Cardiology Test 4-Montepara Atrial Fibrillation

Atrial Fibrillation is a type of ____ arrhythmia

supraventricular

Pathophysiology of Atrial Fibrillation

-triggers mostly arise from premature ___ (foci) in pulmonary veins

beats

Pathophysiology of Atrial Fibrillation

-caused by multiple ___ loops (wavelets) that create a pattern of continuous electrical activity

reentrant

Pathophysiology of Atrial Fibrillation

-AV node will filter some of these impulses but may eventually result in rapid ventricular response

-loss of atrial function or contractility can lead to __ within the left atrium and initiate thrombus formation, resulting in an increased risk of stroke and thromboembolism

stasis

Etiology (Causes) of Atrial Fibrillation

1) ___ atrial stretch

2) ____ atrial stretch

3) high ___ tone

left, right, adrenergic

Causes of Left Atrial Stretch:

-____ ischemia or infarction

-hypertension

-___ disorders

-heart ____

-obesity

myocardial, valvular, failure

Causes of Right Atrial Stretch:

-acute pulmonary ____

-chronic ___ disease

-pulmonary HTN

-obstructive sleep ___

embolism, lung, apnea

Causes of High Adrenergic Tone:

-____ (excess thyroid hormones)

-surgery

-heavy ____ intake/alcohol withdrawal

-sepsis

-excessive ___ exertion

thyrotoxicosis, alcohol, physical

What are the 4 Classifications of AF?

paroxysmal, persistent, long-standing persistent, permanent

Classifications of AF

1) paroxysmal AF - AF that ____ spontaneously or with intervention within __ days of onset

terminates, 7

Classifications of AF

2) persistent AF - continuous AF that is sustained > __ __ and terminates with intervention

7 days

Classifications of AF

3) Long-standing persistent AF - continuous AF that is sustained > __ ___ and terminates with intervention

12 months

Classifications of AF

4) Permanent AF - persistance of AF ___ electrical or pharmacological cardioversion attempts

despite

Valvular AF: AF with moderate-severe ___ __ or an artificial ___ __

Nonvalvular AF: all other cases of AF

mitral stenosis, heart valve

Are DOACs approved for stroke prevention in valvular AF?

no

What is the only medication you can use for stroke prevention in valvular AF (ie to prevent strokes in patients with moderate-severe mitral stenosis or a heart valve)?

warfarin

3 parts of Afib treatment

1) ____ prevention

2) ___ control

3) ____ control

stroke, rate, rhythm

Rate control

-used to minimize symptoms of AF and improve ventricular filling

-treatment of choice for ___ or ___ AF

persistent, permanent

Rate Control Drug Therapy Options

1) ____ ____ (class II) (metoprolol tartrate/succinate, atenolol, esmolol, propanolol, nadolol, carvedilol, bisoprolol)

beta blockers

Rate Control Drug Therapy Options

1) beta blockers (class II) are used to ____ AV nodal conduction and increase refractory period

decrease

Rate Control Drug Therapy Options

2) __-___ ____ (class IV) (verapamil, diltiazem)

non-DHP CCB

Rate Control Drug Therapy Options

2) non DHP CCBs (class IV) are used for their ____ AV nodal effects by blocking L-type calcium channels and increasing refractory period

direct

Rate Control Drug Therapy Options

3) ____ _____ (digoxin)

digitalis glycosides

Rate Control Drug Therapy Options

3) digitalis glycosides (digoxin) has a goal concentration of ___-___ng/mL

0.8-1.2

Rate Control Drug Therapy Options

3) digitalis glycosides (digoxin) increases vagal tone and reduces resting HR, not the optimal agent when ___ rate control is desired

rapid

overview of Rate Control Drug Therapy Options

1) Beta blockers (preferred)

2) Non-DHP CCB (preferred)

3) Digoxin (good for if patient is ____ bc no effect on BP)

hypotensive

1st line drug selection for rate control in AF

if no other CV disease:

1) ___ ___

2) ____

3) ____

beta blocker, diltiazem, verapamil

1st line drug selection for rate control in AF

if HTN or HFpEF

1) ___ ___

2) ____

3) ____

beta blocker, diltiazem, verapamil

1st line drug selection for rate control in AF

if LV dysfunction or HF

1) ___ ___ (only use one of the 3 approved for HF)

2) ____

beta blocker, digoxin

if you are giving a beta blocker to a patient with HF, what are your 3 options?

bisoprolol, carvedilol, metoprolol succinate

1st line drug selection for rate control in AF

if COPD

1) ___ ___ (only use cardioselective)

