AF

Question 1

What is the initial presentation of AF in the elderly?

Answer 1

May be asymptomatic/stroke

Question 2

How de we treat a hemodynamically unstable AF?

Answer 2

Direct current cardioversion

Question 3

How do we treat a hemodynamically stable AF?

Answer 3

Acute ventricular rate control

Select agent based on LV function

Question 4

What medications are used for hemodynamically stable AF?

Answer 4

BB (monitor bradycardia, hypotension)

Non-DHP CCB (monitor constipation, hypotension)

Question 5

According to the Beers list, how is rhythm control compared to rate control?

Answer 5

Rhythm control can have outcomes as good as or better than rate control

Question 6

Is rate or rhythm control more important in symptomatic therapy?

Answer 6

Rhythm control

Question 7

What type of therapy is used in symptomatic AF?

Answer 7

Pharmacologic or electrical cardioversion

Question 8

What type of therapy is used in non-symptomatic AF?

Answer 8

Select agent to maintain HR

Non-DHP CCB, BB (alt: dig, amiodarone)

Question 9

Is rate or rhythm control more important in non-symptomatic AF?

Answer 9

Rate control

Question 10

What other therapy is recommended in AF along with rate/rhythm control?

Answer 10

Consider anticoagulation

Question 11

What does the Beers list say about amiodarone use?

Answer 11

Avoid 1st line (because of increased risk of toxicities) unless pt has HF or substantial left ventricular hypertrophy

Question 12

What does the Beers list say about dronedarone?

Answer 12

Avoid if permanent AF or severe/decompensated HF because potentially worse outcomes

Question 13

What does the Beers list say about disopyramide?

Answer 13

Avoid because highly anticholinergic and as a potent negative inotrope may induce HF

Question 14

What does the Beers list say have digoxin?

Answer 14

Avoid 1st line because other more effective alternatives exist and may be associated with increased mortality

Question 15

What does the CHADSVASC score stand for and how many points go with which pieces?

Answer 15

Congestive HF/LV dysfunction = 1
HTN = 1
Age >/= 75 = 2
DM = 1
Stroke/TIA/systemic embolism = 2
Vscular disease (post-MI, PAD, aortic plaque) = 1 
Age 64-75 years = 1
Female = 1

Question 16

What dose the CHADS score stand for and how many points go with which pieces?

Answer 16

Congestive HF/LV dysfunction = 1
HTN = 1
Age >/= 75 = 2
DM = 1
Stroke/TIA = 2

Question 17

What are the 2012 CHEST guidelines according to the CHADS score?

Answer 17

0 = No antithrombotic
1 = OAC > ASA + plavix > ASA > no treatment
>/= 2 OAC > ASA + plavix > ASA > no treatment

Question 18

Which OAC is preferred?

Answer 18

Dabigatran is preferred over warfarin

Question 19

What are the 2014 AHA/ACC guidelines according to the CHASVASc Score?

Answer 19

0 = no antithrombotic
1 = No antithrombotic or ASA or OAC
>/=2 Warfarin, dabigatran, rivaroxaban, apixiban

Question 20

If a patient has a mechanical heart valve, which OAC is avoided?

Answer 20

Dabigatran

Question 21

Which OAC is used in patients with ESRD/hemodialysis?

Answer 21

Warfarin

Question 22

What doses of warfarin do we start in older patients?

Answer 22

2.5-5mg

Question 23

What is the reversal agent for warfarin?

Answer 23

Vitamin K

Question 24

What is the reversal agent for dabigatran?

Answer 24

Idarucizumab (praxbind)

Question 25

What is the dosing for dabigatran?

Answer 25

150mg BID

Question 26

How is dabigatran adjust with CrCl?

Answer 26

CrCl 15-30 ml/min: 75 mg BID

Question 27

What is the brand for dabigatran?

Answer 27

Pradaxa

Question 28

What trial studied dabigatran?

Answer 28

RE-LY

Question 29

What did the RE-LY trial prove?

Answer 29

Dabigatran is superior for decreased stroke, decreased IC bleed, and increased GI bleed

Question 30

What does the Beers list say about dabigatran?

Answer 30

Caution in those 75 or older and CrCl < 30 d/t increased GI bleeds

Question 31

What is the dose of Xarelto?

Answer 31

20mg QD

Question 32

What is the dose of Xarelto with decreased renal clearance?

Answer 32

CrCl 30-49 ml/min: 15 mg daily

Question 33

What trial studied Xarelto?

Answer 33

Rocket-AF

Question 34

What did the ROCKET-AF trial prove?

Answer 34

Xarelto is noninferior for strokes, emboli, and bleeds

Question 35

What is the brand for apixaban?

Answer 35

Eliquis

Question 36

What is the dosing for apixaban?

Answer 36

5mg BID

Question 37

How do we dose adjust apixaban?

Answer 37

2 of the following is 2.5mg BID: >/= 80 years = 60kg SCr >/= 1.5 mg/dl

Question 38

What trial studied apixaban?

Answer 38

ARISTOTLE

Question 39

What did the ARISTOTLE trial prove?

Answer 39

Apixaban was superior for decreased stroke, emboli and bleeds

Question 40

What is the generic of Savaysa?

Answer 40

Edoxaban

Question 41

What was the trial for edoxaban?

Answer 41

ENGAGE-AF TIMI 48

Question 42

What is the dosing for edoxaban?

Answer 42

>50 ml/min = 60mg QD 15-50 ml/min = 30mg QD Do not use if > 95 ml/min = increased risk of stroke

Question 43

What does the Beers list say about edoxaban?

Answer 43

Avoid if CrCl < 30 = increased bleed

Question 44

What did the ENGAGE-AF TIMI 48 trial prove in edoxaban 60mg?

Answer 44

Superior decrease in stroke, systemic emboli; decreased major/life-threatening bleed; increased GI bleed in those >/= 75 yo

Question 45

What did the ENGAGE-AF TIMI 48 trial prove in edoxaban 30mg?

Answer 45

Non inferior for stroke, systemic emboli (except >/= 75 yo favors warfarin); decreased bleed in all areas (including >/= 75 yo)

Question 46

What are RFs for AF?

Answer 46

HTN CAD HF Rheumatic/valvular heart disease

Question 47

What did the ACTIVE-A trial determine?

Answer 47

Plavix + ASA > ASA monotherapy for stroke and major bleeding

Question 48

What did the BAFTA trial show?

Answer 48

Warfarin > ASA for stroke, ICH, arterial embolism