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Cardio 1228 > Anti-arrhythmics (edited) > Flashcards

Anti-arrhythmics (edited) Flashcards

(137 cards)

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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)?

A

60-100 beats per minute

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3
Q

Can Arrythmias be silent?

A

Yes-a small percentage are silent (asymptomatic)

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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)
  • feeling like heart is skipping a beat
  • 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

drugs- including illicit and antiarrythmics

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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 the rate of ventricular depolarization and repolarization (from beginning of QRS complex-end of T wave) , which can result in a particularly dangerous ventricular tachyarrhythmia called Torsade de Pointes (TdP)-can cause sudden cardiac death

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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)
Class 1a, 1b, 1c antiarrythmthmias target the open Na channel

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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)
-class III antiarrythmics target the open K channel
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, blood becomes stagnant in atria increasing risk of clot formation, 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 I especially Ia (Disopyramide, Quinidine, Procainamide) double quarter pounder ``` and 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), escitalopram
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?
Rhythm Class I and III (used to terminate arrhythmias and restore and maintain normal sinus rhythm) Rate 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? Cardioversion
Class I and III Disopyramide, Quinidine, Procainamide, Lidocaine, Mexiletine 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 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 Lidocaine Mexiletine
50
List drugs that are listed as class Ic
Fries Please Flecainide Propafenone
51
List drugs that are listed as class II
Beta-blockers
52
List drugs that are listed as class III
DDSIA Dieting During Stress Is Awful Dofetilide Dronedarone Sotalol Ibutilide Amiodarone
53
List drugs that are listed as class IV
Verapamil Diltiazem
54
How are class I antiarrhythmics sub-classified?
They are Na channel blockers. Proarrhythmic (increase arrhythmia risk). -Inotrope (decrease force of heart contraction) 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 Lidocaine Mexiletine
57
Define class Ic antiarrhythmics
LONG Na channel blocker Fries Please Flecainide Propafenone
58
MOA of class Ia antiarrhythmics?
REDUCE conduction velocity and automaticity INCREASE refractory period
59
What's the black box warning associated with Quinidine (class Ia)?
Control AV conduction BEFORE initiating-may increase mortality in AFib or flutter Warning: DILE- avoid G6PD deficient-can cause positive Coombs test
60
SE of quinidine (class Ia)? (U)
Diarrhea (35%) Stomach cramping (22%) QT prolongation Hepatotoxicity Nausea/vomiting Lightheadedness Cinchonism (tinnitus, hearing loss, blurred vision, headache, delirium)
61
Are the different salts of quinidine interchangeable
No! 267mg of gluconate = 200mg of sulfate form
62
What's unique about Procainamide injection?
Has a active metabolite - N-acetyl Procainamide (NAPA) NAPA is really cleared
63
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 DILE
64
SEs of Procainamide injection?(u)
Hypotension Rash DILE QT prolongation Agranulocytosis
65
What's the SE of Disopyramide?
Anticholinergics effect (xerostomia, constipation, urinary constipation) Can cause HF, BPH, urinary retention, narrow angle glaucoma, and myasthenia gravis (due to anticholinergic effects
66
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
