AAR

Question 1

What are the four types of atrial fibrillation?

Answer 1

1. Paroxysmal - terminates spontaneously and recurs
2. Persistent - 7D, requiring cardioversion
3. Permanent - >1 year, failed cardioversion
4. Lone afib - afib in young patient (<60) with no cardio-pulmonary disease

Question 2

When do you implement rate control?

Answer 2

In patients who have failed rhythm control, have permanent afib, or no chance of NSR after cardioversion

Question 3

What is the time period that you are monitoring for Afib if someone comes in claiming heart palpitations and what are the interventions?

Answer 3

1. Afib <48 hours - start IV anticoag, cardiovert, do 4 weeks of oral anticoag after
2. Afib >48 hours - Echo for clot
   * If clot - anticoagulate for 4-12 weeks
   * If no clot - cardiovert same day then 4 weeks of anticoag

Question 4

What are the approved PO anticoag’s for Afib?

Answer 4

Warfarin
Dabigatran
Rivaroxaban
Apixaban
Edoxaban

Question 5

What is the CHA2DS2-VASc score?

What is the scoring system?

Answer 5

CHF - 1
HTN - 1
Age >75 - 2
DM - 1
Stroke/TIA - 2
Vascular disease (MI/ACS/PAD) - 1
AGE (64-74) - 1
Sex (Female) - 1

If >2 (M) or >3 (F) - start anticoagulation

Question 6

When is warfarin preferred in Afib?

Answer 6

In valvular heart disease/Afib or mechanical heart valves or if they are on CYP3A4 inhibitors/inducers.

If ESRD or CrCl <15

Question 7

What anticoagulant do you choose for pregnant patients?

Answer 7

LMWH

AVOID WARFARIN AND DOAC

Question 8

Is heparin or LMWH preferred in CrCl <30?

Answer 8

Heparin - because it is hepatically cleared and has a short half life

Question 9

What are the 4 phases of action potential?

And what class of medications do you use for each?

Answer 9

Phase 0 - Depolarization | Class I
Phase 1 - Ca2+ entry/contraction | No meds
Phase 2 - Plateau phase | Class 4
Phase 3 - Repolarization | Class 3
Phase 4 - Na+ out, K+ in | Class 2

Question 10

What are the vaugham williams classifications?

Answer 10

Class 1 - Na+ channel blockers
Class 2 - beta blockers
Class 3 - K+ channel blockers
Class 4 - Non-DHP CCB’s

Question 11

List class 1 medications

Answer 11

Class 1a - (QDP) - Quinidine, disopyramidde, procainamide

Class 1b (PLM) - Phenytoin, lidocaine, mexiletine

Class 1c (PF) - propafenone, flecainide

Question 12

List Class 3 medications

Answer 12

IASDD

Ibutilide (only IV)
Amiodarone
Sotalol - it is a BB but it is class 3 NOT class 2
Dofetilide
Droneadarone

Question 13

Quinidine

Class
Levels
Indications
ADE
Interaction

Answer 13

Class 1a

2-5mcg/mL

Arrhythmias, life threatening malaria

DIARRHEA, CINCHONISM (ringing in ear), hypotension, QT prolongation, thrombocytopenia

Increase digoxin

Question 14

Disopyramide

Class
Brand
Indication
Form
ADE

Answer 14

Class 1a

Norpace

V.arrythmias

ORAL on empty stomach

Anti-cholinergic(anti-sludge), negative inotropic (so NOT for CHF) , QT prolongation

Question 15

Procainamide

Class
Indication
Dosage forms
ADE

Answer 15

Class 1a

threatening v.arrythmias

IV/IM

Lupus-like syndrome , hypotentsion, torsades, agranulocytosis

Question 16

Lidocaine

Class
Brand
Indication
Dose
Plasma levels
ADE

Answer 16

Class 1b

Xylocaine

VF or pulseless VT - NEVER AFIB

IV bolus 1mg/kg
IV infusion 1-4 mg/min in D5W

1.5-5mcg/mL

CNS (SEIZURE), LIGHTHEADES

Question 17

Mexiletine

Class
Dosage
Food counseling

Answer 17

Class 1b

ORAL

Give with food or antacid

Question 18

Propafenone

Class
Brand
Indication
Dose
ADE

Answer 18

Class 1c

Rythmol

Afib or PSVT

PO TID

BB activity, negative ionotropic (so NOT for CHF)

Question 19

Flecainide

Class
Indication
ADE
Dose

Answer 19

Class 1c

Ventricular and supraventricular arrythmias

Proarrythmic, exacerbate CHF

PO BID

Question 20

Which class has no effect on QT interval?

