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Pre Reg Pharmacy > Chaper 2: Cardiovascular - Arrythmia > Flashcards

Chaper 2: Cardiovascular - Arrythmia Flashcards

1
Q

What is an arrhythmia?

A

A problem with the rate or the rhythm of the heartbeat

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2
Q

What are the general symptoms of an arrhythmia?

A 
Palpitations
SOB
Dizziness
Fainting
Chest pain
Fatigue
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3
Q

What are the three types of supraventricular arrhythmias?

A

Atrial fibrillation
Atrial flutter
Paroxysmal supraventricular arrhythmia

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4
Q

What are the two types of ventricular arrhythmia

A 
Ventricular tachycardia (e.g. torsades de pointes)
Ventricular fibrillation
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5
Q

What are ectopic beats and how are they managed?

A

They are extra heartbeats that occur just before a regular heartbeat

They usually don’t require treatment

But if they are troublesome beta-blockers may help

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6
Q

What is atrial fibrillation?

A

An abnormally fast rhythm arising from or above the AV node

It is triggered by rapidly firing electrical impulses

When the AV node receives more impulses that it can conduct, an irregular ventricular rhythm results

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7
Q

What are the causes of atrial fibrillation?

A

Cardiovascular: CHF

Non-cardiovascular: infection, cancer, PE

Lifestyle: alcohol abuse, obesity

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8
Q

What is the main complication of atrial fibrillation and how is this managed?

A

Stroke
Managed using anticoagulants
E.g. warfarin, apixaban, rivaroxaban, dabigatran, edoxaban

But before initiating consider a patients risk of stroke vs risk of bleeding
Assessment tools can help with this

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9
Q

What are the three broad categories for managing atrial fibrillation?

A

Cardioversion

Rate control

Rhythm control

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10
Q

What is the first-line treatment for reversible atrial fibrillation?

A

Cardioversion

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11
Q

What drugs are used for pharmaceutical cardioversion?

A

Oral or IV amiodarone (preferred if there is structural heart disease)

Oral or IV flecainide

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12
Q

When is electrical cardioversion preferred?

A

When atrial fibrillation has been present for more than 48 hours

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13
Q

Anticoagulation and electrical cardioversion?

A

Patients should be anticoagulated for at least 3 weeks before electrical cardioversion

If this is not possible, use parenteral anticoagulation before cardioversion, then oral anticoagulation for at least 4 weeks afterwards

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14
Q

What are the two types of electrical cardioversion?

A

Direct current

Cardiac pacing

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15
Q

What drugs can be used for rate control?

A

Beta-blocker (not sotolol)

Rate-limiting CCB e.g. diltiazem, verapamil

Digoxin

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16
Q

When can digoxin be used in atrial fibrillation?

A

When the patient is predominantly sedentary (it is only effective when at controlling the ventricular rate when the heart is at rest)

For non-paroxysmal atrial fibrillation

For atrial fibrillation and heart failure

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17
Q

In atrial fibrillation, when mono therapy with one of the rate control drugs fails to control the ventricular rate, what do you do?

A

Consider cardioversion

Or use a combination of 2 drugs (beta-blocker, diltiazem or digoxin)

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18
Q

In atrial fibrillation, how to you select which beta-blocker to use

A

First choice is atenolol (cheapest)

Acebutolol, metoprolol, nadolol, oxprendolol and propranolol are also indicated in AF

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19
Q

In atrial fibrillation, when is rhythm control used

A

Post-cardioversion

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20
Q

In atrial fibrillation, what drugs can be used for rhythm control?

A

First line - standard beta-blocker

Other options include anti-arrhythmics e.g. amiodarone, flecainide, sotolol, propane ones

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21
Q

What do you do in the acute presentation of atrial fibrillation?

A

Life-threatening haemodynamic instability:
Electrical cardioversion

Non-life-threatening haemodynamic instability:

Consider cardioversion (remember to anticoagulate the patient for 3 weeks, prior to cardioversion offer rate control)

Less than 48 hours - rate or rhythm control

Over 48 hours - rhythm control

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22
Q

What is paroxysmal atrial fibrillation and how is it managed?

A

Intermittent AF - it begins suddenly and stops on its own within 7 days

Manage with a standard beta-blocker

Or consider an oral anti-arrhythmic e.g. amiodarone, flecainide, sotolol, dronedarone, propafenone

In some patients, the ‘pill in pocket’ approach may be considered

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23
Q

What is the pill in pocket approach and when can it be used in atrial fibrillation?

