Exam (elaborations)
LAST FINAL EVER (NU 665D Exam III)/232 Q’s and A’s
- Course
- Institution
LAST FINAL EVER (NU 665D Exam III)/232 Q’s and A’s
[Show more]
Content preview
LAST FINAL EVER (NU 665D ExamIII)/232 Q’s and A’s
P Wave - -Atrial depolarization
- P-R Interval - -0.12-0.20 seconds
- QRS Complex - -Ventricular Depolarization
0.06-0.10 (up to 0.12) seconds
- ST Segment - -Beginning of repolarization; should be isoelectric
- T Wave - -End of ventricular depolarization
- QT Interval - -Ventricular repolarization
Men <0.44 seconds
Women < (or = to) 0.46 seconds
- Depolarization - -Wave of positively charged sodium ions passing through
the myocardium
- Repolarization - -Returning to a polarized state
Occurs by potassium ions leaving the cells
- Electricity of heart - -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 - -Irregularly irregular rhythm
-Absence of discernible P wave
-Atrial disorganization
- Paroxysmal A. Fib - --Recurrent
>1 episode lasting 30 or more seconds in duration
AF that terminates spontaneously within 7 days
- Persistent A. Fib - -Sustained A. Fib >7 days OR
Lasts <7 days but requires cardioversion
- Permanent A. Fib - -Refractory to cardioversion or accepted as a final
rhythm
- Acute A. Fib - -New onset OR first episode of A. Fib
, - Lone A. Fib - -patients <60yo without evidence of cardiac, pulmonary or
circulatory disease
- A. Fib Associated Cardiac Conditions - --HTN
-CHF
-CAD
-Rheumatic valvular disease
-Atrial and ventricular dilation or hypertrophy
-Congential heart disease
- A. Fib Associated Non-Cardiac Conditions - --Thyroid disease
-ETOH and caffeine abuse
-Pulmonary HTN
-COPD, OSA
-Infections
-Family/genetics (rare cases)
- Clinical Presentation of A.Fib - --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 - --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 - -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 - -CHF (1)
HTN (1)
Age >75 (1)
DM (1)
Prior Stroke (2)
- CHADS 2 VASc 2 - -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 - --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) - -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) - -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
Half life: 5-13 hours
Peak: 2-4 hours
Director Factor Xa inhibitor
- Pradaxa (dabigatran) - -Dose: 150mg BID
, Renal adjustment: 75mg BID; not adequately studied
>10% pts have GI distress
Half life: 12-17hours, Up to 28hours w/renal impairment
Peak: 1-2hours
Direct thrombin inhibitor
- Coumadin - --Obtain baseline PT/INR and investigate if abnormal
-Determine use of potential warfarin interactions (meds)
-Document target INR and RX warfarin tablet strength
-Provide pt edu on safety, monitoring, food and drug interactions
-Recommend 1st INR check on day 3-4
- Coumadin Initiation - -Day 1-3, initial dose: 5mg (10mg)
Day 3-4:
-1.0-1.3 Dose 7.5mg
-1.4-1.5 Dose 5mg
-1.6-1.8 Dose 5/2.5mg alternating dose
->1.0 Dose 2.5mg
->2.0 hold x1 day, then 2.5mg
Reversal agents: Vitamin K 1-10mg IV/PO (not SQ/IM); Takes 6 (IV) to 25 (PO)
hours to reverse warfarin
- Treatment Approach for A.Fib - -3 Elements:
1) Rate control
2) Restoration and maintenance of sinus rhythm (if indicated)
3) Stroke prevention
-Goal is to alleviate sxs and improve QOL
- Rhythm Control - -Focus on restoration of sinus rhythm:
-Palpitations
-SOB
-Dizziness/Lightheadedness
-Activity intolerance
Prevention of tachycardia-induced cardiomyopathy
Prevention of hemodynamic compromise r/t A.Fib
- Rhythm Control Treatment - -Specific tx type depends on several factors:
-Heart disease w/LVH or depressed LVEF
-HF
-Age
-Underlying sinus node dysfunction
-Other arrhythmias (e.g. a. flutter)
-Underlying QT prolongation
-Renal function
Note: pts w/a CHADS2VASc2 score of zero who opt for a rhythm control
strategy may be considered to stop OAC
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Nursephil2023. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $18.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
82871 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now