NU 665
P Wave - Answers Atrial depolarization
P-R Interval - Answers 0.12-0.20 seconds
QRS Complex - Answers Ventricular Depolarization
0.06-0.10 (up to 0.12) seconds
ST Segment - Answers Beginning of repolarization; should be isoelectric
T Wave - Answers End of ventricular depolarization
QT Interval - Answers Ventricular repolarization
Men <0.44 seconds
Women < (or = to) 0.46 seconds
Depolarization - Answers Wave of positively charged sodium ions passing through the myocardium
Repolarization - Answers Returning to a polarized state
Occurs by potassium ions leaving the cells
Electricity of heart - Answers In RA starting at SA node, moving through heart, slowing (d/t Ca++ ions),
pass thru AV node
Conducts rapidly (Na+ ions), through the bundle of His, down through right and left bundle branches
Atrial Fibrillation - Answers Irregularly irregular rhythm
-Absence of discernible P wave
-Atrial disorganization
,Paroxysmal A. Fib - Answers -Recurrent
>1 episode lasting 30 or more seconds in duration
AF that terminates spontaneously within 7 days
Persistent A. Fib - Answers Sustained A. Fib >7 days OR
Lasts <7 days but requires cardioversion
Permanent A. Fib - Answers Refractory to cardioversion or accepted as a final rhythm
Acute A. Fib - Answers New onset OR first episode of A. Fib
Lone A. Fib - Answers patients <60yo without evidence of cardiac, pulmonary or circulatory disease
A. Fib Associated Cardiac Conditions - Answers -HTN
-CHF
-CAD
-Rheumatic valvular disease
-Atrial and ventricular dilation or hypertrophy
-Congential heart disease
A. Fib Associated Non-Cardiac Conditions - Answers -Thyroid disease
-ETOH and caffeine abuse
-Pulmonary HTN
-COPD, OSA
-Infections
-Family/genetics (rare cases)
Clinical Presentation of A.Fib - Answers -Palpitations, tachycardia
,-Fatgiue
-Chest pain
-Dizziness
-Syncope/Pre-syncope
-Sxs associated w/stroke (occult A. Fib)
-12-20% pf pts may be asymptomatic (often discovered by PCP during routine visit)
-Note: Irregular pulse does not always indicate A. Fib; PACs, PVCs, A. Tach; confirm rhythm w/EKG
A.Fib Patient Evaluation - Answers -PE: Heart sounds
-EKG- LA dilation?
-TFTs: should be done during initial discovery/change in condition (e.g. difficult to control rate)
-Electrolytes with Magnesium
-BUN/Creatinine (helpful when trying to decide if AAD or OAC)
-Echocardiogram: valvular disease or reduced LVEF
-Ambulatory monitoring: Holter
Stoke Risk in A. Fib - Answers Thromboembolism: primary morbidity assoc. w/ A.Fib. Thrombus
formation and dislodgement from left atrial appendage (LAA)
-Based on clinical risk factors and NOT on freq/duration of A.Fib
-Non-valvular meaning A. Fib presumably not r/t mitral valve heart disease, specifically mitral stenosis
-In general ~48hrs for clot formation; if duration known to be <48hrs, can cardiovert w/o AC
-Second option: transesophageal echo to confirm absence of LAA thrombus
-Risk of thrombus is increased in first 3-4 weeks after DCCV, when gradual return of atrial mechanical
function can result in high risk for thrombus
CHADS 2 - Answers CHF (1)
HTN (1)
Age >75 (1)
DM (1)
, Prior Stroke (2)
CHADS 2 VASc 2 - Answers CHF (1)
HTN (1)
Age >75 (2)
DM (1)
Prior Stroke (2)
Vascular disease (1)
Age 65-74 (1)
Female (1)
If score >2, oral anticoagulants (or if non valvular A. Fib for prior stoke, TIA)
If pt has nonvalvular A. Fib and CHADS2VASc2 score of 0, reasonable to omit anticoag therapy
New Anticoagulants - Answers -3 currently approved
-Tested against coumadin
-No sign. diff b/w the three of them except for S/Es
-Avoid potent Pgp inducers (rifampin, carbemazepine, phehytoin, phenobarb, St. John's wort) as will
decrease effect
-Riva and Apixa: Avoid potent inhibitors of CYP3A4 and Pgp (Azoles, Protease inhibitors, mycins), as will
INCREASE AC effect
Eliquis (apixaban) - Answers Dose: 5mg BID
Renal adjustment: 2.5mg twice daily, must have 2 or more of the following: Age >80yo, Body wt </=
60kg, Serum creatinine >/= 1.5mg/dL
Half life: 12 hours
Time to Peak: 3-4hours
Direct factor Xa inhibitor
Xarelto (rivaroxaban) - Answers Dose: 20mg daily w/evening meal of at least 500 calories for absorption
Renal Adjustment: CrCl 15-50mg once daily w/evening meal; CrCl <15mL/min: avoid use
