arrhythmia & AF therapeutics

bradyarrhythmia

HR < 60 bpm

tachyarrhythmia

HR > 100 bpm

Wolff-Parkinson-White Syndrome

AV conduction goes through accessory pathway (Belt of Kent)

What meds to avoid in Wolff-Parkinson-White syndrome

BB

non-DHPs

digoxin

amiodarone

atrial fibrillation

uncoordinated atrial activation

irregularly, irregular pulse

atrial flutter

regular atrial activation

variable rapid pulse

paroxysmal AF

lasts ≤ 1 week

persistant AF

>1 week

long-standing persistent AF

>12 months

AF symptoms

often asymptomatic or vague/nonspecific (related to fatigue and negative sensations in chest)

Class 1A meds

moderate

Disopyramide

Quinidine

Procainamide

Class 1B meds

weak/fast

Lidocaine

Mexiletine

Class 1C meds

strong/slow

Flecainide

Propafenone

Class 2 drugs

beta blockers

Class 3 drugs (ADIDS)

K+ channel blockers

amiodarone

dronedarone

ibutilide

dofetilide

sotalol

Class 4 drugs

non-DHP CCBs

diltiazem, verapamil

ventricular rate control

slows HR to decrease symptoms

doesn’t actually get rid of AF

considerations of ventricular rate control (when shouldn’t it be used)

hemodynamically unstable

presence of HF

ventricular rate control resting HR goal

≤80 bpm (80-110 acceptable)

ventricular rate control moderate exercise HR goal

≤100 bpm

Bb contraindications

acute decompensated HF (lowers CO → lowers perfusion)

digoxin therapeutic drug monitoring goal for toxicity

0.8-2 ng/mL

can you use amiodarone as a rate control agent in HF and CV disease?

yes, but its not as effective as non-DHP CCBs

what does amiodarone require to work?

high dose load regimen to accelerate onset of action

why would someone need rhythm control over rate?

hemodynamically unstable

younger

shorter history of HF

more symptoms

high CV event risk

What drug classes are used for rhythm control?

Class 1A: disopyramide, quinidine, procainamide

Class 1C: flecainide, propafenone

Class III: amiodarone, dronedarone, ibutilide, dofetilide, sotalol

rhythm control

changing from AF to normal SR

what should class 1C drugs be avoided in?

patients with CV disease

when are class 1C drugs most effective

if AF ≤7 days

what class 3 drugs are class one recommendations for rhythm control?

dofetilide (PO)

ibutilide (IV)

sotalol efficiency?

low

CHA2DS2-VASc C

heart failure

1

CHA2DS2-VASc H

HTN (>140/>90)

1

CHA2DS2-VASc A2

≥75 y/o

2

CHA2DS2-VASc D

diabetes

1

CHA2DS2-VASc S2

prior stroke or TIA

or thromboembolism (DVT, VTE, etc)

2

CHA2DS2-VASc V

vascular disease

1

CHA2DS2-VASc A

age 65-74

1

CHA2DS2-VASc Sc

Sex category (female)

1

When to use oral anticoags to prevent stroke

CHA2DS2-VASc scores ≥2 (men) or ≥3 (women)

Should antiplatelets be used to prevent stroke?

Not by themselves or in combination therapy, they’re ineffective

In preventing a stroke, when should warfarin bridging be used?

high risk for thromboembolism, low risk for brain bleed (otherwise, don’t have to)

apixaban (eliquis) dose

5 mg PO BID

when to reduce eliquis dose

two of the following:

weight <60 kg

age >80 years

SCr > 1.5 mg/dL

What should eliquis dose be lowered to?

2.5 mg PO BID

older

rate control

younger (<65)

rhythm control

longer history of AF

rate control

shorter history of AF

rhythm control

fewer symptoms

rate control

more symptoms

rhythm control

Class II drugs for pt w/ HF

metoprolol, esmolol, propanolol

initial rhythm control for normal LV function in hospital

IV amiodarone

IV ibutilide

procainamide (only if can’t use above)

initial rhythm control for normal LV function outside of hospital

flecainide

propefanone

initial rhythm control for pt w/ HFrEF

(≤40% EF)

IV amiodarone

first-in-line rhythm control maintenance meds:

normal LV function (no MI or structural heart disease)

Dofetalide

Dronedarone

Flecainide

Propefanone

second-in-line rhythm control maintenance med:

normal LV function (no MI or structural heart disease)

amiodarone

3rd-in-line rhythm control maintenance med:

normal LV function (no MI or structural heart disease)

sotalol

1st-in-line rhythm control maintenance meds:

prior MI or structural heart disease

HFrEF (≤40%)

amiodarone

dofetilide

2nd-in-line rhythm control maintenance med:

prior MI or structural heart disease

HFrEF (≤40%)

sotalol

3rd-in-line rhythm control maintenance med:

prior MI or structural heart disease

HFrEF (≤40%)

flecainide

rate control med class options:

pt w/ LVEF > 40%

Bbs

non-DHP CCBs

(if still need rate control, can add other class option ± amiodarone)

rate control med class options:

pt w/ LVEF ≤ 40%, NOT decompensated HF

Bbs

digoxin

(if still need rate control, add other class option ± amiodarone)

rate control med class options:

pt w/ LVEF ≤ 40%, decompensated HF

digoxin

amiodarone