, abdominal pain, diarrhea, bradycardia, dermatitis, asthenia

25

Which of the following antiarrhythmics are pregnancy category X? (Select ALL that apply).

A. Nexterone
B. Tikosyn
C. Brevibloc
D. Betapace
E. Multaq

E. Multaq is pregnancy category X.

dronedarone (Multaq): PO. with meals. Boxed warning: HF (NYHA Class IV or any with recent hospitalization) and in patients with permanent AFib. CI: 2nd/3rd degree heart block, symptomatic heart failure, HR<50, concomitant use of strong 3A4 inhbitors and drugs that prolong QT, QT≥500ms, PR interval>280ms, lung or liver toxicity, severe hepatic impairment, pregnancy (X), nursing mothers. Warning: hepatic failure, lung disease, marked increase in SCr, prerenal azotemia, heart failure and acute renal failure have been reported in setting of HF or hypovolemia, hypokalemia, hypomagnesemia, concomitant administration of K-depleting diuretics. SE: QT prolongation, increase SCr, nausea, vomiting, abdominal pain, diarrhea, bradycardia, dermatitis, asthenia

26

What is the therapeutic range for digoxin when treating atrial fibrillation?

A. 3 - 5 mcg/mL
B. 0.5 - 0.9 ng/mL
C. 0.5 - 0.9 mcg/mL
D. 0.8 - 2 ng/mL
E. 0.8 - 2 mcg/mL

D. Therapeutic range of digoxin for atrial fibrillation is 0.8 - 2 ng/mL.

digoxin (Digox, Lanoxin): PO, IV. used for rate control but not first line. only reduces resting heart rate (not during exercise). inhibits Na/K ATPase pump which results in positive inotropic effect (increase CO) and provides negative chronotropic effect (decrease HR)therapeutic range for AFib = 0.8-2.0ng/mL. CI: ventricular fibrillation. Warning: 2nd/3rd degree heart block, Wolff-Parkinson-White syndrome with AFib. SE: dizziness, mental disturbances, headache, diarrhea, nausea, vomiting. Signs of toxicity: nausea/vomiting, loss of appetite, bradycardia, blurred/double vision, altered color perception, abdominal pain, confusion, delirium, arrhythmia. Antidote: DigiFab. Therapeutic range for HF: 0.5-0.9ng/mL (higher range for AFib). Decrease dose when CrCl<30. Hypokalemia, hypomagnesemia, and hypercalcemia increase risk of digoxin toxicity.

27

Which of the following medications are first-line treatment of ventricular rate in atrial fibrillation patients?

A. Calcium channels blockers
B. Sodium channel blockers
C. Beta blockers
D. Alpha blockers
E. Potassium channel blockers

C. Beta blockers are first-line for the treatment of atrial fibrillation for controlling ventricular rate.

Atrial fibrillation: 4 types of AFib, use rate control to slow ventricular rate (use beta blockers and CCBs), use rhythm control such as direct current cardioconversion (more effective than drugs) to terminate AFib and restore normal sinus rhythm, goal resting HR <80 in symptomatic patients (may be reasonable HR <110 if patient is asymptomatic and has preserved LF function)

 

28

The half-life of amiodarone is:

A. 4 hours
B. 24 hours
C. 7 days
D. 60 days
E. 1 year

D. Amiodarone's half life is roughly 60 days.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life (40-60 days) Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

29

A patient comes into the emergency department with mental confusion and states he does not feel well as his right hand is covering his heart.  His blood pressure is 154/89 and his pulse is 155 BPM.  ECG reading indicates a tachyarrhythmia.  Past medical history is unknown.  What should be done next to optimize care of this patient?

A. Tell him this is not serious; go home and call your cardiologist in the morning
B. Obtain laboratory parameters such as electrolytes and obtain a toxicology screen
C. Observe the ECG for 2 more hours and see if the condition worsens
D. Start the patient on intravenous amiodarone
E. Sedate the patient and provide direct current cardioversion

B. Before deciding on starting medication for any non life-threatening arrhythmia, electrolytes and a toxicology screen should be obtained to rule out these as potential causes of the arrhythmia.

30

A patient with heart failure uses lisinopril, carvedilol, spironolactone, furosemide, clopidogrel, digoxin, cholestyramine and potassium. He was recently diagnosed with atrial fibrillation. Which agent is preferred to control the patient's heart rhythm?

