Term
| Atrial Fibrillation (AF or Afib) |
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Definition
supraventricular tachyarrhythmia;
uncoordinated, chaotic atrial contraction --> "quivering" --> atria can't contract & efficiently squeeze blood into ventricles;
Atrial Rate: 400-600 bpm
Pulse: Irregular |
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Term
| Atrial Flutter (AFL or aflutter) |
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Definition
Atrial Rate: 250-350 bpm;
Pulse: Regular |
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Term
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Definition
age;
men > women;
smokers;
excessive EtOH and/or caffeine consumption;
periods of extreme stress or fatigue;
Disease states (HTN, DM, Rheumatic heart dx, HF, PE, CAD/MI, chronic lung dx, hyperthyroidism) |
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Term
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Definition
| afib that occurs within 48 hrs |
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Term
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Definition
| Afib episodes that terminate spontaneously in < 7 days |
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Term
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Definition
| AF episodes that fail to terminate within 7 days |
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Term
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Definition
| > or = 2 episodes of AF; Risk is higher if pt has HTN, enlarged LA, AF > 1 yr, HF; |
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Term
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Definition
| palpitations, skips in heart beat, exercies intolerance, fatigue on exertion, cough, chest pain or pressure, dizziness, diaphoresis, dyspnea, overall weakness |
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Term
| Objective Findings (Signs) of Afib |
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Definition
irregular pulse;
irregular jugular venous pulsations;
varation in intensity of first heart sound;
absence of 4th heart sound;
syncope; |
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Term
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Definition
| stroke; other heart rhythm problems; HF; chornic fatigue; mortality; |
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Term
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Definition
control ventricular rate;
prevent thromboembolic events;
restore/maintain sinus rhythm;
resolve symptoms/increase quality of life;
decrease hospitalizations;
decrease cardiovascular morbidity and mortality; |
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Term
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Definition
recommended as initial approach;
less hospitalizations, less adverse drug events;
clinical consequences if uncontrolled:
- hemodynamic instability/symptoms
- tachycardia-mediated cardiomyopathy;
IV: when rapid control of ventricular response is required or oral administration is not feasible;
Oral: hemodynamically stable pts, chronic management; |
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Term
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Definition
At rest: 60-80 bpms;
During moderate exercise: 90-115 bpm |
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Term
| Rate Control Therapy in Acute Setting with LVEF >40% |
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Definition
| IV beta blocker or nondihydropyridine CCB |
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Term
| Rate Control Therapy in Acute Setting with LVEF <40% |
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Definition
1st line - IV digoxin or amiodarone;
AVOID IV nondihydropyridine CCBs;
CAUTION with IV beta blockers (avoid if decompensated HF); |
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Term
| Beta-Blockers (metoprolol) |
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Definition
good for controlling rate at rest, during exercise, & under condition of increased sympathetic dose;
choose Beta-1 selective agent;
Use w/ caution in pts w/ asthma or DM pts; |
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Term
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Definition
good for controlling rate at rest & during exercise;
may not be as effective as beta-blocker;
may cause drop in BP;
good choice for pts w/ asthma; |
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Term
| Drug Interactions with Verapamil |
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Definition
digoxin - monitor for toxicity;
dofetilide - contraindicated, QTC interval prolongation;
simvastatin - do not exceed 20 mg/day;
lovastatin - do not exceed 40 mg/day;
Monitor for rhabdomyolysis with statins; |
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Term
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Definition
not effective for controlling rate during exercise;
Pts that should use:
- HF pt, hypotensive pts, pts who are not physically active, pts w/ C/Is to beta-blockers or CCBs;
Drug Interctions;
Levels: 0.8 ng/mL - 1.0 ng/mL |
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Term
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Definition
3rd line option for rate control;
good for pts w/ HF or C/Is to beta-blockers or CCBs;
