Anti-arrhythmic drugs: Afib and SVT Flashcards
(202 cards)
1
Q
What is A-fib?
A
Loss/incoordination of atrial activity
2
Q
What can A-fib increase the risk of?
A
-Blood pooling due to inadequate emptying of the ventricle
-Thrombosis
3
Q
What is SVT?
A
Tachyarrhythmia originating at the atrial or atrioventricular (AV) nodal tissue
4
Q
SVT is most commonly due to what?
A
AV nodal re-entry
5
Q
Acute SVT can be caused by what?
A
Alcohol, excessive caffeine, recreational drugs, hyperthyroidism
6
Q
Vaughan-Williams Classification of Antiarrhythmics for Class Ic?
A
Na+ channel blockers w/ slow association/dissociation (Flecainide, Propafenone)
7
Q
Vaughan-Williams Classification of Antiarrhythmics for Class II?
A
Beta Blockers (Propanolol, Metoprolol)
*Propanolol also shows some class I action
8
Q
Vaughan-Williams Classification of Antiarrhythmics for Class III?
A
K+ channel blockers (Amiodarone, Sotalol, Dronedrone, Dofetilide)
*Sotalol is also a BB
*Amiodarone has class I, II, III, and IV activity
9
Q
Vaughan-Williams Classification of Antiarrhythmics for Class IV?
A
Ca2+ channel blockers (Verapamil, Diltiazem)
10
Q
Vaughan-Williams Classification of Antiarrhythmics for Class V?
A
Work by unknown mechanisms (Adenosine, Digoxin)
11
Q
Phase 0 of cardiac action potential?
A
Depolarization (Open Na+ channels)
12
Q
Phase 1 of cardiac action potential?
A
Initial Repolarization (K+ leaves)
13
Q
Phase 2 of cardiac action potential?
A
Plateau (K+ out, Ca2+ in)
14
Q
Phase 3 of cardiac action potential?
A
Rapid Repolarization (K+ rushes out, Ca2+ starts to close)
15
Q
Phase 4 of cardiac action potential?
A
Resting potential
16
Q
MOA of Propafenone?
A
Blocks fast inward Na+ current, slows increase of action potential, prolongs conduction and refractoriness in all areas of the myocardium, reduced spontaneous automaticity and exhibits some BB activity
17
Q
Indications for Propafenone?
A
-A-fib (to prevent recurrence)
-Paroxysmal SVT (to prevent recurrence)
18
Q
Any change in dosing of Propafenone in geriatric patients?
A
No, use adult dosing
19
Q
Renal adjustment for Propafenone?
A
None (yet use w/ caution as 50% metabolites are excreted through the urine)
20
Q
Hepatic adjustment for Propafenone?
A
None (yet consider adjustment if necessary as drug undergoes hepatic metabolism)
21
Q
ROA for Propafenone?
A
PO
*swallow whole: do not chew/crush
*with or w/o meals
22
Q
Side effects of Propafenone?
A
N/V, loss of strength/energy, constipation, change in taste, headache, anxiety
23
Q
Frequency of Propafenone?
A
BID or TID
24
Q
Seek assistance/report to prescriber for Propafenone when…?
A
Infection, angina, bradycardia, tachycardia, severe dizziness, passing out, abnormal heartbeat, SOB, excessive wt. gain, swelling in arms/legs, blurred vision
25
Drug-drug interactions of Propafenone?
-QT prolongation w/ fluoxetine (paroxetine increases serum conc. of Propafenone)
-Apiprazole (increased serum conc. when taken w/ Propafenone)
-May inc. serum conc. levels of BB
26
Monitoring parameters for Propafenone?
BP, ECG, Pulse
27
Is Propafenone absorbed well?
Yes
28
How much of Propafenone is protein bound?
95%
29
How long does Propafenone take to peak?
3-8 hours
30
Half life of Propafenone?
2-32 hours
31
MOA of Flecainide?
Slows conduction in cardiac tissue by altering transport of ions across cell membrane, slight prolongation of refractory periods, decreases rate of rise of action potential w/o affecting its duration
32
Indications for Flecainide?
