Therapeutics - Arrhythmias Part 2

Question 1

2 goals for rhythm control for afib

Answer 1

get to NSR
reduce patient’s symptoms

Question 2

what is an “acute transition to NSR”

Answer 2

a cardioversion

Question 3

2 general methods for rhythm control for afib

Answer 3

cardioversion or chronic meds

Question 4

which 2 rhythm control drugs use the “pill in pocket” approach

Answer 4

flecainide, propafenone

Question 5

the choice of anti arrhythmics for afib is severely limited by what

Answer 5

any heart disease

Question 6

ONLY TWO antiarrhythmics that can be given to afib patients who also have MI, HF, or other structural heart disease

Answer 6

amiodarone, sotalol

Question 7

general guideline on when to give anti ARRHYTHMICS for afib

Answer 7

if had afib for less than a year (if over a year – very hard to get back to normal sinus rhythm)

if the pt has concurrent heart failure

pt has persistent symptoms while on rate control

they are hemodynamically unstable

Question 8

dose of flecainide/propafenone for pill in pocket approach

Answer 8

flecainide - 200-300mg once

propafenone - 450-900mg once

Question 9

explain what the “pill in pocket” approach exactly is

Answer 9

patients self administered a dose when they feel symptoms

has been shown to reduce hospital admissions and costs - improved qol

HOWEVER, the patient must first be on an AV nodal blocking agent (otherwise, this approach can cause rapid av conduction and atrial flutter)

Question 10

sotalol contraindication

Answer 10

in creatinine clearance less than 40ml!

Question 11

important monitoring parameter for sotalol (anti-arrhytmic)

Answer 11

monitor QT!!!!! for initial 3 days, and then every 3-6 months

Question 12

patient’s creatinine clearance is 40-60mL/min

what is sotalol dosing

Answer 12

once a day

if below 40 - contraindicated!

Question 13

true or false

amiodarone is very effective at maintaining normal sinus rhythm

Answer 13

true

Question 14

monitoring recommendations for amiodarone ADRs

Answer 14

baseline: chest xray, liver fxn test, EKG

repeat TSH and liver fxn every 6 months

repeat EKG and physical every year

Question 15

loading and maintenance dosing amiodarone

Answer 15

loading - total - 6-10g (400-800mg daily in 2-4 doses) - big dose 1st so it starts working

maintenance is 200mg QD

Question 16

haloperidol + amiodarone

Answer 16

risk torsada

Question 17

methadone + amiodarone

Answer 17

risk torsada

Question 18

dofetilide brand

Answer 18

tikosyn

Question 19

concern with dofetilide

Answer 19

risk for serious ventricular arrhythmias!!!

Question 20

contraindication to dofetlilide

Answer 20

creatinine clearance less than 20

Question 21

explain when dofetilide should be initiated and the monitoring parameters

Answer 21

initiate inpatient for 3 days – monitor EKG! for QT!

then monitor EKG every 3-6 months

Question 22

dronedarone brand name

Answer 22

multaq

Question 23

multaq (dronedarone) dosing

Answer 23

500mcg BID (adjust for renal)

Question 24

differentiate between dronedarone and amiodarone

Answer 24

dronedarone has a shorter half life, no iodine, and less noncardiac toxicities

HOWEVER, it is also less effective, increases serum creatinine, AND has an FDA warning of acute hepatic failure

Question 25

dronederone contraindications does this also apply to amiodarone

Answer 25

NHYA class II-III with recent decompensation HF or NHYA class IV. OR permanent afib amiodarone CAN be used in these cases

Question 26

true or false if hemodynamically unstable, CARDIOVERT

Answer 26

true

Question 27

patient has dizziness, palpitations, blurry vision, and is in afib. has RVR on the EKG (rapid ventricular rate) BP 89/42 HR = 155bpm O2 sat = 82% medical team decides antiarrhythmic approach. what is best?

Answer 27

DIRECT CARDIOVERSION NOW this patient is not hemodynamically stable. we dont have time to wait 3 weeks for them to be anticoagulated however, we can anticoagulate AFTER the cardioversion if the patient was stable, then we could anticoagulate 1st bc we have the time

Question 28

patient with afib is being considered for amiodarone vs dronedarone which would make dronedarone more desirable? -history of class III HF with recent decompensation -excellent kidney function -history of liver disease -pt desire to avoid serious ADR -allergy to shellfish

Answer 28

i think it's patient desire to avoid serious ADR amiodarone doesnt need dose adjustment fir renal failoure

Question 29

define "sudden cardiac arrest

Answer 29

sudden cessation of cardiac activity. victim is unresponsive with non breathing or signs of circulation

Question 30

4 causes of sudden cardiac arrest

Answer 30

pulseless VT VT PEA (pulseless electrical activity) asystole

Question 31

true or false VT (ventricular tachycardia) can occur either with or without a pulse

Answer 31

TRUE if with a pulse, perfusion is still happening

Question 32

what is PVC

Answer 32

"premature ventricular contractions" there is an extra ventricular systolic beat

Question 33

"3 PVCs + HR over 100"

Answer 33

ventricular tachycardia (VT)

Question 34

"hallmark of long QTc

Answer 34

torsada

Question 35

"flatline"

Answer 35

asystole

Question 36

"chaotic asynchronous contraction"

Answer 36

ventricular fibrillation

Question 37

4 cardiac emergency arrhythmias

Answer 37

VT VF PEA asystole

Question 38

"organized, electrical activity that fails to produce mechanical contraction to produce a pulse" also called a non-perfusinf rhythm

Answer 38

PEA "pulseless electrical activitt"

Question 39

what does defibrillation do

Answer 39

try to get to NSR (AKA cardioversion! only dif is that defibrillation is working with a non-life sustaining rhythm)

Question 40

ONLY 2 cardiac emergencies that get defibrillation

Answer 40

for pulseless VT and VF NOT FOR PEA OR ASYSTOLE

Question 41

TRUE OR FALSE never interupt CPR to place an IV or give drugs

Answer 41

TRUE - just focus on CPR

Question 42

3 drugs that can potentially be used in cardiac arrest but do NOT increase survival

Answer 42

epinephrine amiodarone vasopressin (not rec in recent guidelines)

Question 43

when is amiodarone appropriate for cardiac arrest patient

Answer 43

only if failed defibrillation 3x and epinephrine once

Question 44

dose of epi for cardiac arrest

Answer 44

1mg IV/IO.repeat every 3-5 mins (no max)

Question 45

ventilation rate

Answer 45

2 breaths/30 secs or 1 breath/8 secs (if advanced airway available)

Question 46

asystole to vfib

Answer 46

have gone from a nonshockable rhythm to a shockable rhythm