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29 Cards in this Set
- Front
- Back
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What is the goal HR in pts in need of ventricular rate control? |
resting HR < 80; however, HR < 110 may be reasonable in pts who are asymptomatic and have preserved LVEF |
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What drugs can be used to reduce HR for ventricular control? |
BBlockers, nondihydropyridines, digoxin, amiodarone |
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What drugs should be avoided in pts w/ wolff-parkinson-white syndrome? |
BBlockers, nondiphydropyridines, digoxin |
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What BBlockers should be used to ventricular rate control? |
labetalol or carvedilol If pt also has HF then only use bisoprolol, carvedilol, or metoprolol succinate |
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What pts could the nondihydropyridines be a better choice than bblockers? |
pts w/ asthma and COPD |
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What is digoxins role in ventricular rate control? |
usually as add on to CCB or BB rarely used alone since it doesn't help control rate during exercise or any strenuous activity Can be added if pt has systolic HF |
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What pts amiodarone be used for to control ventricular rate? |
those refractory to BB, CCB, and dig for pts who do not have an accessory pathway |
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What must be observed prior to attempting cardioversion (electrical or chemical)? |
no atrial thrombi; cardiovert w/in 24 hrs if thrombi present then 91% chance of stroke after cardioversion |
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How long should anticoag be given prior to cardioversion if the pt is stable and AFib duration is unknown or > 48 hrs? |
3 wks prior to cardioversion continue for 4 weeks after cardioversion |
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What antiarrhythmics are contraindicated in pts w/ structural heart disease (CHD, HF, left vent hypertrophy, valvular)? |
Class 1c -flecanide and propafenone |
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What class III antiarrhythmics are used for chemical cardioversion? How effective are they? |
amiodarone 85-95% efficacy sotolal 50-60% efficacy dofetilide 50-60% efficacy dronedarone 21-25% efficacy |
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How is amiodarone metabolized? Effect on CYP? Drugs to watch for? |
3A4 substrate amio also inhibits CYP, 3A4, 1A2, 2C9, 2D6 ^ dig conc. -reduce dose ~50% ^warfarin -reduce dose ^simvastatin -max dose 20 mg/day ^lovastatin -max dose 40 mg/day |
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What monitoring should be done for amiodarone? |
1. LFTs at baseline and every 6 months 2. Thyroid function test at baseline and every 6 months 3. Chest radiography at baseline and annually 4. Ophthalmologic exam: d/c if optic neuritis 5. Pulmonary fnx test: Baseline and for unexplained dyspnea; -d/c if pulmonary fibrosis develops 6. Neurologic tox: neuropathy 7. GI tox |
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What are contraindications of sotalol cardioversion? |
HF CrCl < 40 QTC > 440 sinus bradycardia 2nd or 3rd AV block w/out functioning pacemaker |
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How long should a pt be in the hospital for sotolal and dofetilide initiation? |
3 days; monitor SCr, K, Mg, QTC |
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How is dofetilide metabolized and excreted? |
CYP3A4 metabolism renal elimination |
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What pts is dofetilide contraindicated in? |
CrCl < 20; or QTC > 400 (500 for pts w/ ventricular conduction abnormalities) Safe in pts w/ HF |
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Besides QTC, K, and Mg what else must be closely monitored prior to initiation of dofetilide? |
Drug Interactions Avoid 3A4 inhibitors: -cimetidine, verapamil, itraconazole, ketoconazole, HCTZ, prochlorperazine, megestrol, dolutegravir, and trimethoprim also avoid tramterene, metformin, amiloride |
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How are dronedarone and amiodarone related, how are they different? |
dronedarone is an amiodarone analog lacking the iodine moiety that contributes to the pulmonary, hepatic, and ocular tox of amiodarone |
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If a pt has structural heart disease what is the test rhythm control agents for, CAD? HF? |
CAD - dofetilie, dronetarone, sotalol ---> if those fail then amio ---> if amio fails then ablation HF - amiodarone, dofetilide ---> if those fail then ablation |
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What drugs are best for rhythm control if the pt has NO structural heart disease? |
dofetilide, dronedarone, fecainide, propafenone, sotalol IF those fail AMIODARONE!!! |
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How is CHA(2)DS(2)VASc score determined? |
C - CHF or LVEF < 40 H - HTN A - Age > 75 +2 D - Diabetes S - Hx stroke, TIA, thromboembolism (2) V - Vascular disease A - Age 65-74 Sc - Sex +1 for female |
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What oral anticoagulant is dialyzable? |
ONLY dabigatran |
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What oral anticoagulants under go NO cyp metabolizm? |
dabigatran and edoxaban |
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What are all oral anticoagulants substrates for? Drugs to avoid? |
P-glycoprotein AVOID RIFAMPIN; in package labeling |
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At what CrCl should is dabigatran need to be renally dosed? |
CrCl 30 - 50 do not administer w/ a p-gp inhibitor CrCl < 30 contraindicated |
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At what CrCl should rivaroxaban be renally dosed? |
CrCl > 50 dose 20 mg a day CrCl < 50 dose 15 mg a day CrCl < 15 avoid use |
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Due to drug interactions, what drugs should be avoided w/ rivaroxaban? |
p-gp inhibitors 3a4 inducers/inhibitors |
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What are the VitK dependent clotting factors t1/2? |
factor VII, 6 hrs factor IX, 24 hrs factor X, 36 hrs factor II, 72 hrs proteins C and S are also inhibited due to long t1/2 of factor II wafarin doesn't reach the full effect until ~7 days after initiation This is also why bridge therapy usually lasts 5 days |
