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Atrial fibrillation Flashcards

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1
Q

What is a significance of the P wave?

A

Atrial contraction

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2
Q

what is the significance of the QRS complex?

A

Ventricular contraction

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3
Q

what is the significance of the T wave?

A

Ventricular repolarizations

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4
Q

what is the significance of the PR interval?

A

it is the impulse through the atria and AV node

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5
Q

what is the significance of the QTc interval? What is the equation?

A

it is the time between the ventricle polarization and depolarization
prolonged QT interval precedes torsades de pointes
QTc= QT interval/sqrt(RR interval)
RR interval is the duration of one cardia cycle

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6
Q

which drugs can cause proarrhythmias

A 
Class 1A /III antiarrhytmics
Macrolides
Quinolones
Famotidine
TCAs, ziprasidone, haloperidol
etc
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7
Q

which factors may contirbute to arrhythmias

A

MI
HF
Medications

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8
Q

what are the class 1 A antiarrhytmics

A

disopyramide (double)
quinidine (quarter)
Procainamide (pounder)

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9
Q

what are the class 1B antiarrhythmics

A

lidocaine (lettuce)
tocainide (tomato)
mexiletine (mayo)
Phenytoin (pickles)

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10
Q

what are the 1C antiarrhytmics

A

moricizine (more)
flecainide (fries)
propafenone (please)

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11
Q

what are the class 2 antiarrhythmics

A

beta blockers (propronolol, esmolol)

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12
Q

what are the class 3 antiarrhytmics

A 
amiodarone
dronaderone
sotalol
ibutilide
dofetilide
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13
Q

what are the class IV antiarrhytmics?

A

Verapamil and diltiazem

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14
Q

quinidine

A 
class 1A Qunidex, quinaglute
MOA=stabilize the membrae channel by interfering with sodium channel influx 
I=Supraventricular Tachy, Ventricular tachycardia
EKG= prolong QT, prolong QRS because block potassium channels also in phase 3
PK= strong cyp3a4 inhibitor/substrate
CI= patients taking quinolines that prolong QT
Se= Diarrhea* hypotension, syncope, QT prolongation, cinchonism (HA, diz, tinitus)
Other: different salt forms gluconate and sulfate not interchangeable, take with food or milk, keep constant Na intake cuz dec Na inc qunidine levels
DDI=digoxin(inc d) warfarin (inc INR), grapefruit juice, verapamil, diltiazem, amiodarone, erythromycin
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15
Q

procainamide

A

class 1A Pronestyl (SR)
MOA=stabilize the membrae channel by interfering with sodium channel influx
I= Supraventricular Tachy, Ventricular tachycardia
EKG= prolong QT, prolong QRS because block potassium channels also in phase 3
has metabolite NAPA that is renally cleared
SE=hypotension, bradycardia, can cause blood dyscrasias , can become ANA+
Other: take on an empty stomach, monitor x 3months for blood dyscrasia

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16
Q

disopyramide

A 
class 1A Norpace
MOA=interfering with sodium channel influx, negative inotrope 
I= Supraventricular Tachy, Ventricular tachycardia
EKG=prolong QT, prolong QRS because block potassium channels also in phase 3
PK=major cyp3a4 substrate
SE= strong anticholinergic
CI=do not use in BPH, urinary retention, glaucoma, myasthenia gravis
Other: take on an empty stomach
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17
Q

lidocaine

A 
class 1B - xylocaine
MOA=block sodium ion channels
I=ventricular tachy, especially faolowing an MI (ischemic tissue)
EKG= decrease the QT
PK=hepatically eliminated
SE=hypotension, hallucinations, diorientation, 
Other:can give in endotrachial tube but need higher dose
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18
Q

mexiletine

A 
class 1B- Mexitil
MOA=block sodium ion channels
I= ventricular tachy
EKG= shorten QT
PK=
SE=GI Side effects*, hypotension, hallucinations, diorientation, 
Other:can give in endotrachial tube but need higher dose
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19
Q

flecainide

A 
class 1 c - Tambocor
MOA=block sodium channels, negative inotrope
I=SVT, (VT)
EKG=really increase QRS
PK=kidney and liver clearance
CI=do not use if Structural changes to the heart like LVH, HF, CAD
SE=dizziness, visual disturbance
Other: not commonly used cuz pro arrhythmia, amiodarone DDI dec dose F 50%
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20
Q

beta blockers

A

esmolol, propranolol, metoprolol, atenolol
MOA= esmolol is b1 selective, propranolol is not
I=SVT, VT
EKG=increase PR segment, can cause AV block
PK=decrease the heart rate
SE=do not use propranolol with patients who hae problem breathing copd asthma
metoprolol/timolon in long-term prophylaxis in pat with an MI, esmolol short acting IV used for acute surgical arrhythmias

