Cardio Exam 3: Tsu AFib

KNOW IMAGE

CHADSVASc Scores

• Congestive HF/LV dysfunction = ______

• HTN = ______

• 75 and older = ______

• DM = ______

• Stroke/TIA/Thromboembolism = ______

• Vascular Disease (previous MI, PAD, aortic plaque) = ______

• 65-74 y/o = ______

• Female = ______

1, 1, 2, 1, 2, 1, 1, 1

CHADSVASc Scores

• ______ = no anticoag and aspirin has no benefit

• ______ = anticoag may be considered

• ______ = anticoag may be considered

• ______ = oral anticoag recommends (Warfarin with INR 2-3 OR DOACs/NOACs such as dabigatran, rivaroxaban, apixaban, or edoxaban)

• ______ = oral anticoag recommends (Warfarin with INR 2-3 OR DOACs/NOACs such as dabigatran, rivaroxaban, apixaban, or edoxaban)

• ______ are preferred over ______ EXCEPT in ______ or ______

0, 1 in men, 2 in women, 2 or more in men, 3 or more in women, DOACs, Warfarin, mitral stenosis, mechanical heart valve

Causes of AF & Aflutter

• Re-entry mechanism4

  • Aflutter: single dominant reentrant wavelet

  • AF: multiple reentrant loops

• Structural heart disease that ______

  • ______

  • ______

  • ______

• High adrenergic states

  • Thyrotoxicosis, surgery, alcohol withdrawal, sepsis

causes atrial distension, MI, Valvular HD, Congenital abnormalities

• Originates from many atrial foci firing at rapid rates

• Atrial rate is ~350-450 bpm; Ventricular rate variable

• Only depolarizations from some of the foci conduct through ventricles; this occurs in an irregular fashion

• Rhythm describe as “irregularly irregular with no discernable p waves”

• May be accompanied by Rapid Ventricular Rate (RVR)

  • Many depolarizations passing through AV node

  • Rapid pulse (based on ventricular rate)

  • Sxs due to the arrhythmia include dyspnea, SoB, palpitations

AFib

Atrial Fibrillation (AF)

• Originates from many atrial foci firing at rapid rates

• Atrial rate is ~______ bpm; ______ rate variable

• Only ______ from ______ of the foci conduct through ventricles; this occurs in an irregular fashion

• Rhythm describe as “______ with ______”

• May be accompanied by ______

  • Many depolarizations passing through AV node

  • Rapid pulse (based on ventricular rate)

  • Sxs due to the arrhythmia include dyspnea, SoB, palpitations

350-450, ventricular, depolarization, some, irregularly irregular, no discernable p waves, Rapid Ventricular rate

______

• Atrial impulses faster than SA node impulses

• Originates from a single ectopic focus

• Rate of firing is ~220-350 per minute

• AV node does not allow all impulses to conduct through to ventricles (usually a 2:1 or 3:1 ratio, can be 4:1)

• Appears as a “saw tooth” pattern on ECG

• Rhythm is regular (unlike AF) – “regularly irregular”

• Occurs less frequently than AF

• Similar in precipitating factors, consequences and treatment

  • For rest of lecture, assume discussion is for both AF and Aflutter unless otherwise noted

Aflutter

Atrial Flutter

• Atrial impulses ______

• Originates from a ______ ectopic focus

• Rate of firing is ~______ BPM

• AV node does not allow all impulses to conduct through to ventricles (usually a 2:1 or 3:1 ratio, can be 4:1)

• Appears as a “______” pattern on ECG

• Rhythm is regular (unlike AF) – “______”

• Occurs ______ frequently than AFib

• Similar in precipitating factors, consequences and treatment

  • For rest of lecture, assume discussion is for both AF and Aflutter unless otherwise noted

faster than SA node impulses, single, 220-350, sawtooth, regularly irregular, less

Determine whether each statement describes Afib or Aflutter.

