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CV > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

Class 1 (Na+ blockers)

A 
Membrane stabilising drugs 
E.g. 
1. Disopyramide
2. Lidocaine 
3. Flecainide / Propafenone (contraindicated in asthma/severe COPD. Avoid in structural/ischemic heart disease)
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2
Q

Class 2 (Beta-blockers)

A
  1. Propranolol

2. Esomeprazole

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3
Q

Class 3 (K+ channel blockers)

A
  1. Amiodarone (4 weeks before and 12 months after electrical cardioversion to increase success)
  2. Sotalol
  3. Dronedarone (hepatotoxicity and HF side effects)
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4
Q

Class 4 (Calcium Channel Blockers, rate limiting)

A
  1. Verapamil

2. Diltiazem (unlicensed)

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5
Q

Other

A
  1. Adenosine

2. DIGOXIN (effective in sedentary patients with non-paroxysmal AF an in patients with associative congestive HF)

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6
Q

Atrial Fibrillation

A

Abnormal, disorganized electrical signals fired cause atria to fibrillate = rapid and irregular heartbeat

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7
Q

Symptoms of AF

A

Heart palpitations = pounding/fluttering

Dizziness, SOB, tiredness

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8
Q

AF complications

A
  1. Stroke

2. HF

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9
Q

Types of AF

A
  1. Paroxysmal AF = episodes stop within 48hrs without treatment
  2. Persis tend AF = episode lasts >7dys
  3. Permanent AF = present all the time
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10
Q

Rate Control

A 
FIRST LINE 
Control ventricular rate
1. Verapamil (rate-limiting CCB)
2. Beta-blocker (NOT SOTALOL) 
3. Digoxin 
monotherapy, dual therapy then rhythm control
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11
Q

Rhythm control

A

SECOND LINE
Restore and maintain sinus rhythm
1. Beta-blocker e.g. sotalol
2. OR oral anti-arrhythmic e.g. amiodarone/flecainide

CARDIOVERSION

  1. Electrical - direct current
  2. Pharmacological - anti-arrhythmic e.g. amiodarone/flecainide
    - cant give if symptoms >48hrs due to increased rik of stroke
    - electrical preferred if >48hrs
    - wait until full anticoagulated for 3 weeks before cardioversion and continue 4 week after
    - if hemodynamically unstable = electrical cardioversion, give parental anticoagulant and rule out left atrial thrombus immediately before procedure
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12
Q

Paroxysmal and symptomatic AF treatment

A

Rhythm control

  1. Standard beta-blocker
  2. Oral anti-arrhythmic

Infrequent episodes - “pill in pocket” self treatment

  1. Flecainide
  2. Propafenone
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13
Q

Atrial Flutter

A

Similar to AF but CATHETER ABLATION more suitable

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14
Q

Anticoagulation

A 
CHA2DS2VASc tool - give if score 2 or more 
C - chronic HF or LV dysfunction 
H - hypertension 
A - age >75 
D - diabetes 
S - stroke/transient ischemic attack/VTE hx 
V - vascular disease 
A - age 65-74 years 
S - sex e.g. female
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15
Q

Ventricular Tachycardia

A
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16
Q

Torsade de pointes (prolonged QT interval)

A

Causes

  1. Sotalol and other QT prolongation drugs
  2. HypOKalaemia
  3. Bradycardia

Treatment
1. Mg sulphate

17
Q

Paroxysmal Supraventricular Tachycardia

A

Short circuit rhythm develops in the upper chamber of the heart

results in a regular but rapid heartbeat that starts and stops abruptly

can be recurrent - requires catheter ablation or drugs (verapamil, diltiazem, beta-blockers, flecainide or propaferone)

terminates spontaneously or with reflex vagal nerve stimulation e.g. Valsalva manoeuvre (breathing technique), carotid sinus massage or immersing face in cold water

Treatment

  1. IV adenosine
    * contraindicated in COPD/asthma
  2. IV verapamil

If haemodynamically unstable = direct current cardioversion

18
Q

AMIODARONE (Class 3 anti-arrhythmic)