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21
Q

amiodarone

A

class III -Cordarone
MOA=increase refractory period, block potassium channels, Na channels, beta blocker
I=SVT, VT, most arrhythmias
EKG=prolong QT
PK=VERY LONG half-life and Vd
CI=
SE=HYPOTHYROID*/hyperthyroid, hypotension, inc LFTs, photosensitivity/blue skin discoloration if extended sun, <3% Pulmonary fibrosis (5-15%)
BBW: lung damage, liver toxicity, exacerbate arrythmias, corneal micro deposits
Other: most popular, preg cat D, dec IV50% of PO,

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22
Q

dronaderone

A 
MOA=increase refractory period, block potassium channels
I=SVT, VT
EKG=prolong QT
PK=cyp3a4 substrate, 
CI=class 4 HF, recent decompensated HF, QTc > 500msec, bradycardia < 50, strong cyp inhibitor, severe heaptic impairment, 400mg po 
SE=GI side effects
Other:pregnancy category X
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23
Q

sotalol

A 
class III
MOA=increase refractory period, block potassium channels, non selective beta blocke
I=SVT, VT
Dose 80-160mg BID, adjust by CrCL
EKG=prolong QT
CI= If baseline QTc > 450 , betapace AF in CrCl =160mg/day, Magnesium can be given to reverse torsades de pointes w/ these agents
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24
Q

ibutilide

A

Class 3-Corvert
MOA=increase refractory period, block potassium channels
I=SVT, VT
EKG=prolong QT
PK=
SE=
Other: class 1A or 3 should be avoided withing 4 hours after infusion

