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Therapeutics - Cardio > Arrhythmia - Guidelines/Tx > Flashcards

Arrhythmia - Guidelines/Tx Flashcards

1
Q

Which arrhythmia is irregularly irregular?

A

Afib

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2
Q

Which arrhythmia is irregularly regular?

A

A flutter

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3
Q

What is Step 1 of AFib management

A
  • Evaluate the need for acute tx (HR control +/- cardioversion)
  • Start anticoag (UFH, LMWH)
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4
Q

What are the signs of hemodynamic instability?

A

Severe HoTN
Angina
Pulmonary edema

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5
Q

In Step 1 of Afib management, if the pt is hemodynamically unstable, what do we do?

A
  • Cardiovert immediately w/o regard to embolic risk

- Post cardioversion 4 weeks warfarin (INR 2-3) or target selective oral anticoags

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6
Q

In Step 1 of Afib management, if the pt is NOT hemodynamically unstable, what do we do?

A

DO NOT CARDIOVERT

Proceed w/ controlling ventricular rate using AV node blocking agents

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7
Q

Which class(s) of drugs should be avoided during Step 1 of AFib: HR control?

A

Class Ia & III

These may allow more impulses to cross AV node –> Inc HR

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8
Q

If LVEF > 40%, which classes of drugs are we looking to use for HR control for Afib?

A

Class II and IV

Can use digoxin but not really

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9
Q

How are the drugs used in HR Control of Step 1 of Afib administered?

A

IV bolus + continuous infusion

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10
Q

If LVEF < 40%, which classes of drugs are we looking to use for HR control for Afib?

A

Digoxin (slow onset though)

IV Amiodarone

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11
Q

What is a risk of using IV Amiodarone for LVEF <40% in Afib?

A

It may facilitate conversion to NSR –> risk of thromboembolic event if a clot is present

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12
Q

If Afib or Aflutter is precipitate by a state of increased adrenergic tone, ____ resistance may be found and ____ may be a better choice

A

Digoxin resistance

Beta Blocker is an excellent choice

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13
Q

What is Step 2 for Afib management?

A

Restoration of sinus rhythm VS. continue ventricular rate control + leave pt in arrhythmia

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14
Q

Restoration of sinus rhythm is associated w/ inc risk of ______

A

Thromboembolism, because NSR promotes effective atrial contractions, which may dislodge poorly adherent thrombi

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15
Q

What was the outcome of the PIAF trial?

A

Improvement of symptoms w/ rhythm control (Amiodarone) but higher ADR and hospitalization

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16
Q

What was the outcome of the AFFIRM trial?

A

Rhythm control offered no survival advantage over rate control

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17
Q

What was the outcome of the STAF trial?

A

No difference in long-term cardiovascular outcomes between rhythm and rate control

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18
Q

When is it NOT necessary to use anticoag prior to cardioversion, and why?

A

Afib or Aflutter w/ recent onset (<48 hrs); there hasn’t been enough time for atrial thrombi to form

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19
Q

What role does TEE play in cardioversion?

A

Determine whether a thrombus is present or not

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20
Q

What do we do if a thrombus is present?

A 
Do not cardiovery until thrombus is gone
Continue anticoag (UFH/LMWH + Warfarin until goal INR 2-3 OR can use DARE)
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21
Q

DARE anticoag abbrevieation

A

dabigatran
apixaban
rivaroxaban
edoxaban

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22
Q

If a thrombus is not present?

A

Continue heparin during TEE + cardioversion

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23
Q

When is 4 week post-cardioversion necessary if AF<48 hrs?

A

If the pt has a stroke risk or if AF has occurred in the past or is likely to recur

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24
Q

What are the options for rhythm control?

A

Direct current cardioversion (DC cardioversion)

AAD (Ia, Ic, III, w/ Ic & III pure K+ blockers working the best)

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25
Q

Which Class III are used for chronic rhythm therapy and NOT acute?

A

Sotalol

Dronedarone

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26
Q

Which Class III are only used for acute rhythm therapy?

A

Ibutilide

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27
Q

Which AAD are okay to restore NSR if the pt has structural heard dz?

A

Amiodarone

Dofetilide

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28
Q

Which AAD are okay to restore NSR as long as the pt doesn’t have structural heart dz?

A

Ic
Ibutilide
Amiodarone
Dofetilide

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29
Q

If we are not doing rhythm control and are just doing rate control, what are our HR goals?