-Paroxysmal A-fib
-Paroxysmal SVT (prevention)
33
Any changes in dosing for Flecainide in geriatric patients?
No, adult dosing used
34
Renal adjustment for Flecainide?
Decrease dose/interval
35
Hepatic adjustment for Flecainide?
None (yet use w/ caution, check plasma conc.)
36
ROA for Flecainide?
PO
*may need to watch dietary changes of milk intake
37
Side effects of Flecainide?
Headache, dizziness, visual disturbances, dyspnea, nausea, fatigue, tremor
38
Seek assistance/report to prescriber for Flecainide when...?
Hepatic impairment, angina, severe dizziness, syncope, arrhythmia, bradycardia, tachycardia, dyspnea, excessive wt. gain, edema in extremities, tremors, vision changes, ecchymosis (bleeding under skin), hemorrhage
39
Disease related concerns for Flecainide?
Contraindicated in those w/ structural heart disease
40
Drug-drug interactions of Flecainide?
Watch meds w/ QT prolongation effects
41
Monitoring for Flecainide?
ECG, BP, Pulse, Periodic serum trough concentrations
42
When does Flecainide peak?
3 hours
43
Half life of Flecainide?
8-20 hours depending upon age
44
Selectivity of Metoprolol?
B-1 selective
45
MOA of Metoprolol?
Select inhibitor of B-1-adrenergic receptors, competitively blocks B-1 R's w/ little to no efffect on B-2 R's at oral doses <100mg in adults
46
Indications for Metoprolol?
-A-fib: acute & maintenance
-SVT: off label use for acute & maintenance
47
Any dose changes for Metoprolol in geriatric patients?
No, use adult dosing
48
Renal or Hepatic adjustments for Metoprolol?
None
49
ROA of Metoprolol?
IV bolus or PO (with food)
50
Side effects of Metoprolol?
Diarrhea, loss of strength/energy, vomiting, hypotension, dizziness, fatigue
51
Dose frequency of Metoprolol?
QD or BID
52
Seek assistance/report to prescriber for Metoprolol when...?
Depression, illogical thinking, memory impairment, severe dizziness, passing out, skin discoloration, sensation of cold, angina, arrhythmias, bradycardia, SOB, excessive wt. gain, swelling of extremities, vision changes
53
Disease related concerns with Metoprolol?
DM, bradycardia, peripheral vascular disease/Raynaud's, thyroid disease, depression
54
Can you withdraw Metoprolol abruptly?
NO, slow taper over 1-2 weeks to avoid rebound tachycardia
55
Drug-drug interactions with Metoprolol?
NSAIDs, Sulfonylureas, Theophylline
56
Monitoring with Metoprolol?
IV: ECG, HR, BP
PO: HR, Rhythm, BP
57
Onset of action for PO Metoprolol?
3-6 hours
58
Onset of action for IV Metoprolol?
20 min
59
Half life of Metoprolol?
3-9 hours depending on Hepatic function
60
MOA of Amiodarone?
Adrenergic stimulation (alpha & beta blocking properties), affects sodium, potassium, and calcium channels, prolongs action potential and refractory period in myocardial tissue, decreases AV conduction and sinus node function
61
Indications for Amiodarone?
-A-fib: acute, maintenance, off-label
-SVT: not first line, acute
62
Changes for Amiodarone dosing in geriatric patients?
Adult doses but typically on the lower end of dosing, slow taper
63
Renal adjustment for Amiodarone?
None
64
Hepatic adjustment for Amiodarone?
In more severe impairment, dose reduce or avoid
65
ROA of Amiodarone?
-IV over 1 or more hours
-PO (with food, divide dose if GI upset, avoid grapefruit juice**)
66
Black box warning/side effects for Amiodarone?
Arrhythmia, pulmonary toxicity
Constipation, N/V, loss of strength/energy, lack of appetite
67
Seek assistance with Amiodarone if...?
Liver problems, signs of severe pulmonary disorder, signs of thyroid problems, signs of SJS-TEN, bradycardia, vision changes, eye pain, severe eye irritation, sensitivity to light, SOB, bruising/bleeding, joint/muscle pain
68
Drug-drug interactions of Amiodarone?
