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Anti-arrhythmics Flashcards

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1
Q

What’s heart rate (u)

A

HR describes the frequency of depolarization of the ventricles

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2
Q

What’s the normal resting HR (normal sinus rhythm - NSR)? (U)

A

60-100 beats per minute

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3
Q

Can Arrythmias be silent? (U)

A

Yes

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4
Q

In most pts that experience sx, what do they experience?

A

Palpitations (feeling like there’s fluttering or racing)

Dizziness

Lightheadedness

SOB

Chest pain

Fatigue

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5
Q

In severe cases, what sx may one experience?

A

Syncope

Heart failure

Death

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6
Q

What’s the most common etiology of arrhythmias?

A

Myocardial ischemia

OR

Infarction secondary to coronary artery dx

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7
Q

List the non-cardiac conditions that may trigger arrhythmias.

A

Electrolyte imbalances especially those involving potassium, magnesium, sodium and calcium

Elevated sympathetic states such as hyperthyroidism and infection

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8
Q

List the electrolytes that may trigger arrhythmias when they are out of balance

A

Potassium

Magnesium

Sodium

Calcium

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9
Q

What’s QT prolongation?

A

Drug- induced slowing of repolarization, which can result in a particularly dangerous ventricular tachyarrhythmia called Torsade de Pointes (TdP)

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10
Q

What’s the resting value?

A

-90 mV

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11
Q

What happens in phase 0 of action potential?

A

Depolarization (determines conduction velocity)

Na channels OPEN (entering cell)

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12
Q

What determines conduction velocity?

A

Depolarization

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13
Q

What’s the value of phase 1 of action potential?

A

+ 10mV

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14
Q

What happens in phase 1 of action potential?

A

PEAK

Na channels CLOSE

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15
Q

What happens in phase 2 (plateau)?

A

PLATEAU

Ca channels OPEN (entering cell)

K channels OPEN (EXITING cell)

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16
Q

What happens in phase 3?

A

Repolarization

Ca2+ channels CLOSE
K channel stays open (continue exiting cells)
Na may enter cell (late inward Na current)

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17
Q

What happens in phase 4?

A

Automaticity

Slow increase in potential

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18
Q

When is refractory period of action potential?

A

Phase 1 to end of phase 3

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19
Q

How’s arrhythmias classified?

A

Based on their location of origin into:

Supraventricular

OR

Ventricular

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20
Q

What’s Supraventricular arrhythmias?

A

Arrhythmias originating ABOVE atrioventricular node

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21
Q

What’s ventricular arrhythmias?

A

Originating BELOW the atrioventricular node

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22
Q

What’s the most common Supraventricular arrhythmias? (U)

A

Atrial fibrillation (AFib)

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23
Q

What’s AFib?

A

Results from multiple waves of electrical impulses in the atria, resulting in an irregular and usually RAPID VENTRICULAR RESPONSE

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24
Q

Why does the mgt of AFib involve anticoagulation?

A

Due to disorganized depolarization of the atria, coordinated atrial contraction is impaired, which increases the risk of thromboembolism and stroke

