[02.06b] CMD - Disorders of Rhythm (Part 2) V2.1.pdf

Regular

What is the rhythm pattern of regular supraventricular tachyarrhythmias such as sinus tachycardia and SVT

Irregular

What is the rhythm pattern of irregular supraventricular tachyarrhythmias such as atrial fibrillation and atrial flutter

Ventricular tachycardia and ventricular fibrillation

What are the two major ventricular tachyarrhythmias discussed in the summary

Benign

What is the typical clinical prognosis of ventricular premature beats

First detected

What is the atrial fibrillation classification when the physician does not yet know if it is paroxysmal or persistent

Less than seven days

What is the duration threshold for paroxysmal atrial fibrillation

Sinus rhythm

In what cardiac rhythm does a patient with paroxysmal atrial fibrillation reside between episodes

Seven days or more

What is the duration threshold for persistent atrial fibrillation

Persistent

Which atrial fibrillation classification is crucial for making long term decisions like stroke prevention

Greater than one year

What is the duration threshold defining permanent atrial fibrillation

Stroke

What major neurological risk is increased in atrial fibrillation due to blood stagnancy in the weak left atrium

Heart failure

Which cardiovascular syndrome promotes atrial fibrillation while simultaneously being aggravated by it

Left atrium

In which specific chamber of the heart do thrombi typically form during atrial fibrillation due to blood stagnancy

Mortality

Along with stroke and heart failure what primary endpoint is managed in AFib to prolong life

Blood thinners

What class of drugs is used to prevent thromboembolic stroke in patients with atrial fibrillation

Rate control and rhythm control

What are the two primary therapeutic strategies used to manage ventricular responses in AFib

Hyperthyroidism

Along with heart failure hypertension and electrolyte abnormalities what endocrine disorder is a key etiology to treat in AFib

Rate control

Which strategy controls the ventricular rate with no commitment to restore or maintain sinus rhythm

Rhythm control

Which strategy attempts to restore and maintain normal sinus rhythm in AFib patients

AV node

What anatomical structure of the heart is targeted by rate control drugs to slow the ventricular response

AFFIRM trial

Which major clinical trial demonstrated no difference in mortality or stroke rate between rate and rhythm control strategies

RACE trial

Which clinical trial showed that rate control is not inferior to rhythm control for preventing death and morbidity

Flecainide

Which Class Ic antiarrhythmic is a main rhythm control drug used in the Philippines

Amiodarone

Which Class III antiarrhythmic is a major rhythm control drug in the Philippines

They are not normally combined

What is the clinical rule regarding the combination of Flecainide and Amiodarone

Dronedarone

Which rhythm control drug from Figure 2 is no longer available in the Philippines

BGC

Where is Sotalol uniquely available in the Philippines according to the lecture

Beta blockers

What class of drugs represents Class II rate control agents that slow the AV node

Calcium channel blockers

What class of drugs represents Class IV rate control agents used in AFib

Verapamil and Diltiazem

What are two specific non-dihydropyridine calcium channel blockers used for AFib rate control

Digoxin

Which rate control drug is uncommonly used as a stand alone agent but slows down the AV node

Bradycardia

What is a common side effect in elderly patients if their rate or rhythm control medications slow the ventricular rhythm too much

Pacemaker

What device is used to manage a slow sinus node in elderly patients presenting with fast and slow sinus node dysfunction

At least twelve hours

After how many hours of AFib presentation should IV heparin anticoagulation be considered

Digoxin

In a patient with AFib at 160 bpm and a blood pressure of 90/60 mmHg what is the best drug to give

Beta blockers and calcium channel blockers

Which rate control drug classes must be avoided in a hypotensive AFib patient because they further decrease blood pressure

Pharmacologic and electrical DC cardioversion

What are the two primary options available for executing rhythm control

Dofetilide

Which oral pharmacological cardioversion agent has proven efficacy as shown in Table 1

Flecainide and Propafenone

Which two pharmacological cardioversion agents are available in both oral and intravenous forms

Ibutilide

Which intravenous pharmacological cardioversion agent has proven efficacy as shown in Table 1

Intravenous

Which route of administration for Flecainide is unavailable in the Philippines

Stable patients

To what specific patient group is oral Flecainide given to terminate palpitations

Two

How many oral tablets of Flecainide are usually sufficient to terminate atrial fibrillation in tolerant patients

DC cardioversion

What procedure is performed if oral Flecainide fails to terminate AFib

Hemodynamic instability

DC cardioversion is the treatment of choice in sudden AFib with what clinical finding

Biphasic

If you are unsure whether a defibrillator is monophasic or biphasic which type should you assume it is

Two hundred Joules

What energy level is usually selected for a biphasic synchronized shock in AFib cardioversion

Over ninety percent

What percentage of patients establish normal sinus rhythm after receiving DC cardioversion

Amiodarone Flecainide and Sotalol

What are three oral medications used for the long term maintenance of rhythm control in AFib