-Numerous due to extensive metabolism (CYP3A4, 2C8, 2C9, 2D6, 1A2)
-MAJOR INTERACTION: Sofosbuvir (severe bradycardia)
-Watch w/ meds that have QT prolongation effects
69
Monitoring for Amiodarone?
BP, HR (ECG) & rhythm throughout therapy, lethargy, edema of hands/feet, weight loss, pulm. toxicity (Baseline PFTs & CXR, continue monitoring CXR annually w therapy), LFTs (semiannually), serum electrolytes (esp. K+ and Mg), thyroid function tests
70
Onset of Amiodarone?
2 days-3 weeks
71
Half life of Amiodarone?
40-55 days
72
How much of Amiodarone is protein bound?
96%
73
MOA of Dronedarone?
Structurally related to amiodarone.
Inhibits sodium and potassium channels prolonging AP and refractory period in myocardial tissue w/o reverse-use dependent effects, decreases AV conduction & sinus node function through inhibition of calcium channels, Beta-1 R blocking activity
74
Indications for Dronedarone?
Paroxysmal or persistent A-fib
75
Any changes in dosing of Dronedarone in geriatric patients?
No, use adult dosing
76
Renal adjustments for Dronedarone?
None
77
Hepatic adjustments for Dronedarone?
Contraindicated in severe impairment
78
ROA for Dronedarone?
PO (w/ morning & evening meal, avoid grapefruit**)
79
Side effects of Dronedarone?
Diarrhea, N/V, loss of strength/energy, abdominal pain
80
Frequency of dosing for Dronedarone?
BID
81
Seek assistance with Dronedarone if...?
Signs of kidney problems, signs of heart problems, signs of liver problems, signs of severe pulmonary disorder, dizziness, bradycardia, abnormal heartbeat, QT prolongation
82
Drug-Drug interactions of Dronedarone?
-Increases conc. of Atorvastatin
-BB: bradycardia
-CCB
-Avoid cyclosporine
-Reduce Digoxin by 50%
-Avoid propafenone (QT-prolongation)
-Increases conc. of Fentanyl
83
Monitoring for Dronedarone?
ECG (at least q3months), BP, HR & rhythm throughout, signs of lethargy, edema of hands/feet, serum electrolytes (esp. K+ & Mg), serum liver enzymes & bilirubin (periodically, esp. in first 6 months)
84
Peak for Dronedarone?
3-6 hours
85
Half life of Dronedarone?
13-19 hours
86
How much of Dronedarone is protein bound?
>98%
87
Sotalol has what kind of slectivity?
Non-selective BB
88
MOA of Sotalol?
Increased sinus cycle length, slowed HR, decreased AV nodal conduction, increased AV nodal refractoriness, has both Beta-1 & Beta-2 R blocking activity
89
Seek assistance with Sotalol if..?
Dizziness, passing out, angina, bradycardia, tachycardia, abnormal heartbeat, severe loss of strength/energy, vision changes, SOB, excessive wt. gain, swelling of extremities, *injection site pain/irritation/edema, *excessive sweating
90
Warnings for Sotalol?
Proarrhythmia, QT-prolongation, do not stop abruptly, avoid if asthma, use w/ caution in DM
91
Drug-drug interactions with Sotalol?
Watch for additive effects (esp. meds that may cause bradycardia or QT prolongation)
92
Monitoring for Sotalol?
Serum creatinine, magnesium, & potassium
HR, BP, ECG
93
Onset of IV Sotalol?
5-10 min
94
Onset of PO Sotalol?
1-2 hrs
95
Half life of Sotalol?
12 hrs (up to 69 hrs in renal impairment)
96
Labelling of Sotalol (Betapace brand)?
"AF" - drug more expensive but is the same drug w/ the same efficacy
97
Frequency of dosing for Sotalol?
BID
98
Indications for Sotalol?
-Symptomatic A-fib
-SVT (off label)
99
Any dose changes for Sotalol in geriatric patients?
No, use adult dosing
100
Renal adjustment for Sotalol?
Extend interval if CrCl <60 mL
101
Hepatic adjustment for Sotalol?
None
102
ROA for Sotalol?
IV over 5 hours
PO (without regards to meals)
103
Side effects of Sotalol?