A

It is when patients can self-treat when an episode occurs

It can be used in paroxysmal atrial fibrillation, where there are infrequent episodes

Drug options include oral flecainide or propafenone

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24
Q

What are the risk factors for stroke in atrial fibrillation?

A

Prior ischaemic stroke, TIA or thromboembolic events

Other heart conditions e.g. HF, LVSD

Other CV conditions e.g. diabetes, hypertension

Patient factors e.g. over the age of 65, female

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25
Q

What are the signs of haemodynamic instability?

A 
Rapid pulse (>150 beats per minimum)
Low blood pressure (systolic BP <90mmHg
Ongoing chest pain
Increasing breathlessness
Severe dizziness
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26
Q

Describe the two screening tools to determine whether anticoagulation should be initiated in atrial fibrillation

A 
CHADSVAS - stroke risk
C - CHF/LVSD (1)
H - Hypertension (1)
A - Age >75 (2)
D - Diabetes (1)
S - Stroke/TIA/systemic arterial embolism (2)
V - Vascular disease (precious MI, aortic plague (1)
A - Age 65-74 (1)
S - Sex, male 0, female 1
HASBLED
H -Hypertension (1)
A - Abnormal liver function (1)
A - Abnormal renal function (1)
S - Stroke (1)
(Major) Bleeding history (1)
L - Labile INR
E - Elderly (>65)
Drugs and alcohol (Drugs includes anticoagulants and NSAIDS (1), alcohol abuse (1))
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27
Q

What oral anticoagulants can be used for stroke prevention in atrial fibrillation?

A

Vitamin K antagonists:
Warfarin
Apixaban, rivaroxaban, edoxaban, dabigatran

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28
Q

What is atrial flutter and how does this differ from atrial fibrillation?

A

Atrial flutter is when the atria beat faster than the ventricles, causing for the heart rhythm to be out of sync

In atrial fibrillation, the atria beat irregularly. In atrial flutter that beat regularly but faster than usual and more often than the ventricles

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29
Q

How is atrial flutter managed?

A

First, rate control
Beta-blockers, rate-limiting CCB, digoxin
Note, IV is preferred if a rapid rate control is required

Then conversion of sinus rhythm by:
Electrical cardioversion (preferred if the atrial flutter has been present for more than 48 hours)
Pharmacological cardioversion
Catheter ablation
Remember, fully anticoagulate for 3 weeks prior to cardioversion

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30
Q

How do you manage paroxysmal supraventricular tachycardia?

A

First, reflex vagal stimulation

If this is not adequate or if symptoms are severe, use IV adenosine

IV verapamil is an alternative to IV adenosine, but avoid in patients recently treated with beta-blockers

In patients who are haemodynamically unstable or do not respond to either of the above do electrical cardioversion

Prophylaxis can include verapamil, diltiazem, beta-blockers, flecainide, propafenone

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31
Q

What can be used to treat an arrhythmia after an MI?

A

Lidocaine

Disopyramide

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32
Q

How do you manage ventricular tachycardias?

A

Pulseless patients:
Defibrillation

Sustained ventricular tachycardia and haemodynamically unstable:
Electrical cardioversion (direct current)

Sustained ventricular tachycardia and haemodynamically stable:
IV anti-arrhythmics e.g. amiodarone

Non-sustained ventricular tachycardia and haemodynamically stable:
Beta-blocker

Most patients will require maintenance therapy, e.g. beta-blocker, or beta-blocker and amiodarone

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33
Q

What is torsades de pointes?

A

A form of ventricular tachycardia that is associated with a long QT interval syndrome

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34
Q

How is torsades de pointes managed?

A

IV magnesium sulfate
Beta-blocker

Avoid anti-arrhythmics as these also prolong the QT interval and so can worsen the condition

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35
Q

Which drugs can be used to manage which types of arrhythmia s?

A

Supraventricular arrhythmia:
Digoxin, adenosine, verapamil

Ventricular arrhythmia:
Lidocaine

Both:
Everything else

36
Q

What are the class I anti-arrhythmics?

A

Lidocaine (IA)
Disopyramide (IB)
Flecainide (IC)
Propafenone (IC)

37
Q

What are the class II anti-arrhythmics?

A

Beta-blockers

38
Q

What are the class III anti-arrhythmics?

A

Amiodarone

Dronedarone

39
Q

What are the class IV anti-arrhythmics?

