Afib Flashcards
1
Q
True or False: Apixaban dosing for Afib is 10mg 2x/day for 1 week then 5mg 2x/day?
A
False, this is VTE dosing. In Afib, dosing is 5mg 2x/day.
2
Q
What are the renal dosing adjustments for Afib in Apixaban?
A
2.5mg 2x/day if 2 of 3 items are met: 1)SCr:>1.5 2) Weight is under 60kg 3) Age: >80 years
3
Q
True or False: Afib dosing of Rivaroxaban is 20mg daily?
A
True
4
Q
What are the renal adjustments for rivaroxaban for Afib?
A
In Afib it is 15mg daily, as long as CCL is between 15-50ml/min; avoided if under that value
5
Q
What is the generic name for Betapace?
A
Sotalol
6
Q
What is the MOA of Sotalol (Betapace)?
A
(potassium channel blockade) Extends the refractory period (prolongs action potential
duration) + beta-blocker
7
Q
Are there any DDI or metabolism concerns with Sotalol?
A
Additive QT prolongation with other medications
8
Q
What needs to happen at the start of Sotalol initiation?
A
3 day hospital stay for initiation to monitor QT prolongation
9
Q
What is the dosing scheme for Sotalol?
A
Dose: 40-120 mg depending on QT prolongation (start = 80)
Frequency: dependent on renal function
• CrCl > 60 mL/min: Q12H
• CrCl 40-60 mL/min: Q24H
10
Q
Sotalol is contraindicated in what populations?
A
CrCl < 40 mL/min
11
Q
What class of Antiarrhythmics is Sotalol in?
A
CLASS III ANTIARRHYTHMICS
12
Q
Sotalol is part of a first line treatment option in _________ and can also be used to treat_________.
A
Patients with no structural Heart
Disease ; CAD
13
Q
What type of administration should be used in ACUTE rate control?
A
IV agents (bolus +/- IV infusion) Transition to oral agents
14
Q
What type of administration should be used in CHRONIC rate control?
A
Oral agents
15
Q
True or False: both acute and chronic rate control may require multiple agents in order to control symptoms.
A
True
16
Q
What two agents used to control rate should NOT be used in combination if possible in both acute and chronic rate control?
A
Beta Blockers with Non-DHP Calcium Channel Blockers
17
Q
Amiodarone:
What Class of antiarrythmic is Amiodarone/it’s MOA?
A
Amiodarone is a Class 3 antiarrhythmic, with class 3 being potassium channel blockers BUT amiodarone has characteristics of ALL classes as well (1,2,3,&4 ie Sodium, Beta [Receptor], Potassium, and Calcium channel Blockade)
18
Q
What is the Half-Life of Amiodarone?
A
50 Days!
Hence why it needs a loading period
19
Q
How effective is amiodarone compared to other antiarrhythmics?
A
Amiodarone is the Best One but…. it also comes with the most side effects
20
Q
Which CYPs or Transporters does Amiodarone inhibit which lead to many of its DDI’s?
A
Amiodarone inhibits CYP3A4, 2D6, 2C9, and P-gp
21
Q
Besides its enzyme/transporter inhibition, what other DDIs can amiodarone have?
A
It can have additive QT prolongation with other QT prolonging drugs (Can lead to Torsades de Pointes which is deadly!)
22
Q
What are the side effects of Amiodarone?
A
The usual ones + Some unique ones
Usual:
•Bradycardia
•QT prolongation
Then:
•Pulmonary Fibrosis (Don’t use with COPD!)
•Hypo OR Hyperthyroidism (The hypothyroidism is relatively easy to treat but the hyperthyroidism can be a reason to stop amiodarone)
•Corneal Deposits (Adds up over time/years, can lead to progressive vision loss)
•Acute OR Chronic Hepatotoxicity (not as bad as dronedarone)
•Bluing/Graying of the skin (This is harmless but it is PERMANENT!- also it’s on by sun exposure!)
23
Q
What’s the initial dosing for Amiodarone?
A
8-10 grams over 2-4 weeks –> varies by clinician but as long as you meet the total dosage and timeline its fine.
24
Q
What’s the maintenance dosing of Amiodarone?
A
200mg QD –> 100-200mg QD technically but 100mg QD is rarely used
25
MOA of class IC antiarrhythmics (flecainide and propafenone)
sodium channel blockade (membrane stabilizers) decrease the excitability of cardiac tissue
26
metabolism of class IC antiarrhythmics (flecainide and propafenone)
metabolized by CYP2D6, some people can be fast or slow metabolizers
27
flecanide acute dosing
50mg BID (MDD 300mg)
28
propafenone acute dosing IR
150mg Q8H (MDD 900mg)
29
propafenone acute dosing ER
225mg BID (MDD 850mg)
30
propafenone AE
metallic taste
31
MOA of class 3 antiarrhythmic drugs (dofetilide, amiodarone, ibutilide)
potassium channel blockade, extends the refractory period preventing another depolarization/action potential
32
What's required when starting a patient on a class 3 antiarrhythmic like dofetilide?