Headache, diarrhea, N/V, fatigue, weakness, sleep disorders
104
MOA of Dofetilide?
Blockade of cardiac K+ ion chqannel using delay of repolarization
105
Indications for Dofetilide?
A-fib
SVT (ongoing managment, off label use)
106
Dose changes for Dofetilide in geriatric patients?
Adult dosing, but be cautious with renal dysfunction
107
Renal adjustment for Dofetilide?
Dose reduction necessary
108
Hepatic adjustment for Dofetilide?
None, but use w/ caution
109
ROA for Dofetilide?
PO (with or w/o food)
110
Side effects of Dofetilide?
Headache, common cold/flu-like sx, nausea, dizziness
111
Frequency of dosing for Dofetilide?
BID
112
Seek assistance with Dofetilide if...?
Angina, dizziness, passing out, bradycardia, tachycardia, abnormal heartbeat, SOB, *Torsades de pointes
113
Drug-drug interactions with Dofetilide?
-Cimetidine: increases serum conc. of Dofetilide (avoid)
-Antifungals: decrease metabolism of Dofetilide (avoid)
-QT prolongation meds (avoid)
-Verapamil: increases serum conc. of Dofetilide
114
Monitoring for Dofetilide?
ECG (w/ attention to QT), serum creatinine (baseline and changes), K+ and Mg levels
115
Peak of Dofetilide?
Fasting: 2-3 hours
116
Half life of Dofetilide?
10 hours (prolonged w/ renal impairment)
117
What kind of CCBs are Verapamil and Diltiazem?
Non-dihydropyridine
118
MOA of Diltiazem?
Inhibits Ca2+ from entering slow channels during depolarization, produces relaxation of coronary vascular smooth muscle/coronary vasodilation
119
Indications for Diltiazem?
A-fib (acute) (rate control -off label)
SVT (ongoing management, off label)
120
Changes in dosing of Diltiazem in geriatric patients?
None, adult dosing used
121
Renal and Hepatic adjustment for Diltiazem?
None, but use w/ caution
122
ROA for Diltiazem?
IV bolus over 2 min, then continuous infusion
PO (depends on formulation-> w/ meals, empty stomach, or before bedtime)
123
Side effects of Diltiazem?
Edema, *flushing, headache, nausea, loss of strength/energy, *rhinorrhea, *pharyngitis, *infection site irritation
124
Frequency of dosing for Diltiazem?
QD or QID
125
Seek assistance with Diltiazem if....?
Liver problems, severe dizziness, passing out, bradycardia, abnormal heartbeat, SOB, excessive wt. gain, swelling of extremities, signs of *SJS-TEN
126
Drug-drug interactions of Diltiazem?
-Atorvastatin: each can inc. serum concentration of other
-Cimetidine: increases serum conc. of CCB
-Increases serum conc. of Fentanyl
127
Monitoring for Diltiazem?
LFTs, kidney function, BP, ECG, HR
128
Onset for Diltiazem?
IV: 1-3 min
PO: 30-60 min
129
Half life of Diltiazem?
IV: 3.5-4 hrs
PO: 3-9.5 hrs (depending on formulation)
130
Changes in Verapamil for geriatric patients?
None, use adult dosing
131
MOA for Verapamil?
Inhibits calcium from entering slow channels during depolarization, relaxation of coronary vascular smooth muscle/coronary vasodilation, slows automaticity and conduction of AV node
132
Indications for Verapamil?
-A-fib (rate control)
-SVT (acute treatment, off label)
133
Renal adjustment for Verapamil?
None unless Verelan PM (initial 100mg QD at bedtime), otherwise just use w/ caution
134
Hepatic adjustment for Verapamil?
Reduce dose, % reduction dependent on formulation
135
ROA of Verapamil?
IV over 2-3 min
PO dependent upon formulation (w/ food, watch splitting, no crushing!)
136
Side effects of Verapamil?
Constipation, headache, gingival hyperplasia, edemae
137
Frequency of dosing for Verapamil?
QD or QID
138
Monitoring for Verapamil?
BP, HR, periodic LFTs, ECG
139
Onset of Verapamil?