may cause pts to convert to NSR; |
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Term
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Definition
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Term
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Definition
| risk stratification score for stroke prevention in pts w/ AFIB; |
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Term
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Definition
| CHADS2 score or 0 or no risk factors for stroke |
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Term
| ASA 81-325 mg daily OR warfarin (INR goal 2-3) |
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Definition
| 1 pt in CHADS2 score or at least 1 moderate risk factor for stroke |
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Term
| Moderate Risk Factors for Pts w/ Afib for Thromboembolism/Stroke |
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Definition
Age >= 75 yrs;
HTN;
HF;
LVEF <+35%;
DM; |
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Term
| High Risk Factors for Thromboembolism with Afib |
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Definition
previous CIA, TIA, or VTE;
mitral stenosis;
prosthetic heart valve |
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Term
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Definition
Manage other risk factors for stroke:
HTN, cholesterol levels, quit smoking, physical activity, heart-health diet, healthy weight, control DM; |
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Term
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Definition
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Term
| electrical cardioversion (Direct Current [DC} Cardioversion) |
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Definition
involves giving electric shocks to the heart;
momentarily depolarizes cardiac cells, allows sinus node to resume normal pacemaker activity;
high success rate; |
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Term
| pharmacological cardioversion |
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Definition
MoA:
- suppress abnormal firing of pacemaker tissue OR depress transmission of impulses in tissues that either conducts too rapidly or participate in reentry;
If initiated within 7 days after onset of AF episode;
Can be used in combination; |
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Term
| Risks/Disadvantages of Pharmacological Cardioversion |
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Definition
thromboembolism;
torsades de pointes;
other arrhythmias;
less effective than electrical cardioversion; |
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Term
| Risks/Disadvantages of Electrical Cardioversion |
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Definition
thromboembolism;
requires sedation or anesthesia; |
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Term
| Class I - Sodium Channel Blockers |
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Definition
| disopyramide (Norpace), procainamide (Procanbid), quinidine (Quinidex, Quinaglute) |
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Term
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Definition
sodium channel blockers;
- used for conversion and/or maintenance;
- use has been declining (3rd line behind Class IC & III;
- can worsen underlying HF; |
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Term
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Definition
Class I sodium channel blockers;
used for conversion and/or maintenance;
causes Lupus-like rxn; |
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Term
| quinidine (Quinidex, Quinaglute) |
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Definition
Class I sodium channel blocker;
Usually 3rd line agent;
use sustained-release formulations --> enhances compliances;
- not used for long-term therapy;
SEs:
- N/V, diarrhea, cinchonism (abnormal hearing, abnormal vision, CNS changes);
Drug Interactions:
- increases digoxin conc.;
- inhibits CYP2D6 (carvedilol, codeine, desipramine, propafenone); |
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Term
| Class IB - lidocaine, mexilitene, tocainide |
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Definition
DO NOT USE FOR ATRIAL ARRHYTHMIAS;
greates potential for proarrhythmias;
used for VENTRICULAR arrhythmias; |
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Term
| Class IC - flecainide (Tambocor), propafenone (Rythmol) |
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Definition
used for cardioversion and maintenance;
DO NOT USE in pts w/ Structural Heart Dx (CAD, valvular dx, HF, MI, LVH, ventricular dysfunciton);
ADRs:
- hypotension, AFL w/ high ventricular rate, caution if hepatic impairment;
Do not repeat in within 24 hrs;
Consider in pts w/:
- normal sinus rhythm & AV node function;
- normal baseline QTc;
- DO NOT have bundle of branch block (BBB);
- have had a successful initial tx as inpatient;
- with recurrent paroxysmal Afib; |
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Term
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Definition
| NOT used for rhythm control, only for rate control |
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Term
| amiodarone (Pacerone, Cordarone) |
