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29 Cards in this Set

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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

What drugs can be used to reduce HR for ventricular control?

BBlockers, nondihydropyridines, digoxin, amiodarone

What drugs should be avoided in pts w/ wolff-parkinson-white syndrome?

BBlockers, nondiphydropyridines, digoxin

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

What pts could the nondihydropyridines be a better choice than bblockers?

pts w/ asthma and COPD

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

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



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

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

What antiarrhythmics are contraindicated in pts w/ structural heart disease (CHD, HF, left vent hypertrophy, valvular)?

Class 1c


-flecanide and propafenone

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



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

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

What are contraindications of sotalol cardioversion?

HF




CrCl < 40




QTC > 440




sinus bradycardia




2nd or 3rd AV block w/out functioning pacemaker

How long should a pt be in the hospital for sotolal and dofetilide initiation?





3 days; monitor SCr, K, Mg, QTC

How is dofetilide metabolized and excreted?


CYP3A4 metabolism


renal elimination

What pts is dofetilide contraindicated in?

CrCl < 20;


or QTC > 400 (500 for pts w/ ventricular conduction abnormalities)




Safe in pts w/ HF

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

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

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

What drugs are best for rhythm control if the pt has NO structural heart disease?

dofetilide, dronedarone, fecainide, propafenone, sotalol




IF those fail




AMIODARONE!!!

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





What oral anticoagulant is dialyzable?

ONLY dabigatran

What oral anticoagulants under go NO cyp metabolizm?

dabigatran and edoxaban

What are all oral anticoagulants substrates for?




Drugs to avoid?

P-glycoprotein




AVOID RIFAMPIN; in package labeling





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

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

Due to drug interactions, what drugs should be avoided w/ rivaroxaban?

p-gp inhibitors




3a4 inducers/inhibitors

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