A

LVEF < 40% :

  • <80 bpm at rest
  • <100 bpm during exercise

LVEF > 40% :
<110 bpm at rest

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30
Q

What AV node blocking drug do we use for rate control if LVEF > 40%?

A

Oral CLass II
Class IV
+/- digoxin

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31
Q

What AV node blocking drug do we use for rate control if LVEF < 40%?

A

Metoprolol succinate
Carvedilol
+/- digoxin

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32
Q

Prevention of long term consequences in paroxysmal, persistent, or permanent AF - Low risk (CHA2DS2VASc = 0 in men, 1 in women)

A

Reasonable to omit therapy

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33
Q

Prevention of long term consequences in paroxysmal, persistent, or permanent AF - Medium risk (CHA2DS2VASc = 1 in men, 2 in women)

A

Consider Warfarin (INR 2-3) or DARE

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34
Q

Prevention of long term consequences in paroxysmal, persistent, or permanent AF - High risk (CHA2DS2VASc = 2+ in men, 3+ in women)

A

Start Warfarin (INR 2-3) or DARE

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35
Q

What are warfarin dose lowering factors?

A

Weight < 45 kg
Baseline INR >1.3
Malnourishment
Albumin < 3 g/dL
Liver dz
Catabolic conditions (recent surgery, hyperthyroidism, ADHF, pneumonia)
Azole antifungals, Metronidazole, Septra, Amiodarone

36
Q

What are warfarin dose raising factors?

A 
Weight > 90 kg
Untreated hypothyroidism
Receiving enteral feeds
Drugs:
-Rifampin
-Carbamazepine
-Dicloxacillin
-Phenobarb
-Bosentan
37
Q

What baseline labs are needed for warfarin?

A 
PT
INR
CBC
LFTs
Albumin
38
Q

Which DARE has the least amount of renal elimination?

A

Apixaban (25%)

39
Q

Which DARE has risk of osteoarthritis and back pain?

A

Rivaroxaban

40
Q

Which DARE has risk of GI distress, rash, and hives?

A

Dabigatran

41
Q

What are the first line agents in preventing recurrence of Afib or Aflutter w/ AAD’s - no structural heart dz?

A 
Dofetilide
Dronedarone
Flecainide
Propafenone
Sotalol
42
Q

What are the first line agents in preventing recurrence of Afib or Aflutter w/ AAD’s - HF?

A

Amiodarone

Dofetilide

43
Q

What are the first line agents in preventing recurrence of Afib or Aflutter w/ AAD’s - CAD?

A

Dofetilide

If EF > 40% :
Dronedarone
Sotalol

44
Q

What are the first line agents in preventing recurrence of Afib or Aflutter w/ AAD’s - HTN w/ LV hypertrophy?

A

Amiodarone

45
Q

What are the Second line agents for preventing recurrence of Afib or Aflutter w/ AAD’s - no structural heart dz, HF, CAD, or HTN w/ LVH?

A

Catheter ablation (all)

Amiodarone (CAD or no structural heart dz)

46
Q

How do we terminate acute PSVT in mild-moderately symptomatic pts?

A

Carotid Massage
Valsalva maneuver
Ice water facial
Induce retching

47
Q

How do we terminate acute PSVT in symptomatic patients?

A

DC cardioversion

48
Q

What do we use to terminate acute PSVT if non drug measures fail - narrow complex PSVT?

A

Adenosine
Verapamil
Diltiazem

49
Q

What do we use to terminate acute PSVT if non drug measures fail - wide complex PSVT (regular arrhythmia)?

A

Adenosine

Procainamide

50
Q

What do we use to terminate acute PSVT if non drug measures fail - wide complex PSVT (irregular arrythmia)?

A

Procainamide

Amiodarone

51
Q

What is a wid complex PSVT?

A

QRS >= 0.12 seconds

52
Q

When is prophylactic therapy needed for Acute PSVT?

A
  • Frequent episodes requiring intervention

- Infrequent episodes w/ severe sxs

53
Q

What is VT?

A

Wide complex QRS tachycardia

54
Q

What can cause VT?

A

Hypoxemia
Severe electrolyte abnormalities
MI
Digoxin toxicity

55
Q

What is sustained VT?

A

> 30 seconds

56
Q

What is incessant VT?

A

VT occurs more often than NSR

57
Q

What is polymorphic VT?

