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CardioPulm II > Afib > Flashcards

Afib Flashcards

1
Q

Selection of Agent: No Structural heart disease

First line

A

dronedarone

flecainide, propafenone, sotalol

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2
Q

Selection of Agent: No Structural heart disease

Second Line

A

amiodarone, Dofetilide

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3
Q

IC is contraindicated?

A

In all Structural heart disease

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4
Q

Selection of Agent: Hypertension (no LVH)

First Line

A

dronedarone

flecainide, propafenone, sotalol

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5
Q

Selection of Agent: Hypertension (no LVH)

Second line

A

amiodarone, dofetilide

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6
Q

Hypertension (with LVH)

First line ( only line)

A

amiodarone

Class IC: Contraindicated

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7
Q

Selection of Agent: CAD

First line

A

Dofetilide
dronedarone
Sotalol

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8
Q

Selection of Agent: CAD

Second Line

A

Amiodarone

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9
Q

Selection of Agent: CAD

Contraindication

A

Class IC

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10
Q

Selection of Agent: Heart failure

First Line

A

Amiodarone, dofetilide

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11
Q

Selection of Agent: Heart failure

Contraindication

A

Class IC
Sotalol
Dronedarone*

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12
Q

AF ablation: Potential cure

Indications

A

Have structurally normal heart

Very symptomatic

Failed at least one antiarrhythmic drug therapy

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13
Q

CHADS-2 Scoring System to Predict CVA Risk

A 
Risk Factor	                  Points
CHF	                                1
Hypertension                  	1
Age ≥ 75 years	                1
Diabetes                          	1
History of TIA/CVA  (Stroke)	2

0 points Use CHADS2-Vasc
≥ 1 point usually requires anticoagulation

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14
Q

CHADS-2 Scoring System: What to take

ASA, Nothing or anticoagulation???

A

CHA2DS2 Vasc
0= Choose nothing or ASA
1= Choose nothing, ASA or anticoagulation
≥2= Anticoagulation

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15
Q

Dabigatran

A

Pradaxa®

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16
Q

Rivaroxaban

A

Eliquis®

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17
Q

Edoxaban

A

Savaysa®

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18
Q

Antithrombotic Therapy:
Risk of CVA (stroke)

Factors which increase risk for stroke in pts with AFib

A

Prior stroke or transient ischemic attack

Age (> 65)

Hypertension

Diabetes Mellitus

Gender (female > male)

EF < 40%

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19
Q

Maintenance Antithrombotic TherapyAspirin or Anticoagulation

A

Anticoagulation is more effective than ASA for stroke prevention, but has higher bleeding risk and quality of life concerns

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20
Q

Maintenance Antithrombotic TherapyAspirin or Anticoagulation??

Drugs and dosing

A

Estimate stroke and bleeding risk first then choose:

Oral Anticoagulation Options
Warfarin: Treat to INR 2-3 
Dabigatran 150 mg PO BID 
Rivaroxaban 20 mg PO Daily with a meal
Apixaban 5 mg PO BID
Edoxaban 60 mg PO Daily
       OR
ASA: 81-325mg daily (usually 81 mg)
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21
Q

CHADS-2 Scoring System to Predict CVA Risk

Standards

A

0= Choose nothing or ASA

1= Choose nothing, ASA or anticoagulation

≥2= Anticoagulation

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22
Q

CHADS-2 Scoring System to Predict CVA Risk:

Point system

1pt each

A

CHF
Hypertension
Age ≥ 75 years
Diabetes

History of TIA/CVA 2pts
(Stroke)

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23
Q

Anticoagulation Options for Atrial Fibrillation

Warfarin

A

“Bridge” with UFH or LMWH only in** high risk** patients

Use lower initial UFH dose of 70 units/kg IV push then 15 units/kg/hr and adjust to PTT