1. Originates from a single ectopic focus in atrium → ______

2. Rhythm is described as “regularly irregular” → ______

3. No discernable p waves → ______

Aflutter, Aflutter, Afib

Presentation

• Fatigue, Palpitations, SoB, Hypotension, Syncope, Chest pain, and AF with RVR if HR >100 bpm

• *However, many pts can be asymptomatic, especially if HR is normal

KNOW

Treatment of AF

• ______ (and systemic thromboembolism) ______

  • Stratify risk by CHA2DS2-VASC score

• Treatment of tachyarrhythmia

  • ______ control

  • ______ control

Stroke, prevention, rate, rhythm

KNOW IMAGE

Thromboembolism Risk

• Thrombus can form in atrium due to blood pooling

• Highest risk in ______

• Most common thromboembolic event is ______

  • NOT ______

left atrial appendage, ischemic stroke, PE or MI

RB is a 74 year old, 70kg female who presents to the hospital with

new symptoms of cardioembolic stroke, and is diagnosed with new AF.

• PMH: hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction 2010, GI bleed 2012

• SH: 1-2 glasses of wine/night, quit smoking 17 years ago

• Vitals: BP 140/86 mmHg, HR 80 bpm, RR 20

• Labs: Scr 0.8, AST/ALT WNL, electrolytes WNL, H/H 9.9/29.8, HgbA1c 7.2

• Current medications: aspirin 81mg PO daily, carvedilol 12.5mg PO BID, simvastatin 40mg PO at bedtime, metformin 500mg PO BID

Assess RB’s risk of stroke versus her risk of bleeding

CHADVASC Score = 8 and HAS-BLED = 5

RB is a 74 year old, 70kg female who presents to the hospital with

new symptoms of cardioembolic stroke, and is diagnosed with new AF.

• PMH: hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction 2010, GI bleed 2012

• SH: 1-2 glasses of wine/night, quit smoking 17 years ago

• Vitals: BP 140/86 mmHg, HR 80 bpm, RR 20

• Labs: Scr 0.8, AST/ALT WNL, electrolytes WNL, H/H 9.9/29.8, HgbA1c 7.2

• Current medications: aspirin 81mg PO daily, carvedilol 12.5mg PO BID, simvastatin 40mg PO at bedtime, metformin 500mg PO BID

Determine if RB should be treated with anticoagulation

Yes bc his CHADVASC score is 3 and more and periodically assess for bleeding RFs

Anticoagulant Options

• ______

• ______

  • ______

  • ______

  • ______

  • ______

• ______ preferred over ______ EXCEPT with ______, antiphospholipid Ab syndrome or ______

  • DOACs superior or non-inferior in both efficacy and safety

• Does NOT usually require parenteral anticoagulation overlap of ______ (since there is not usually a formed clot yet, but bridging is required if there is a confirmed clot)

Warfarin, DOACs, Dabigatran, Rivaroxaban, Apixaban, Edoxaban, DOACs, Warfarin, mitral stenosis, mechanical heart valve, 5-10 days

Dosing of DOACs in AF

• Note that some dosing and renal adjustment is different than for VTE indication

• Dabigatran (Pradaxa®) ______

  • CrCl ______ mL/min: ______

150 mg PO BID, 15-30, 75 mg PO BID

Dosing of DOACs in AF

• Rivaroxaban (Xarelto®) ______

  • CrCl ______ mL/min: ______

20 mg PO QD, 15-50, 15 mg PO QD with food

Dosing of DOACs in AF

• Apixaban (Eliquis®) 5 mg PO BID

  • If 2 of 3 are met (age ______, weight ______ kg, Scr ≥ ______): ______

  • Some data for use in pts with ESRD and dialysis

5 mg PO BID, >80, <60, 1.5, 2.5 mg PO BID

Dosing of DOACs in AF

• Edoxaban (Savaysa®) ______

  • CrCl 15 – 50 mL/min: 30mg PO daily

  • Do not use if CrCl > 95 mL/min

60 mg PO QD

Anticoagulant DDIs

KNOW IMAGE

Back to RB…

• RB is a 74 year old, 70kg female who presents to the hospital with new symptoms of cardioembolic stroke, and is diagnosed with new AF.

• PMH: hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction 2010, GI bleed 2012

• SH: 1-2 glasses of wine/night, quit smoking 17 years ago

• Vitals: BP 140/86 mmHg, HR 80 bpm, RR 20

• Labs: Scr 0.8, AST/ALT WNL, electrolytes WNL, H/H 9.9/29.8, HgbA1c 7.2

• Current medications: aspirin 81mg PO daily, carvedilol 12.5mg PO BID, simvastatin 40mg PO at bedtime, metformin 500mg PO BID

Which of the following is the best recommendation for anticoagulation for RB?