A

VT w/ varying QRS complexes (includes TdP)

58
Q

What indicates that a VT pt is unstable?

A

Altered mental status
Chest pain
HoTN

59
Q

How do we tx unstable VT?

A

Synchronized cardioversion

May consider Adenosine if regular narrow complex

60
Q

How do we tx stable VT pt w/ narrow QRS, regular rhythm?

A

Vagal maneuvers

Adenosine

61
Q

How do we tx stable VT pt w/ narrow QRS, irregular rhythm?

A

Diltiazem

Beta blockers

62
Q

How do we tx stable VT pts w/ wide QRS, regular and monomorphic?

A

Adenosine

63
Q

How do we tx stable VT pts w/ wide QRS, irregular rhythm or polymorphic?

A

Amiodarone
Procainamide

If TdP suspected: IV Mg2+

64
Q

Tx of chronic, nonsustained VT

A

Conservative (no AADs beyond Beta blockers)

Empiric Amiodarone

65
Q

TdP - hemodynamically unstable:

A

Electrical cardioversion

66
Q

TdP - hemodynamically stable:

A

Restore K+ to 4.5-5 mmol/L

Mg Sulfate 2g IV over 60 sec, repeat 5-15 in later if refractory TdP + consider repeat doses Q6Hr if QTc> 500 ms

67
Q

Secondary tx of TdP:

A

Class IB (don’t inhibit K+ which is a good thing)
Cardioacceleration w/ Isoproterenol (1-4 mcg/min)
Tranvenous pacing

68
Q

Drugs that risk TdP:

A 
Disopyramide
Quinidine
Ibutilide
Dofeteilide
Sotalol
Amiodarone
TCA
Antipsychotics
Phenothiazines
IV Erythromycin
Quinolones
Antihistamines
Ketoconazole
Thiazides (Low K+, Mg2+)
69
Q

Sinus bradycardia tx

A

No

70
Q

Bradyarrhythmias - drugs to avoid

A

Those used in SVTs

71
Q

Bradyarrhythmias - drugs to use w/ caution

A

SA/AV node blockers (B blockers, CCB)

72
Q

1st degree AV block characteristics

A

1:1 conduction

Inc PR interval

73
Q

2nd degree Type I AV block characteristics

A

Mobitz I or Wenkebach
Less than 1:1 conduction
Progressive lengthening of PR until a QRS complex is dropped

74
Q

Which AV blocks are usually due to prolonged conduction in AV node?

A

1st and 2nd Type I

75
Q

2nd degree Type II AV block

A

Mobitz II or Non-Wenkebach

Intermittently dropped ventricular beats in random fashion w/o progressive PR interval prolongation

76
Q

What AV blocks are usually due to conduction defect below the AV node?

A

2nd degree Type II

77
Q

3rd degree AV block

A

“Complete heart block” w/ dissociation between atria and ventricle

May be due to dz at any level of conduction system

Usual degree of automaticity of ventricular pacemakers declines as block moves down conduction system

78
Q

Acute, symptomatic AV block tx

A

Immediate transcutaneous pacin
Atropine during pacemaker placement
Epi or dopamine if atropine fails

79
Q

When will catecholamine infusion not work for AV block?

A

If level of block is below AV node (2nd degree Type II, possibly 3rd degree)

80
Q

Under which two conditions does ventricular fibrillation most commonly occur?

A
  • IHD

- Primary myocardial diseases associated w/ LV dysfxn

81
Q

What kind of drugs should not be used w/ Vfib?

A

Prophylactic AADs; Inc mortality risk

82
Q

Vfib drug of choice?

A

Amiodarone 300 mg bolus; superior to Lidocaine 1-1.5 mg/kg IV bolus

83
Q

What are potential etiologies of PEA?

A

Hypo:

  • volemia
  • oxia
  • k+
  • thermia
Acidosis
Hyper-K+
Cardiac tamponade
PE
ACS 
Trauma
Drug OD
84
Q

What is the first line choice for pulse-less VTach and VFib?

A

Amiodarone

85
Q

Epi Cardiac Arrest indications

A

Pulseless VTach, Vfib, asystole, PEA

86
Q

Vasopressin Cardiac Arrest indications

A

Pulseless VTach, Vfib, asystole, PEA

Used only as an alternative to 1st or 2nd dose of Epi

Therapeutics - Cardio (4 decks)

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