Cardio Exam 3: Simplified Tsu (AFib)

Abnormal Heart Rhythms

• Bradycardia → ______

• Supraventricular arrhythmias → ______

• Ventricular arrhythmias → ______

AV Blocks, AFlutter, AFib, and SVT, VTach, Torsades de Pointes, and Asystole

______ Degree AV block

• Impulse conduction ______ (______ block) at AV node for a ______ interval

• Usually ______

• AV nodal blockers (______, ______, ______)

• stimulates the ______ (e.g. vasovagal reflex)

• ______ conduct through (followed by QRS complex)

1st, slowed, partial, fixed, asymptomatic, BBs, non-DHP CCBs, Digoxin, PNS, All P waves

______ Degree AV block

• Mobitz type 1 (______)

  • Conduction ______ slows at AV node, and then ______ to follow

  • Which means ______ → ______

  • Usually ______

  • Can be due to ______ (AV node blockers) or ______

• Mobitz type 2

  • Block is ______ the AV node

  • ______ rate is ______

  • Can be ______

  • PR interval = ______ + ______ are dropped

  • Note in Mobitz type 1, it’s a ______ dropping of QRS complexes, whereas here it is ______ timing

2nd, Wenckebach, progressively, QRS complex fails, lost ventricular contraction, decreases CO, asymptomatic, drugs, PNS, below, atrial, regular, symptomatic if bradycardia, constant, random QRS complexes, predictable, random

______ Degree AV Block

• ______

• “AV” dissociation: atrium + ventricles are ______

• ______ are conducting

  • Ventricle = 30-40 BPM when it is not receiving input from SA node so patients are generally ______ due to the ______

• Requires ______ to control the ______ rate

3rd, complete heart block, independent, No p waves, symptomatic, bradycardia, pacemaker, ventricular

______

• ______, ______ firing of SVT automaticity focus

• ~______ → ______ rate with ______ or ______

• Non-pharm therapy

  • Mild-Moderate Sxs

    • ______ techniques: ______, ______, ______ 

  • Severe Sxs (eg. ______, ______, ______)

    • ______

• Pharmacological therapy

  • Increase vagal tone → ______

  • Slow, Ca-dependent tissue → ______

  • Fast, Na-dependent tissue → ______

Paroxysmal SVT, sudden, rapid, 150-250, fast, absence of P waves, abnormal-looking P waves, Vagal, Carotid Sinus massage, valsalva maneuver, ice water facial, syncope, angina, HF, Direct Current Cardioversion (DCC), Digoxin, Adenosine, BBs, and Non-DHP CCBs, Quinidine, Procainamide, Disopyramide, and Flecainide

QT interval

• QT interval varies with ______

• A prolonged QT interval can predispose patients to the formation of dangerous rhythms (e.g. ______)

• Males: >______ msecs

• Females: >______ msecs

• Highest risk of TdP >______ msecs

HR, torsades de pointes, 450, 460, 500

______ is the most common sustained atrial arrhythmia

• Two main issues to treat

  • ______ with ______

  • Treatment of ______ with ______

• Calculate this score in all pts with ______ to determine their risk of ______, and therefore if they need ______

• Structural HD that causes atrial distension

  • ______

  • ______

  • ______

• ~______ bpm

• Rhythm describe as “______ be accompanied by ______

• ______ firing at ______ rates

AFib, stroke prevention, anticoags, Tachyarrhythmias Sxs, rate and rhythm control, AFib, stroke, anticoags, MI, Valvular HD, Congenital abnormalities, 350-450, irregularly irregular with no discernable P waves, Rapid Ventricular Rate, Atrial foci, rapid

______

• faster than ______ impulses

• ______ BPM

• Appears as a “______” pattern on ECG

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

• Occurs ______

• ______ ectopic focus

AFlutter, SA node, 220-350, sawtooth, regular, AFib, regularly irregular, less frequently than AFib, single

Treatment of AFib

• Stroke (and systemic thromboembolism) prevention

  • Stratify risk by CHA2DS2-VASC score

    • ______ → 1

    • ______ → 1

    • Age (> ______y/o) → 2

    • ______ → 2

    • ______ (prior episode) → 2

    • ______ (______) → 1

    • Age (______ y/o) → 1

    • ______ Category (______) → 1

  • ______ in Men OR ______ in Women → No anticoag + ASA has no benefit

  • ______ in Men OR ______ in Women → Anticoag may be considered

  • ______ in Men OR ______ in Women → Oral anticoag RECOMMENDED (______, ______)

