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arrythmias, VTE Flashcards

1
Q

what is arrythmia?

A

abnormal rate and rhythm

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2
Q

what is the normal heart rate in beats per minute?

A

60-100

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3
Q

what does a heart rate of under 60 beats per min indicate?

what does a heart rate of over 100 beats per min indicate?

A

under 60 = bradycardia

over 100=tachycardia [taky taky rumba]

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4
Q

what is paroxysmal atrial fibrillation?

this is managed by something known as pill in pocket. explain this.

A

episodes of AF that stop within 7 days [usually 48 hours] without treatment

pt can just take anti-arrythmic drugs only when an episode of AF occurs

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5
Q

what are the signs and symptoms of arrythmia?

A

sad palpitations

shortness of breath
abnormal fast/slow heart rate
dizziness
palpitations

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6
Q

what are some causes of arrythmias?

A

anything that affects the heart

coronary heart disease
valvue disease
hypertension
ageing
cardiomyopathy
congenital birth defects
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7
Q

list the different types of arrythmias and which is the most common one? [6]

A 
artrial fibrillation - most common
ectopic beats
supraventricular arrhythmia's
 ventricular arrhythmia
paroxysmal AF
atrial flutter
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8
Q

what is the treatment aim for treating arrhythmias?

A

treat the underlying cause of the arrythmia eg hypertension

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9
Q

what are the treatment options for arrythmias?

A

medication
cardioversion: electrical [electrical shock] or pharmacological
artificial pacemakers
implantable cardioverter defibrillators

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10
Q

what is the treatment aim for atrial fibrillation?

what do patients with AF have a high risk of?

A

reduce symptoms and prevent complications

high risk of stroke

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11
Q

what 2 things must be assessed in patients with AF prior and during anticoagulation?

A

assess risk of stroke and bleeding

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12
Q

what tools are used to assess risk of stroke? what tools are used to assess risk of bleeding?

A

stroke: CHA2DS2VASC

Bleeding: HASBLED / orbit

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13
Q

when are anticoagulants considered for patients with AF?

A

when risk of stroke greater than risk of bleeding

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14
Q

what are the associated risk factors with stroke for the CHA2DS2VASC and the associated scored?

A 
c - congestive heart failure 1
H - hypertension 1
A - age over 75 2
a - age 65-74 1
d- diabetes = 1
S - stroke/tia/thromboembolism  2
V - vascular disease - 1
s - sex / gender female 1
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15
Q

what does a score of 2 or more on the chadsvasc tool indicate?

A

you will need an anticoagulant regardless of gender

anTWOcoagulants

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16
Q

what is the chadsvasc score for males and females generally?

A 
male = 0
female = 1
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17
Q

what score must you get for hasbled that would indicate high risk of bleeding?

A

3

THREE makes you BLEED so do not give anticoagulant

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18
Q

what are the risk factors for HASBLED and the associated score?

what is the maximum score?

A 
hypertension.   1 
abnormal renal/liver function.  1 or 2
stroke.    1
bleeding tendency.   1
labile INR.    1
age greater than 65.   1
drugs [nsaids, concomitant aspirin] or alcohol.     1 or 2

max score 9

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19
Q

what are the risk factors for ORBIT and the associated scores?

what is the max score for orbit?

A 
older than 74  - 1 
reduced haemoglobin - 2
bleeding history - 2
inadequate renal function - 1
treatment with antiplatelet - 1

max score = 7

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20
Q

interpret the following ORBIT scores:
0-2
3
4-7

A

0-2 low bleeding risk
3 medium
4-7 high bleeding risk

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21
Q

what drugs are used in RATE control AF [1st line]?

A

DI2 VE BETA

dilitiazem
digoxin
verapamil
beta blockers [not sotalol]

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22
Q

when is digoxin monotherapy for rate control AF considered? [4]

A

only when pt does little to no exercise
when all other rate limiting drugs were unsuccessful
those with congestive heart failure
those suffering with NON paroxysmal AF

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23
Q

what can you consider if monotherapy for rate control AF fails?

A

dual therapy with BB DD:

beta blockers
diltiazem
digoxin

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24
Q

what must you consider if a patient fails to have controlled AF with rate control monotherapy and dual therapy?

A

rhythm control strategy

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25
Q

which is 1st line treatment for AF: rhythm or rate control

A

rate

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26
Q

rate control is 1st line treatment in AF except in which types of people? [5]

A
  • ppl with new onset AF
  • ppl with atrial flutter suitable for surgery
  • ppl with a reversible cause of their AF [eg MI, hyperthyroidism]
  • ppl who have heart failure originally thought to be caused by AF
  • ppl who rhythm control strategy would be better
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27
Q

what drug class must you AVOID in heart failure and AF?