2) ___

3) ____

beta blocker, diltiazem, verapamil

if you are giving a beta blocker to a patient with COPD, make sure to only give a ____ beta blocker (atenolol, betaxolol, bisoprolol, esmolol, metoprolol tartrate/succinate, nebivolol)

cardioselective

Drug selection for rate control

____ is a last line option for rate control (except never use in COPD pt)

amiodarone

Stroke prevention

-conversion of AF to sinus rhythm is associated with increase risk of ___ and systemic ___

stroke, embolism

Stroke prevention

-anticoagulation is used to prevent strokes and systemic emboli in patients with AF by reducing the formation of ___ in the left atrium or left atrial appendage

clots

Stroke prevention

-anticoagulation is essential when AF duration is > ___ hours

48

Stroke prevention

-must use anticoagulant __ weeks before and at least __ weeks after cardioversion

3, 4

Stroke prevention

-use transesophageal echocardiography (___) to determine presence of a clot

TEE

Stroke prevention

-in patients without risk factors for stroke, anticoagulation can be ___ 4 weeks after cardioversion

discontinued

CHA2DS2-VASc Scoring

-recommended for assessment of annual ___ ___ in patients with nonvalvular AF

stroke risk

CHA2DS2-VASc Scoring

CHF or LVEF≤ _____ (give 1 point)

40

CHA2DS2-VASc Scoring

_____ (give 1 point)

hypertension

CHA2DS2-VASc Scoring

age ≥ ____ (give ____ points)

75, 2

CHA2DS2-VASc Scoring

____ (give 1 point)

diabetes

CHA2DS2-VASc Scoring

___/TIA/thromboembolism (give ____ points)

stroke, 2

CHA2DS2-VASc Scoring

____ ___ (give 1 point) (like MI, CAD, PAD)

vascular disease

CHA2DS2-VASc Scoring

age ___-___ (give 1 point)

65-74

CHA2DS2-VASc Scoring

sex category of ____ (give 1 point)

female

HAS-BLED Score is used to tell us the patients ___ risk

bleed

Treatment recommendations

For patients with AF and a CHA2DS2-VASc score of ___ (in men) or ___ (in women) anticoagulation is recommended

2, 3

Treatment recommendations

For patients with AF and a CHA2DS2-VASc score of ___ (in men) or ___ (in women) anticoagulation is reasonable

1, 2

Treatment recommendations

-in nonvalvular AF, _____ (dabigatran, rivaroxaban, apixaban, and edoxaban) are preferred over warfarin for stroke prevention

DOACs

Treatment recommendations

-in valvular AF (patient has moderate-to-severe mitral stenosis or a mechanical heart valve), ____ is used for stroke prevention

warfarin

Treatment recommendations

-in patients who meet the criteria for anticoagulation and have a creatinine clearance <15 mL/min or are on dialysis, what 2 medications are preferred for stroke prevention?

warfarin, apixaban

Warfarin

-used for pt with valvular AF (moderate-to-severe mitral stenosis or mechanical heart valve)

-an option for pt with poor renal function (CrCl<15 mL/min, dialysis)

-monitoring required with an INR goal of __-__

2-3

Warfarin

-many drug ___ and __ considerations

-less expensive anticoagulant

interactions, diet

What is dabigatran dosing for nonvalvular AF? (without renal dose adjustments)

150mg BID

dabigatran use in a patient with CrCl 30-50 mL/min does not require a dose adjustment unless the patient is receiving concomitant ____ or oral ____, then reduce to ____mg BID

dronedarone, ketoconazole, 75

dabigatran dosing in a patient with CrCl 15-30 mL/min is ___mg BID unless patient is receiving concomitant ___-__ inhibitor, then avoid use

75, P-gp

dabigatran in a patient with CrCl < ___ mL/min is NOT recommended

15

What is rivaroxaban dosing for nonvalvular AF? (without renal dose adjustments)

20mg daily with evening meal

rivaroxaban dosing in a patient with CrCl 15-50 mL/min is ___mg daily with evening meal

15

rivaroxaban in a patient with CrCl < ___ mL/min is NOT recommended

15

What is apixaban dosing for nonvalvular AF? (without renal dose adjustments)

5 mg BID

to remember apixaban renal dose adjustment, think "ABC 2 or 3". If patient has 2 or 3 of the characteristics, then reduce dose to ____mg BID

2.5

Patient must have 2 or 3 of the following for their apixaban dose to be reduced to 2.5mg BID