1. Increase aspirin to 325mg PO daily

2. Start warfarin 10mg PO daily, titrate to INR 2-3

3. Start rivaroxaban 15mg PO BID x 21 days, then 20mg daily

4. Start edoxaban 60mg PO daily and enoxaparin 70mg SC BID

5. Start apixaban 5mg PO BID

5

KNOW IMAGE

Rate vs Rhythm Control in AF AFFIRM trial

• Two groups

  • ______: cardioversion then antiarrhythmic drugs to maintain NSR

  • ______: rate-control medications

Rhythm control, rate control

2023 Guideline updates to rate vs rhythm discussion

KNOW IMAGE

Rate control strategy

• Goals

  • Sx control: palpitations, chest pain, SoB, syncope

  • Increase ventricular filling time

• Goal HR

  • Rest: <______-110 bpm

• Medications

  • ______

  • ____________

  • Digoxin

100, BBs, Non-DHP CCBs, Digoxin

Indications for specific rate control drugs

• BBs

  • ______: ______, ______ succinate, bisoprolol

  • ______

• Non-DHP CCBs

  • If BB use is limited → ______, severe reactive ______ disease

• Digoxin

  • ______, ______, and Sedentary

HF with low EF, Carvedilol, Metoprolol, CAD, Acute HF exacerbation, airway, systolic HF, Hypotension

Indications for specific rate control drugs

• ______

  • HF with low EF: carvedilol, metoprolol succinate, bisoprolol

  • CAD

• ______

  • If BB use is limited → Acute HF exacerbation, severe reactive airway disease

• ______

  • Systolic HF, Hypotension, and Sedentary

BBs, Non-DHP CCBs, Digoxin

______

• MOA: binds competitively to Na-K-ATPase

  • Positive inotrope, negative chronotrope

• Only slows HR at rest, not during exertion

• Is BP neutral

• Dosing

  • Usually 125-500 mcg daily

  • Can give an IV or PO load (0.75-1.5 mg total) for faster effect

    • Longer time for full effect than other rate control options

• Renally-excreted

  • Dose must be adjusted in renal insufficiency

• Narrow therapeutic index

  • HF: 0.5-0.8 ng/mL

  • Arrhythmias: < 1.2 ng/mL

  • Toxicity risk: > 2 ng/mL

• Signs & symptoms of toxicity

  • Early: anorexia, nausea, vomiting, diarrhea, visual disturbances (yellow halos), headaches

  • Late: premature ventricular contractions (PVCs), AV block, ventricular tachycardia & fibrillation

Digoxin

Digoxin

• MOA: binds competitively to Na-K-ATPase

  • ______, ______

• Only ______ at rest, not during exertion

• Is ______ neutral

• Dosing

  • Usually 125-500 mcg daily

  • Can give an IV or PO load (0.75-1.5 mg total) for faster effect

    • ______ time for full effect than other rate control options

• ______

  • Dose must be adjusted in renal insufficiency

• ______ therapeutic index

  • HF: 0.5-0.8 ng/mL

  • Arrhythmias: < 1.2 ng/mL

  • Toxicity risk: > 2 ng/mL

• Signs & symptoms of toxicity

  • Early: anorexia, nausea, vomiting, diarrhea, visual disturbances (yellow halos), headaches

  • Late: premature ventricular contractions (PVCs), AV block, ventricular tachycardia & fibrillation

Positive inotrope, negative chronotrope, slow HR, BP, longer, renally excreted, narrow

Acute management of AF with rapid ventricular response (RVR)

• ______ if hemodynamically unstable

• Medication options (stable but HR high)

  • ______

    • Most commonly used except in ______

  • ______

    • ______

  • ______

  • ______

cardioversion, IV non-DHP CCBs, HF, IV BBs, Metoprolol and esmolol, IV digoxin, IV amiodarone

KNOW IMAGE

TM is a 78 year old male who is presenting with fatigue, dizziness, and syncope. He is currently on metoprolol succinate 50mg daily succinate for rate control. His home BP log shows that his HRs are 80-90s, and his BP readings are 100-110s/60-70s. How should we adjust TM’s rate control therapy?