Non-dihydropyridines

Which specific subclass of calcium channel blockers is used for long term oral rate control in AFib

Mitral stenosis

What is the most common valvular lesion associated with valvular atrial fibrillation

Rheumatic heart disease

What is the most common etiology of mitral stenosis in valvular atrial fibrillation

Warfarin

What is the only anticoagulant indicated for stroke prophylaxis in valvular AFib

Non-valvular AFib

What is the most common cardiac disease associated with cerebral embolism

Five percent

What is the annual incidence of stroke in patients with non-valvular atrial fibrillation

Six times

By how many times does non-valvular AFib increase stroke risk compared to normal sinus rhythm

One of every six

What fraction of all strokes is attributed to atrial fibrillation

Female

Which gender is no longer recognized as an independent risk factor for stroke in the updated CHA2DS2-VA score

Two

A score of what value or higher on the CHA2DS2-VA system warrants mandatory anticoagulation

Consider anticoagulation

What is the clinical recommendation for a patient with a CHA2DS2-VA score of one

Two point five

What is the target INR when using warfarin for stroke prophylaxis in atrial fibrillation

Two point zero to three point zero

What is the acceptable range for INR when titrating warfarin

Mitral stenosis and prosthetic valves

In which two patient groups is only Warfarin indicated because DOACs have not been evaluated in clinical trials

Aspirin and Clopidogrel

Which antiplatelet drugs have been shown by recent studies to have no role in stroke prevention in AFib

Concomitant coronary artery disease

Under what specific clinical circumstance is Aspirin given to an AFib patient

Direct Oral Anticoagulants

What does the modern acronym DOAC stand for

Dabigatran

Which direct thrombin inhibitor is classified as a DOAC

Rivaroxaban

Which Factor Xa inhibitor is administered once daily for non-valvular AFib

Apixaban and Edoxaban

What are two other Factor Xa inhibitors used for stroke prophylaxis in non-valvular AFib

Renal function

Upon what physiological parameter is DOAC dosing based as opposed to INR monitoring

Creatinine clearance

What laboratory measure of kidney function is used to adjust DOAC doses

One hundred fifty milligrams twice daily

What is the standard full dose of Dabigatran for patients with normal renal function

One hundred ten milligrams twice daily

What is the reduced dose of Dabigatran for patients with renal insufficiency

Twenty milligrams once daily

What is the standard full dose of Rivaroxaban for AFib stroke prophylaxis

Fifteen milligrams once daily

What is the reduced dose of Rivaroxaban for patients with renal insufficiency

Five milligrams twice daily

What is the standard full dose of Apixaban for AFib stroke prophylaxis

Two point five milligrams twice daily

What is the reduced dose of Apixaban for patients with renal insufficiency

Sixty milligrams once daily

What is the standard full dose of Edoxaban for AFib stroke prophylaxis

Thirty milligrams once daily

What is the reduced dose of Edoxaban for patients with renal insufficiency

Many drug-drug interactions

What is a major reason for shifting away from Warfarin to DOACs in clinical practice

Green leafy vegetables

What dietary restriction is required for patients on Warfarin because it antagonizes vitamin K

Radiofrequency catheter ablation

What procedure is performed on top of cardioversion medications to restore sinus rhythm in AFib

Crossing the interatrial septum from the right

How does the electrophysiologist physically access the left atrium to perform catheter ablation

Pulmonary veins

Along what anatomical structures in the left atrium are ablation lines drawn to isolate AFib foci

MAZE procedure

What concomitant surgical procedure can open heart surgeons perform to ablate AFib pathways

Point-by-point radiofrequency ablation

Which ablation method uses a heated tip catheter to isolate the pulmonary veins

Virtual 3D image

What must be recreated during point-by-point radiofrequency ablation because cardiac structures are not easily seen in fluoroscopy

Cryoablation

Which ablation method freezes the area around the pulmonary veins using balloons

Left atrial appendage closure device

What device is indicated for stroke prevention in patients who are intolerant to blood thinners

Left atrial appendage

What is the specific anatomical structure where thrombi usually form in the left atrium

Plication of the left atrial appendage

What term refers to open heart surgeons tying up the left atrial appendage from the outside

Right atrium

From which cardiac chamber does typical atrial flutter originate

Sawtooth pattern

What classic ECG pattern is produced by typical atrial flutter

Two hundred beats per minute

What is the typical atrial rate during typical atrial flutter

Pediatric patients with congenital heart disease

In what specific patient population is typical atrial flutter more common

Macro-reentrant atrial tachycardia

What is the alternative electrophysiological name for atrial flutter

Stroke prevention and rate control

In what two aspects is the management of atrial flutter identical to atrial fibrillation

No structural heart disease

In what clinical setting does paroxysmal atrial flutter typically occur

Structural heart disease

With what clinical finding is chronic atrial flutter typically associated

Three hundred beats per minute

What is the classic atrial rate of atrial flutter seen when the flutter waves are exactly one big square apart