Answer 20

Class 1c

Question 21

Which class shortens QT interval?

Answer 21

Class 1b

Question 22

What are the acute ventricular rate control options in Afib or flutter?

Answer 22

Metoprolol
Esmolol
Propranolol

Question 23

What is the antidote to beta blockers?

Answer 23

Glucagon

Question 24

Ibutilide

Class
Brand
Form
Indication
ADE

Answer 24

Class 3

Corvert

IV only

Afib - a chemical cardioversion

Torsades (within 3 hours typically)

Question 25

Amiodarone Class Brand Indications Dosage forms ADE Monitoring Half-life Drug interactions Stability

Answer 25

Class 3 Tablets - cordarone/pacerone IV - Nexterone V.arrythmias PO/IV Photosensitivity, pulmonary toxicity, corneal microdeposits, thyroid dysfunction, gray/blue skin, torsades, LFT TSH, LFT, eyes, Chest XRAY, PFT's, ECG, electrolytes 30-60 days Increase digoxin, increase INR Stable for 24 hours in glass and 2 hours in PVC - store at room temp

Question 26

Dronedarone Class Brand Indication Dose ADE Interactions

Answer 26

Class 3 Multaq Afib/flutter 400mg BID with FOOD Liver failure, heart failure Drugs that prolong QT

Question 27

which medication should you avoid giving harvoni with and why?

Answer 27

Amiodarone because it has sofosbuvir in it which increases bradycardic effect

Question 28

Sotalol Class Brand Dosage forms Monitoring Renal adjustment

Answer 28

Class 3 Betapace, betapace AF - NOT INTERCHANGEABLE IV/ solution/ PO Betapace - v.aarythmias Betapace AF - Afib PT should be in facility for >3 days with ECG monitoring Contraindicated in CrCl <40

Question 29

Dofetilide Class Brand Indication Monitoring Renal adjustments

Answer 29

Class 3 Tikosyn Afib/flutter Placed in facility for 3 days to monitor CrCl, ECG, K+/Mg2+ Contraindicated CrCl <20

Question 30

What are the dosage forms and indications for verapamil?

Answer 30

PSVT - PO Afib - IV/PO

Question 31

What are the dosage forms and indications for Diltiazem?

Answer 31

Afib/ PSVT - IV Afib rate control (off label) - PO

Question 32

Adenosine Brand Indication Dose Monitoring

Answer 32

Adenocard PSVT 6mg rapid IV push Will cause asystole for a few seconds then revert to NSR

Question 33

What is the main purpose of IV magnesium?

Answer 33

Treat Torsades

Question 34

What is the most effective therapy for ventricular fibrillation? What is the treatment algorithm?

Answer 34

Defibrillation Continious CPR --> shock --> Epi 1mg --> shock --> amiodarone/lidocaine

Question 35

What is the most effective therapy for PSVT?

Answer 35

Adenosine

Question 36

What is the DOC for pulseless electrical activity or asystole?

Answer 36

Epinephrine 1mg IV q3-5min

Question 37

What is DOC for symptomatic bradycardia? What if it doesn't work?

Answer 37

Atropine 0.5mg Q3-5 min (max 3mg) Dopamine or epinephrine

Question 38

What is DOC for SVT? (HR >150) What if it doesn't work?

Answer 38

Adenosine IV push - 6mg --> NS flush --> 12mg NS flush --> 12mg NS flush BB or NonDHP CCB( IV verapamil )

Question 39

What are the preferred options for acute BP control during CVA? What is the goal BP before IV tPA? What is the goal glucose?

Answer 39

Labetalol, nicardipine, clevidipine <185/110 before administration and keep <180/105 for the first 24 hours after administration 140-180