Atrial Fibrillation

Front 1

Atrial Fibrillation (AFib)

Back 1

supraventricular tachyarrythmia

Front 2

Atrial Rate, Ventricular Rate, Pulse in Atrial Fibrillation

Back 2

AR: 400-600 bpm
VR: 120-180 bpm
P: 'irregularly irregular'

Front 3

Atrial Rate, Ventricular Rate, Pulse in Atrial flutter

Back 3

AR: 270-330 bpm
VR: factors of 300 (150, 100, 75)
P: regular

Front 4

Which rate is indicative of patient's pulse

Back 4

ventricular rate

Front 5

Main overview of Atrial Fibrillation Treatment

Back 5

1. Rate Control (control ventricular rate)
2. Rhythm Control (restore/maintain NSR)
3. Stroke prevention

Front 6

Afib conduction pathophysiology

Back 6

1. SA node
2. Ectopic sites
3. atrial muscle
4. AV node
5. bundle of His
6. right and left bundle branches
7. ventricular myocardium

Front 7

a) normal heart rate
b) heart rate in Afib

Back 7

a) 60-100 bpm
b) 120-180 bpm

Front 8

Risk Factors for Atrial Fibrillation

Back 8

1. age
2. male
3. smoker
4. excessive alcohol/caffeine
5. extreme stress/fatigue
6. disease states (HTN, HF, CAD, lung disease, PE, DM)

Front 9

Diagnosis of Afib

Back 9

1. ECG
2. TTE or TEE

Front 10

Classification of Afib

Back 10

*lasts > 30 seconds and no identifiable cause*

1. Paroxysmal - < 7 days, can go back to normal
2. Persistent - > 7 days, cant go back to normal
3. Permanent - >/= 1 year, live with it

Front 11

Clinical Presentation of Afib

Back 11

*may be asymptomatic*
1. palpitations
2. fatigue
3. exercise intolerance
4. cough
5. syncope
6. dizziness
7. worsening HF symptoms

Front 12

Complications of Afib

Back 12

1. stroke
2. other heart rhythm problem
3. heart failure
4. chronic fatigue
5. mortality

Front 13

Rate Control - Goal ventricular rate

Back 13

< 110 bpm (RACE II trial)

Front 14

Rate Control Drugs

Back 14

*slow AV nodal conduction*

1. Beta Blockers
2. Non-DHP CCBs
3. Digoxin
4. Amiodarone - LAST LINE

Front 15

Dosing of Metoprolol (Rate Control of Afib)

Back 15

Loading: 2.5-5mg IV over 1-2 minutes every 5 minutes for total of 15mg

Front 16

Dosing of Diltiazem (Rate Control of Afib)

Back 16

LOADING: 0.25mg/kg IV over 2 minutes

Maintenance: 5-15mg/h IV infusion

Front 17

Dosing of Verapamil (Rate Control of Afib)

Back 17

LOADING: 0.075 - 0.15mg/kg IV over 2 minutes

Maintenance: 120-360mg PO daily

Front 18

Dosing of Digoxin (Rate Control of Afib)

Back 18

LOADING: 0.5mg, then 0.25mg q6h x2

Maintenance: 0.125-0.375mg PO/IV daily

Front 19

Initiate lower dose 0.125mg of Digoxin daily if

Back 19

1. age > 65
2. CrCl < 60ml/min
3. IVW < 70kg

Front 20

Desired Digoxin level in Afib and symptoms of Dig toxicity

Back 20

1. 0.8 - 1.2 ng/mL

GI distress, CNS, visual changes, arrhythmias, HR < 60)

Front 21

Beta Blockers for Rate Control

Back 21

*Usually 1st Line*
1. Controls HR at rest and exercise (symptoms)
2. careful with asthma or DM patients

Front 22

Non-DHP CCBs in Rate Control

Back 22

1. Controls HR at rest and exercise
2. maybe not as effective
3. avoid in deceompensated HF or LVEF < 40%

Front 23

Digoxin in Rate Control

Back 23

*usually NOT 1st line*
1. not effective for rate control during exercise
2. reserved for HF patients and hypotensive patients

Front 24

Goal of Rhythm Control

Back 24

restore normal sinus rhythm (NSR)

Front 25

Role of Anticoagulation before/after cardioversion

Back 25

3-4 weeks before AND at least 4 weeks after

1. do not need to anticoagulate BEFORE if TEE shows no thrombus, Afib duration < 48 hours
2. ALWAYS anticoagulate after

Front 26

Drugs for Rhythm Control in Afib

Back 26

1. Class 1a antiarrhythmics
2. Class 1c antiarrhythmics
3. Class 3 antiarrhythmics

Front 27

Quinidine (Class Ia)

Back 27

1. Rarely used
2. increased mortalitiy
3. Tolerability - GI upset, cinchonism, abnormal hearing and vision

Front 28

Propafenone & Flecainide (Class Ic)

Back 28

1.used for cardioversion and maintenance
2. Do NOT use in structural heart disease

Front 29

Amiodarone (Class 3)

Back 29

1. highly effective for maintenance and cardioversion
2. lowest risk of proarrhythmia
3. 30-55 day half life (requires loading dose
4. CYP 450 enzyme inhibitor (interactions)
5. OK to use in structural heart disease

Front 30

Common drug interaction with Amiodarone

Back 30

1. Warfarin - monitor INR q1-2 weeks; may need to lower warfarin dose
2. Statins: lovastatin 40mg daily, simvastatin 20mg daily
3. Digoxin - decrease dose of dig by 50%