May start warfarin monotherapy in low risk patients

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24
Q

Apixaban

A

Eliquis

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25
Novel Oral Anticoagulants (NOACs) Direct Thrombin Inhibitors
Dabigatran (Pradaxa®)
26
Novel Oral Anticoagulants (NOACs) Direct Xa Inhibitors
Rivaroxaban (Xarelto®) Apixaban (Eliquis®) Edoxaban (Savaysa®)
27
Warfarin INR Goal?
2-3
28
Warfarin over 3?
Intracranial bleeding
29
Warfarin under 2?
Ischemic Stroke
30
Benefits of NOACs
Similar or superior efficacy to warfarin Similar or less bleeding in studies --Less intracranial hemorrhage No monitoring needed for efficacy Rapid onset of action eliminates need for “bridge” therapy Limited drug-drug interactions No apparent drug-diet interactions
31
Concerns With NOACs
New agents currently have no test to measure therapeutic effect and no antidote - Emergency surgery needed? - Serious bleeding? Drugs accumulate in renal dysfunction - Dose reduce and/or avoid use in severe CKD - Check SCr at least yearly Non-adherence in clinical practice -Effects on efficacy? Cost and Insurance Coverage
32
NOACs: Contraindications
Hemodynamically significant valve disease CrCl < 15 ml/min or dialysis (doxzyban?) Dosing adjustments different for each med Advanced liver disease (increased baseline INR)
33
Antithrombotic therapy: Initiation: When is anticoagulation appropriate
Always initiate anticoagulation before and after cardioversion (even in ASA patients)
34
Antithrombotic therapy: Initaiation: When is anticoagulation appropriate? ASA and Warfarin COMBO??
Warfarin and ASA may be used in combo if patient has embolic event on warfarin alone or compelling indication for both meds - -Combo always increases risk of bleeding - -Newer anticoagulants have increasing data in combo with antiplatelet agents
35
Acute AFIB treatment
HR control Consider cardioversion Antithrombotic therapy
36
Chronic AFIB treatment
HR control Antithrombotic therapy Consider antiarrhythmic to maintain NSR Consider ablation
37
Atrial Fibrillation Ablation
Ablation entails destruction of myocardial tissue necessary for the tachycardia “reentry circuit
38
What's the benefit of Ablation therapy?
Potential Cure
39
Ablation indications?
Have structurally normal heart Very symptomatic Failed at least one antiarrhythmic drug therapy
40
Should anticoagulation be stopped forAblation?
No data on whether anticoagulation can eventually be stopped
41
Ablation Complications?
Stroke, perforation, pulmonary vein stenosis, death Recurrence of Afib or Aflutter Should be performed in experienced centers
42
Permanent Atrial Fibrillation:
May decide NOT to attempt cardioversion May be unable to maintain sinus rhythm Long-term management -Rate Control -Antithrombotic therapy
43
How long should AFib patient be anticoagulation prior to cardioversion?
3 weeks of anticoagulation prior to cardioversion or Anticoagulation with TEE to rule out thrombus
44
How long should AFib patient be anticoagulation after cardioversion?
And for 4 weeks following!!!
45
Whats the restrictions of cardioversion?
All patients with AF > 48 hours must be anticoagulated prior to cardioversion to prevent stroke
46
Prior to elective cardioversion must determine if thrombus has developed in left atrium? TWO OPTIONS
Transesophageal echocardiogram (TEE) --->If thrombus present – 3 weeks of anticoagulation, then attempt cardioversion -->If no thrombus is present – initiate anticoagulant and attempt cardioversion as soon as therapeutic 2. Treat with anticoagulation, in therapeutic range, for at least 3 weeks then attempt cardioversion - Can use warfarin (INR 2-3), dabigatran, rivaroxaban, apixaban, edoxaban or LMWH (treatment doses)
47
CVA Prevention with Elective Cardioversion. How long must you coagulate after cardioversion?
Following cardioversion it can take up to 4 weeks for mechanical contraction of the atrium to return to normal, “atrial stunning Regardless whether a thrombus was present prior to cardioversion, you MUST anticoagulate for 4 weeks following cardioversion Warfarin (Target INR 2 – 3), dabigatran, rivaroxaban , apixaban, edoxaban or LMWH (treatment doses)
48
Ion Block: IA
Na (intermediate)
49
Ion Block: IC
Na (slow)
50
Ion Block: III
K
51
Meds: IA
quinidine, procainamide, disopyramide
52
Meds: IC
propafenone flecainide
53
Meds: III
amiodarone, dofetilide, ibutilide, sotalol,dronedarone
54
Use for Atrial Fibrillation | IA
Cardioversion and Maintenance NSR
55
Use for Atrial Fibrillation | IC
Cardioversion and Maintenance of NSR
56
Use for Atrial Fibrillation | III
Cardioversion and Maintenance NSR Ibutilide-Cardiovers Sotalol-Maintenance
57
Indications for Oral Pharmacologic Cardioversion
Patients with paroxysmal Afib and unbearable symptoms despite rate control Patients with persistent Afib, and unbearable symptoms, who return to Afib after electrical cardioversion. -Oral agents have low chance of restoring NSR, may repeat DCC and use meds for maintenance if needed.
58
Who should be Returned to NSR?
People who still feel sick even after rate control. May try one electrical cardioversion in most persistent Afib patients Relief of severe symptoms -->Especially CHF and syncope Intolerable palpitations Prevention of cardiac remodeling- a fib alone
59
Why not Cardiovert Everyone Immediately?
Cardioversion and maintenance of NSR has not been shown to improve mortality: -Electrical and/or pharmacologic cardioversion has risks associated with use (ie proarrhythmia) Pharmacologic > Electrical -Anti-arrhythmics decrease AFib burden, may not eliminate Afib and stroke risk – They redcue burden only symtomatic eposoides only Risk of stroke is highest at time of cardioversion
60
What is Electrical Cardioversion?
Direct current cardioversion (DCC) Initially preferred over oral meds for persistent Afib due to efficacy and lack of long-term adverse effects -->Ibutilide can be used instead to avoid anesthesia, but decreased efficacy vs DCC
61
Rhythm Control = Restoring and/or Maintaining NSR
Restore atrial kick. Restore NSR. Heart will return to normal beat Restoration of NSR or Cardioversion: Electrical: Direct Current Cardioversion (DCC) -DCC-Depolarize whole heart, hope sinus can be re-instated Pharmacologic alternative: Ibutilide -10 minute infusion??? -Ibutilide is a 10 min infusion that has a high rate of cardioversion (not a s high as DCC), Requires no anesthesia Restoration AND Maintenance of NSR: Pharmacologic: Oral antiarrhythmic agents in classes IA, IC and III (sotalol only maintains NSR, does not restore

CardioPulm II (11 decks)

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