Phar 451 - Atrial Fibrillation

Front 1

What is the Normal Sinus Rhythm pathway?

Back 1

Sinus Node --(Atrium)-->AV node --> Bundle of His --(Ventricles)--> Purkinje Fibres

Front 2

What is the definition of Atrial Fibrillation?

Back 2

An irregularly, irregular supraventricular arrhythmia with atrial rates of 350-450bpm

Front 3

What is the EKG presentation of Atrial Fibrillation?

Back 3

No p waves, irregular, narrow QRS

Front 4

What are the classifications of Atrial Fib?

Back 4

1) First Episode

2) Paroxysmal

3) Persistent

4) Permanent

Front 5

What is Paroxysmal Atrial Fib?

Back 5

Atrial Fib alternates with NSR, patient reverts spontaneously

Front 6

What is Persistent Atrial Fib?

Back 6

Atrial Fib alternates with NSR, patient requires treatment (electrical or pharmacological) to convert to NSR

Front 7

What is Permanent Atrial Fib?

Back 7

Inability to convert to NSR with Therapy

Front 8

What are the symptoms of Atrial Fibrillation?

Back 8

1) Reduced Exercise tolerance

2) Weakness 3) Fatigue 4) Dizziness

5) Lightheadedness 6) Palpitations

7) Chest Pain 8) Shortness of Breath

9) Syncope

Note: AF can be asymptomatic

Front 9

"Valvular and Non-Valvular Atrial Fib both increase stroke risk" True or False?

Back 9

TRUE

Front 10

What are the outcome goals of Atrial Fibrillation?

Back 10

1) Reduce Symptoms

2) Reduce Morbidity [Heart Function, Stroke, Emergency Department Visits]

3) Improve Quality of Life

4) Reduce Mortality

5) Promote Cost-effective therapy

Front 11

What are Specific therapeutic goals of Atrial Fibrillation?

Back 11

1) Control/Cure precipitating causes

2) Control Rapid ventricular rate

3) Prevent thromboembolic complications

4) Convert Atrial Fib to NSR

5) Reduce recurrences of Atrial Fib by attempting to maintain NSR

Front 12

What is the approach to acute Atrial Fib with unstable, serious signs or symptoms?

Back 12

Check 02 Stats, Intubation equipment ready.

Pre-medicate and Electrical Cardioversion

Front 13

What is the approach to acute Atrial Fib with stable signs or symptoms?

Back 13

Rate Control/Anticoagulation/Conversion to NSR

Front 14

What is Acute Ventricular Rate Control?

Back 14

Slows Heart Rate to allow ventricles to fill better, improving cardiac hemodynamics

Front 15

What are the benefits of Acute Ventricular Rate Control?

Back 15

May reduce AF symptoms and reduce Emergency Department treatment time.

May prevent Hospitalizations.

Front 16

Which drugs are used in Acute Ventricular Rate Control?

Back 16

The drugs must work to BLOCK THE AV NODE: 1) Beta Blockers

2) Calcium Channel Blockers

3) Digoxin

4) Amiodarone

Front 17

What is the "Target" HR for Acute Ventricular Rate Control?

Back 17

Traditionally <100 bpm and <120 for critically ill patients

Front 18

Which drugs for Acute Ventricular Rate Control are used if Normal cardiac function?

Back 18

IV Beta Blockers or IV Calcium Channel Blockers (Verapamil, Diltiazem)

Front 19

Which drugs for Acute Ventricular Rate Control are used if EF<40% or Heart Failure?

Back 19

IV Digoxin or IV Amiodarone

Front 20

"IV digoxin and IV beta blockers work in 15 mins" True or False?

Back 20

False; Digoxin takes a few hours to work

Front 21

After managing a person's Atrial Fibrillation with Rate Conrol, what would be the next recommendation?

Back 21

Acute Antithrombotic Prophylaxis

Front 22

Why are people with Atrial Fibrillation at higher risk for Clots?

Back 22

Because of the blood stasis in fibrillating atria leads to clot formation inside atrial chambers

Front 23

How can you manage a clot with Atrial Fibrillation?

Back 23

Electrical/Pharmacological/Spontaneous cardioversion to NSR may restore atrial contraction and eject clot

Front 24

What is the risk of Stroke during active cardioversion without Antithrombotic therapy?

Back 24

0.8% in AF <48hrs duration

5.0% in AF >48hrs duration

Front 25

What Acute Antithrombotic Prophylaxis is recommended in Acute AF <48hrs?

Back 25

No antithrombotic therapy is required

Front 26

What Acute Antithrombotic Prophylaxis is recommended in Acute AF >48hrs or unknown?

Back 26

Convential: Warfarin x3weeks and then Cardioversion.

Followed by Warfarin x4weeks.

TEE guided approach: IV heparin/LMWH

[The TEE detects a clot then give Warfarin x3weeks]

Front 27

What is Acute Conversion to Normal Sinus Rhythm?

Back 27

Using either Electrical or Drugs to acutely convert Atrial Fib to Normal Sinus Rhythm.

Front 28

What are the benefits of Acute Conversion to Normal Sinus Rhythm?

Back 28

May reduce symptoms and improve cardiac hemodynamics by restoring atrial "kick" and eliminating the rapid ventricular response.

May reduce Emergency Department time and prevent Hospitalizations.

Front 29

Which drugs are used in Acute Conversion to Normal Sinus Rhythm?

Back 29

Drugs must ACT ON ATRIAL TISSUE

1) Class 1A: Qunidine, Procainamide

2) Class 1C: Propafenone, Flecainide

3) Class 3: Sotalol, Amiodarone, Ibutilide

Front 30

Would you convert someone to Normal Sinus Rhythm if symptoms have already been resolved with rate control?