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Definition
Route: IV & Oral;
Long half life (50 days) --> requires Loading Doses;
Use in pts w/ following dx states:
- structural heart dx, AF >7 days, HF, HTN, CAD;
Drug Interactions:
- decreases warfarin metabolism, decreases digoxin clearance, inhibits CYP3A4 (statins);
ADRs:
Acute - phlebitis (IV);
Chronic - pulmonary fibrosis, hyper/hypothyroidism, hepatotoxicity, optic neuritis/neuropathy, corneal microdeposits, bradycardia/heart block, photosensitivity, skin discoloration, neurological effects (tremors, ataxia, peripheral neuropathy); |
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Term
| Amiodarone drug interaction with warfarin |
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Definition
decreases warfarin metabolism;
- monitor INR closely q1-2 wks;
- usually requires warfarin dosage decrease of 25-50% |
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Term
| Amiodarone drug interaction with digoxin |
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Definition
decreases digoxin clearance;
- start digoxin at 0.125 mg daily (normal renal fcn) OR give every other day (if renal dysfunction);
- already on digoxin --> decrease digoxin by 50% on day 1 |
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Term
| Amiodarone drug interaction with Statins |
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Definition
max lovastatin dose = 40 mg daily;
max simvastatin dose = 20 mg daily;
can use pravastatin or fluvastatin instead |
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Term
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Definition
- usually occurs within 1st 12 months of tx;
Monitor Parameters & Frequency:
- CXR baseline & yearly, pulmonary fcn tests baselin & PRN;
Tx:
- d/c amiodarone +/- corticosteroids;
Risk Factors: age, increased amiodarone dose, pre-existing lung dx; |
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Term
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Definition
when taking amiodarone, daily intake of I is 75 mg if taking 200 mg daily dose;
Monitoring Parameters & Frequency:
- thyroid fcn tests (TSH, T3, T4) baseline and q6 months;
Low T3/T4 --> thyriod supplementation;
High T3/T4 --> antithyroid meds; |
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Term
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Definition
chronic amiodarone therapy;
Monitoring Parameters & Frequency:
- LFTs baseline & q6 months;
Tx: lower dose of amiodarone or d/c if LFTs >3x ULN |
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Term
| Optic Neuritis/Neuropathy |
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Definition
Monitoring Parameter & Frequency:
- ophthalmic exam baseline & yearly;
Tx:
- d/c amiodarone |
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Term
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Definition
- dry eyes, photophobia, halos;
Monitoring Parameters & Frequency:
- slit lamp exam PRN;
Tx:
- none |
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Term
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Definition
Monitoring Parameters & Frequency:
- ECG baseline & q3-6 months;
Tx:
- lower dose or d/c amiodarone if severe; |
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Term
| photosensitivity/skin discoloration |
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Definition
Monitoring Parameters & Frequency:
- PhEX at every office visit;
Tx:
- wear sunblock |
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Term
| Neurological Effects (tremors, ataxia, peripheral neuropathy) |
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Definition
Monitoring Parameters & Frequency:
- PhEX every office visit;
Tx:
- lower dose or D/C amiodarone if severe |
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Term
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Definition
Class III K-channel blockers;
structurally related to amiodarone but NO I;
Short half-life (24 hrs) --> no loading dose;
Inhibitor of CYP3A4 & 2D6;
ADRs:
- QT prolongation, bradycardia, skin discoloration, photosensitivity, GI upset, increases SCr, hypokalemia;
C/I:
- ALL pts w/ NYHA Class IV;
- NYHA Class II or III with recent decompensation;
- 2nd or 3rd degree AV block;
- bradycardia <50 bpm;
- QTc interval >500 msec;
- severe hepatic impairment;
- pregancy (Cat. X);
- CYP3A4 inhibitors (keto-, itraconazole, cyclosporine, telithromycin, clarithromycin, nefazodone, ritonivir);
- CYP3A4 inducers (rifampin, phenobarbital, carbamazepine, St. John's wort);
Decrease digoxing by 50%; |
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Term
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Definition
Class III K-channel blockers;
Indications:
- both acute cardioversion & maintenance NSR;
- use in pts w/ structural heart dx;
Dosing (based on CrCL:
- >60 ml/min: 500 mcg BID;
- 40-60 ml/min: 250 mcg BID;
- 20-39 ml/min: 125 mcg BID;
- <20 ml/min: C/I;
High risk of TdP (mandatory min of 3 days of ECG monitoring);
ADRs: HA, dizziness, QT prolongation;
Drug Interactions:
- Increases drug conc: cimetidine, ketoconazole, megestrol, prochlorperazine, trimethoprim, metformin, amiloride, triamterene;
- May cause TdP: HCTZ, verapamil;
- inhibitors of CYP3A4: amiodarone, azole antifungals, diltiazem, nefazadone, protease inhibitors, quinine, SSRIs, zafirlukast; |