3 day hospital stay to monitor QT prolongation
33
drug interactions with dofetilide
1. verapamil: increases absorption of dofetilide which can cause QT prolongation
2. HCTZ: effects clearance and electrolytes (must maintain K>4 and Mg >2)
3. metformin and trimethoprim will decrease the clearance of dofetilide from the body due to competing for active tubular secretion in the kidneys, increasing the risk of QT prolongation
34
dosing of dofetilide in someone with normal renal function
500mcg PO BID
35
dosing of dofetilide in someone with CrCL 40-60ml/min
250mcg PO BID
36
dosing of dofetilide in someone with CrCl 20-40ml/min
125mcg PO BID
37
dosing of dofetilide in someone with CrCl <20ml/min
contraindicated
38
amiodarone MOA
class 3 antiarrythmic, has all the properties of all the classes of antiarrythmics: sodium channel blocker, potassium channel blocker, calcium channel blocker. beta blocker: it is the most effective antiarrhythmic but comes with a lot of side effects
39
half life of amiodarone
about 50 days
40
metabolism of amiodarone
inhibits CYP3A4, CYP2D6, CYP2C9, and PGP
take caution with other medications that have QT prolongation
41
loading dose of amiodarone
8-10 grams over 2-4 weeks
42
maintenance dose of amiodarone
100-200mg PO daily
43
adverse effects of amiodarone
bradycardia, QTc prolongation, pulmonary fibrosis, thyroid dysfunction (hypo and hyperthyroidism), corneal deposits (blindness), hepatotoxicity, blue/gray skin color (permanent)
44
amiodarone monitoring
1. ECG at baseline and every 3-6 months
2. thyroid function tests at baseline and every 6 months
3. LFTs at baseline and every 6 months
4. Chest x ray at baseline and every 12 months
5. pulmonary function tests at baseline and every 12 months
6. eye tests (corneal deposits)
45
```
All of the following can be used for chronic afib treatment in patients with coronary artery disease EXCEPT
A. Dofetilide
B. Propafenone
C. Dronedarone
D. Sotalol
E. Amiodarone
```
B. Propafenone
46
True or False: Propafenone is appropriate for acute cardioversion when DCCV is unsuccessful and the patient has an ejection fraction of AT LEAST 40%
true
47
Specific adverse effect of Propafenone
metallic taste
48
What is unique about Propafenone as a Class 1C antiarrhythmic?
Class 1C has the highest potency so they can also cardio convert
49
What antiarrhythmic class does Dronedarone belong to?
Class III
50
What is Dronedarone's MoA?
Structural analog of amiodarone (minus the iodine), exhibits properties of all the classes of antiarrhythmics
51
Dronedarone is contraindicated in patients with ___?
Heart failure and permanent AF
52
Dronedarone inhibits ___?
CYP3A4, CYP2D6, PGP
53
When taken with other medications, dronedarone can have additive ___?
QT prolongation
54
Dronedarone dosing
400mg PO q12h
55
Adverse effects of dronedarone
Bradycardia, QTc prolongation, hepatotoxicity
56
What kinds of patients would we use dronedarone in?
Patients with structurally normal hearts (and CAD is also okay)
57
Dronedarone brand name
Multaq
58
What rate control drugs are options in patients who have no other CV disease?
beta blockers, diltiazem, verapamil, and amiodarone
59
What rate control drugs are options in patients who have HTN or HFpEF?
beta blockers, diltiazem, verapamil, and amiodarone
60
MOA of edoxaban
factor Xa inhibitor
61
Afib dose of edoxaban
60mg daily
62
VTE dose of edoxaban
(after 5 days parenteral) > 60kg: 60mg daily; if < or = 60kg: 30mg daily
63
What is the route of administration for edoxaban?
oral
64
MOA of dabigatran
direct thrombin inhibitor
65
Afib dose of dabigatran
150mg twice daily
66
VTE dose of dabigatran
(after 5 days parenteral) 150mg twice daily
67
route of administration of dabigatran
oral
68
Edoxaban monitoring?
monitor hemoglobin, hematocrit, platelets & serum creatinine
69
Afib dosing for Edoxaban
60 mg daily
70
What population do you want to avoid Edoxaban in?
