AFib/Aflutter Management

AFib Classification: Acute AF

onset w/in 48 hours

AFib Classification: Paroxysmal AF

terminates spontaneously in <7 days

AFib Classification: Recurrent AF

two or more episodes

AFib Classification: Persistent AF

Duration >7 days and doesn’t terminate spontaneously

AFib Classification: Permanent AF

Doesn’t terminate even w/ meds or DCC

Generic: Atenolol

Tenormin

• 25-100 mg QD

• cardioselective BB

Generic: Bisoprolol

Zebeta (cardioselective)

Generic: Metorpolol Tartrate

Lopressor (cardioselective)

Generic: Metoprolol Succinate

Toprol XL (cardioselective)

Generic: Nadolol

Corgard (non-cardioselective)

Generic: Propanolol

Inderal (non-cardioselective)

Generic: Carvedilol

Coreg

• 3.125-25mg BID

• mixed Alpha/Beta Blocker

BB ADR:

• bradycardia

• Hypotension

• Fatigue

• Dizziness

ADR/CI/DDI of NDCCB - long term rate control

• peripheral edema

• worsen systolic dysfunction

• CI: severe LVD ( EF less than 40%)

• DDI: CYP3A4

Amiodarone DDI/Pearls

• CYPs (many)

• Warfarin, Digoxin, Simva/Lova, Azithromycin

  • ↑ Warfarin concentration = ↑ INR

  • may not occur STAT but rather days → wait and do not increase dose

• Recommended in pts w/ HF

• Used as last line (no response to BB or NDCCB)

Generic: Digoxin

Digitek, Digox, Lanoxin

Digoxin maintenance dose

0.125-0.250 mg QD

Digoxin Dose Adjustment

CRCL:

• 10-50 → 25-75% of usual dose Q24-36 H

• < 10 → 10-25% of usual dose

• need to adjust for renal function

Digoxin Monitoring - Serum Concentration

• 0.8-2.0 ng/mL → aim for < 1.2

• > 2.0 → toxic

Digoxin toxicity signs/sx

• N/V

• loss of appetite

• Bradycardia

• blurred vision → altered colors, green/yellow halos

• Confusion

• Arrhythmia

Digoxin - when to check levels

• Draw levels Q6-8 H after last dose

• Loading Dose → draw w/in 12-24 H after a dose

• No loading dose → obtain after 3-5 days

• dose changes → 5-7 days

Rate Control Recommendations

• Resting HR < 80 for symptomatic management

• Resting HR < 100-110 as long as pt doesn’t have HF

Rhythm Control - Meds for Cardioversion

• Flecainide

• Propafenone

• IV:

  • Ibutilide

  • Procainamide

  • Amiodarone

Generic: Flecainide

Tambocor

Generic: Propafenone

Rythmol

Generic: Ibutilide

Corvert

Generic: Amiodarone

Pacerone, Nexterone, Cordarone

Flecainide - CI/DDI/Monitoring

• CI: structural heart disease

• DDI: Class 1A or III

• Monitor: BP, HR, Electrolytes + ECG Q6 months

Propafenone - CI/DDI

CI: structural heart disease

DDI: Class 1A or III

Generic: Dofetilide

Tikosyn

• use actual BW for CrCl calculations

• ADR: QT prolongation

Generic: Dronedarone

Multaq

CI:

• permanent AF

• HF + recent decomp or NYHA Class III or IV symptoms (w/in 4 weeks)

• Bradycardia ( < 50 BPM)

DDI: Strong CYP 3A4 inhibitors

Sotalol ECG monitoring

ECG continuously for first 3 days, then Q3-6 months

Generic: Disopyramide

Norpace

Generic: Quinidine

Quinidex

• CI: thrombocytopenia

• DDI: hydroxyquinolone, Ritonavir, quinolone abx

Antithrombotics is the umbrella for which drug classes?

• Anticoagulants

  • Warfarin

  • DOAC

• Antiplatelets

  • ASA

  • P2Y12 inhibitors

Generic: Apixaban

Eliquis

• 5mg BID

• 2.5 mg BID if 2 of the following:

  • 80 + y/o

  • 60 kg +

  • SCr 1.5+

• Antidote: Andexxa

Generic: Dabigatran

Pradaxa

• CrCl > 30 → 150 mg BID

• CrCl 15-30 → 75 mg BID

• CrCl < 15 → not recommended; even w/ dialysis

• Antidote: Praxbind

• Adjust dose to 75 mg BID for DDI w/ dronedarone/ketoconazole or CrCl 30-50

Generic: Edoxaban

Savaysa

• CrCl 51-95 → 60mg QD

• CrCl 15-50 → 30 mg QD

• CrCl < 15 → not recommended in dialysis

• do NOT use if CrCL > 95 or < 15

Generic: Rivaroxaban

Xarelto

• CrCl > 50 → 20 mg QD w/ evening meal

• CrCl 15-50 → 15mg QD w/ evening meal

• CrCl < 15 → not recommended for dialysis

• Antidote: Andexxa

DOACs are preferred anticoagulants over Warfarin unless:

pt has mitral stenosis or mechanical heart valve