Arrhythmias Flashcards
(30 cards)
What are arrhythmias?
abnormal rate or rhythm
tachycardia
- atrial fibrillation, atrial flutter (same as AF Tx), ventricular fibrillation, ventricular tachycardia
bradycardia
- sick sinus syndrome, conduction block
What are the different durations of arrhythmias?
parxosymal: < 7 days
persistant: > 7 days
permanent: present all the time
What are the symptoms of arrthymias?
SAD Palpitations
S - SOB
A - abnormally SLOW, FAST or IRREGULAR pulse
D - dizziness, feeling faint
P - palpitations
How do you diagnose arrhythmias? What are the risks associated?
diagnosis: pulse, HR + rhythm, ECG
risks: stroke, thromboembolism
How do you treat acute presentation of atrial fibrillation? What does it depend on?
life threatening haemodynamic instability: electrical cardioversion
onset < 48 hrs: rate OR rhythm control
onset: > 48 hrs: rate control
How do you choose between electrical and pharmacological cardio version?
electrical: if >48 hr onset
- must give 3 weeks anti-coagulation first and 4 weeks after: A, E, W
- rule out atrial thrombus and give heparin
pharmacological: if <48 hr onset
- flecainide
- amiodarone
What are the lines of treatment for arrhythmias?
1st rate control: standard beta blocker, rate limiting CCB or digoxin
2nd dual therapy rate control: any two of the above
3rd rhythm control: beta blocker
4th rhythm control: flecainide/propafenone, amiodarone, dronedarone
Which beta blocker is NOT used in arrhythmias?
sotalol
- except for last line rhythm control
- except in ventricular arrhythmias
What are the conditions for exclusion or inclusion with medications used for rate control?
rate limiting CBB: CI in decompensated HF, only used if LVEF < 40%
digoxin: only used with a sedentary lifestyle, CI in non-paroxysmal arrhythmias
digoxin: used in AF + CHF
cardio-selective BB: diabetes mellitus
- BE A MAN: bisoprolol, atenolol, metoprolol, acebutolol, nebivolol
What are the conditions for exclusion or inclusion with medications used for rhythm control?
flecainide: avoid in structural or ischaemic heart disease
propafenone: CI in COPD and asthma, avoid in structural or ischaemic heart disease
amiodarone: good for LV impairment or HF
dronedarone: good for persistent/paroxsymal AF, avoid in permanent AF, avoid in HF and LV systolic dysfunction
What is pill in pocket?
for paroxysmal and symptomatic AF
- flecainide or propafenone
When would you choose rhythm control over rate control?
new onset AF
AF with reversible causes
AF caused by HF
atrial flutter suitable for ablation
when rhythm control is more suitable
How do you assess stroke risk with AF?
CHA2DS2-VASc
congestive heart failure or LV dysfunction
hypertension, >140mmHg
age, > 75 yrs
diabetes mellitus
stroke/TIA/ thromboembolism
vascular disease
age, 65-74 yrs
sex, female
How do you assess bleeding risk with AF?
ORBIT
older than 74 yrs
reduced haemoglobin (M<130g/L, F<120g/L)
bleeding history
inadequate renal function (eGFR<60)
treatment with anti-platelets
How do you treat paroxysmal supraventricular tachycardia?
spontaneous termination or reflex vagal stimulation
- valsalva manoeuvres, carotid sinus massage, immerse face in ice water
IV adenosine: CI in asthma and COPD
IV verapamil: avoid if recent treatment with BB
What is Torsades de pointes? What is the treatment for it?
form of ventricular tachycardia associated with QT prolongation
IV magnesium sulphate
What are the drug causes of TDP/QT prolongation?
ABCDDEs
anti-Arrhythmics: amiodarone, sotalol
anti-Biotics: quinolones, macrolides, aminoglycosides
anti-psyChotics: haloperidol, quetiapine, risperidone
anti-Depressants: SSRIs, TCAs
Diuretics: loop diuretics, thiazides
anti-emetics: ondansetron
What is the dosing for amiodarone and why?
loading dose DOWN: 200mg TDS, 200mg BD then 200mg OD
has a long life
What are the MHRA warnings for amiodarone?
Eyes: vision impairment, optic neuritis, optic neuropathy
Heart: myopathy
Lungs: pulmonary toxicity (SOB, cough)
Skin: photo-toxic, blue-grey discolouration
Liver: hepatoxicity
Thyroid: hypo or hyperthyroidism
Peripheral neuropathy
What monitoring is needed for amiodarone?
chest X-ray: before
serum potassium concentration: before
LFTs: before, every 6 months
TFTs: before, every 6 months, several months after discontinuation
What counselling is needed for amiodarone?
shield from sun + sunscreen
alert card
What are the side effects of amiodarone?
Ami is a photogenic bitch
photosensitivity: skin reaction, blue/grey discolouration
bradycardia: arrhythmias
interstitial lung disease: pneumonitis, PF
thyroid: hypo or hyper
corneal: corneal deposits
hepatic: toxicity
n: peripheral neuropathy
What does amiodarone interact with?
enzyme INHIBITOR
statins: myopathy risk - dose reduce simvastatin
warfarin, phenytoin, digoxin, ciclosporin: increased concentration
grapefruit: avoid
What is the therapeutic level for digoxin? What are the toxic levels for digoxin?
therapeutic: 0.7-2mcg/L
toxic: >1.5mcg/L
definitely toxic: >3mcg/L