A. Verapamil
B. Amiodarone
C. Adenosine
D. Quinidine
E. Procainamide

B. Amiodarone is a preferred anti-arrhythmic for patients with heart failure.

amiodarone (Cordarone, Pacerone, Nexterone): PO, IV. infusions longer than 2 hours need non-PVC. drug of choice in HF patients. long half life (40-60 days). Boxed warning: only for life-threatening arrhythmias due to toxicity (patients should be hospitalized when therapy is initiated), pulmonary toxicity, liver toxicity, exacerbation of arrhythmias. CI: severe sinus-node dysfunction, 2nd/3rd degree heart block, bradycardia causing syncope, cardiogenic shock, hypersensitivity to iodine. SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, GI upset, constipation, peripheral neuropathy, tremor, hypo/hyper-thyroidism (more hypo), optic neuritis, pulmonary fibrosis, photosensitivity, increase LFts, slate blue (blue-grayish) skin discoloration, pregnancy (D). when starting amiodarone, decrease digoxin dose by 50% and warfarin by 30-50%.

31

Which of the following antiarrhythmics is most notable for causing drug-induced lupus erythematosus?

A. Digoxin
B. Adenosine
C. Quinidine
D. Dofetilide
E. Procainamide

E.

procainamide: IV. active metabolite called NAPA is renally cleared (reduce dose if CrCl <50). Boxed warning: fatal blood dyscrasias (agranulocytosis), leads to positive ANA test resulting in DILE (30%), myocardial infarction patients with asymptomatic non-life-threatening ventricular arrhythmias did not benefit (CAST trial). CI: 2nd/3rd degree heart block, SLE, torsade de pointes, procaine or other ester-type local anesthetics. SE: hypotension, rash, lupus-like syndrome, QT prolongation

32

To which Vaughan Williams classification does esmolol belong?

A. Ia
B. Ib
C. Ic
D. II
E. III

D.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

33

Which of the following is a class Ib antiarrhythmic according to the Vaughn Williams classification system?

A. Procainamide
B. Lidocaine
C. Ibutilide
D. Atenolol
E. Dronedarone

B.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

34

What class of antiarrhythmic is propafenone in according to the Vaughn Williams classification system?

A. Ia
B. Ib
C. Ic
D. III
E. IV

C.

Ia: procainamide, disopyramide, quinidine

Ib: lidocaine, mexiletine

Ic: flecainide, propafenone

"police department questions liquored man for peeing"

II: beta blockers

III: amiodarone, dronedarone, sotalol, ibutilide, dofetilide "after drinking scotch in dark"

IV: diltiazem, verapamil

35

What is the goal resting heart rate in patients with symptomatic atrial fibrillation, particularly if they have left ventricular dysfunction?

A. HR < 150 BPM
B. HR < 110 BPM
C. HR < 100 BPM
D. HR < 80 BPM
E. HR < 60 BPM

D.

Atrial fibrillation: 4 types of AFib, use rate control to slow ventricular rate (use beta blockers and CCBs), use rhythm control such as direct current cardioconversion (more effective than drugs) to terminate AFib and restore normal sinus rhythm, goal resting HR <80 in symptomatic patients (may be reasonable HR <110 if patient is asymptomatic and has preserved LF function)

36

The primary pathway of metabolism of procainamide is:

A. Oxidation
B. Esterification
C. Glucuronidation
D. Acetylation
E. Sulfation

D. Procainamide is metabolized in the liver by acetylation to N-acetylprocainamide (NAPA), an active metabolite. Both compounds contribute to the efficacy of the drug as an antiarrhythmic. Due to ethnic and individual differences in acetylation status, the ratio of procainamide and NAPA is different in each patient.

37

For a patient being initiated on dofetilide, which of the following are considered mandatory monitoring parameters that must be documented? (Select ALL that apply.)

A. Magnesium
B. Potassium
C. ECG
D. Liver function tests
E. Renal function

A, B, C, E. Dofetilide must be initiated in a hospitalized setting. The initial dose is chosen and adjusted based on the patient's renal function and QT-interval duration.

dofetilide (Tikosyn): PO. Boxed warning: must be initiated (or reinitiated) in a setting with continuous ECG monitoring for minimum of 3 days or 12 hours after cardioversion. CI: congenital/acquired QT syndrome, concurrent use of dolutegravir, HCTZ, itraconazole, ketoconazole, megestrol, prochlorperazine, trimethoprim, verapamil, HR<50, CrCl<20, QT>440ms. SE: headache, dizziness, ventricular tachycardias, QT prolongation

38

List the following statements regarding the normal electrical conduction pathway of the heart in the order they occur.  Please select and move each statement with your cursor or mouse.

A. SA node
B. AV node
C. Bundle of His
D. Right and left bundle branches
E. Purkinje fibers

A, B, C, D, E.

Decks in Pharmacy Class (61):