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25
What type of ventricular tachycardia is a medical emergency?
Ventricular tachycardia without a pulse
26
What's a risk factor for Torsade De Pointes (TdP)? (U)
Prolongation of the QT prolongation
27
What's Torsade de Pointes (TdP)? What can it result in?
TdP is a particularly lethal ventricular tachyarrhythmia which is most commonly ass. with drugs and can result in SUDDEN CARDIAC DEATH
28
How is QT interval measured? What's the measured space define?
From beginning of the QRS complex to the end of the T wave Reflect ventricular depolarization and repolarization
29
What pre-existing condition may cause additive QT prolongation?
Any pre-existing cardiac condition
30
What class of antiarrhythmics also result in additive QT prolongation? (U)
Class Ia (Disopyramide, Quinidine, Procainamide) double quarter pounder Class III (Amiodarone, Ibutilide, Dofetilide, Dronedarone, Sotalol) AIDDS
31
Name main antibiotics that may cause additive QT prolongation. (U)
Quinolones (Ciprofloxacin, Levo, Moxi, Nor, Ofloxacin, Gemi, Spar) Macrolides (Azithromycin, Erythromycin, Clarithromycin, Telithromycin)
32
Which Azole antifungal is most responsible for causing additive QT prolongation? (U)
Voriconazole
33
Which anticancer is most responsible for causing additive QT prolongation? (U)
Nilotinib
34
Which SSRI is most responsible for causing additive QT prolongation? (U)
Citalopram (Celexa)
35
What's the max dose of citalopram to prevent additive QT prolongation?
40mg/d
36
When is 20mg citalopram the max dose to prevent additive QT prolongation?
``` 60+ years Liver impairment HF S/P MI 2C19 poor metabolizer Pt on 2C19 inhibitors Taking QT prolonging drugs ```
37
Whats the max dose in for Escitalopram (Lexapro) to prevent additive QT prolongation? In the elderly?
20mg/d Don't exceed 10mg/d
38
What's the preferred antidepressant in cardiac pts to prevent QT prolongation?
Sertraline (Zoloft)
39
What antidepressant should be avoided if pt has cardiac risk?
Citalopram
40
Which antiemetic agent is most responsible for causing additive QT prolongation? (U)
5-HT3-receptor antagonists (Dolasetron, Ondansetron, Granisetron, Palonosetron)
41
Which antipsychotic is most responsible for causing additive QT prolongation? (U)
Thioridazine
42
Which other agent is most responsible for causing additive QT prolongation? (U)
Methadone
43
What's the 2 main reasons antiarrhythmic drugs are used?
Class I and III (used to terminate arrhythmias and restore and maintain normal sinus rhythm) Class II and IV and Digoxin (used to slow ventricular rate during a Supraventricular arrhythmias)
44
What class of antiarrhythmic drugs is used to terminate arrhythmias and restore and maintain normal sinus rhythm?
Class I and III Disopyramide, Quinidine, Procainamide, Lidocaine, Mexiletine, Phenytoin, Flecainide, Propafenone, Amiodarone, Ibutilide, Dofetilide, Dronedarone, Sotalol (AIDDS)
45
What class of antiarrhythmic agent is used to slow ventricular rate during a Supraventricular arrhythmias?
Class II Beta-blockers e.g. Esmolol, Propranolol) Class IV Verapamil, Diltiazem Digoxin
46
What must be done prior to starting any medication for NON-LIFE-THREATENING arrhythmia? (U)
Check pts electrolytes AND Run a toxicology screen
47
What's the Vaughan Williams classification of antiarrhythmics?
Class I a, b, c Class II Class III Class IV
48
List drugs that are listed as class Ia.
Double Quarter Pounder Disopyramide Quinidine Procainamide
49
List drugs that are listed as class Ib
Lettuce, Mayo, Pickles Lidocaine Mexiletine Phenytoin
50
List drugs that are listed as class Ic
Fries Please Flecainide Propafenone
51
List drugs that are listed as class II
Beta-blockers e.g. Esmolol, Propranolol
52
List drugs that are listed as class III
AIDDS Amiodarone Ibutilide Dofetilide Dronedarone Sotalol
53
List drugs that are listed as class IV
Verapamil Diltiazem
54
How are class I antiarrhythmics sub-classified?
They are Na channel blockers. They are divided based on the DURATION of time they bind to Na channel Ia - Intermediate Na channel blockers and they also block K channel Ib - Fast Na channel blockers Ic - Long Na channel blockers
55
Define class Ia antiarrhythmics
INTERMEDIATE Na + K channel blockers Double Quarter Pounder Disopyramide Quinidine Procainamide