A

calcium channel blockers

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28
Q

what is the 1st line treatment for rhythm control in AF?

A

beta blockers not sotalol

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29
Q

what is the 2nd line treatment options for rhythm control in AF?

A

consider flecainide , amiodarone, sotalol, propafenone and dronedarone

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30
Q

rhythm control

which 2 drugs must be AVOIDED in people with ischaemic or structural heart disease?

A

flecainide and propafenone

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31
Q

rhythm control

which drug should be CONSIDERED for people with heart failure or left ventricular impairment?

A

amiodarone

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32
Q

when should ELECTRICAL cardioversion be considered?

A

when AF has been present for more than 48 hours

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33
Q

what kinds of treatment should the patient be on before electrical cardioversion is attempted?
what is the alternative if this is not possible?

A

anticoagulants 3 weeks before electrical cardioversion bc risk of stroke

alternative: heparin just before

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34
Q

what 2 medications MUST a patient be given after electrical cardioversion and for how long?

A

oral anticoagulants for at least 4 weeks after

amiodarone to control sinus rhythm

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35
Q

what is acute atrial fibrilation?

A

someone who has just had a new onset AF less than 48 hours

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36
Q

what is the treatment for a patient with new onset AF and life threatening haemodynamic [abnormal BP and heart rate]?

A

emergency electrical cardioversion

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37
Q

what should patients with NON life threatening haemodynamic instability be offered?

A

rate or rhythm control if arrythmia occurred LESS than 48 hours

rate control if arrythmia occurred more than 48 hours or unsure how long they had it

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38
Q

what should be offered to a patient with new onset AF who are receiving no oral anticoagulation yet?

A

parenteral anticoagulant eg heparin

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39
Q

which oral anticoagulants are 1st line recommended for patients with AF?
what should be given if this is contraindicated eg pt has renal impairment?

A

DOAC first line

vitamin K antagonists second line eg warfarin

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40
Q

what drugs should be used to treat supraventricular arrythmias? [3]

A

verapamil
cardiac glycosides eg digoxin
adenosine

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41
Q

which drugs should be used to treat ventricular arrythmias? [2]

A

lidocaine

sotalol

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42
Q

which drugs should be used to treat supraventricular and ventricular arrythmias [2]

A

amiodarone

beta blockers

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43
Q

what are the 4 classes of anti-arrythmic drugs and give examples of each?

A 
class 1: sodium channel blockers [flecainide, lidocaine]
class 2: beta blockers
class 3: potassium channel blockers [amiodarone]
class 4: calcium channel blockers [verapamil]
44
Q

sotalol is in 2 classes of anti-arrythmic drugs. which are they?

A

it is in class 2 beta blockers and class 3 potassium channel blockers

45
Q

what is torsade de pointes?

A

A type of arrythmia caused by QT interval prolongation. not enough oxygen gets pumped around body and brain becomes starved of oxygen

46
Q

what is the treatment of torsade de pointes?

A

iv magnesium sulphate

47
Q

what are the causes of torsade de pointes? [4]

A
  • stress
  • strenous exercise
  • drugs
  • sudden noises
48
Q

which drugs cause torsade de pointes? [6]

A

ANTI ABCDDE

anti arrythmics [sotalol, amiodarone]
anti biotics [macrolides, quinolones]
antipsychotics [haloperidol]
Diuretics
anti depressants [SSRIs, TCAs]
anti emetics [ondansetron]
49
Q

is amiodarone an enzyme inhibitor or inducer?

what is the adult dose of amiodarone to treat arrythmia?

A

enzyme inhibitor

200mg three times a day for 1 week then 200mg twice daily for 1 week. maintenance dose 200mg once daily

50
Q

what are the side effects of amiodarone?

A

ami is a photogenic bitch?

photosensitivity
bradycardia
interstitual lung disease [shortness of breath]
thyroid [hyper or hypo bc amiodarone contains iodine]
corneal micro deposits [dazzled headlights]
hepatic [liver]

phototoxicity [skin reaction slate grey skin]
optic neuropathy [blurred vision]
peripheral neurotoxicity [numbness/tingling]
pulmonary toxicity [lungs]

51
Q

what are the 2 contraindications of amiodarone?

A

iodine deficiency

thyroid dysfunction

52
Q

what are the monitoring requirements with amiodarone?

A

CASTLE

chest x ray before treatment
annual eye test
serum potassium before treatment [causes hypokalaemia]
thyroid function before treatment and annually
liver function before treatment and every 6 months
ECG and blood pressure

53
Q

what is the patient and carer advice for amiodarone?