1. Increase metoprolol to goal HR 60-80

2. Decrease metoprolol, start diltiazem 120mg ER daily

3. Decrease metoprolol, start digoxin 0.125 mg daily

4. Discontinue metoprolol

3 (fatigue, dizziness, syncope), Goal HR <100, not commonly used in AFib, need to taper and treat Sxs

KNOW IMAGE

Rhythm Control

• ______

• ______

• ______ (only if undergoing cardiac surgery for another reason)

Meds, catheter ablation, surgery

Rhythm Control strategy

• Goal: restore and maintain ______

• Cardioversion

  • Direct current cardioversion (DCCV)

  • Pharmacological cardioversion

  • Efficacy: DCCV 80 – 90% compared to pharmacologic 40-60%

• Most patients require anti-arrhythmic drugs (AADs) to maintain NSR after cardioversion

normal sinus rhythm

Electrical Cardioversion

• Direct current cardioversion (DCCV)

• Electric “shock” attempt to restore NSR

• Indications

  • Emergent (Urgent)

    • ______

  • Elective

    • ______

    • ______

    • ______

Hemodynamically unstable, rate control not effective, <60 y/o, physically active and poor exercise tolerance with rate control

AADs for pharmacological cardioversion

• Medications can also be used to attempt to restore NSR

  • ______ effective than DCCV

• Proven efficacy

  • ______

  • ______ 

  • ______ (IV only)

  • ______

  • ______

• Less effective

  • Disopyramide

  • Procainamide

  • Quinidine

Less, Amiodarone, Dofetilide, Ibutilide, Flecainide, Propafenone

Anticoagulation for Cardioversion

• Risk of thromboembolism (stroke) if pt has ______

• ______> ______ in visualizing atrium

• If thromboembolism seen, need AC for at least ______ to dissolve clot

• Anticoagulate for at least ______, then assess risk of stroke based on CHA2DS2-VASc score

AF for more than 2 days, TEE, TTE, 3 weeks, 4 weeks after cardioversion

WE is a 56 year old male who presents to the hospital with new AF with RVR. He states that his symptoms have been on-and-off for the last week, and he came to the hospital since he is feeling more dizzy and nauseated. His BP is 88/58 mmHg and HR 132 bpm.

• Is emergent cardioversion an option for WE?

No bc it’s only for hemodynamically unstable pts (<90 SBP)

WE is a 56 year old male who presents to the hospital with new AF with RVR. He states that his symptoms have been on-and-off for the last week, and he came to the hospital since he is feeling more dizzy and nauseated. His BP is 88/58 mmHg and HR 132 bpm.

• Which echo modality should be used to visualize his left atrium?

Transesophageal Echocardiogram (TEE)

WE is a 56 year old male who presents to the hospital with new AF with RVR. He states that his symptoms have been on-and-off for the last week, and he came to the hospital since he is feeling more dizzy and nauseated. His BP is 88/58 mmHg and HR 132 bpm.

• Is elective cardioversion an option?

Yes can wait 3-4 weeks as outpatient, need some other way to control sxs now (anticoag for 3 or more weeks so no need to TEE)

WE is a 56 year old male who presents to the hospital with new AF with RVR. He states that his symptoms have been on-and-off for the last week, and he came to the hospital since he is feeling more dizzy and nauseated. His BP is 88/58 mmHg and HR 132 bpm.

• Based on his medical chart, you find his CHADS2-VASc score = 6. What recommendation do you have for his antithrombotic therapy (include dosing)?

Need long-term full anticoagulation Warfarin INR 2-3, Pradexa, 150 mg BID, Varelto 20 mg QD, etc.