Back 30

No

Front 31

In what cases would it be more difficult to Acute Convert to Normal Sinus Rhythm?

Back 31

1) Longer duration of AF

2) Larger Left Atrium

3) Low Ejection Fraction/Clinical CHF

4) Mitrial Valve Regurgitation

Front 32

When would you consider Converting to Normal Sinus Rhythm?

Back 32

1) Acute AF duration <48hrs

2) First episode/paroxysmal AF [i.e NOT persistent/permeant]

3) Patients who are symptomatic despite HR control

Front 33

When would you consider TEE guided strategy or delayed cardioversion?

Back 33

If Atrial Fib>48 hours

Front 34

How many people with recent onset Atrial Fib will return to NSR without Cardioversion or Drugs?

Back 34

60% will return to NSR by 12 hours

Front 35

What are the acute conversion regimen drugs?

Back 35

Ibutilide, Procainamide, Propafenone, Flecainide

Front 36

What are the acute conversion regimen for Ibutilide?

Back 36

1mg IV over 10mins repeat x 1 PRN

Front 37

What are the acute conversion regimen for Procainamide?

Back 37

1g IV over 30mins then 2mg/min

Front 38

What are the acute conversion regimen for Propafenone?

Back 38

600mg PO Single Dose

Front 39

What are the acute conversion regimen for Flecainide?

Back 39

300mg PO Single Dose

Front 40

What are the contraindications for Ibutilide?

Back 40

History of Torsades de pointes, Unstable Angina, CHF, MI or CABG in past 6months

Front 41

What are the contraindications for Procainamide?

Back 41

History of hypersensitivity or Torsades de pointes

Front 42

What are the contraindications for Propafenone?

Back 42

>80 years old,

Unstable Angina,

MI in past 6 months,

CHF >NYHA class II, Sick Sinus Syndrome

Front 43

What are the contraindications for Flecainide?

Back 43

SAME AS PROPAFENONE:

>80 years old,

Unstable Angina,

MI in past 6 months,

CHF >NYHA class II,

Sick Sinus Syndrome

Front 44

"High doses IV or Oral Amiodarone may convert AF, but convential doses do not convert to NSR" True or False?

Back 44

TRUE

Front 45

"Oral Sotalol is effective for acute conversion to NSR" True or False?

Back 45

FALSE

Front 46

"Both Amiodarone and Sotalol are effective for Maintenance of NSR" True or False?

Back 46

TRUE

Front 47

What were the results of the PIAF study?

Back 47

Both improved symptoms.

Rate control had less hospital admissions and less people d/c due to ADRs.

Rhythm had more people with NSR at 1 year.

Front 48

What were the results of the AFFIRM study?

Back 48

More people in Rhythm had hospitalizations and asked to be crossed over from the Rhythm arm.

Front 49

How does all cause mortality compare between Rate or Rhythm control regimens?

Back 49

No difference

Front 50

How does Ischemic Stroke compare between Rate or Rhythm control regimens?

Back 50

Rate control is better at preventing strokes

Front 51

"There is no difference in mortality rates or worsening CHF between rate or rhythm regimens" True or False?

Back 51

TRUE

Front 52

What is the optimal long term strategy for Atrial Fibrillation?

Back 52

Rate control should be the preferred initial long term strategy

Front 53

When should you consider Rhythm control long term strategy ?

Back 53

Patients who remain symptomatic with frequent and/or severe episodes despite rate control therapy

Front 54

What were the results of the RACE II trial?

Back 54

Comparing "strict" HR target of 80-110 versus "lenient" target >110bpm showed no difference in outcomes

Front 55

"Digoxin is less effective in younger patients and does not control exercise induced HR" True or False?

Back 55

TRUE

Front 56

When is Digoxin an option for Rate Control?

Back 56

Elderly patients with CHF who cannot tolerate Beta Blockers

Front 57

Which rate control drugs improve exercise tolerance? Which rate control drugs worsen exercise tolerance?

Back 57

CCB and Digoxin may improve exercise tolerance.

BB may worsen exercise tolerance.

Front 58

Which rate control drugs is recommended for patients with previous Heart Failure?

Back 58

Beta Blockers ± Digoxin

Front 59

Which rate control drugs is recommended for patients with previous CAD?

Back 59

Beta Blockers/ Calcium Channel Blockers/ Combo therapy

Front 60

Which rate control drugs is recommended for patients with no CAD or Heart Failure?

Back 60

Beta Blockers/ Calcium Channel Blockers/ Digoxin/ Combo therapy

Front 61

"Chronic Antiarrhythmic therapy is indicated after a single episode of AF" True or False?

Back 61

FALSE

Front 62

What are the main concerns for using Dronedarone?

Back 62

1) Increases mortality in populations with Heart Failure patients with Class II, III, IV

2) Increased risk of Rash, N/V/D, QTc Prolongation. Creatinine Increase, Drug Interactions, Withdrawals due to ADEs

Front 63

How does Dronedarone's efficacy compare to Amiodarone?

Back 63

Was not as effective as Amiodarone at preventing EKG recurrences

Front 64

When would Dronedarone be contraindicated for Atrial Fib patients?

Back 64

If they have Heart Failure, Rate Control for permanent AF or patients at risk of Liver Toxicity

Front 65

Which rhythm control drugs is recommended for patients with previous Heart Failure?

Back 65

Amiodarone [Alternative: Dofetilide]

Front 66

Which rhythm control drugs is recommended for patients with previous CAD?

Back 66

Sotalol or Amiodarone [Alternative: Dofetilide]

Front 67

Which rhythm control drugs is recommended for patients with no CAD or Heart Failure?

Back 67

Sotalol, Flecainide or Propafenone [Alternative:Amiodarone, Dofetilide]