A

LOADING DOSES

  • 200mg TDS for 7 days
  • 200mg BD for 7 days
  • 200mg OD as maintenance
19
Q

AMIODARONE SIDE EFFECTS

A
  1. Eyes - corneal micro-deposits (night-time glares when driving) and optic neuropathy/neuritis (blindness) STOP
  2. Skin - phototoxic, slate-grey skin on light exposed areas, shield skin from light, use high SPF suncream for months after therapy
  3. Nerves - peripheral neuropathy, numbness, tingling in hand and feet
  4. Lungs - pneumonitis, pulmonary fibrosis, SOB, dry cough
  5. Liver - hepatotoxic, jaudice, n+v, itching, burning, bruising, abdo pain, 3x raised liver transaminases
  6. Thyroid - CONTAINS IODINE
    - Hyperthyroidism (weight loss, heat intolerant, tachycardia). Withdraw amiodarone. Give carbimazole if necessary
    - Hypothyroidism (weight gain, cold intolerance, bradycardia). Start levothyroxine without withdrawing amiodarone
20
Q

AMIODARONE MONITORING

A
  1. Annual eye tests
  2. Chest X-ray before treatment
  3. LFTs every 6 months
  4. Monitor TSH, T3, T4 before and every 6 months
  5. BP and ECG - causes hypotension and bradycardia
  6. Serum K+ - causes HYPOkalaemia, enhances arrhythmic effects
21
Q

AMIODARONE INTERACTIONS

A

EXTREMELY LONG 1/2 LIFE (50 days) = interactions several months after stopping

  1. Increased plasma amiodarone conc with enzyme inhibitors
    e. g. SICKFACES.COM GAVID
  2. Amiodarone is an enzyme inhibitor = reduce dose of warfarin, phenytoin, digoxin (half-dose)
  3. Increased risk of myopathy with statins
  4. Bradycardia, AV block and myocardial depression with beta-blockers, rate limiting CCB e.g. Verapamil and Diltiazem
  5. QT prolongation = increased risk of ventricular arrhythmias with quinolones, macrolides, TCAs, SSRIs, lithium, quinine, hydroxychloroquine, anti-malarial (chloroquine, mefloquine) and antipsychotics (esp sulpiride, pimozide, amisulpride)
22
Q

DIGOXIN (Cardiac glycoside)

A

Action

Increases force of myocardial contraction (positive inotrope)
Reduces conductivity in the AV node (negative chronotrope)

23
Q

Digoxin concentration

A

1-2mcg/L (6hrs after dose)
Regular monitoring is NOT required during maintenance treatment unless toxicity suspected or renal impairment (renally cleared)

24
Q

Digoxin doses

A

Loading (long 1/2 life)

Maintenance OD

  1. Atrial flutter and non-paroxysmal AF in sedentary pts = 125-250mcg
  2. Worsening or severe HF (in sinus rhythm) = 62.5-125mcg

Different dosage forms have different bio.a
e.g. Elixir = 75% Tablet = 90% IV = 100%

25
Q

Digoxin toxicity

A

SLOW AND SICK

  1. HYPO Mg2+
  2. HYPER Ca2+
  3. Hypoxia
  4. Renal impairment
  5. Bradycardia / heart block
  6. N+V, diarrhoea, abdo pain
  7. BLURRED YELLOW VISION (DY)
  8. Confusion, delirium
  9. Rash
26
Q

Digoxin Interaction Effects

A
  1. HYPOKALAEMIA with diuretics (loop/thiazide) B2 agonist, steroids, theophylline. If K+ <4.5mmol/L give K+ supplements or K+ sparing diuretic
  2. Toxicity with amiodarone (half digoxin dose), rate limiting CCB, macrolides, ciclosporin
    * ENZYME INHIBITORS
  3. Sub-therapeutic (decrease plasma conc) with St John Wort, Rifampicin
    * ENZYME INDUCERS
  4. Reduce renal excretion = TOXICITY with NSAIDs, ACEi/ARBS

CV (9 decks)

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