>120 kg or BMI > 40 kg/m^2 (basically obese pts)
71
Clinical pearl of Edoxaban
it is rarely used
72
What is the CHA2DS2VASc Score used for?
Anticoagulation: Determine Risk of Stroke
73
What does the "C" stand for within the CHA2DS2VASc Score?
Congestive Heart Failure
74
How many points is Congestive Heart Failure, "C," worth?
1 Point
75
What does the "H" stand for within the CHA2DS2VASc Score?
Hypertension
76
How effective is direct current cardioversion (DCCV) in converting an irregular heart rhythm, into a sinus rhythm (normal heart rhythm)?
Almost 100%.
| It can reset the heart to a sinus rhythm but the problem is keeping the patient in a sinus rhythm.
77
What does the "A2" stand for within the CHA2DS2VASc Score?
Age > 75
78
How many points is Age > 75, "A2," worth?
2 Points
79
What does the "D" stand for within the CHA2DS2VASc Score?
Diabetes Mellitus
80
How many points is Diabetes Mellitus, "D," worth?
1 Point
81
What does the "S2" stand for within the CHA2DS2VASc Score?
Stroke/TIA/Systemic Embolism
82
How many points is Stroke/TIA/Systemic Embolism, "S2," worth?
2 Points
83
What does the "V" stand for within the CHA2DS2VASc Score?
Vascular Disease
84
How many points is Vascular Disease, "V," worth?
1 Point
85
What does the "A" stand for within the CHA2DS2VASc Score?
Age 65-74
86
How many points is Age 65-74, "A," worth?
1 Point
87
What does the "Sc" stand for within the CHA2DS2VASc Score?
Sex Category (Female)
88
How many points is being the Female sex, "Sc," worth?
1 Point
89
What score would indicate that a male patient would need to have an anticoagulation agent added?
> or equal to a score of 2
90
What score would indicate that a female patient would need to have an anticoagulation agent added?
> or equal to a score of 3
91
What is the Stroke Risk per Year?
```
This would depend on the patient's CHA2DS2VASc Score.
1 Point = 1.3%
2 Points = 2.2%
3 Points = 3.2%
4 Points = 4.0%
5 Points = 6.7%
6 Points = 9.8%
7 Points = 9.6%
8 Points = 6.7%
9 Points = 15.2%
```
92
Why would you want to delay cardioversion (ex. DCCV) in a patient with MILD symptoms who has AFIB for over 48 hours?
To allow time (3 weeks) for anticoagulation therapy and reduce the risk of a clot being dislodged and causing a stroke in the patient.
93
True of False: In early cardioversion, if a thrombus is observed on a transesophageal echocardiogram (TEE), we should immediately consider DCCV.
False: Anticoagulate the patient for 4 weeks, then repeat the TEE.
94
A patient presents to the ER with a systolic blood pressure of 85 mmHg and an abnormal heart rhythm: Which cardioversion method should be used in this patient?
A) Chemical Cardioversion
B) Direct Current Cardioversion (DCCV)
C) Both
B) DCCV
| Hemodynamically unstable
95
What is DCCV?
Direct current cardioversion, and it involves utilizing a defibrillator to shock the patients heart into normal sinus rhythm
96
How effective is direct current cardioversion(DCCV) in converting an irregular heart rhythm, into a sinus rhythm(normal heart rhythm)?
Almost 100%. Can reset the heart to a sinus rhythm but the problem is keeping the patient in a sinus rhythm.
97
True or False: You can earn multiple points per section of the CHA2DS2VASc Score.
False
You would NOT count multiple disease states for each section.
For example, if a patient had PAD, DVT, CAD, and T2DM, and age >75, then the score would be 4.
2 Points = A2
1 Point = D
1 Point = V
PAD, DVT and CAD are all vascular diseases, however, they would not earn a point each; instead, the entire category of "V" would only earn 1 point regardless of the amount of vascular diseases present.
98
Paroxysmal Atrial fibrillation
Terminates within 7 days of onset
99
Persistent Atrial Fibrillation
Last > 7 days
100
Longstanding, Persistent
Lasts > 12 months
101
Permanent Atrial Fibrillation
Patient and Clinician have decided that there will be no more effort to restore or maintain sinus rhythm
102
The following conditions require amiodarone as a second line option for rate control:
No other CV disease
HTN or HfPEF
LV dysfunction or HF
103
Which condition does not require amiodarone as a second line option for rate control?
COPD
104
True or false: we give IV bolus always in acute rate control
True, we +/- IV infusion
105
What is the MOA for flecainide (how does it work)
Sodium Channel Blocker = membrane stabilizer. Decrease excitability of cardiac tissue.