A
  • shield skin from sunlight several months after treatment and during
  • use wide spectrum suncream
  • alert medical attention if any of these symptoms show [light headed, fainting, palpitations, chest pain]
54
Q

what are the important interactions of amiodarone?

A

enzyme inhibitor
increases plasma conc of warfarin, digoxin, phenytoin, ciclosporin

interacts with lithium and increases its conc [causes arrythmia]

interacts with statins and increases its conc [causes Myopathy]

interacts with drugs that cause QT interval prolongation [anti abcdde]

55
Q

what is the mechanism of action of digoxin?

A

increases force of contraction of heart and decreases heart rate by reducing conductivity in atrioventricular node

56
Q

what are the indications of digoxin?

A

Atrial flutter
atrial fibrillation
heart failure

57
Q

what is the dose of digoxin based on for management of Atrial fibrillation?

A

based on ventricular rate at rest which should not fall below 60 beats per min

58
Q

which route is NOT recommended for digoxin?

A

IM route

59
Q

does digoxin have a long half life or short half life?
how many times during the day is it normally taken?
sometimes it is taken twice daily - why?

A

long half life
once daily
due to nausea side effect

60
Q

what is the digoxin maintenance dose for Atrial fibrillation or atrial flutter?
is a loading dose required with this?
how should the dose be altered in elderly?

A

125mcg -250mcg once daily

loading dose needed

reduce dose in elderly

61
Q

what is the dose of digoxin for worsening/severe heart failure in sinus rhythm?

is a loading dose required?

A

62.5mcg - 125mcg once daily

no loading dose required

62
Q

what is the digoxin dose for rapid digitalisation for atrial fibrillation or atrial flutter?

A

0.75mg - 1.5mg in divided doses, dose to be given over 24 hours

63
Q

what is the digoxin dose for emergency loading dose for atrial fibrillation or atrial flutter?

A

by IV infusion: 0.75mg - 1mg loading dose to be given over at least 2 hours

64
Q

is digoxin a narrow therapeutic drug?

A

yes

65
Q

what is the therapeutic range for digoxin?

what is the toxicity range for digoxin?

A

therapeutic: 1-2mcg/L
toxicity: 1.5mcg/L - 3mcg/L

66
Q

everything you need to know about digoxin is in the term 2kidneys.
explain this term

A

2 = therapeutic conc of 1mcg-2mcg/L. anything outside this conc is toxicity
K =monitor potassium levels. low potassium levels leads to digitalis toxicity
i = digoxin is positively inotropic and increases force of contraction of heart
D = decreasing potassium levels means digitalis toxicity
N = nausea common s/e
e = emesis/vomiting common s/e
y = yellow vision s/e
s = potassium sparing diuretic
kidneys = monitor renal function

67
Q

what can you give to prevent hypokalaemia in people who take digoxin?

A

potassium sparing diuretics

potassium supplements

68
Q

why must you reduce the dose of digoxin in the elderly?

A

they are at risk of digitalis toxicity

69
Q

what must you do if digoxin toxicity occurs?

A

withdraw digoxin

if there is a life threatening overdose: reverse with digoxin specific antibody fragments

70
Q

what are the side effects of digoxin? [8]

A 
nausea, vomiting, yellow vision
skin reactions
dizziness
diarrhoea
cardiac conduction disorder
arrythmias
71
Q

what are the monitoring requirements of digoxin? [4]

A

plasma digoxin conc - should be taken 6 doses after dose
renal function
oxygen - hypoxia
serum electrolytes: potassium, calcium, magnesium

72
Q

what are the important drug interactions with digoxin? [6]

A

crased

calcium channel blockers eg verapamil
rifampicin
amiodarone
st johns wort
erythromycin
diuretics
73
Q

what do antifibrinolytic drugs and haemostatics do?

A

stop bleeding

74
Q

what is the dose of tranexamic acid for the management of menorrhagia?

A

1g three times a day for up to 4 days. start on day of period. max 4g daily

75
Q

what is the dose of tranexamic acid of epistaxis [bleeding from nose]?

A

1g three times a day for 7 days

76
Q

what is the side effects of tranexamic acid? [3]

A

diarrhoea
nausea
vomiting

77
Q

what is the monitoring requirements of tranexamic acid?

A

regular liver function tests

78
Q

what is there a risk of when taking tranexamic acid with contraceptive pill?

A

increased risk of DVT

79
Q

what is the age requirement for menorrhagia otc?

A

18 and over

80
Q

what are the red flags with using tranexamic acid?

A
  • legs/arms painful or swollen
  • anaphylactic reaction
  • coughing/coughing up blood
  • colour vision/vision impairment
81
Q

what are the contraindications of tranexamic acid?