    • ______ preferred over ______, EXCEPT in ______ or ______ 

Congestive HF/LV Dysfunction, HTN, 75, Diabetes, Stroke/TIA/Thromboembolism, Vascular Disease, PAD, HA, CAD, and aortic plaque, 65-74, Sex, Female, 0, 1, 1, 2, 2 or more, 3 or more, Warfarin with INR 2-3, DOACs/NOACs, DOACs, Warfarin, mitral stenosis, mechanical heart valve

Treatment of AFib

• Treatment of tachyarrhythmia

  • ______: ______ then ______ to maintain NSR

  • ______: ______

Rhythm Control, cardioversion, antiarrhythmic drugs, Rate Control, rate-control meds

Thromboembolism Risk

• ______ can form in ______ due to ______

• Highest risk in ______

• Most common thromboembolic event is ______, NOT ______

Thrombus, atrium, blood pooling, left atrial appendage, ischemic stroke, PE or MI

Dosing of DOACs in AF

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

• Dabigatran (______®) ______ mg PO ______

  • CrCl ______ mL/min: ______ mg PO ______

Pradaxa, 150, BID, 15-30, 75, BID

Dosing of DOACs in AF

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

• Rivaroxaban (______®) ______ mg PO ______

  • CrCl ______ mL/min: ______ mg PO ______

Xarelto, 20, QD, 15-50, 15, QD with food

Dosing of DOACs in AF

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

• Apixaban (______®) ______ mg PO ______

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

Eliquis, 5, BID, >80, <60, 1.5, 2.5, BID

Dosing of DOACs in AF

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

• Edoxaban (______®) ______ mg PO ______

Savaysa, 60, QD

Anticoagulant DDIs

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Rate Control Meds

• ______

• ______

• ______

BBs, Non-DHP CCBs, Digoxin

Rate Control Meds

• BBs

  • ______: ______, ______, and ______

  • ______

HF with low EF, Carvedilol, Metoprolol Succinate, Bisoprolol, CAD

Rate Control Meds

• Non-DHP CCBs

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

BB, Acute HF exacerbation, airway disease

Rate Control Meds

• Digoxin → ______, ______, and Sedentary

  • Only ______, NOT during exertion

  • Is BP neutral?

  • ______ time for full effect than other rate control options

  • ______

  • ______ → in ______

Systolic HF, Hypotension, slows HR at rest, longer, renally-excreted, NTI, ng

Acute management of AFib with Rapid Ventricular Response (RVR)

• ______ if hemodynamically ______

• Medication options (______)

  • ______

    • Most commonly used except in ______

  • ______

    • ______

    • ______

    • ______

Cardioversion, unstable, stable but high HR, IV Non-DHP CCBs, HF, IV BBs, Metoprolol and Esmolol, Digoxin, Amiodarone

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Rhythm Control

• ______

• ______

• ______ (only if undergoing ______ for another reason)

Meds, Catheter Ablation, Surgery, cardiac surgery

Rhythm Control strategy

• Goal: restore and maintain ______ (NSR)

• ______

  • ______ cardioversion (DCCV)

  • ______ cardioversion

  • Efficacy: ______ 80-90% compared to ______ 40-60%

normal sinus rhythm, Cardioversion, Direct Current, Pharmacological, DCCV, pharmacologic

______ Cardioversion

• ______

• Electric “shock” attempt to restore ______

• Indications

  • Emergent (Urgent)

    • ______

  • Elective

    • ______ NOT effective

    • ______ patients (______ y/o)

    • ______ & ______ tolerance with rate control

Electrical, DCCV, NSR, Hemodynamically unstable (SBP <90), Rate control, younger, <60, Physically active, poor exercise

AADs for pharmacological cardioversion

• Medications can also be used to attempt to restore NSR

  • ______ effective than DCCV

• Proven efficacy (ADIFP)

