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T/F: the incidence of A-fib decreases as we age
false you silly lady
what can a-fib be caused by?
Ischemic heart disease, cardiomyopathy, fibrotic disease, electrolyte abnormalities, drugs, genetic diseases
which conditions cause scarring or fibrotic tissue in the heart?
ischemic heart disease, cardiomyopathy, and fibrotic diseases
what can cause changes to the cardiac action potential?
electrolyte abnormalities
what is a-fib?
a progressive disease that occurs when atrial tissue is modified due to abnormalities in structure or function and requires different strategies at different stages.
what does an ECG look like for a-fib
disorganized and irregular atrial activity; has no distinguishable atrial depolarization/contraction (p-waves); makes the atria look like they are quivering instead of contracting
rates for the atria in a-fib
600-800 bpm
rates for the ventricles in a-fib
usually 100-180 bpm
how is a-fib triggered
rapidly firing ectopic beats in the atria - most commonly where pulmonary veins connect to the atria
risk factors for a-fib?
concomitant cardiac disease, diabetes mellitus, obesity, obstructive sleep apnea, hyperthyroidism, smoking, and many more
Types of a-fib
paroxysmal, persistent, longstanding persistent, permanent
what is paroxysmal afib
terminates within 7 days on onset
what is persistent afib
lasts > 7 days
what is longstanding, persistent afib
lasts > 12 months
what is permanent afib?
the patient and clinician have decided that there will be no more effect to restore or maintain sinus rhythm :(
afib clinical manifestations
fatigue, palpitations, SOB, hypotension, dizziness, lightheadedness, syncope
T/F: many patients with afib experience symptoms
False!!
what do you have an increased risk of getting/having due to afib?
stroke, heart failure, dementia, hospitalization, and mortality (and poor costs lots to treat 😐)
what is afib with rapid ventricular rate (RVR)
a generally acute presentation with higher HRs from more conduction through the AV node; often needs immediate intervention as it may lead to syncope/loss of consciousness
afib prevention overview:
foundation of optimal management is to treat risk factors and implement lifestyle changes to decrease the likelihood of developing Afib
Once afib develops what are the 3 important care processes that must be addressed?
stroke risk assessment and treatment, optimizing all modifiable risk factors, and symptom management using rate and rhythm control strategies
T/F: patients can move between substages of a-fib
true <3
what does HEAD-2-TOES stand for?
risk factors and behavioral changes for afib: Heart failure, Exercise, Arterial hypertension, Diabetes, Tobacco, Obesity, Ethanol, Sleep
what scoring tool is used to determine who should be anticoagulated to prevent stroke?
CHA2DS2VASc Score
T/F: strokes are less detrimental to the quality of life in patients with afib than those without it
FALSE!!!!!!!!!
where can blood clots form in the heart ?
clot can form in the left atrial appendage
categories of patient absolute risk of stroke?
low, intermediate, and high
what is a low risk of stoke?
< 1 % annualized risk of stroke
what is intermediate risk of stroke
1-2% annualized risk of stroke
what is high risk of stroke
> 2% annualized risk of stroke
what does the C in CHA2DS2VASc Score stand for?
congestive heart failure
what does the H in CHA2DS2VASc Score stand for?
Hypertension
what does the A2 in CHA2DS2VASc Score stand for?
age > 75
what does the D in CHA2DS2VASc Score stand for?
diabetes mellitus
what does the S2 in CHA2DS2VASc Score stand for?
Stroke/TIA/Systemic Embolism
what does the V in CHA2DS2VASc Score stand for?
Vascular disease
what does the A in CHA2DS2VASc Score stand for?
Age 65-74
what does the Sc in CHA2DS2VASc Score stand for?
Sex Category (female)
points for congestive heart failure in CHA2DS2VASc Score
1
points for hypertension in CHA2DS2VASc Score
1
points for age > 75 in CHA2DS2VASc Score
2
points for diabetes mellitus in CHA2DS2VASc Score
1
points for stroke/TIA/Systemic embolism in CHA2DS2VASc Score
2
points for vascular disease in CHA2DS2VASc Score
1
points for age 65-74 in CHA2DS2VASc Score
1
points for being female in CHA2DS2VASc Score
1
how many points do males need on the CHA2DS2VASc Score for anticoagulation
>= 2
how many points do females need on the CHA2DS2VASc Score for anticoagulation
>= 3
define congestive hf
signs/symptoms of left or right ventricular failure or objective evidence of cardiac dysfunction (ex: on ECHO)
define hypertension <3
a resting BP of > 140 systolic and/or > 90 mmHg diastolic on at least 2 occasions OR active treatment with antihypertensives
define diabetes mellitus
fasting plasma glucose >= 126 mg/dL or treatment if antidiabetic medication
define stroke/TIA/systemic embolism
ischemic stroke, transient ischemic attack, peripheral embolism, pulmonary embolism
define vascular disease
CAD or PAD
decisions about anticoagulation must balance the risk of __________ with the risk of _______________ on anticoagulation
stroke; bleeding
what are some interventions we can suggest to reduce bleed risk on anticoagulants?
discontinuing antiplatelets if/when appropriate, discontinuing NSAIDs
what med is the HAS-BLED score validated for?
warfarin - not DOACs
what can the HAS-BLED score be used in?