(A) age ≥ ____

(B) body weight ≤ ___kg

(C) Scr ≥ ____mg/dL

80, 60, 1.5

What is edoxaban dosing for nonvalvular AF? (without renal dose adjustments)

60 mg daily

edoxaban dosing in a patient with CrCl 15-50 mL/min is ___mg daily

30

edoxaban in a patient with CrCl > ___ mL/min or CrCl < ___ mL/min is NOT recommended

95, 15

Rhythm control uses

-___ episode of AF

-____ patient despite rate control

first, symptomatic

Rhythm control uses

-hemodynamically ____ condition

-patients with ___ ___

unstable, heart failure

Rhythm control

-NOT used for ___ AF (these patients can ONLY be on rate control)

permanent

Rhythm control

-selection of the optimal agent is primarily based on drug's ____ and then by efficacy

safety

Class Ia (double quarter pounder)

1) ___

2) ____

3) ____

disopyramide, quinidine, procainamide

Class Ib (lettuce mayo )

1) ___

2) ____

lidocaine, mexiletine

Class Ic (fries please)

1) ___

2) ____

flecainide, propafenone

Class II

- ___ ___

beta blockers

Class III (addis)

1) ___

2) ___

3) ____

4) ____

5) ____

amiodarone, dronedarone, dofetilide, ibutilide, sotalol

Class IV

1) non DHP CCBs (___ and ___)

verapamil, diltiazem

antiarrhythmic classes

Which are used only for ventricular arrhythmias?

Ib

antiarrhythmic classes

Which are used for rhythm control?

Ia, Ic, III

antiarrhythmic classes

Which are used for rate control?

II, IV

Class Ia antiarrhythmics (not first line)

1) disopyramide (brand name ___) (oral)

2) quinidine (oral)

3) procainamide (IV)

Norpace

Disopyramide Adverse Effects

1) _____ effects (dry mouth, constipation, urinary retention)

anticholinergic

Disopyramide Adverse Effects

2) because of the anticholinergic effects, use caution in ___, urinary retention, narrow-angle ___, and ____ ___

BPH, glaucoma, myasthenia gravis

Disopyramide Adverse Effects

3) proarrhythmic

4) hypotension

5) caution in ____ _____ (bc negative inotrope)

heart failure

Disopyramide contraindications

-2nd or 3rd degree heart ___ (unless pt has pacemaker)

-cardiogenic ___

-congenital long ___ sydrome

block, shock, QT

Disopyramide monitoring

-ECG

-BP

-____ effects

-signs and symptoms of ___ ___

anticholinergic, heart failure

Quinidine Adverse Effects

1) N/V/D

2) ___ cramping

3) dizziness

stomach

Quinidine Adverse Effects

4) ____ (tinnitus, hearing loss, blurred vision, headache, delirium)

5) proarrhythmic

cinchonism

Quinidine Adverse Effects

6) drug-induced ___

7) ____ (avoid in G6PD deficiency)

lupus, hemolysis

Quinidine Adverse Effects

8) caution in ___ __

9) ____ (this is why we monitor LFTs)

heart failure, hepatotoxicity

Quinidine Contraindications

-2nd or 3rd degree heart ___ (unless pt has pacemaker)

-concurrent use of ___ that prolong the QT interval or ____

block, quinolones, ritonavir

Quinidine Contraindications

-______ or thrombotic thrombocytopenia purpura (TTP) (this is why we monitor CBC)

-____ gravis

thrombocytopenia, myasthenia

Quinidine Monitoring

-ECG

-SCr, BUN

-_____ (bc hepatotoxicity)

-____ (bc thrombocytopenia)

-_____ titers (bc drug-induced lupus)

LFTs, CBC, ANA

Procainamide Adverse Effects

1) ___-__ ___

2) fatal blood dyscrasias (_____)

drug-induced lupus, agranulocytosis

Procainamide Adverse Effects

3) proarrhytmic

4) hypotension

5) caution in ___ ___

6) N/V/D

heart failure

Procainamide Contraindications

-2nd or 3rd degree heart ___ (unless pt has pacemaker)

-systemic ____ erythmatosus (SLE)

-____ de pointes

block, lupus, torsades

Procainamide Monitoring

-ECG

-BP

-_____ (bc agranulocytosis)

-SCr, BUN

-____ titers (bc drug-induced lupus)

CBC, ANA

Class Ic antiarrhythmics

1) flecainide

2) propafenone (brand name is ___)

Rythmol