P Wave - Answers Atrial depolarization
P-R Interval - Answers 0.12-0.20 seconds
QRS Complex - Answers Ventricular Depolarization
0.06-0.10 (up to 0.12) seconds
ST Segment - Answers Beginning of repolarization; should be isoelectric
T Wave - Answers End of ventricular depolarization
QT Interval - Answers Ventricular repolarization
Men <0.44 seconds
Women < (or = to) 0.46 seconds
Depolarization - Answers Wave of positively charged sodium ions passing through the myocardium
Repolarization - Answers Returning to a polarized state
Occurs by potassium ions leaving the cells
Electricity of heart - Answers In RA starting at SA node, moving through heart, slowing (d/t Ca++ ions),
pass thru AV node
Conducts rapidly (Na+ ions), through the bundle of His, down through right and left bundle branches
Atrial Fibrillation - Answers Irregularly irregular rhythm
-Absence of discernible P wave
-Atrial disorganization
,Paroxysmal A. Fib - Answers -Recurrent
>1 episode lasting 30 or more seconds in duration
AF that terminates spontaneously within 7 days
Persistent A. Fib - Answers Sustained A. Fib >7 days OR
Lasts <7 days but requires cardioversion
Permanent A. Fib - Answers Refractory to cardioversion or accepted as a final rhythm
Acute A. Fib - Answers New onset OR first episode of A. Fib
Lone A. Fib - Answers patients <60yo without evidence of cardiac, pulmonary or circulatory disease
A. Fib Associated Cardiac Conditions - Answers -HTN
-CHF
-CAD
-Rheumatic valvular disease
-Atrial and ventricular dilation or hypertrophy
-Congential heart disease
A. Fib Associated Non-Cardiac Conditions - Answers -Thyroid disease
-ETOH and caffeine abuse
-Pulmonary HTN
-COPD, OSA
-Infections
-Family/genetics (rare cases)
Clinical Presentation of A.Fib - Answers -Palpitations, tachycardia
,-Fatgiue
-Chest pain
-Dizziness
-Syncope/Pre-syncope
-Sxs associated w/stroke (occult A. Fib)
-12-20% pf pts may be asymptomatic (often discovered by PCP during routine visit)
-Note: Irregular pulse does not always indicate A. Fib; PACs, PVCs, A. Tach; confirm rhythm w/EKG
A.Fib Patient Evaluation - Answers -PE: Heart sounds
-EKG- LA dilation?
-TFTs: should be done during initial discovery/change in condition (e.g. difficult to control rate)
-Electrolytes with Magnesium
-BUN/Creatinine (helpful when trying to decide if AAD or OAC)
-Echocardiogram: valvular disease or reduced LVEF
-Ambulatory monitoring: Holter
Stoke Risk in A. Fib - Answers Thromboembolism: primary morbidity assoc. w/ A.Fib. Thrombus
formation and dislodgement from left atrial appendage (LAA)
-Based on clinical risk factors and NOT on freq/duration of A.Fib
-Non-valvular meaning A. Fib presumably not r/t mitral valve heart disease, specifically mitral stenosis
-In general ~48hrs for clot formation; if duration known to be <48hrs, can cardiovert w/o AC
-Second option: transesophageal echo to confirm absence of LAA thrombus
-Risk of thrombus is increased in first 3-4 weeks after DCCV, when gradual return of atrial mechanical
function can result in high risk for thrombus
CHADS 2 - Answers CHF (1)
HTN (1)
Age >75 (1)
DM (1)
, Prior Stroke (2)
CHADS 2 VASc 2 - Answers CHF (1)
HTN (1)
Age >75 (2)
DM (1)
Prior Stroke (2)
Vascular disease (1)
Age 65-74 (1)
Female (1)
If score >2, oral anticoagulants (or if non valvular A. Fib for prior stoke, TIA)
If pt has nonvalvular A. Fib and CHADS2VASc2 score of 0, reasonable to omit anticoag therapy
New Anticoagulants - Answers -3 currently approved
-Tested against coumadin
-No sign. diff b/w the three of them except for S/Es
-Avoid potent Pgp inducers (rifampin, carbemazepine, phehytoin, phenobarb, St. John's wort) as will
decrease effect
-Riva and Apixa: Avoid potent inhibitors of CYP3A4 and Pgp (Azoles, Protease inhibitors, mycins), as will
INCREASE AC effect
Eliquis (apixaban) - Answers Dose: 5mg BID
Renal adjustment: 2.5mg twice daily, must have 2 or more of the following: Age >80yo, Body wt </=
60kg, Serum creatinine >/= 1.5mg/dL
Half life: 12 hours
Time to Peak: 3-4hours
Direct factor Xa inhibitor
Xarelto (rivaroxaban) - Answers Dose: 20mg daily w/evening meal of at least 500 calories for absorption
Renal Adjustment: CrCl 15-50mg once daily w/evening meal; CrCl <15mL/min: avoid use