67
What are class Ib agents (Mayo, Lettuce) ONLY used for?
Ventricular arrhythmias (no efficacy for Supraventricular arrhythmias such as AFib)
68
When are class Ic agents absolutely contraindicated?
Structural Heart issues: Patients with heart failure (HF) OR myocardial infarction (MI)
69
MOA of class II antiarrhythmics?
Block beta-blockers (block the sympathetic activity that may be causing the arrhythmia) AND Indirectly block Ca channels= decrease in ion conduction speed slows the rate
70
What are class II antiarrhythmics used for?
To slow the ventricular rate in Supraventricular tachyarrhythmia (eg. AFib)
71
MOA of class III agents? (AIDDS)
Blocks K channels -> significant increase in refractory period
72
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
73
In addition to blocking K channel, what other channels/receptors do Amiodarone and Dronedarone act on?
They also block Alpha & beta adrenergic receptors Ca channels Na channels
74
In addition to blocking K channel, what other channels/receptors do Soltalol act on?
Significant B-adnerergic receptor blocker
75
What's the class of amiodarone? And brand name?
Class III Pacerone Nexterone
76
What's the black box warning of amiodarone?
Pulmonary toxicity, hepatotoxicity, proarrhythmic- use ONLY for life-threatening arrhythmias. Pts should be hospitalized when LOADING DOSE is given
77
SE of amiodarone (cordarone/pacerone)
``` WARNING: hyper/HYPO thyroidism (inhibits T3->T4) ----chemical structure contains iodine(like thyroid hormone) Optic neuropathy photosensitivity- SLATE BLUE SKIN neurotoxicity-(peripheral neuropathy) SJS/TEN ``` ``` Hypotension Bradycardia Corneal microdeposits Dizziness Ataxia GI upset N/V Constipation Tremor Photosensitivity DILE ``` Hypo/hyperthyroidism (more hypo than hyper) Bradycardia
78
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 such as polyolefin or glass Recommended to be added to D5W
79
What's the advantage of premixed IV bag? (U)
Comes in GALAXY container (nonPVC, nonDEHP) Longer stability-24 months at room temp PVC bag not an issue Comes in commonly used concentrations
80
What's the half- life of amiodarone?
40-60 days
81
When's amiodarone recommended?
Commonly used antiarrhythmic despite all it's side effects | Antiarrhythmic drug of choice in pts with heart failure
82
Which is the class III agent has to be given with meals?
Dronedarone - 400mg PO BID with meals
83
What's the black box warning of Dronedarone?
Increased risk of death, stroke, or HF in pts with decompensated HF (class IV or any class with a recent hospitalization) or permanent AFib
84
SE of Dronedarone? (U)
Warning: hepatic failure, pulmonary disease (including fibrosis and pneumonitis) ``` QT prolongation Bradycardia Increased SCr (and possibly BUN) N/V/D ab pain Hypokalemia Hypomagnesemia ``` note: no iodine in structure so little/no thyroid effects
85
What's the pregnancy cat. of Dronedarone?
X
86
When's Dronedarone used?
Only in pts who can be converted to normal sinus rhythm
87
What's the monitoring parameters for Tikosyn (Dofetilide)?
Box: continuous ECG monitoring | and CrCl monitoring for a minimum of 3 days after initiation or re-initiation
88
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
89
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
90
What's the consequence of not correcting electrolyte before initiating antiarrhythmics?
Risk of arrhythmia is increased
91
What should be avoided with use of class III antiarrhythmics?
Grapefruit juice/pdts Ephedra St. John's wort (P-glycoprotein inducer)
92
What meds should be reduced when starting amiodarone? By how much?
Digoxin (reduce by 50%) and Warfarin (reduce by 30%-50%)
93
What class of drugs should use lower doses with amiodarone?
Simvastatin, Lovastatin, Atorvastatin
94
T/F? Monitor INR after initiating Dronedarone in pts with Warfarin
True
95
MOA of class IV agents?
They block L-type Ca channels, slowing SA and AV nodal conduction velocity
96
Uses of class IV agents?
