Chaper 2: Cardiovascular - Arrythmia Flashcards Preview

Pharmacy Pre-Reg 2020/2021 > Chaper 2: Cardiovascular - Arrythmia > Flashcards

Flashcards in Chaper 2: Cardiovascular - Arrythmia Deck (87)
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What is an arrhythmia?

A problem with the rate or the rhythm of the heartbeat


What are the general symptoms of an arrhythmia?

Chest pain


What are the three types of supraventricular arrhythmias?

Atrial fibrillation
Atrial flutter
Paroxysmal supraventricular arrhythmia


What are the two types of ventricular arrhythmia

Ventricular tachycardia (e.g. torsades de pointes)
Ventricular fibrillation


What are ectopic beats and how are they managed?

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


What is atrial fibrillation?

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


What are the causes of atrial fibrillation?

Cardiovascular: CHF

Non-cardiovascular: infection, cancer, PE

Lifestyle: alcohol abuse, obesity


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

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


What are the three broad categories for managing atrial fibrillation?


Rate control

Rhythm control


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



What drugs are used for pharmaceutical cardioversion?

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

Oral or IV flecainide


When is electrical cardioversion preferred?

When atrial fibrillation has been present for more than 48 hours


Anticoagulation and electrical cardioversion?

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


What are the two types of electrical cardioversion?

Direct current

Cardiac pacing


What drugs can be used for rate control?

Beta-blocker (not sotolol)

Rate-limiting CCB e.g. diltiazem, verapamil



When can digoxin be used in atrial fibrillation?

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


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

Consider cardioversion

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


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

First choice is atenolol (cheapest)

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


In atrial fibrillation, when is rhythm control used



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

First line - standard beta-blocker

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


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

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


What is paroxysmal atrial fibrillation and how is it managed?

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


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

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


What are the risk factors for stroke in atrial fibrillation?

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


What are the signs of haemodynamic instability?

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


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

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

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))


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

Vitamin K antagonists:
Apixaban, rivaroxaban, edoxaban, dabigatran


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

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


How is atrial flutter managed?

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


How do you manage paroxysmal supraventricular tachycardia?

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