56
Define class Ib antiarrhythmics
FAST Na channel blockers Lettuce, Mayo, Pickles Lidocaine Mexiletine Phenytoin
57
Define class Ic antiarrhythmics
LONG Na channel blocker Fries Please Flecainide Propafenone
58
Which class I sub- Grp especially have a black box warning?
Class Ic (fries pls - Flecainide, Propafenone)
59
MOA of class Ia antiarrhythmics?
REDUCE conduction velocity and automaticity INCREASE refractory period
60
What's the black box warning associated with Quinidine (class Ia)? (U)
Control AV conduction BEFORE initiating
61
SE of quinidine (class Ia)? (U)
Diarrhea (35%) Stomach cramping (22%) QT prolongation Nausea/vomiting Anorexia Lightheadedness Cinchonism (tinnitus, hearing loss, blurred vision, headache, delirium)
62
Are the different salts of quinidine interchangeable
No! 267mg of gluconate = 200mg of sulfate form
63
What's unique about Procainamide injection metabolite? (U)
Has a active metabolite - N-acetyl Procainamide (NAPA)
64
What's the black box warning associated with Procainamide injection?
Fatal blood dyscrasias e.g. Agranulocytosis Long-term use -> Positive antibody (ANA) in 50% of pts which may result in DRUG-INDUCED LUPUS ERYTHEMATOSUS-like syndrome
65
SEs of Procainamide injection?(u)
Hypitension Rash Lupus-like syndrome QT prolongation Agranulocytosis
66
What's the SE of Disopyramide?
Anticholinergics effect (xerostomia, constipation, urinary constipation)
67
Effect of class Ia agents (double quarter pounder) on QT prolongation?
ALL class Ia can have additive QT prolongation with other agents that also prolong the QT interval
68
What are class Ib agents (Mayo, Lettuce, Pickles) ONLY used for?
Ventricular arrhythmias (no efficacy for Supraventricular arrhythmias such as AFib)
69
T/F? All class Ib antiarrhythmics can't cross the blood-brain barrier.
False. All can cross the blood-brain-barrier
70
When are class Ic agents absolutely contraindicated?
Patients with heart failure (HF) OR Those who just experienced an acute myocardial infarction (MI)
71
MOA of class II antiarrhythmics (Esmolol, Propranolol)?
Block beta-blockers AND Indirectly block Ca channels in the SA and AV nodes
72
What are class II antiarrhythmics (Esmolol, Propranolol) used for? (U)
To slow the ventricular rate in Supraventricular tachyarrhythmia (eg. AFib)
73
MOA of class III agents? (AIDDS)
Blocks K channels -> significant increase in refractory period
74
What's the exception to the MOA of class III agents?
Ibutilide - works by activating the late inward Na current which also results in increased refractory period
75
In addition to blocking K channel, what other channels/receptors do Amiodarone and Dronedarone act on?
They also block Alpha-adrenergic receptors Beta-adrenergic receptors Ca channels Na channels
76
In addition to blocking K channel, what other channels/receptors do Soltalol act on?
Significant B-adnerergic receptor blocker
77
What's the class of amiodarone? And brand name?
Class III Cordarone Pacerone Nexterone
78
What's the black box warning of amiodarone?
Pts should be hospitalized when therapy is initiated becuz of (pulmonary toxicity, liver toxicity, proarrhythmic)
79
SE of amiodarone (cordarone/pacerone/nexterone)
Hypotension (IV only) GI upset Hypo/hyperthyroidism (more hypo than hyper) Dizziness Bradycardia Peripheral neuropathy/paresthesias Ataxia Tremor Corneal microdeposits, Optic neuritis Pulmonary fibrosis Photosensitivity Increased LFTs Slate blue (blue-grayish) skin discoloration
80
What considerations are taken when amiodarone (cardarone, pacerone, nexterone) will be infused over 2 hrs?
Should be admin in a non-polyvinyl chloride (non-PVC) container should as polyolefin or glass Recommended to be added to D5W
81
What's the advantage of premixed IV bag? (U)
Longer stability PVC bag not an issue Available in most commonly used conc If hypotension occurs, can slow rate or d/c
82
What's the half- life of amiodarone?
40-60 days
83
When's amiodarone recommended? (U)
Drug of choice I pts with concomitant heart failure
84
Which is the class III agent has to be given with meals?
Dronedarone - 400mg PO BID with meals
85
What's the black box warning of Dronedarone?
HF (class IV or any class with a recent hospitalization) AND In pts with permanent AFib
86
SE of Dronedarone? (U)