Front 31

Dosing of Amiodarone

Back 31

LOADING: ~10 grams

Maintenance: 100-200mg daily PO

*Don't give more than 400mg - GI issues

Front 32

ADRs of Amiodarone

Back 32

1. Skin (photosensitivity, blue/gray discoloration) - office visit
2. Liver (increased LFTs) - B, q6 months
3. Eyes (optic neuritis/neuropathy) - B, yearly
4. Pulmonary (fibrosis) - B, yearly
5. Thyroid (hypo/hyper) - B, q6 months
6. Neuro (peripheral neuropathy) - office visit
7. Cardiac (bradycardia, hypotension) - B, q3-6months

Front 33

Dronedarone (Multaq) - Class 3

Back 33

1. less effective - only for maintenance
2. shorter half life
3. Contraindicated: class IV HF, class II or III w/ recent decompensation, bradycardia, permanent Afib

Front 34

Dosing of Dronedarone (Multaq)

Back 34

400mg PO BID WITH MEALS

Front 35

Dofetilide (Tikosyn)

Back 35

1. used for cardioversion and maintenance
2. requires prescriber training and registration
3. OK for structural heart disease
4. Contraindicated with: verapamil, HCTZ, ketoconazole, cimetidine, trimethoprim

Front 36

Precaution with Dofetilide (Tikosyn)

Back 36

Can prolong the QT interval
1. mandatory minimum of 3 day EKG monitoring
2. Contraindicated if Baseline QT > 440

Front 37

Dosing for Dofetilide (Tikosyn)

Back 37

*RENALLY DOSED*

CrCl > 60 = 500mcg BID
CrCl 40-59 = 250mcg BID
CrCl 20-39 = 125mcg BID
CrCl < 20 = Contraindicated

Front 38

Sotalol (Betapace AF) - class 3

Back 38

1. has beta blocking properties
2. used for maintenance
3. minimum of 3 days of EKG monitoring
4. ADRs: bradycardia, dizziness, GI disturbances

Front 39

DOSING of Sotalol (betapace)

Back 39

*Renally dose*

CrCl > 60 = 80mg PO BID
CrCl 40-60 = 80mg QD
CrCl < 40 = contraindicated

Front 40

Ibutilide (Class 3)

Back 40

1. Used for cardioversion
2. IV only (hospital)
3. needs EKG monitor for at least 4 hours post dose

Front 41

Ideal Candidate for Rate Control therapy

Back 41

1. 65 years old or older
2. Less symptomatic
3. hypertension
4. recurrent afib

Front 42

Consider Rhythm control therapy when

Back 42

1. persistent symptoms despite rate control
2. inability to achieve rate control < 110bpm
3. younger patients
4. preference

Front 43

Cardiac stroke pathophys

Back 43

1. chaotic atrial movement
2. disruption of blood flow
3. blood pooling
4. clot forms and dislodges
5. travels to brain

Front 44

Communicating anticoagulation therapy to the patient

Back 44

1. heart's 2 small upper chambers dont beat the way they should - they beat irregularly (not normal) and too fast - quiver like a bowl of jello

2. can live with AFib, lead to other rhythm problems, chronic fatigue, HF, and stroke - AFib allows blood to pool in heart which can form a clot - carried to brain

Front 45

Risk Stratification (CHADS2)

Back 45

1. CHF (1 point)
2. HTN (1 point)
3. Age >/= 75 (1 point)
4. DM (1 point)
5. Stroke/TIA (2 points)

Front 46

CHADS2 score = 0

Back 46

LOW

No therapy or ASA 81mg

Front 47

CHADS2 score = 1

Back 47

ASA 81mg or Anticoagulate

Front 48

CHADS2 score = 2+

Back 48

Anticoagulate

Front 49

Dabigatran (Pradaxa)

Back 49

1. anticoagulant for non-valvular Afib
2. lower rate of stroke, higher rate of GI bleeds than warfarin (RELY trial)
3. ADRs: bleeding, stomach upset
4. Strorage - original container, refil after 4 months after opening

Front 50

Dosing of Dabigatran (Pradaxa)

Back 50

RENALLY DOSED

CrCl > 30 = 150mg PO BID
CrCl 15-30 = 75mg PO BID
CrCl < 15 = not recommended

Front 51

Rivaroxaban (Xarelto)

Back 51

1. Direct factor Xa inhibitor
2. anticoagulant for non-valvular Afib
3. lower rate of stroke, higher rate of GI bleeds than warfarin (ROCKET-AF trial)
4.

Front 52

Dosing of Rivaroxaban (Xarelto)

Back 52

CrCl > 50 = 20mg PO daily with PM meal
CrCl 15-50 = 15mg PO daily with PM meal
CrCl < 15 = not recommended

Front 53

Apixaban (Eliquis)

Back 53

1. NEW direct factor Xa inhibitor
2. Anticoagulant for non-valvular afib
3. lower rate of stroke and GI bleed than warfarin (ARISTOTLE trial)
4. AHA recommend not to use in CrCl < 25

Front 54

Advantages of new anticoagulants OVER warfarin

Back 54

1. no therapeutic monitoring (INR)
2. predictable PK
3. No dietary limitations (Vit K)
4. Less drug interactions

Front 55

Disadvantages of new anticoagulants to Warfarin

Back 55

1. BID dosing (Dabigatran and apixaban)
2. Cost
3. Limited data in renal/hepatic failure
4. lack of antidote or reversal agent (Vit K)
5. Limited data

Front 56

Drugs for NSR with NO structural heart disease

Back 56

1. dronedarone
2. flecainide
3. propafenone
4. sotalol

Front 57

Drugs for NSR with HTN and NO substantial LVH

Back 57

1. Dronedarone
2. Flecainide
3. Propafenone
4. Sotalol

Front 58

Drugs for NSR with HTN and substantial LVH, CAD, HF

Back 58

1. Amiodarone

Front 59

Creatnine Clearance equation

Back 59

= (140 - age) (weight) / (72 x SCr) x(0.85) if woman