AADs for Maintenance of Normal Sinus Rhythm

• Amiodarone (Cordarone, Pacerone)

• Dronedarone (Multaq)

• Dofetilide (Tikosyn)

• Sotalol (Betapace AF)

• Flecainide (Tambocor)

• Propafenone (Rythmol)

• Specific choice of agent depends on:

  • Underlying structural heart disease

  • Renal function

  • Potential toxicities

KNOW

KNOW IMAGE

______ (______ → ______ but ______)

• Cordarone, Pacerone

• MOA: Class III, activity from all 4 Vaughn-Williams classes

  • Prolongs QT and refractoriness

  • Slows HR, AV node conduction, and intracardiac conduction

• Extremely prolonged half-life

  • ~ 60 days

  • Adverse effects and DDIs can last months after drug discontinuation

• Most effective AAD (not 1st line bc of associated with most toxicities)

• Frequency of toxicity related to total exposure to medication

  • Duration

  • Dosage

Amiodarone, 2nd line, most effective, more toxic

Amiodarone (2nd Line → most effective but more toxic)

• Cordarone, Pacerone

• MOA: ______, activity from ______ Vaughn-Williams classes

  • ______ and refractoriness

  • ______, ______, and intracardiac conduction

• ______ half-life

  • ~ 60 days

  • Adverse effects and DDIs can last months after drug discontinuation

• ______ (______)

• Frequency of toxicity related to total exposure to medication

  • Duration

  • Dosage

Class III, all 4, prolongs QT, slows HR, AV node conduction, extremely prolonged, most effective AAD, not 1st line bc it’s more toxic

______

• Used in elderly or older adults

• Eyes (eye exam), thyroid (hypo- and hyperthyroidism), liver (liver injury/toxicity), skin, neurological

• Pulmonary fibrosis most serious toxicity

  • Symptoms: cough, dyspnea, patchy infiltrates on CXR, reduced PFTs

• DDIs: due to CYP inhibition and P-gp inhibition

  • CYP 2C9, 2D6, 3A4

  • Extensive: always run an interaction check

Amiodarone

Amiodarone

• Used in ______

• Eyes (______), thyroid (______), liver (______), skin, neurological

• ______ most serious toxicity

  • Symptoms: cough, dyspnea, patchy infiltrates on CXR, reduced PFTs

• DDIs: due to CYP inhibition and P-gp inhibition

  • CYP 2C9, 2D6, 3A4

  • Extensive: always run an interaction check

elderly or older adults, eye exam, hypo/hyperthyroidism, liver injury/toxicity, Pulmonary fibrosis,

Which statements are accurate regarding amiodarone therapy? SATA.

1. It can cause renal fibrosis with prolonged use

2. Drug interactions occur with substrates of CYP 3A4 and P-gP

3. PFTs and LFTs should be monitored at baseline

4. Amiodarone’s effects can persist for years

B and C, pulmonary fibrosis, months

______ (______)

• Multaq, monitor LFTs and QT interval

• MOA: Class III, activity from all 4 Vaughn-Williams classes

• Structurally similar to amiodarone

  • Less lipophilic, shorter t1/2

  • Not associated with extensive SEs like amiodarone

• BBW: Increased risk of death with decompensated HF or permanent AF

Dronedarone, Second 1st line med

Dronedarone (Second 1st line med)

• Multaq, monitor ______

• MOA: ______, activity from ______ Vaughn-Williams classes

• Structurally similar to amiodarone

  • ______, ______ t1/2

  • Not associated with extensive SEs like amiodarone

• ______: Increased risk of death with decompensated ______ or permanent ______

LFTs and QT interval, Class III, all 4, less lipophilic, shorter, BBW, HF, Afib

______ (______)

• Betapace AF

• MOA: Class III, also non-selective BB

  • NOT used for HTN or rate control

• Precautions

  • Avoid in systolic HF

• Monitoring

  • Renal function

  • QT prolongation

    • C/I if QT interval > 450 msec

Sotalol, last line

Sotalol (Last Line)

• Betapace ______

• MOA: ______, also ____________

  • NOT used for HTN or rate control

• Precautions

  • Avoid in ______

• Monitoring

  • ______

  • ______

    • C/I if QT interval > 450 msec

AFib, Class III, non-selective BB, HTN or rate control, systolic HF, renal function, QT prolongation

______ (______)

• Tikosyn

• MOA: Pure class III

• Highest risk of Torsades de Pointes

  • 0.3 – 4.7%

  • Previously required hospitalization for first 5 doses

• Can be used for cardioversion and maintenance of NSR

• Monitoring

  • Renal function

  • QT interval

  • Drug interactions (increases QT interval)

    • Verapamil, HCTZ, cimetidine, ketoconazole, prochlorperazine, trimethoprim

    • Any other drug that prolongs QT interval

Dofetilide, Second 1st line med

Dofetilide (Second 1st line med)