QT prolongation Bradycardia Increased SCr (and possibly BUN) Diarrhea Nausea Hypokalemia Hypomagnesemia
87
What's the pregnancy cat. of Dronedarone?
X
88
When's Dronedarone used?
Only in pts who can be converted to normal sinus rhythm
89
Which class III agent requires a REMS program?
Dofetilide (Tikosyn)
90
What's T.I.P.S?
Tikosyn (Dofetilide) in pharmacy system - allows retail pharmacies to stock and dispense Tikosyn
91
What's the monitoring parameters for Tikosyn (Dofetilide)?
ECG Renal fxn K Mg HR BP In the first few days
92
What's the effect of ALL class III agents on QT prolongation?
Can have additive QT prolongation with other agents that also prolong the QT interval
93
What should be considered wrt to electrolytes and ALL anti-arrhythmic?
Electrolyte abnormalities (k, Na, Ca, Mg) should be corrected before any antiarrhythmics is initiated
94
What's the consequence of not correcting electrolyte before initiating antiarrhythmics?
Risk of arrhythmia is increased
95
What should be avoided with use of class III antiarrhythmics?
Grapefruit juice/pdts Ephedra St. John's wort (P-glycoprotein inducer)
96
What meds should be reduced when starting amiodarone? By how much?
Digoxin (reduce by 50%) and Warfarin (reduce by 30%-50%)
97
What class of drugs should use lower doses with amiodarone?
Simvastatin, Lovastatin, Atorvastatin
98
T/F? Monitor INR after initiating Dronedarone in pts with Warfarin
True
99
MOA of class IV agents?
They block L-type Ca channels, slowing SA and AV nodal conduction velocity
100
Uses of class IV agents?
Used to slow ventricular rate in Supraventricular tachyarrhythmia
101
List agents under class IV antiarrhythmics?
Diltiazem (Cardizem) Verapamil (Calan/ Verelan/ Covera HS)
102
What type of CCBs are used in antiarrhythmics?
Only non-dihydropyridine CCBs are used
103
When is CCB is preferred over b-blocker in pts with arrhythmias?
If co- existing asthma/COPD in pts
104
Other antiarrhythmics not included in Vaughan Williams classification?
Adenosine (Adenocard) Digoxin (Lanoxin)
105
MOA of adenosine?
Slows conduction through the AV node via activation of adenosine-1 receptors
106
Uses of adenosine in arrhythmias?
Used to restore normal sinus rhythm in Supraventricular re-entrant tachyarrhythmia
107
Effects of digoxin?(u)
Digoxin enhances vagal tone, resulting in decrease ventricular rate in atrial tachyarrhythmia
108
What's the brand name of digoxin? (U)
Lanoxin
109
What's the therapeutic range of digoxin (lanoxin) for AFib?
0.8-2 ng/mL
110
What's the antidote for Digoxin (lanoxin)?
DigiFab
111
Whats the first signs of digoxin (lanoxin) toxicity? (U)
Nausea/vomiting Loss of appetite Bradycardia
112
Other signs of digoxin (lanoxin) toxicity? (U)
Blurred/ double vision Altered color perception Greenish-yellow halos around lights or objects Abdominal pain Confusion Delirium Arrhythmia (prolonged PR interval, accelerated junctional rhythm, bidirectional ventricular tachycardia)
113
Is digoxin (lanoxin) used alone?
No! Used in combo with b-blockers or CCB
114
Since digoxin is mostly renally cleared, whats the concern with digoxin (lanoxin) use here?
In decreased renal fxn -> reduce digoxin dose In acute renal failure -> hold digoxin
115
What increases risk of digoxin (lanoxin) toxicity?
Hypokalemia (K < 3.5 mEq/L) Hypomagnesemia Hypercalcemia
116
Role of medication guide in amiodarone dosing?
Dispense medication guide with amiodarone
117
Should amiodarone be taken with food?
Amiodarone can be taken with/ without food. BUT, if you should stick to which ever method you use e.g. If you start taking amiodarone with food, then you need to continue taking it with food, while on the med
118
What body organs need to be monitored while in amiodarone?
Eyes - vision should be checked before and during the time you're using amiodarone Blood - blood should be checked regularly Chest x-ray during tx Thyroid Liver Lungs
119
Photosensitivity and amiodarone?
Amiodarone may cause your skin to be more sensitive to the sun. Stay out of the sun
120
What's the brand name for Dronedarone?
Multaq
121
What's the potassium safe range for pt on digoxin?
3.5-5 mEq/L
122
What's arrhythmias?
Caused by abnormalities in the formation and/or conduction of these electrical impulses

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