A
  • epilepsy
  • dvt
  • PE eg shortness of breath
  • irregular periods
  • renal problems
  • pregnancy
82
Q

what are the 2 types of venous thromboembolism?

A

1 - pulmonary embolism: clot in artery in lung

2 - deep vein thromboembolism: clot in body usually legs

83
Q

give examples of antiplatelets, anticoagulants and thrombolytics.
which is the strongest one that causes highest risk of bleeds?

A

antiplatelets: clopidogrel, aspirin, dipyridamole
anticoagulants: warfarin, doacs
thrombolytics: highest bleed risk eg alteplase

84
Q

which patients have the highest risk of venous thromboembolism? [9]

A 
pt over 60
pt with blood disorder
pt with history of VTE
pt who are obese/overweight
pt with reduced motility 
pt with malignant disease eg cancer
dehydration
pt taking hrt/combined hormonal contraception
pregnancy and postpartum periods
85
Q

what are the 2 methods of thromboprophylaxis?

A

mechanical prophylaxis

pharmacological prophylaxis

86
Q

what is mechanical prophylaxis of VTE?

A

anti-embolism stockings to be worn for pt due for surgery

worn all the time until pt is mobile again

87
Q

who must not be offered anti-embolism stockings?

A

pt with acute stroke, peripheral arterial disease, neuropathy and leg oedema

88
Q

in which patients should pharmacological prophylaxis of VTE be initiated?

when should this be initiated?

A

in pt undergoing surgery where the risk of VTE is higher than the risk of bleeding.

as soon as possible or within 14 hours of admission

89
Q

what are the 2 types of heparins and which ones are preferred?

A

low molecular weight heparins - preferred

unfractionated heparins

90
Q

give examples of low molecular weight heparins

A

enoxaparin, dalteparin, tinzaparin

91
Q

in which patients are unfractionated heparins preferred?

A

those with renal impairment or risk of overdose

92
Q

what should be given to patients undergoing hip or knee replacement surgery, hip fracture surgery, day surgery or GI bariatric surgery?

A

fondaparinux sodium

93
Q

how long should pharmacological prophylaxis in general surgery continue for?

A

at least 7 days post surgery or until pt is mobile again

94
Q

in which surgery is low molecular weight heparins suitable for?

A

all

95
Q

in which surgery/pt type are unfractionated heparins suitable for?

A

ppl with renal impairment 15-50

or pt with higher risk of bleeding/overdose

96
Q

in which surgery are DOACS suitable for?

A

elective knee/hip replacement surgery after LMWH or low dose aspirin

97
Q

what is first line for treatment of VTE or PE?

A

rivaroxaban or apixaban

98
Q

what is 2nd line treatment for confirmed VTE or PE?

A

if rivaroxaban or apixaban unsuitable:

  • give LMWH for at least 5 days then dabigatran or edoxaban OR
  • give LMWH together with vitamin K antagonist for at least 5 days or until INR is 2 for 2 consectutive readings followed by vitamin K antagonist on its own
99
Q

what are the 4 treatment options of confirmed VTE or PE in renally impaired patients?

A
  • offer apixaban
  • offer rivaroxaban
  • offer LMWH for at least 5 days followed by either dabigatran [if estimated crcl is 30ml/min] or edoxaban
  • LMWH or unfractionated heparin together with vitamin K antagonist for 5 days or until iNR is 2 for 2 consecutive readings then vitamin K antagonist on its own
100
Q

how is VTE treated in pregnancy>

A

LMWH or unfractionated heparins used bc they do not cross the placenta

101
Q

which heparins are preferred in treatment of VTE in pregnancy and why?

A

LMWH bc lower risk of osteoporosis and heparin induced thrombocytopenia

102
Q

what is the common side effect of heparin and how is it reversed?

A

haemorrhage

withdraw heparin and give protamine sulphate as an antidote to reverse effects

103
Q

what is proximal deep vein thrombosis?

what is isolated deep vein thrombosis?

A

proximal: clot in femoral thigh
isolated: clot below knee confined in calf veins

104
Q

what is the anticoagulant treatment duration for someone who has confirmed proximal DVT or PE?
what is the duration for someone with active cancer in addition?

A

3 months

3-6 months for active cancer?

105
Q

what is the anticoagulant treatment duration for someone with provoked DVT or PE?
provoked by pregnancy, HRT eg

what if they have active cancer?

A

3 months

3-6 months for active cancer

106
Q

what is the anticoagulant treatment duration for unprovoked DVT or PE?

what if they have active cancer

A

beyond 3 months

beyond 6 months for active cancer

CVS (7 decks)

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