• Tikosyn

• MOA: ______

• Highest risk of ______

  • 0.3 – 4.7%

  • Previously required ______

• Can be used for ______ and maintenance of ______

• Monitoring

  • ______

  • ______

  • ______ (______)

    • Verapamil, HCTZ, cimetidine, ketoconazole, prochlorperazine, trimethoprim

    • Any other drug that prolongs QT interval

Pure class III, torsades de Pointes, hospitlization for 1st 5 doses, cardioversion, NSR, renal function, QT interval, DDIs, increases QT interval

______ (______)

• Tambocor and Rythmol

• MOA: Class IC agents

• C/I in patients with structural heart disease (MI or HF, increases risk of death)

• “Pill-in-the-pocket” approach

  • Pt only takes oral medication when having an episode of AF

Flecainide and Propafenone, 1st line

Flecainide & Propafenone (1st line)

• Tambocor and Rythmol

• MOA: ______ agents

• C/I in patients with ______ (______, increases risk of ______)

• “Pill-in-the-pocket” approach

  • Pt only takes ______ when having an episode of ______

Class IC, structural HD, MI or HF, death, oral med, AFib

Adverse Effects Oral AASs

• Amiodarone → order ______ (______ tests, ______, ______) to ensure pt doesn’t develop ______

baseline tests, thyroid function, EKG, LFTs, SEs

HH is a 72-year-old, 80 kg male who presents to the emergency department with a racing heart, shortness of breath, wheezing, and syncope.

• EKG: atrial fibrillation

• HR: 140 bpm

• BP: 120/86 mmHg

• PMH: hypertension, diabetes

• Medications prior to admission: aspirin 81mg PO daily, amlodipine 10mg PO daily, insulin glargine 10 units at bedtime

• TEE: negative for thrombus

The medical team wants to start an anti-arrhythmic treatment for the patient. Which antiarrhythmic would be the best choice for HH?

1. Amiodarone

2. Sotalol

3. Dronedarone

4. Dofetilide

5. Atenolol

3, 2nd line, n/a, high risk of torsades bc of renal dysfunction, n/a

HH is a 72-year-old, 80 kg male who presents to the emergency department with a racing heart, shortness of breath, wheezing, and syncope.

• EKG: atrial fibrillation

• HR: 140 bpm

• BP: 120/86 mmHg

• PMH: hypertension, diabetes

• Medications prior to admission: aspirin 81mg PO daily, amlodipine 10mg PO daily, insulin glargine 10 units at bedtime

• TEE: negative for thrombus

Which statement regarding AADs for maintenance of NSR is most accurate?

1. Sotalol and dronedarone are first-line options for HF patients

2. Flecainide and propafenone should not be used in structural heart disease

3. Amiodarone is the first-line AAD for pts with and without structural heart disease

4. Lidocaine is a second-line option

2, Flecainamide and Propafenone, Dofetilide, Amiodarone

HH is a 72-year-old, 80 kg male who presents to the emergency department with a racing heart, shortness of breath, wheezing, and syncope.

• EKG: atrial fibrillation

• HR: 140 bpm

• BP: 120/86 mmHg

• PMH: hypertension, diabetes

• Medications prior to admission: aspirin 81mg PO daily, amlodipine 10mg PO daily, insulin glargine 10 units at bedtime

• TEE: negative for thrombus

Which statement regarding sotalol use for AF is most accurate?

1. It can be used for both pharmacological cardioversion and maintenance of NSR

2. Monitoring parameters include HR, BP, and LFTs

3. It can cause QT prolongation leading to TdP

4. Its main mechanism in AF is for rate control

3, Dofetilide, Renal function, QT interval, BP, HR, and electrolytes, NOT used for HTN or rate control, but for rhythm control

Catheter Ablation

• Pulmonary vein isolation

  • Can be ______

  • Anticoagulation based on ______

• AV node ablation

  • ______

  • AF persists → ______

• Indications

  • If ______ are ineffective, C/I, or not tolerated

  • ______ in ______ pts with few comorbidities to improve ______ + prevent ______

curative for AFib Sxs, risk assessment, permanent pacemaker, continue anticoag, anti-arrhythmic meds, 1st line, younger, Sxs, AFib progression

Review of AF management

KNOW IMAGE