IV 3-5 min
PO 1-2 hrs
140
Half life of Verapamil?
4-12 hours
141
How much of Verapamil is protein bound?
90%
142
Drug-drug interactions of Verapamil?
-Antifungals
-May increase conc. of Dofetilide and Fentanyl
-Simvistatin: limit adult max of Simv. to 10mg/day
-Ethanol: may increase blood ethanol levels, prolong effects
-Grapefruit juice may increase serum conc. of Verapamil
143
Seek assistance with Verapamil if...?
Liber problems, bradycardia, arrhythmia, severe dizziness, passing out, SOB, excessive wt. gain, swelling of extremities
144
MOA of Digoxin?
Direct suppression of AV nodal conduction increasing effective refractory period and decreasing conduction velocity, positive inotropic effect, enhanced vagal tone, dec. ventricular rate to fast atrial arrhythmias
145
Indications for Digoxin?
A-fib (rate control) (off label dose)
SVT (rate control, off label use)
146
Adjustment of Digoxin for geriatric patients?
Do not exceed 0.125 mg/day in pts 65+y/o
147
Renal adjustment for Digoxin?
Reduce by 50% or avoid (may need to alter dose interval to q48hrs)
148
Hepatic adjustment for Digoxin?
None
149
ROA of Digoxin?
Total digitalizing dose (TDD)-
-IV: 8-12 mcg/kg (administer half of TDD over 5 min w/ remaining as 25% fractions at 4-8 hr intervals) OR (may administer 0.25mg w/ repeat dosing to max of 1.5 mg over 24 hrs followed by oral maintenance regimen)
-IV over 5 min
-IM (not preferred)
-PO (maintain adequate amounts of K+)
150
Side effects of Digoxin?
Headache, dizziness
151
Dosing frequency of Digoxin?
QD
152
Seek assistance with Digoxin if...?
N/V, severe diarrhea, vision changes, visual halos o bright colors around lights, weight loss, lack of appetite, black/tarry/bloody stools, confusion, brady/tachycardia, hallucinations, irregular heartbeat, mood changes, severe abdominal pain, enlarged breasts
153
Condition interacting with Digoxin?
Hypothyroidism may cause increased digoxin levels (due to decreased clearance)
154
Drug-drug interactions with Digoxin?
Amiodarone: increases digoxin levels
155
Monitoring with Digoxin?
-Digoxin toxicity levels over 2ng/mL
-Electrolytes (hypercalcemia can cause toxicity despite digoxin levels)
-HR, rhythm, periodic ECGs to assess effects/signs of toxicity
156
Onset of Digoxin?
IV 50-60 min
PO 1-2 hrs
157
Half life of Digoxin?
36-48 hours
158
MOA of Adenosine?
Slows conduction time through AV node, interrupting re-entry pathways through AV node, restoring NSR
159
Indications for Adenosine?
Paroxysmal SVT
160
Adjustment of Adenosine for geriatric patients?
None, use adult dosing
161
Renal & Hepatic adjustment with Adenosine?
None
162
ROA for Adenosine?
IV push
163
Side effects of Adenosine?
Abdominal pain, flushing
164
Seek assistance with Adenosine if....?
*Severe cerebrovascular disease (change in strength, one side > other, difficulty speaking/thinking, change in balance or vision), SOB, angina, severe dizziness, passing out, brady/tachycardia, abnormal heartbeat, seizures, severe headache, *neck pain, *jaw pain, *throat pain
165
Interactions with Adenosine?
-Caffeine: diminishes effects of adenosine
-Nicotine: enhances effect of AV blocking, may inc. HR, inc. severity of chest pain
166
Monitoring for Adenosine?
ECG, HR, BP
167
Onset on Adenosine?
Rapid
168
Half life of Adenosine?
<10 seconds
169
What is the "pill-in-the-pocket" approach for single-dose outpatient tx of select patients?
Single PO dose of meds can be given to terminate SVT outside of hospital in selected patients once safety is established
170
Who is the "pill-in-the-pocket" approach an option for?
-Infrequent (1-2hrs) SVT episodes which are hemodynamically tolerated
-Only one episode of SVT
171
Drug options for "pill-in-the-pocket" approach?