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Term
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Definition
Class III K-channel blockers;
- available as IV;
Dosing (weight-based):
- <60 kg: 0.01 mg/kg (0.1 mL/kg);
- >60 kg: 1 mg (entire vial);
- Infused over 10 min, may repeat 1 time;
Conversion rate:
- 35-50% - administering Mg may increase rate of conversion;
ADRs:
- QT prolongation, Torsades de Pointes; |
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Term
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Definition
Class III K-channel blocker;
- Used for maintenance of normal sinus rhythm;
- Needs min of 3 days of ECG monitoring: monitor QTc q2-4 hrs after each dose, C/I if CrCl <40 ml/min;
ADRs: bradycardia, dizziness, GI disturbances, TdP;
Decrease dose if QTc is > 500 msec; |
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Term
| Class IV - Calcium Channel Blockers - non-dihydropyridines |
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Definition
| NOT used for rhythm control; used for rate control; |
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Term
| Recommended Agents with Proven Efficacy for Pharmacological Cardioversion of Afib that has occurred < 7 days ago |
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Definition
dofetilide;
flecainide;
ibutilide;
propafenone;
amiodarone; |
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Term
| Recommended Agents with Proven Efficacy for Pharmacological Cardioversion of Afib that has occurred > 7 days ago |
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Definition
dofetilide;
amiodarone;
ibutilide;
dronedarone; |
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Term
| Agents that are less effective for Pharmacological Conversion of Afib < 7 days ago |
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Definition
disopyramide;
procainamide;
quinidine; |
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Term
| Agents that are less effective for Pharmacological Conversion of Afib > 7 days ago |
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Definition
disopyramide;
flecainide;
procainamide;
propafenone;
quinidine; |
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Term
| Agents that SHOULD NOT be used for Pharmacological Cardioversion of Afib < 7 days ago |
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Definition
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Term
| Agents that SHOULD NOT be used for Pharmacological Cardioversion of Afib > 7 days ago |
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Definition
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Term
| 1st line recommendations for Maintenance of Sinus Rhythm in pts w/ NO STRUCTURAL HEART DX |
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Definition
flecainide;
propafenone;
sotalol; |
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Term
| 1st line recommendations for Maintenance of Sinus Rhythm in pts w/ HEART FAILURE |
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Definition
amiodarone;
dofetilide;
dronedarone; |
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Term
| 1st line recommendations for Maintenance of Sinus Rhythm in pts w/ CAD |
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Definition
| sotalol (if normal LV function) |
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Term
| 1st line recommendations for Maintenance of Sinus Rhythm in pts w/ HTN WITHOUT LVH |
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Definition
flecainide;
propafenone;
sotalol; |
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Term
| 1st line recommendations for Maintenance of Sinus Rhythm in pts w/ HTN WITH LVH |
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Definition
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Term
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Definition
radiofrequency energy is directed at areas of arrhythmogenic foci causing cells to die & stop conducting extra impulses that cause rapid heartbeats;
- success rate >90%, pt resumes normal activities in a few days;
Indications:
- pts w/ symptomatic recurrent AF who fail or can't tolerate antiarrhythmic drugs (Class I or III drugs);
- pts w/ AF that is causing cardiomyopathy leading to HF and/or decreased HF;
Risks: pulmonary vein stenosis, thromboembolism, cardiac tamponade, new AFL;
Requires anticoagulatoin; |
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Term
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Definition
dissection of right & left atrium --> creates a maze through which electrical activation is compartmentalized --> prevents formation & perpetuation of AF;
- performed if pt is also getting mitral valve surgery or CABG;
>60-90% success rate; |
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Term
| Left Atrial Appendage Occlusion |
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Definition
prevents blood clots from forming in LAA;
WATCHMAN device implanted behind or at opening of LAA;
consider in pts who cannot take warfarin; |
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Term
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Definition
Indications:
- pts w/ paroxysmal Afib (when in Afib, HR is fast; when not in Afib, HR is slow);
Used if pt gets AV nodal ablation; |
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