Atrial Fibrillation and Bradycardia

a fib

disease of disordered atrial depolarization; stimulus to allow for ventricular depolarization is always on

advanced age, HTN, cardiac hypertrophy, valvular disease, thyroid disorder, obesity, European

risk factors for atrial fibrillation

duration, mechanism

A fib is classified by ____________ and ____________

paroxysmal

A fib that is intermittent and lasts for <7 days

persistent

A fib that lasts >7 days

longstanding persistent (permanent)

A fib that lasts >1 year

pre-excited A fib

accessory pathway a fib classification

valvular a fib

a fib in patients with mechanical heart valve or severe mitral valve stenosis classification

mechanical heart valve;

mitral valve stenosis

Valvular atrial fibrillation is in patients with patients with a ______________ or __________________

AV node

gate keeper of ventricular depolarization

ischemic stroke; hypotension

complications of a fib

chest pain, palpitations, signs of HF, weakness/dizziness, SOB, irregular pulse

physical findings of a fib

absence of P wave;

irregular QRS

ECG findings in a fib

thromboembolic, arrhythmia

Management of Atrial fibrillation is focused on reducing ______________ risk and management of the ________________

anticoagulation

Patients who need _____________________ include those with a high CHA2DS2-VASC score and those who have been in AF for >48 h and are undergoing cardioversion

CHA2DS2VASC

estimates a patient's annual stroke risk

≥2

Oral anticoagulation is indicated in males at a score of ______

≥3 (sex adjusted score of ≥2)

Oral anticoagulation is indicated in females at a score of ______

1

You can consider anticoagulation or nothing in males at a score of _______

1-2 (sex adjusted score of 1)

You can consider anticoagulation or nothing in females at a score of

0

Omitting anticoagulation be considered in males at a score of _________

0 or 1 (sex adjusted score of 0)

Omitting anticoagulation be considered in females at a score of _____

dabigatran, apixaban, rivaroxaban, edoxaban

First line agents for anticoagulation if no contraindications exist

warfarin

First line anticoagulation agent if there is a contraindication to dabigatran, apixaban, rivaroxaban, or edoxaban

warfarin

only recommended anticoagulant for valvular a fib

warfarin, apixaban

anticoagulants that can be used in ESRD or dialysis

stable, medications (rate or rhythm control)

if a patient with an arrythmia has minimal symptoms and is normotensive, they are ____________ and should be managed with ______________

unstable, DCCV (direct current cardioversion)

if a patient with an arrythmia has signs of heart failure, ischemia/shock, or hypotension, they are _____________ and should be managed with _____________

mortality, stroke

The Affirm trial (and other smaller trials) demonstrated that rate control and rhythm control had the same incidence of _________ and ________

rhythm control

does rate or rhythm control have more adverse effects and hospitalization, according to the Affirm trial?

<110

heart rate goal for patients with normal ejection fraction in rate control management

< 80

Heart rate goal for patients with depressed ejection fraction or who are symptomatic in rate control management

beta blockers, non-DHP CCBs

first-line agents for rate control

beta blocker

Preferred rate control agent in stable heart failure or AF caused by thyrotoxicosis, acute coronary syndrome, or cardiothoracic surgery

decompensated HF, severe pulmonary disease/reactive airway disease, pre-excited AF

when to avoid beta blockers in rate control

atenolol, metoprolol, esmolol, propranolol, carvedilol

beta blockers used for rate control

atenolol

only beta blocker to be renally cleared

esmolol

beta blocker with the shortest half life

non-DHP CCB

rate control agents preferred in pulmonary disease

decompensated HF, pre-excited AF

when to avoid non-DHP CCBs in rate control

digoxin, amiodarone

agents that can be used in heart failure with reduced ejection fraction

digoxin

agent for rate control that is preferred in acute RVR or stable HF (reduced ejection fraction)

no CHF, pre-excitation AF, rate control during exertion alone

when should digoxin be avoided in rate control?

Class I (Na blocker);

Class II (beta blocker);

Class IV (CCB)

amiodarone MOA in rate control

amiodarone

agent for refractory AF and is preferred when other agents have refractory, in critically ill patients, and in ADHF

150

Oral rate control is usually not acceptable at rates greater than _______ bpm

HR, BP, ECG

acute use monitoring for beta blockers and CCBs in rate control

HR, BP

chronic use monitoring for beta blocker and CCBs in rate control

electrolytes (K+), renal function, ECG

acute use monitoring for digoxin in rate control

digoxin levels, visual disturbances, electrolytes (K+)

chronic use monitoring for digoxin in rate control

LFTs, ECG

acute use monitoring for amiodarone in rate control

TSH, pulmonary function test, chest radiograph, LFT, eye exam

chronic use monitoring for amiodarone in rate control

>48 hours

Patients pursuing a rhythm control strategy must be anticoagulated prior to cardioversion if they have been in atrial fibrillation for ___________

3, 4

Anticoagulation should occur for _______ weeks prior and ______ weeks after cardioversion at minimum, regardless of CHA2DS2VASC

1C; flecainide, propafenone

for pharmacologic cardioversion, pill-in-pocket may be done with class _____ agents: ____________ and ____________

structural heart disease, CAD

must avoid both flecainide and propafenone in _______________

asthma

must avoid propafenone in ______________

renal dysfunction

must avoid flecainide in _______________

QT prolongation

AE/warning of all class III agents

dofetilide, sotalol, ibutilide, amiodarone

class III antiarrythmics

dofetilide

class III agent that can be used to convert; must be initiated in hospital and monitor due to risk of QT prolongation/Torsades; requires renal adjustments

sotalol

class III agent that is technically only indicated to maintain NSR; has beta blocker properties and should be avoided in decompensated CHF and asthma; requires renal adjustments

ibutilide

Class III antiarrhythmic that is given as a 1 mg infusion given over 10 minutes, effective at converting, cant be used for maintenance; must be given by experienced electrophysiologist due to high risk of torsades

50

1 in ________ patients will experience torsades with ilbutilide use

bradycardia

HR

SA node

pacemaker of the heart

palpitations, chest pain, signs of HF, weakness/dizziness, SOB

bradycardia physical findings

1st degree HB

type of heart block in which there is a conduction delay between atria and ventricles, resulting in a PR interval >200 ms; still have a P with each QRS

Mobitz I

heart block in which there is a prolonging PR interval until depolarization is blocked

Mobitz II

heart block in which there is regular PR with occasional non conducted depolarization

3rd degree

type of heart block in which ventricles depolarize independent of the atria

nothing

treatment of asymptomatic bradycardia

atropine + dopamine or epinephrine

treatment of symptomatic bradycardia

signs of HF, ischemia/shock, hypotension

signs of symptomatic bradycardia

epinephrine or dopamine

treat bradycardia by increasing HR; induce sympathetic

atropine

treat bradycardia by blocking the slowing of the heart; inhibit parasympathetic