A

CCBs e.g. verapamil

40
Q

What is a side-effect of most anti-arrhythmic drugs?

A

Arrhythmia

Hypokalaemia can enhance this effect

41
Q

What is lidocaine indicated for and how is it administered?

A

Arrhythmia in MI

IV

42
Q

What should you do if both flecainide and amiodarone are given?

A

Reduce the flecainide dose by half

43
Q

Which is preferred in pregnancy/breastfeeding out of amiodarone and flecainide for arrhythmia?

A

Flecainide

44
Q

Should propafenone be taken with or without food?

A

With food

45
Q

What is the dose of amiodarone in arrhythmias?

A

Oral
200mg TDS for 1 week, then 200mg BD for 1 week, then a maintenance dose of 200mg OD

IV
5mg/kg, to be given over 20-120 minutes
Maximum 1.2g

46
Q

What is the dose of amiodarone for ventricular fibrillation, or pulseless ventricular tachycardia refractory to defibrillation?

A

Only considered after the administration of adrenaline

IV injection
300mg in a pre-filled syringe or 20ml glucose
Then 150mg if required

IV infusion
900mg over 24hours

47
Q

What are the contraindications of amiodarone?

A

Thyroid dysfunction
Iodine sensitivity

Sinus node disease
Sino-atrial block
Sinus bradycardia
Severe conduction disturbances

With IV use
Severe arterial hypotension, severe respiratory failure
Bolus - CHF, cardiomyopathy

48
Q

What should you consider if you see an amiodarone prescription in the elderly?

A

STOPP criteria

49
Q

What should you consider with regards to amiodarone and it’s interactions?

A

It’s long half life

There is a potential for drug interactions for weeks/months after amiodarone has been stopped

50
Q

What are 10 side effects of amiodarone

A 
Hyperthyroidism 
Hypothyroidism 
Nausea
Vomiting
Hepatic disorders
Corneal deposits
Bronchospasm
Respiratory disorders
Arrythmia
Skin reactions
Delirium 
Pancreatitis
Photosensitivity reactions
Headache
Erectile dysfunction
Constipation
Sleep disorders
Altered smell or taste
Thrombocytopenia, neutropenia, agranulocytosis
51
Q

Can amiodarone be given in pregnancy or breastfeeding?

A

Avoid in pregnancy unless essential

Avoid in breastfeeding

52
Q

What are the monitoring requirements of amiodarone?

A

Before treatment:
Chest X-ray
Serum potassium concentration

6 monthly
During treatment
T4 and TSH
LFT

53
Q

Patient counselling with amiodarone?

A

Phototoxocity - during and after treatment

May affect driving and skilled tasks

54
Q

What is the risk of the concurrent use of amiodarone and sofobusir, and what symptoms should patients look out for?

A

Heart block and severe bradycardia

Symptoms include:
SOB
light-headedness 
Palpitations 
Fainting
Fatigue
Chest pain
55
Q

Can amiodarone be given to patients with Wolff-Parkinson-White syndrome?

A

Yes

56
Q

What is the indication for adenosine?

A

Paroxysmal supraventricular arrhythmia

For rapid conversion to sinus rhythm (including those associated with accessory conducting pathways e.g. Wolff-Parkinson-White syndrome)

57
Q

What is the indication of sotalol?

A

Maintenance of sinus rhythm following cardioversion of atrial fibrillation or atrial flutter

Treatment of non-sustained ventricular Arrythmia

Prophylaxis of paroxysmal atrial fibrillation

Life-threatening arrhythmias

It is no longer indicated in
Angina
Hypertension 
Thyrotoxicosis
Secondary prevention after an MI
58
Q

What is the dose of sotalol?

A

Initially 80mg daily in 1-2 divided doses

Increased gradually to 160-320mg daily in 2 divided doses

59
Q

What effect does sotalol have on the QT interval?

A

QT interval prolongation

60
Q

What are the symptoms of digoxin toxicity?

A

Nausea, vomiting
Neurological symptoms e.g. confusion
Increased heartbeat
Reduced appetite

61
Q

How do you manage digoxin toxicity?

A

Withdraw digoxin and correct electrolyte abnormalities

Administer digoxin-specific antibody fragments

62
Q

What should the ventricular rate at rest be above whilst on digoxin?

A

60 beats per minute

63
Q

Is digoxin used for rapid control of heart rate?

A

No, it has a long half life.

Do electrical cardioversion

64
Q

Can digoxin be administered orally, by IV, by IM and by SC?

