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AF-Pogge- DSM 3

Terms in this set (60)

What will you see in the pulse of a patient with AF?
Faster Rate
Irregularly irregular rhythm
What heart sounds are expected the pulse of a patient with AF?
Normal heart sounds S1 & S2
Extra heart sound 3
Volume overload... normal in kids common in HF
Extra heart sound 4
increased resistance to filling
HTN, coronary artery disease, aortic stenosis, severe anemia, hypothyroid
Carotid Bruits
Murmur-like sound in carotid artery due to narrowing of vessels
Type of Ischemic stroke- Arterial
related to the process of atherosclerosis: plaque formation, arterial narrowing, plaque rupture
Type of Ischemic stroke-Cardiac (cardioembolic)
formed in the heart from a blood pooling issue
Caused by AFib, MI, valular heart disease
Hemorrhagic stroke
Ateries in the brain leak blood or rupture
Caused by HTN or aneurysms
Paroxysmal AF
AF that terminates within 7 days
Persistent AF
AF for longer than 7 days
Long standing persistent AS
AF longer than 12 months
Permanent AF
Patient and clinician make joint decision to cease attempts at restoring normal sinus rhythm
Valvular AF
AF in the presence of moderate to sever mitrial stenosis or the presence of a mechanical valve
Treatment- Reduce ASCVD risk factors in all patients when possible by
Determining 10 yr ASCVD risk
Dietary Changes
Physical Activity
Special populations-obese/overweight (lose weight), T2DM (initiate metformin first-line, or SGLT-2 and/or GLP-1)
Initiate pharmacotherapy for comorbidities
-hypertension
-hyperlipidemia
-smoking cessation
Treatment- initiate anti thrombotic therapy for primary ASCVD prevention WITH NO AF
Low dose ASA might be considered for select adults 40-70 yrs at higher ASCVD but lower bleed risk
Low dose ASA should NOT be considered for >70 yrs
What are the 3 areas of focus for managing AF?
Reduce ASCVD risk factors
Initiate Antithrombotic therapy
Initiate rate or rhythm control
Treatment- initiate anti thrombotic therapy for secondary ASCVD prevention of ischemic stroke WITH NO AF
Antiplatelet therapy NOT anticoagulant
-ASA
-ASA + dipyridamole
-clopedigrel 75 mg/ day
ASA+ Clopedigrel w/i 24 hr of minor ischemic stroke or TIA & continued 21 days
What are the guidelines for treatment based on CHADSVASc score 1 in men 2 in women?
Anticoagulation is preferred
ASA monotherapy or no antithrombotic therapy may be considered
What are the guidelines for treatment based on CHADSVASc score 0 in men 1 in women?
No antithrombotic therapy preferred
What are the guidelines for treatment based on CHADSVASc score >/= 2 in men >/= 3 in women?
Anticoagulation is strongly recommended
How often should patients with AF be assessed for bleeding risk assessment?
At every office visit
In HASBLED scoring system what value is considered "high risk"?
>/= 3
What does HASBLED score predict?
1 year risk id major bleeding in AF patients
If Warfarin is used as an anticoagulant in AF what should the TTR be?
>/= 70%
What is/are the agents of choice in patients with high risk of bleeding?
Apixaban
Edoxaban
Dabigatran 110 mg (not available in US)
What is/are the agents of choice in patients with Prior GI bleeding?
Apixaban
Dabigatran 110 mg (not available in US)
What is/are the agents of choice in patients with High risk of stroke?
Dabigatran 150 mg
What is/are the agents of choice in patients with End-stage chronic kidney disease (CrCl < 15 mL/min) or on dyalsis?
apixaban
Warfarin
How often should renal and hepatic function be evaluated?
Before initiation of DOAC and reevaluated at least annually
What is a counseling point dabigatran?
It must be stored in it's original packaging. Patients can not put in daily pill box
Once bottle is opened it must be used in 120 days
Capsule contains tartaric acid and may cause dyspepsia
What is the reversal agent for dabigatran?
Idarucizumab
What is the reversal agent approved for apixaban and rivaroxaban?
Andexxa
What monitoring needs to be done for patients on DOAC therapy?
Renal and hepatic function
CBC to assess for bleeding
Patient monitor for S/S of bleed
What are common agents that are CYP 34A inhibitors?
Amiodarone
Clarithromycin
Diltiazem/verapamil
Dronedarone
Cyclosporine/tacrolimus
Ketoconazole/itroconazole
What are common agents that are CYP 3A4 inducers?
Carbamazepine
Levetiracetam
Phenytoin
Rifampin
St Johns wort
Valproic acid
Primidone
What should be assessed at each visit for follow up?
Adherence
Thromboembolism- stroke or TIA?
Bleeding
Side Effects
Drug interactions
Manage modifiable risk factors
Reassess if anticoagulant is appropriate
What should be monitored every 6 months to 1 year?
Renal and hepatic function
hemoglobin/hematocrit
Platelets
if >/= 75 q 6 months
Which is preferred: rate or rhythm control?
Equally effective
less hospitalization in rate control
What are the drugs given for rate control?
Beta Blockers
non-DHP CCB
Digoxin
Amiodarone
What is the goal heart rate?
80-110 BPM
may be lower if pats have HFrEF
What drugs are associated with rhythm control?
amiodarone
propafenone
dofetilide
flecainide
sotalol
dronedarone
When is pharmacological cardioversion most effective?
If initiated w/i 7 days
-no preferred agent
What is a procedure that can rate control as opposed to pharm therapy?
Ablation of AV node and implantation of pacemaker
What is a procedure that can rhythm control as opposed to pharm therapy?
cardioversion (electrical)
MAZE procedure
pulmonary vein isolation via catheter ablation
implantable atrial defibrillator
Amiodarone SE- Brain
Temors, ataxia, neuropathy
watch for S/S
Amiodarone SE- eyes
corneal deposits & optic neuritis
Eye exam yearly
Amiodarone SE- Thyroid
Hyper/hypothyroid
TSH every 6 months
Amiodarone SE- Lungs
Non-reversible pulmonary fibrosis
Chest X-ray and pulm funct test yearly
Amiodarone SE- Heart
Bradycardia QT prolongation
EKG q 6 months
Amiodarone SE- Liver
hepatotoxicity
LFT Q 6 months
Amiodarone SE- GI
Stomach upset
S/S
Amiodarone SE- Skin
photosensitivity/ Blue skin
S/S- avoid sun exposure
Common agents that can cause QT prolongation
Antiarrhythmics
Antidepressants
Macrolides
FQ
Antiemetics
Antipsychotics
Direct Current Cardioversion
Recommended for patients with rapid ventricular rate that does not respond to pharm or w/ hemodynamic instability
MAZE procedure
Used when pt is undergoing other cardiac surgery OR for highly symptomatic AF not well managed
catheter ablation
Used for symptomatic AF refactory or intolerant of at least 1 artiarrhythmic medication
lowers mortality and reduces hospuitalization
most effective when pt is younger with no structureal heart disease. Less effective longer AF has been present
If a patient has HF EV <40% what agents can be used
Amiodarone
Dofetilide
If a patient has AF and EV <40% what can be used for rate control
BB
Digoxin
If AF has been present less than 48 hours
Rate control
Electical or pharm cardioversion
OAC >/= 4 weeks based on CHADSVASc
If AF has been present >/= 48 hours or unknown
Rate control
Visualize left atria with TEE--> OAC >/= 3 weeks (consider 4-12 weeks)
No clot--> Electical or pharm cardioversion
OAC >/= 4 weeks based on CHADSVASc
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