Arrhythmias

Question 1

Define: paroxysmal AFib

Answer 1

terminates spontaneously or with intervention within 7 days, “episodic”

Question 2

Define: Persistent AFib

Answer 2

continuously sustained > 7 days from onset

Question 3

Define: Long-standing AFib

Answer 3

continuous sustained > 12 months

Question 4

Define: Permanent AFib

Answer 4

not a pathophysiological state but stage of Afib aka Stage 4= no more attempts to restore or maintain normal sinus rhythm

Question 5

What are the symptoms of AFib?

Answer 5

-fatigue
-palpitations
-dyspnea
-hypotension
-tachycardia induced cardiomyopathy

Question 6

What are treatable risk factors for AFib?

Answer 6

-heart failure
-exercise
-tobacco
-obesity
-HTN
-ethanol
-diabetes
-sleep

Question 7

What does CHA2DS2-VASc stand for?

Answer 7

point system for predicting stroke risk
-congestive HF: 1
-HTN: 1
-age 75+: 2
-DM: 1
-previous stroke, TIA, or thromboembolism: 2
-vascular disease (prior MI, PAD, aortic plaque): 1
-age 65-74: 1
-female: 1

Question 8

When would oral anticoagulant therapy be recommended for stroke risk in AFib pts?

Answer 8

CHA2DS2VASc score of 2 or greater in men or 3 or greater in women OR moderate to severe mitral stenosis or mechanical valve

Question 9

What does a HAS-BLED score 3 or greater mean?

Answer 9

high risk of bleeding

Question 10

What is the recommended anticoagulant for stroke risk reduction?

Answer 10

DOAC > warfarin

Question 11

When would Warfarin be preferred over DOAC for stroke reduction therapy?

Answer 11

ESRD (eGFR < 15mL/min) OR severe mitral stenosis or mechanical heart valve

Question 12

What are the dosing recommendations for Apixaban?

Answer 12

-typically 5 mg po BID
-2.5mg po BID if pt has 2 of the following: 80+ yo, less than 60kg, SCr 1.5mg/dL or greater

Question 13

What DOAC may be used in ESRD?

Answer 13

apixaban

Question 14

What is the dosing recommendations of Edoxaban?

Answer 14

60mg po daily

Question 15

When would you avoid using Edoxaban in a pt?

Answer 15

CrCl > 95mL/min due to increased risk of stroke

Question 16

What are the monitoring parameters for DOACs?

Answer 16

-renal function
-hepatic function
-signs of bleeding
-signs of stoke

Question 17

What may be used to reverse the effects of oral Xa inhibitors (apixaban, edoxaban, rivaroxaban)?

Answer 17

andexanet alfa

Question 18

What can be done if pt is poor candidate for oral anticoagulation therapy?

Answer 18

watchman device

Question 19

What is the target HR for a patient with AFib?

Answer 19

resting HR < 100-110

Question 20

What are the rate control treatment options for AFib?

Answer 20

-beta blockers
-nonDHP CCB
-digoxin
-amiodarone

Question 21

When would nonDHP CCB be used for AFib?

Answer 21

rate control in pt who do not have HF (LVEF > 40%)

Question 22

How would you convert IV diltiazem to PO?

Answer 22

PO(mg)= [rate (mg/hr) x 3 + 3] x 10

Question 23

What is the usual dosing for metoporol treatment of AFib?

Answer 23

2.5-5mg IV bolus over 2 minutes for up to 3 doses

Question 24

What is the maintenance dosing of metoprolol?

Answer 24

-tartate: 25-100mg
-succinate: 50-400mg

Question 25

What is the use of beta blockers in AFib?

Answer 25

may be used first line whether pt has HF or not

Question 26

What is the risk of using Amiodarone for AFib?

Answer 26

lots of interactions and toxicity, chronic monitoring required so not preferred for long term therapy

Question 27

What are the side effects of Amiodrone?

Answer 27

-CV= bradycardia, QTc prolongation -CNS= impaired memory, tremor -GI= N/V, anorexia, heptotoxicity -Ocular= halovision, photophobia -Pulmonary= interstitial pneuonitis, fibrosis -Skin= photosensitivity, blue discoloration -hyper or hypo thyroidism

Question 28

What are the monitoring recommendations for Amiodarone?

Answer 28

-TSH -hepatotoxicity= AST, ALT -QT prolongation= ECG -chest xray of lungs -overall physical exam

Question 29

What is the concern of using Digoxin?

Answer 29

small therapeutic window= risk of toxicity

Question 30

What are the side effects of Digoxin?

Answer 30

-AV block -arrhythmias -toxicity= N/v, abdominal pain, diarrhea, yellow-green vision, fatigue, dizziness

Question 31

What needs to be done before cardioversion (whether it is electrical or pharmacological)?

Answer 31

anticoagulation therapy 3 weeks before then 4 weeks after

Question 32

When would rhythm control therapy be indicated for AFib?

Answer 32

-persistent symptoms -cannot obtain rate control -young -tachycardia induced cardiomyopathy -patient preference -LV dysfunction

Question 33

What drugs may be used for conversion to sinus rhythm?

Answer 33

-amiodarone -ibutilide -procainamide -flecainide -propafenone

Question 34

What are the adverse effects of Ibutilide?

Answer 34

-QT prolongation, MUST MONITOR ECG -TdP risk, do not give to patients with HFrEF

Question 35

What cardioversion drug cannot be used in patients with MI in the past 2 years (Black Box Warning)?

Answer 35

procainamide

Question 36

Which drugs for cardioversion can be given to patients as "pill in pocket" therapy?

Answer 36

propafenone and flecainide

Question 37

What drugs can be used to maintain sinus rhythm?

Answer 37

-amiodarone -dofetilide -dronedarone -flecainide -propafenone -sotalol

Question 38

What drugs must be monitored before outpatient administration?

Answer 38

-propafenone -flecainide -dofetilide (at least 3 days to monitor ECG) -sotalol

Question 39

What drugs may be used for maintenance rhythm with HFrEF?

Answer 39

amiodarone and dofetilide

Question 40

What are the adverse effects of Dofetilide?

Answer 40

QT prolongation (contraindicated if QT > 440 seconds) and must be monitored (ECG) for 3 days after initiation

Question 41

What are the dosing considerations of Sotalol?

Answer 41

must be renally adjusted

Question 42

What are the adverse effects of Sotalol?

Answer 42

QT prolongation (high risk!) must initiate inpatient to monitor ECG

Question 43

What is the pros of using Dronedarone?

Answer 43

better safety profile compared to amiodarone