A

Oral and IV - yes

IM and SC - no

65
Q

Do patients with heart failure and are in sinus rhythm require a loading dose?

A

No - their levels will be satisfactory in about a week

66
Q

How often is digoxin given?

A

Usually OD

Can sometimes be BD e.g. due to nausea

67
Q

What concentration of digoxin is more likely to be toxic?

A

1.5-3mcg/L

68
Q

What is the risk of hypokalaemia for patients on digoxin and how is this managed?

A

It predisposes the patient do digoxin toxicity

Manage with a potassium sparing diuretic or potassium supplements

69
Q

How do you give digoxin to a patient with thyroid disease?

A

Reduce the dose in hypothyroidism

May need to increase the dose in hyperthyroidism

Thyrotoxicosis
Reduce the dose until it is in control

70
Q

What are the indications and doses for digoxin

A

Maintenance of atrial fibrillation or atrial flutter
125-250mcg OD

Heart failure (for patients in sinus rhythm)
62.5-125mcg OD

Rapid digitalisation of atrial fibrillation or atrial flutter
0.75-1.5mg in divided doses
Given over 24 hours

Emergency loading dose for atrial fibrillation or atrial flutter
0.75-1.5mg in divided doses
Given over at least 2 hours

71
Q

When should the dose of digoxin be reduced?

A

Elderly

Renal impairment

Concurrent use of amiodarone, dronedarone, quinine (reduce by half)

If another cardiac glycosides has been given in the preceding 2 weeks

72
Q

When switching from IV digoxin to oral digoxin, how much should the dose be increased by in order to maintain the same digoxin-plasma concentration?

A

20-33%

73
Q

What are the contraindications and cautions of digoxin?

A

Contraindications
Ventricular tachycardia or fibrillation, heart block, myocarditis

Cautions
Hypercalcaemia
Hypokalaemia, hypomagnaesia
Hypoxia
Recent MI
Elderly (STOPP criteria?)
74
Q

What are 8 side-effects of digoxin?

A 
Arrythmias
Dizziness
Diarrhoea
Vomiting
Skin reactions
Vision changes (yellow vision)
Thrombocytopenia 
Depression
Nausea
Increased appetite
Confusion
Malaise
GI disorders
Headache
75
Q

What are the monitoring requirements for digoxin?

A

Monitor digoxin-plasma concentration and serum electrolytes in renal impairment

Monitor digoxin-plasma if digoxin toxicity is suspected

When doing a plasma-digoxin concentration assay, take blood 6 hours after a dose

Heart rate (should be maintained over 60 beats per minute)

76
Q

Which class of medication for atrial fibrillation does verapamil interact with, and what is the consequence?

A

Beta-blockers

Increased risk of severe hypotension and bradycardia
AVOID

77
Q

What is a shared contraindication for digoxin and verapamil?

A

Arrythmia associated witch conduction pathways s.g. WPW syndrome

78
Q

Which LFT in particular do we monitor to assess for amiodarone liver toxicity?

A

Transaminases

79
Q

Which drugs are interact with amiodarone by increasing the risk of Tordades de pointes?

A 
Sotalol
Co-trimoxazole
Erythromycin 
Chlorpromazine 
Haloperidol
Amisulpride
Amitripyline
Anti-malarials
80
Q

What is the rescue drug for severe bradycardia following IV amiodarone being administered too quickly?

A

Atropine

81
Q

In which groups of patients should flecainide and propafenone not be used in?

A

Asthma
COPD
Structural/ischaemic heart disease

82
Q

What can cause QT interval prolongation and therefore Torsades de Pointes?

A

Drugs
Hypokalaemia
Bradycardia

83
Q

Does amiodarone cause hypo or hyperkalaemia?

What is the problem with this?

A

Hypokalaemia

This increases the pro-arrythmic effect of amiodarone

84
Q

For paroxysmal supraventricular tachycardia, when might IV verapamil be preferred over IV adenosine?

A

Asthma or COPD

85
Q

Why does hypokalaemia need to be corrected before starting soltolol?

A

Both hypokalaemia and sotolol can prolong the QT interval and increase the risk of arrhythmias

86
Q

How can digoxin toxicity affect vision?

A

It can cause yellow vision

87
Q

What is valvular AF?

A

AF + artificial heart valve

Valvular AF - warfarin
Non-valvular AF - warfarin or DOACs

Pre Reg Pharmacy (36 decks)

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