A-Fib Flashcards by Jessyka Yard

this is the dominant pacemaker in the heart as it has the fastest rate of depolarization

SA node

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what is the path of conduction in the heart

SA node –> AV node –> bundle of HIS (left and right bundle branches) –> Purkinje fibres

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this wave on a normal ECG represents ventricular depolarization where the pressure inside the ventricles increase and the atrioventricular values shut

QRS

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this wave on a normal ECG represents atrial depolarization where the valves between the atria and ventricles open

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this wave on a normal ECG represents ventricle depolarization where the ventricle walls relax and recovers from the contraction

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what are the two ways arrhythmias can form

abnormal impulse formation
abnormal impulse conduction (due to ischemic tissue)

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with a normal sinus rhythm, where does the impulse originate from?

SA node

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this represents a normal rate

60-100bpm

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this represents a normal rhythm

normal ECG pattern

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this occurs when the atria are contracting too fast, thus the ventricles are not being filled properly resulting in a decreased cardiac output. this occurs above the ventricles. it results in unsynchronized atrial contractions and irregular activation of the ventricles. it is usually characterized by an “irregularly irregular” pulse (irregular rate and irregular rhythm)

AFib / supra ventricular tachycarida

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in AFib, erratic electrical impulses in the upper chambers of the heart (atria) cause those chambers to fibrillate or quiver. this results in an irregular and frequently rapid heart rate. the irregular, __________ pattern in the ECG show these impulses

sawtooth

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true or false: AFib is the most common arrhythmia and the risk increases with age

true

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true or false: routine screening is recommended for AFib

false

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true or false: if a patient is over 65 and they present to someone in the healthcare system, screening for A-fib should be done

true

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if there are any abnomarlaities in pulse palpitation, blood pressure monitoring, Apple Watch/smartphone readings, etc. the patient should be referred to have this done

12-lead EKG

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this is a continuous AFib episode lasting longer than 30 seconds but terminating within 7 days of onset

paroxysmal AFib

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this is a continuous AFib episode lasting longer than 7 days but less than 1 year

persistant AFib

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this is continuous AFib > 1 year in duration in patients in whom rhythm control management is being pursued

“longstanding” persistant AFib

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this is continuous AFib for which a therapeutic decision has been made not to pursue sinus rhythm restoration (just doing rhythm control and leave them with abnormal ECG pattern)

permanent AFib

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AFib in the presence of any mechanical heart valve, or in the presence of moderate to severe mitral stenosis (Enlargement of the mitral valves)

valvular AFib

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what are the established risk factors for AFib

advancing age
male
HTN
HF with reduced ejection fraction
valvular heart disease
hyperthyroidism
obstructive sleep apnea
obesity
excessive alcohol intake
congenital heart disease

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what is the most common symptom of AFib

palpitations!!!!!

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what are some other signs and symptoms of AFib

lightheaded
dyspnea
chest pain
fatigue
weakness/reduced exercise tolerance
syncope (fainting)
*increased HR usually leads to these symptoms due to decreased cardiac output

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what are some complications of AFib

angina
heart failure
cardiogenic stroke (atria are quivering and blood pools in the atria b/c not getting fully expelled; this can form a clot which can then be passed down into the ventricle which can go to the aorta and then the brain and get into a vessel that it cannot pass through causing a stroke)

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true or false: AFib related stroke are more fatal than non-AFib related strokes

true

what are the two main management strategies for AFib

rate control and rhythm control

how should a patient who is hemodynamically unstable (e.g. AF with hypotension, ACS or pulmonary edema) be treated?

direct current cardioversion (DCCV) / aka paddles

is rate or rhythm control normally used in these patients? < 65

rhythm control

is rate or rhythm control normally used in these patients? anti-arrhythmic ADRs

rate control

is rate or rhythm control normally used in these patients? > 65

rate control

is rate or rhythm control normally used in these patients? new onset AF (within a year)

rhythm control

is rate or rhythm control normally used in these patients? less symptomatic

rate control

is rate or rhythm control normally used in these patients? hypertension present

rate control

if a patient has paroxysmal AF (spastic episodes of AF / < 7 days), what are the treatment options?

if not frequent episodes: observation or PRN dose of anti-arrhytmic drug if experience frequent episodes: maintenance anti-arrhythmic drug *may lead to catheter ablation*

if a patient (hemodynamically stable) presents to the ER with sx's of AFib (increased HR), what is always the first step?

initiate rate control (e.g. beta-blocker, CCB) * KNOW THAT EVERYONE THAT COMES IN GETS RATE CONTROL*

what should you do if a patient is already on a beta-blocker and present with sxs of AFib

- make sure their dose of beta-blocker is correct - could add on another rate control agent (e.g. CCB) - switch to rhythm control

these two agents are the first-line agents for acute AFib rate control in patients without significant LV dysfunction (e.g. patients with an LVEF > 40%)

beta blockers or nondihydropyridine calcium channel blockers (e.g. diltiazem or verapamil)

what is used for acute AFib rate control in patients that have LVEF < 40%

bisoprolol, carvedilol or metoprolol

how is the choice between beta blockers and ND-CCBs made for acute rate control

based on comorbidities, contraindications and s/e profile

if IV rate control is given upon ER presentation for rapid control, why does the oral med need to be co-administered?

