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- Atrial Fibrillation is prevalent and clinically significant conditions in cardiology. Clinical pharmacists play a critical role in the management of these arrhythmias, ensuring optimal treatment outcomes for patients. Understanding the clinical presentation, pathophysiology, diagnostic approach, pharmacotherapy, and key guidelines is essential for providing comprehensive care.
- Atrial Fibrillation can present with a range of symptoms, including palpitations, irregular heart rate, shortness of breath, and syncope. Several risk factors, such as advanced age, hypertension, and structural heart disease, contribute to their development. Key guidelines, such as ACC/AHA/HRS and ESC guidelines, provide evidence-based recommendations for the management of atrial fibrillation.
- AV nodal reentrant tachycardia is the most common type of paroxysmal supraventricular tachycardia
- It involves reentry through dual AV nodal pathways with different electrophysiologic properties
- Patients present with sudden onset/offset palpitations, normal QRS complexes, heart rates 140-250 bpm
- Adenosine terminates AVNRT by transiently blocking AV nodal conduction
- Definitive treatment is catheter ablation of the slow pathway within the AV node
- Antiarrhythmic medications like beta blockers and non-DHP CCBs agents can also be used for rhythm control
- Acute management focuses on terminating episodes, while long-term therapy aims to prevent recurrences
- Monomorphic VT is characterized by a regular, monomorphic wide complex tachycardia, often occurring in structural heart disease
- Hemodynamically unstable patients warrant immediate electrical cardioversion
- For stable VT, procainamide is first-line based on recent evidence showing superiority over amiodarone
- Lidocaine offers an alternative with less negative inotropy but lower efficacy
- All medications should be paired with monitoring for effectiveness, recurrence of VT, and adverse events
- Correct reversible causes and consult electrophysiology for recurrent VT refractory to medications
- Clinical pharmacists play a vital role in appropriate antiarrhythmic selection, dosing, administration, and monitoring to optimize outcomes in monomorphic VT
- Polymorphic VT is characterized by irregular, continuously changing QRS complexes, often with QT prolongation
- It is caused by heterogeneous repolarization that facilitates triggered activity and reentry
- Precipitants include electrolyte disturbances, medications, bradycardia, myocardial ischemia, and congenital channelopathies
- Diagnosis is by 12-lead ECG along with testing to identify reversible triggers
- IV antiarrhythmics like magnesium and amiodarone are first-line for acute termination
- Avoid amiodarone if QTc is markedly prolonged as it may worsen torsades de pointes
- Correct any reversible electrolyte, medication, or bradycardia triggers
- ICDs help provide backup protection against sudden death from recurrence
- Quinidine, ablation, or ICDs manage refractory cases