CCBs, BBs, Flecainide 100-300mg, Propafenone 150-450mg
172
"ABC" treatment method for A-fib?
Avoid stroke, Better symptoms, Comorbidity management
173
How to avoid stroke in A-fib patients?
Anticoagulants (VKAs-Warfarin, NOACS-dabigatran, rivaroxaban, apixaban)
LA Appendage exclusion (surgery, precutaneous)
174
How to better symptoms in a-fib patients?
HR control (BB, CCB, Digoxin)
Rhythm control (Cardioversion, Antiarrhythmetics- Amiodarone, etc., Ablation/Surgery)
175
Comorbidity management with A-fib?
Obesity, BP, DM, CAD, CPAP if sleep apnea, Avoid excessive ETOH (abstinence ideal), Moderate physical activity, HF control
176
What is the best option for anticoagulation in poor renal function?
Warfarin
177
What is the best option for anticoagulation in mechanical heart valves?
Warfarin
178
What is the best option for anticoagulation in rheumatic mitral stenosis?
Warfarin
179
What is the best option for anticoagulation in those who may easily miss doses?
Warfarin
180
Warfarin frequency of dosing?
Once daily
181
INR target w/ Warfarin?
2-3
182
Good option for anticoagulation for reducing stroke risk/major bleed?
Apixaban
183
Apixaban frequency of dosing?
BID
184
Which anticoagulant has an increased risk for GI bleed or MI?
Dabigitran
185
Dabigitran frequency of dosing?
BID
186
Which anticoagulant requires close monitoring of renal function?
Edoxaban
187
Edoxaban frequency of dosing?
Once daily
188
Which anticoagulant should be used in caution with Diltiazem, Dronedarone, and Verapamil, and also has an increased risk of GI bleed?
Rivaroxaban
189
Rivaroxaban frequency of dosing?
Once daily
190
Drugs for rate control in A-fib?
BB, Non-DHP CCBs, Digoxin, Amiodarone
191
Which medications should be used in A-fib with COPD?
BB, Diltiazem, Verapamil
192
Which medications should be used in A-fib with LV dysfunction or HF?
BB, Digoxin
Amiodarone
193
Which medications should be used in A-fib with HTN or HFpEF?
BB, Diltiazem, Verapamil
Amiodarone
194
Which medications should be used in A-fib with no other CV disease?
BB, Diltiazem, Verapamil
Amiodarone
195
Antiarrhythmic drugs for A-fib?
Flecainide, Propafenone, Amiodarone, Varnakalant, Ibutilide
196
Antiarrhythmic drugs for maintenance doses in A-fib?
Amiodarone, Flecainide, Propafenone, Disopyramide, Sotalol
197
Strategies for rhythm control in patients with paroxysmal and persistent A-Fib with no structural heart disease?
Dofetilide, Dronedarone, Flecainide, Propafenone, Sotalol
Amiodarone
+/- Catheter ablation
198
Strategies for rhythm control in patients with paroxysmal and persistent A-Fib with structural heart disease (CAD)?
Dofetilide, Dronedarone, Sotalol
Amiodarone
+/- Catheter ablation
199
Strategies for rhythm control in patients with paroxysmal and persistent A-Fib with structural heart disease (HF)?
Dofetilide, Amiodarone
+/- Catheter ablation
200
Acute tx of SVT of unknown mechanism?
Vagal maneuvers and/or IV adenosine (Class I)
--> if ineffective or not feasbile:
-Hemodynamically stable pts: IV BB, IV diltiazem or IV verapamil (Class IIa), if still ineffective: synchronized cardioversion
-Non-stable pts: Synchronized cardioversion
201
Tx of ongoing SVT of unknown mechanism?
Ablation candidate?
Yes- EP study/catheter ablation (if pre-excitation and a candidate, or if no pre-excitation and prefers ablation)
No- med therapy (if ineffective, catheter ablation)
202
Drug options for ongoing SVT of unknown mechanism?
-Recommended: BB, diltiazem or verapamil (in absence of pre-excitation)
-Flecainide or Propafenone (in absence of SHD)
-Amiodarone, Dofetilide, or Sotalol
-Digoxin (in absence of pre-excitation)