A risk-benefit discussion to determine safety of anticoagulation
what is are risk-factors listed in HAS-BLED
hypertension, abnormal liver or kidney function, stroke history, bleeding history, labile INR, elderly (> 65), drug or alcohol abuse
chronic anticoagulation oral agents
warfarin, dabigatran, rivaroxaban, apixaban, edoxaban
acute anticoagulation parenteral agents
heparin, LMWH, direct thrombin inhibitors, fondaparinux
in patients with a-fib and without a history of moderate to severe rheumatic mitral stenosis or mechanical heart valve who are also candidates for anticoagulants, what can be given to them?
DOACs (if can’t have DOAC give them warfarin)
patients with afib and moderate-severe mitral stenosis or mechanical heart valves, what can be given to them for anticoagulation
warfarin
patients with afib and a moderate-high risk of stroke and a CI to long-term anticoagulation due to a non-reversible cause, what is a reasonable treatment option?
A percutaneous left atrial appendage occlusion (LAAO)
in patients with a moderate-high risk of bleeding on oral anticoagulation, what may be a reasonable treatment for them?
A LAAO based on patient preference, which careful consideration of procedural risk with the understanding that data for oral anticoagulation is more extensive
how to optimize heart failure due to being a risk factor for afib?
follow those HF guidelines as appropriate (good luck queen)
how to optimize exercise for afib
moderate-to-vigorous exercise training to a target of 210 minutes per week is recommended
why is exercise beneficial for afib?
reduced afib symptoms and burden, increase maintenance of sinus rhythm, increase functional capacity and improve quality of life
how to optimize arterial hypertension
optimal BP control is recommended to reduced afib recurrence and afib related CV events
how to optimize diabetes
follow guidelines as appropriate…
how to optimize tobacco use in patients
strongly advise them to quit smoking and receive GDMT for tobacco cessation to help mitigate the increased risks of afib related CV complications and other adverse outcomes
how to optimize the fatties (BMI >= 27 kg/m2)
weight loss is recommended with an ideal target of at least 10% weight loss to reduce afib symptoms, burden, recurrence, and progression to persistent afib
how to optimize ethanol usage in patients
patients seeking a rhythm control strategy should minimize or eliminate alcohol consumption to reduce afib recurrence and burden
T/F: the role of treatment of sleep-disordered breathing to maintain sinus rhythm is uncertain but screening for obstructive sleep apnea is reasonable in afib patients
true
how can symptoms of afib be managed?
with either rate or rhythm control
what is rate control?
allowing patients to remain in atrial fibrillation but control the heart rate to control symptoms
what is the heart rate target
should be guided by underlying symptoms but in general aiming at a resting rate of < 100-110 bpm
what is rhythm control
the goal of maintaining sinus rhythm
how can rhythm control be achieved?
via medications, ablation, or a combination.
what is cardioversion
the change from afib to sinus rhythm
what are the two methods to maintain sinus rhythm?
chemical (utilizing antiarrhythmic drugs) and ablation (utilizing a procedure to block conduction in the tissue causing the arrythmia
patient factors/variables that favor rate control for afib
patient preference, “older,” longer history of afib, fewer symptoms
patient factors/variables that favor rhythm control for afib
patient preference, “younger,” shorter history of afib, more symptoms
physical examination anatomy that favors rate control for afib
easily controlled heart rate, larger LA, less LV dysfunction, and less AV regurgitation
physical examination anatomy that favors rhythm control for afib
difficult to control HR, small LA, more LV dysfunction, and more AV regurgitation
drugs used for rate control
beta-blockers, non-DHP CCBs, digoxin, and amiodarone
Adverse events for beta-blockers in afib
AV block, bradycardia, hypotension
adverse events for non-DHP CCBs in afib
AV block, hypotension, bradycardia
adverse events for digoxin in afib
anorexia, N/V, ventricular arrhythmias
adverse events for amiodarone in afib
AV block, bradycardia, and hypotension
DDI for non-DHP CCBs
CYP3A4 inhibitors
DDI for digoxin
P-gp substrate (concentrations increased by amiodarone, dronedarone, and verapamil)
DDI for amiodarone
inhibits CYP1A2, CYP2C9, CYP2D6, and CYP3A4 which can increase concentrations of warfarin and select statins
which drugs are recommended for long-term rate control with the choice of agent according to underlying substrate and comorbid conditions?
beta-blockers and non-DHP CCBs (diltiazem, verapamil)
which drugs should not be administered to patients with afib and and EF < 40%?
non-DHP CCBs
which drug is a reasonable long-term rate control option when used in combo with other rate-controlling agents or as monotherapy if other agents are not tolerated or CI for patients with afib and HF symptoms
digoxin <3
what is the target serum concentration of digoxin?
goal < 1.2 ng/mL
long term rate control first-line agent in patients with EF <= 40%
beta-blockers
if patients with EF <= 40% need more rate control what can be added or used as monotherapy as a second line agent?
digoxin
long term rate control first-line agent in patients with EF > 40%
beta-blockers or non-DHP CCBs
if patients with EF > 40% need more rate control what can be added on or used as monotherapy as a second line agent?
queen digoxin