Used to slow ventricular rate in Supraventricular tachyarrhythmia
97
List agents under class IV antiarrhythmics?
Diltiazem (Cardizem) Verapamil (Calan/ Verelan/ Covera HS)
98
What type of CCBs are used in antiarrhythmics?
Only non-dihydropyridine CCBs are used
99
When is CCB is preferred over b-blocker in pts with arrhythmias?
If co- existing asthma/COPD in pts
100
Other antiarrhythmics not included in Vaughan Williams classification?
Adenosine (Adenocard) Digoxin (Lanoxin)
101
MOA of adenosine?
Slows conduction through the AV node via activation of adenosine-1 receptors
102
Uses of adenosine in arrhythmias?
Used to restore normal sinus rhythm in Supraventricular re-entrant tachyarrhythmia
103
Effects of digoxin?(u)
Digoxin enhances vagal tone, resulting in decrease ventricular rate in atrial tachyarrhythmia
104
What's the brand name of digoxin? (U)
Lanoxin, Digitek, Digox
105
What's the therapeutic range of digoxin (lanoxin) for AFib?
0.8-2 ng/mL
106
What's the antidote for Digoxin (lanoxin)?
DigiFab
107
Whats the first signs of digoxin (lanoxin) toxicity? (U)
Nausea/vomiting Loss of appetite Bradycardia
108
Other signs of digoxin (lanoxin) toxicity? SEVERE
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)
109
Is digoxin (lanoxin) used alone?
Not usually Used in combo with b-blockers or CCB
110
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
111
What increases risk of digoxin (lanoxin) toxicity?
Hypokalemia (K < 3.5 mEq/L) Hypomagnesemia Hypercalcemia
112
Role of medication guide in amiodarone dosing?
Dispense medication guide with amiodarone
113
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
114
What body organs need to be monitored while in amiodarone?
ECG BP HR electrolytes pulmonary function (chest x-ray) Thyroid- baseline q 3-6 mo LFTs- baseline and q 6 mo eye exams
115
Photosensitivity and amiodarone?
Amiodarone may cause your skin to be more sensitive to the sun. Stay out of the sun Can cause skin to turn blue-gray (not harmful & goes away months after drug is stopped)-infrequent
116
What's the brand name for Dronedarone?
Multaq
117
What's the potassium safe range for pt on digoxin?
3.5-5 mEq/L
118
What's arrhythmias?
Caused by abnormalities in the formation and/or conduction of these electrical impulses
119
Amiodarone unique injection info
Incompatible with heparin-use saline flush | Use 0.22 micron filter
120
adenosine brand?
Adenocard t 1/2 less than 10 seconds used in paroxysmal supra ventricular tachycardia (PSVT)-activates adenosine receptors=decrease AV node conduction
121
dofetilide brand?
Tikosyn
122
Ibutilide brand?
Corvert
123
Sotalol brand?
Betapace, Sotylize, Sørine Non-selective beta blocker Box: adjust dosing interval based on CrCl (QT prolongation directly related to stall concentration)
124
Propafenone brand
Rythmol Note: can cause metallic taste disturbance
125
lidocaine brand
Xylocaine used for refractory VT/ cardiac arrest
126
disopyramide brand
Norpace
127
non-DHP CCB side effects
edema, HA, dizzy, hypotension, arrhythmia, HF, constipation (more with verapamil), gingival hyperplasia
128
Amiodarone inhibits
2C9, 2D6, 3A4, P-gp
129
Amiodarone is a substrate of
3A4, 2C8, and p-gP Avoid strong inducers/inhibitors
130
amiodarone + digoxin
when starting amiodarone decrease Digoxin by 50%
131
amiodarone+ warfarin
when starting amiodarone decrease warfarin by 30-50%
132
amiodarone + statin
simvastatin max 20mg/d | lovastatin max 40 mg/d
133
Do NOT use amiodarone with
sofosbuvir (Sovaldi) used for Hep C it enhances the bradycardia effect of amiodarone
134
statins that are not 3A4 metabolized
prava, rosuva, pitava
135
typical digoxin dose
0.125-0.25 mg PO daily when CrCl<50 decrease dose or decrease dose frequency
136
oral to IV
decrease oral 20-25% when going to IV
137
digoxin use
to help heart beat at more regular RATE ``` Na-K-ATPase blocker: blocking that pump= Increase force (+inotrope) Decrease HR (-chronotrope) ```

Cardio 1228 (17 decks)

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