to avoid rebound tachycardia as IV formulation wears off

these two agents are only used for acute rate control in patients with significant LV dysfunction (LVEF < 40%), decompensated HF or hypotension when immediate electrical cardioversion is not indicated

IV amiodarone or IV digoxin *note: IV amiodarone not normally used for rate control and digoxin is usually an adjunct to beta-blocker or CCB if HR is not controlled

what's the target when titrating acute rate control

achieve a resting heart rate of < 100 bpm

true or false: long term rate control depends on whether or not there is inadequate symptom or heart rate control (resting heart rate > 100 bpm)

true

true or false: diltiazem has worse s/e than verapamil

false - verapamil has worse s/e profile

this is a method of acute rhythm control; an electrical shock synchronized with the intrinsic activity of the heart

direct current cardioversion (DCCV) / aka paddles

what is a disadvantage of DCCV

requires sedation/analgesia pt is usually fasting

this method of acute rhythm control is immediately feasible in a non-fasting patient and avoids delays and risks withs sedation

anti-arrhythmic drugs (AAD)

what is a main s/e of AAD

ventricular arrhythmias, torsades de pointes, hypotension

this class Ia agent is the most common AAD used for acute rhythm control. it is more effective for recent onset of AFib

Procainamide IV

when should Procainamide be avoided?

- hypotension - ischemic heart disease - HF - conduction system disease

should the following patients be given cardioversion as soon as possible or oral anticoagulation tx first? - valvular AF or - NVAF duration < 12 hrs and recent stroke/TIA or - NVAF duration 12-48 hrs and CHADS2 score of at least 2 or - NVAF duration > 48 hrs

therapeutic OAC for at least 3 weeks before cardioversion (need to reduce clot risk)

should the following patients be given cardioversion as soon as possible or oral anticoagulation tx first? - hemodynamocially unstable acute AF or - NVAF duration < 12 hrs and no recent stroke/TIA or - NVAF duration 12-48 hrs and CHADS2 score less than 2

cardioversion right away

what treatment should be initiated for ALL patients post cardioversion

anticoagulation for 4 weeks *note: Long term anticoagulation is based on CHADS-65 score*

describe the CHADS2 score

C - congestive heart failure (1 point) H - hypertension (>140/90) (1 point) A - age > 75 (1 point) D - diabetes mellitus (1 point) S2 - prior stroke or TIA (2 points)

what is the main reason cardioversion may be delayed in specific patients?

cadioversion could dislodge a formed clot causing a stroke

this is an alternative to the 3 week OAC treatment prior to cardioversion; the tip of the probe is inserted near the heart to see if there is a clot present. if there is no clot there, cardioversion may be done

transesophageal echocardiogram (TEE)

true or false: anticoagulation should be given just before cardioversion in all patients

false - given to patients who are hemodynamically unstable - give either a DOAC or if that is contraindicated, a dose of heparin or low molecular weight heparin with bridging to warfarin

when should maintenance AAD therapy be considered

in patients who remain symptomatic with rate control or in whom rate control does not work

which two AAD are contraindicated in CAD and HF

felcanide and propafenone

which AAD can be used in a patient with HF with LVEF < 40%

amiodarone

which AAD can be used in a patient with HF with LVEF > 40%

amiodarone & sotalol

which AAD can be used in patients with CAD

amiodarone, sotalol and dronedarone

which AAD can be used in patients that DONT have HF or CAD

amiodarone, sotalol, dronedarone, flecanide and propafenone

these are sodium channel blocking drugs. need to use concomitant AV nodal blocking drugs (e.g. beta0blockers) to prevent drug induced arrhythmia

flecanide and propafenone

what are the side effects of amiodarone

*THINK C THE GILLS* C - CNS (tremor, neuropathy) T - Thyroid H - heart (bradycardia, TdP) E - Eyes (photosensitivity) Gi - GI upset L - liver (hepatic toxicity) L - lungs (pulmonary toxicity) S - skin (photosensitivity)

this works on potassium channels and is also a beta-blocker. exhibits "reverse-use dependance" meaning at faster HR when potassium channels are being used more, the antiarryhtmic effect is less. biggest concern with use is QT prolongation and TdP

sotalol

when should sotalol be avoided?

- pre-existing QT prolongation - AV conduction disorder - renal impairment - LVEF < 40% - significant risk factors for TdP (women > 65 on diuretics or with renal impairment)

this is a multichannel blocking drug. has the highest efficacy of AAD but large s/e profile

amiodarone

when should amiodarone be avoided>

- AV node disorders - hepatitis/chornic liver disease - interstitial lung disease - QT prolongation - iodine hypersensitivity + many drug interactions

what should be monitored and how often if a patient is on amiodarone

monitor liver and thyroid function test every 6 months

this AAD is similar to amiodarone but has a shorter half life and less tissue accumulation

dronedarone

true or false: DOAC is preferred over warfarin for long term thromboprophylaxis

true

is long term thromboprophlyaxis needed in the following patient? over 65 y/o

yes: DOAC

is long term thromboprophlyaxis needed in the following patient? any of the CHADS2 risk factors

yes: DOAC

is long term thromboprophlyaxis needed in the following patient? CAD or peripheral arterial disease

yes: anti platelet therapy

what are some non Pharm therapy for arrhythmias

1. ablation 2. pacemakers 3. automatic implantable cardio-defibrillator