106
What class antiarrhythmic does flecainide fall into. Use the Vaughan-Williams classification.
Class 1C
107
True or false. Flecainide is a high potency sodium channel blocker.
True
108
True or false. Flecainide can be used for acute chemical cardioversion if a patient has a EF<40%
False
109
When can flecainide be used for chronic rhythm control?
It can be used as a first line agent in patients with no structural disease.
110
What are two structural heart disease conditions in which flecainide cant be used for chronic rhythm control?
1. Heart failure
| 2. Coronary Artery Disease
111
True or false. Flecainide is metabolized by CYP3A4
False. Metabolized by CYP2D6 and some of the population may be fast of slow metabolizers.
112
How do we monitor dronedarone?
ECG- look out for QT prolongation
113
Name the 4 types of Afib.
Paroxysmal, Persistent, Longstanding Persistent, Permanent Afib
114
What are you able to conclude from knowing the type of Afib a patient has?
You are able to know how frequent the Afib occurs and how it will respond to treatment.
115
How is Propafenone metabolized?
Metabolized by CYP2D6
116
What is the mechanism of action of propafenone?
Sodium channel blocker → membrane stabilizer (decrease excitability of cardiac tissue). It has the highest potency in this specific antiarrhythmic class.
117
Define Afib
Disorganized and irregular atrial electrical activity
| -"quivering"
118
What triggers Afib to occur?
-triggered by rapidly firing ectopic beats in the atria
119
What the are risk factors for Afib?
- concomitant cardiac disease
- DM
- obesity
- obstructive sleep apnea
- hyperthyroidism
- smoking
- etc.
120
What portion of the ECG will appear abnormal during Afib
No visible P waves and an irregular QRS complex
121
What is the HASBLED score?
Determines Bleed Risk during anticoagulation
122
What does each letter in HASBLED stand for?
```
H= Hypertension (SBP >160mmHg)
A= Abnormal liver or kidney function
S= Stroke history
B= Bleeding risk
L= Labile INR
E= Elderly (> 65)
D= Drug or Alcohol abuse
```
123
How do you score each letter in HASBLED?
```
H= 1
A= 1 each (If patient has both abnormal liver function and abnormal kidney function they score 2)
S= 1
B= 1
L= 1
E= 1
D= 1 each (If patient abuses both drugs and alcohol then they score 2)
```
124
How does the HASBLED score correlate to bleed risk?
```
0= 1.13 bleeds/ 100 patient years
1= 1.02 bleeds/ 100 patient years
2= 1.88 bleeds/ 100 patient years
3= 3.74 bleeds/ 100 patient years
4= 8.70 bleeds / 100 patient years
5= 12.5 bleeds/ 100 patient years
```
125
HASBLED pearls
- No "threshold for withholding anticoagulation
- Only validated for Warfarin (not DOACs)
- Can be used in a risk-benefit discussion to determine safety of anticoagulation
126
What first line rate control drugs are options in patients who have HFrEF?
beta blockers or digoxin
127
What rate control drugs are options in patients who have COPD?
beta blockers, diltiazem, verapamil
128
True/False: dabigatran is recommended for patient with Afib and ESRD
False. Direct thrombin inhibitor is not recommended.
129
True/False: Dabigatran is used as a chronic anticoagulation for patients w/ A.fib
True
130
What are the clinical manifestations of AFIB?
```
Fatigue
Palpitations
Shortness of breath
Hypotension
Dizziness, light-headedness
Syncope
```
131
True or False, a patient can have AFIB and be asymptomatic
True
132
When are dabigatran and edoxaban recommended?
For patients with Afib and an elevated CHA2DS2VASc score of 2 or greater in men or 3 or greater in women
(oral anticoagulation is recommended)
133
What chronic rhythm control options are available for CAD patients with Afib?
Dofetilide, dronedarone, sotalol, amiodarone
134
What is a second line option for chronic rhythm control in patients with CAD?
amiodarone
135
What are first line options for chronic rhythm control in patients with CAD?
dofetilide, dronedarone, sotalol, amiodarone
136
When do patients require conversion to sinus rhythm?
When they are:
1. ) Hemodynamically unstable (SBP<90, or patient loses a pulse)
2. ) Symptomatic despite rate control
3. ) Inability to achieve rate control (when you've tried everything & patient is still not able to achieve goal).
137
What treatment options are available to patients who have chronic rhythm control and NO structural heart disease?
```
ALL 5 of them!
Dofetilide
Dronedarone
Flecainide
Propafenone
Sotalol
```
138
Why is Amiodarone second line in chronic rhythm control with NO structural heart disease?