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25
dofetilide
``` class 3 Tikosyn MOA=increase refractory period, block potassium channels I=SVT, VT EKG=prolong QT PK=metabolized by CYP3A4 CI=baseling QTc > 440 msec, CrCl <20, cimetidine, TMP, prochlorparezine, megestrol, ketoconazole, verapamil SE= Other:mandatory 3 day hospitalization for initiation, MD must be certified to prescribe, Pharmacy msut be enrolled in TIPS to dispense ```
26
verapamil
``` class IV MOA=calcium channel blocker I=supraventricular arrhytmias invovling AV nodal reentry EKG= PK= CI= SE=can worsen AV block and ventricular failure Other: ```
27
diltiazem
``` MOA= I= EKG= PK= CI= SE= Other: ```
28
propafenone
``` MOA= I= EKG= PK= CI= SE= Other: ```
29
digoxin
``` MOA=enhances vagal tone I= EKG=increase PR PK= CI= SE= Other: ```
30
adenosine
``` MOA=activates adenosine receptor, activating the potassium Kach receptor, hyper polarization, decrease HR I= EKG=increases PR PK= CI= SE= Other: ```
31
atropine
``` MOA= I= EKG= PK= CI= SE= Other: ```
32
what are the pathophysiologic consequnces of atrial fibrillation/atrial flutter?
1. hemodyanmic symptoms: palpiations, can induce tachyardia-mediated cardiomyopathy, angina, fatigue, syncope 2. Thromboembolic complications like stroke 3
33
compare rate and rhythm control strattegies in atrial fibrillation/flutter
Rate attempts to control only the ventricular response rate (heart rate=pulse) can releive hemodynamic symptoms prevents tachycardia mediated Cardiomyopathy no use of antiarrhythmics requires long term anticoagulation Rhythm control attempts otresotre and maintain normal sinus rhythm prevents hemodynamic symtpos and prevents tachycardiamediated CMP reduces thromboembolic risk
34
what is the stroke provention theraphy for a patient with atrila fibrillation/flutter
warfarin dabigatran rivaroxaban ASA+/- clopidogrel
35
which drugs can cause bradycardia?
beta blockers | calcium channel blockers non dihydropyridines
36
what are the primary and secondary preventions of sudden cardiac death?
1
37
how do you identify a patient that requires and implantable cardioverter defibrillator?
1
38
develop an appropriate treatment and monitoring plan for a patient with a fib/atrial flutter
Mx: electrolytes
39
develop an appropriate treatment and monitoring plan for a patient with a bradyarrhytmia
Mx: electrolytes
40
develop an appropriate treatment and monitoring plan for a patient with a ventricular tachycardia/fibrillation
Mx: electrolytes
41
calculate the dose for an antiarrhytmic agent using appropriate pahrmacokinetic parameters
1
42
which medications lead to QT prolongation
Class I, Class III : amiodarone, disopyramide, dronaderone, procainamide, sotalol quinolone antibiotics macrolide antibiotics azole antifungals TCAs antipsychotics:chlorpromazine, thioridazine, pimozide, ziprasidone, haloperidol droperidol, apomorphine, foscarnet, methadone, pentamidine
43
what is the black box for all antiarrhythmics
antiarrhythmic drugs have not been shown to enhance survival in non-life threatening ventricular arrhythmias and may increase mortality, greatest risk in pts with structural heart disease.
44
which electrolytes can affect arrhythmias?
Na K | Ca Mg
45
how does potassium affect digoxin?
hypokalemia can increase risk of digoxin toxicity
46
what risk factors contribute to torsades de pointes
``` bradycardia cardiac hypertrophy baseline long qt hypokalemia, hypomagnesemia renal failure ```
47
which medications prolong the qt
K channel blockers like class 1A/3 antiarrhythmics, macrolides, quinolines, famotiidine, TCAs
48
what should you monitor for amiodarone?
Chest X ray and pulmonary function test baseline Thyroid & liver function test & ECG baseline and every 3-6 months Eye exam baseline and every year
49
what are the difference between dronaderone and amiodarone
``` lower efficacy better side effect profile more GI side effects shorter half life = 30hr no interaction with warfarin ```
50
what defines atrial fibrillaiton
supraventricular tachycardia with rapid atrial rate of 400-600bpm and disorganized. Ventricualr rate can be normal to rapid 100-160bpm and irreguarly irregular
51
what define atrial flutter
rapid but organized atrial activation 270-330bpm with regular to irrgular ventriacular response
52
in evaluating patients with possible atrial fibrialltion, what should you evaluate?
ECG Thyroid, renal, hepatic function history and physical triggers: alcohol, caffeine, exercise, sleep depvation, emothinal stress
53
what are the three categories of atrial fibriallation
Paroxysmal 7 days | Permanent > 1 year or cardioversion failed
54
what three stages of acuity for atrial fibrillation
acute: new episode < 48 hours recurrent >= 2 episodes lone afib : > 60yo without cardiopulmonary dz inc hypertension
55
what is the goal for HR for Rate control?
60-80bpm at rest and 90-115 for exercise
56
what agents do you use for rate control?
beta blockers non-dyhydropyridine CCB digoxin amiodarone
57
what is the CHADS2 score
``` prior stroke or TIA 2 Age >75 1 hypertension 1 diabetes Mellitus 1 HF 1 ```
58
what is recommended if they have a chads 0
ASA 81-325 daily + clopidogrel 75mg daily
59
what is recommended for stroke prevention if they have a CHADS1
``` ASA 81-325mg daily + clopidogrel 75mg daily OR Warfarin INR 2-3 OR Dabigatran ```
60
what is reccommended for stroke prevention in CHADS 2 or more
warfarin INR 2-3 OR Dabigatran
61
dabigatran
pradaxa MOA= direct thrombin inhibitor (factor II) PK= rapid onset and short half life (12-17 hours) twice daily dosing Dosing: ClCr: > 30 150mg BID, 15-30 75mg bid, < 15 not recommended
62
what are the differences between Electrical shock vs pharmacological cardioversion
EC more effective but causes myocardial injury and requires sedation PC convenient and may facilitate EC but less effective and varries with the agents. Can put patients at risk for proarrhytmias and durg interactions.
63
what should you check before performing a cardioversion
electrolytes K, MG and digoxin levels
64
who should get cardioversion
if hemodyanmically unstable based on low CO, hypotension, acute MI, shock, angina, pulmonary edema= USE EC If hemodyanmically stable, you can used EC, EC + PC , or PC
65
Should you use anticoagulation if a patient is undergoing cardioversion?
yes need it before and after cardioversion if patient has had Afib > 48 hours because at risk for developing atrial thrombi
66
what is the anticoagulation therapy for elective cardioversion?
before cardioversion warfarin for 3 weeks or more INR 2-3, TEE w/o anticoagulation After cardioversion warfarin for >= 4 weeks INR 2-3
67
what is the anticoagulation therapy for immediate cardioversion?
Before cardioversion: heparin bolus and infusion | After cardiversion Warfarin 4 weeks or more INR 2-3
68
What are the non-pharm treatments for atrial fibrillation
1. radioffrequency catheter ablation: ablate ectopic foci 2. pulmonary vein isolation ablation : ablation of av node 3. surgical maze procetur
69
what is AV block
partial or ocmplete of interpution of impulse transmission of the atrial to theventricles
70
how do you treate AV block?
``` atropine dopamine, epinephrine, isoproterenol transcutaneous pacing (external pacing) ``` If it's chronic : permanent pacemaker
71
what is a PVC
premature ventricular contraction | ventricles contract without the presence of a P wave
72
define ventricular tachycardia
series of PVCs at > 100bpm | non-sustained is <30 seconds, after 30 seconds is sustained
73
how to treat VT
If hemodynamically unstable: electric shock | long term suppression dependend on SCD sudden cardiac death risk
74
ventricular fibrrilaltion tx
electric shock IV epinephrine amiodarone

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