  • ______

  • ______ 

  • ______

  • ______

  • ______

Less, Amiodarone, Dofetilide, Ibutilide (IV only), Flecainide, Propafenone

Anticoagulation for Cardioversion

• Risk of thromboembolism (______) if pt has ______ >______

• ______ Echocardiogram (TEE)> Transthoracic Echocardiogram (TTE) in visualizing ______

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

• Anticoagulate for at least ______ cardioversion

• REMEMBER → HEMODYNAMICALLY UNSTABLE = ______

stroke, AFib, 2 days, Transesophageal, atrium, 3 weeks, 4 weeks after, SBP <90

AADs for Maintenance of Normal Sinus Rhythm

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Rhythm Control Meds

• ______ (Tambocor and Rythmol)

• ______ (Cordarone, Pacerone)

• ______ (Tikosyn)

• ______ (Multaq)

• ______ (Betapace AF)

Flecainide and Propafenone, Amiodarone, Dofetilide, Dronedarone, Sotalol

Flecainide & Propafenone (______)

• ______ for ______, ______ or significant ______ 

• ______ in patients with ______

• “Pill-in-the-pocket” approach → ______ med → episode of ______

• ______ options for ______ patients, BUT should NOT be used in ______

Tambocor and Rythmol, 1st line, Normal LV function, no prior MI, structural HD, C/I, structural HD (MI/HF and increases risk of death), Oral, AFib, 1st line, HF, structural HD

Amiodarone (______)

• ______ for ______ or Significant ______ (______ < ______)

• ______ (use after Dofetilide, Dronedarone, Flecainanide, Propafenone) for ______, ______ or significant ______

• ______ but ______

• Extremely ______ (for ______)

• ______, ______ conduction, and ______ conduction

• Most ______ (not 1st line bc of associated with ______)

• Used in ______

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

• ______ most serious toxicity

• Symptoms: ______

• DDIs: Extensive → always run an interaction check

• ______ (thyroid function tests, EKG, LFTs) to ensure pt doesn’t develop SEs

Cordarone, Pacerone, 1st Line, Prior MI, Structural HD (HFrEF w/LVEF, 40%, 2nd Line, normal LV dysfunction, no prior MI, structural HD, most effective, more toxic, prolonged half-life, months, Slows HR, AV node, intracardiac, effective AAD, toxicities, elderly or older adults, Pulmonary fibrosis, cough and dyspnea, order baseline tests

Dofetilide (______)

• ______ for ______, ______ or significant ______

• ______ (after Amiodarone) for ______ or Significant ______ (HFrEF w/ LVEF <40%)

• ______ for pts ______

• Highest risk of ______ (______) → required hospitalization for ______

• Can be used for ______ and ______

• Monitoring

  • ______

  • ______

  • Drug interactions (______)

Tikosyn, 2nd 1st Line, Normal LV Function, no prior MI, Structural HD, 1st line, prior MI, structural HD, 1st line AAD, w/ or w/o structural HD, Torsades de Pointes, renal dysfunction, first 5 doses, cardioversion, maintenance of NSR, Renal Function, QT interval, increases QT interval

Dronedarone (______)

• ______ for ______, ______ or significant ______

• ______ for ______ or Significant ______

• Monitor ______

• ______ lipophilic, ______ t1/2

• ______: Increased risk of death with ______ or ______

Multaq, 2nd 1st line, Normal LV function, no prior MI, structural HD, 1st line, Prior MI, Structural HD AND NO recent decompensated HF, LFTs and QT interval, Less, shorter, BBW, decompensated HF, permanent AFib

Sotalol (______)

• ______ for ______, ______ or significant ______

• ______ for ______ or Significant ______

• ______ used for ______ or ______

• Avoid in ______

• Monitoring

  • ______

  • ______

Betapace AF, Last line, Normal LV function, no prior MI, structural HD, 2nd line, Prior MI, Structural HD, NOT, HTN, rate control, systolic HF, Renal Function, QT prolongation

Catheter Ablation

• ______ isolation

  • Can be curative for ______

  • ______ based on risk assessment

• ______ ablation

  • ______

  • ______ → continue ______

• Indications

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

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

Pulmonary Vein, AFib Sxs, anticoag, AV Node, permanent pacemaker, AFib persists, anticoag, anti-arrhythmic meds, 1st Line, younger, improve Sxs, prevent AFib progression

KNOW IMAGE