Because of all its side effects (Bradycardia, QTc prolongation, pulmonary fibrosis, thyroid dysfunction, corneal deposits, hepatotoxicity, blue/gray skin color)
139
What is first line treatment for chronic rhythm control with no structural heart disease?
First line treatment is pending patient preference: we could do a catheter ablation or dofetilide, dronedarone, flecainide, propafenone, sotalol treatment
140
What is ablation?
Catheter inserted through groin or neck and guided through the vessel until they reach the heart.
141
When is ablation not feasible?
When many areas/the whole heart has diseased tissue.
142
What are the two methods used to treat chronic rhythm control?
Chemical (treat with antiarrhythmic drugs to keep sinus rhythm)
&
Ablation
143
What does HASBLED stand for?
```
Hypertension
Abnormal liver or kidney function
Stroke history
Bleeding history
Labile NR
Elderly >65
Drug or acohol abuse
```
144
What does the HASBLED score measure?
Determines patietn's bleeding risk
145
If a patient has been in Afib for more than 48 hours what is the treatment regimen for acute cardioversion?
anticoagulate for 3 weeks then DCCV
146
Why does Amoidarone need close monitoring?
The half-life of Amiodarone is 50 days, and there are many potential drug interactions with drugs metabolized with CYP3A4, CYP2D6, CYP2D9, PGP, and other QT elongating drugs.
147
What are the necessary monitoring tests during Amoidarone therapy?
- ECG at baseline and every 3-6 months
- Thyroid function tests at baseline and every 6 months
- Liver function tests at baseline and every 6 months
- Chest X-ray at baseline and every 12 months
- Pulmonary function tests at baseline and every 12 months
148
What are some adverse effects associated with Amiodarone therapy?
- Bradycardia
- QTc Prolongation
- Pulmonary fibrosis
- Thyroid dysfunction
- Corneal deposits
- Hepatotoxicity
- Irreversible Blue/gray skin tone
149
How fast do adverse effects from Amiodarone culminate? (AE other than Bradycardia & AV block)
AEs like pulmonary fibrosis, corneal deposits, the skin tone change & thyroid dysfunction generally develope slowly over 10 years. Bradycardia & AV block develops quickly.
150
what is the extremely common type of A.fib?
Paroxysmal A.fib
151
Is DRONEDARONE commonly used?
no
152
DRONEDARONE brand name
multaq
153
DRONEDARONE MOA
Structural analog of amiodarone (without the iodine) -
| exhibits properties of all the classes of antiarrhythmics
154
DRONEDARONE ci
Contraindicated in patients with HF and permanent AF
155
DRONEDARONE adverse effects
Bradycardia, QTc prolongation, hepatoxicity
156
DRONEDARONE okay to use in patients with structurally abnormal heart rates?
no- normal only
157
DRONEDARONE okay in CAD?
yes
158
T/F:
| The first-line agents for No Structural Heart Disease are Dofetilide, Dronedarone, Sotalol, and Amiodarone
False because Amiodarone is second line agent
159
What is the minimal duration of hospital monitoring when initiating Dofetilide
3 days to monitor QT prolongation
160
Dofetilide
Class 3
| extends refractory period (repolarization)
161
When to DCCV?
Symptomatic despite rate control, OR unable to reach rate control, OR hemodynamically unstable.
162
When to DCCV ONLY
Hemodynamically unstable, sbp greater than 90 or no pulse (syncope)
163
DCCV success rate in cardioverting?
100%
164
What are the two methods of chronic rhythm control?
Chemical and Ablation
165
What is the chemical method?
Utilizes antiarrhythmic drugs to maintain sinus rhythm
166
What is the Ablation method?
Utilizes a procedure to block conduction in the tissue causing the arrhythmia.
167
What are the three types of ablation?
Radiofrequency, cryotherapy, and thermal.
168
Chronic rhythm control class I drug
```
Sodium Channel Blockade =
membrane stabilizers (decrease excitability
of cardiac tissue)
Ia. Moderate potency:
Disopyramide, quinidine, procainamide
Ib. Low potency:
Lidocaine, mexiletine
Ic. High potency:
Flecainide, propafenone
```
169
Chronic rhythm control class II drug
Beta-Blockade = blocks sympathetic input
All beta-blockers
170
Chronic rhythm control class III drug
Potassium Channel Blockade = extends refractory period
Sotalol, dofetilide, amiodarone,
dronedarone, ibutilide
171
Chronic rhythm control class IV drug
Calcium Channel Blockade =
negative inotrope and chronotrope
Verapamil, diltiazem
