Tag Archives: ccs

A Fib 2: CCS 2012 Treatment Guidelines

The CHADS2 and HAS-BLED predictive index are useful in assessing a patient’s thromboembolic risk and in predicting which antithrombotic therapy is most suitable; and that is either aspirin, clopidogrel, or anticoagulants. The 3 new anticoagulants may be simpler to use and may have less intracranial hemorrhage side effect than warfarin, there has been longer clinical experience with warfarin and an antidote is present if needed.

As for rate control and rhythm control, there is no significant difference in controlling survival and mortality between the two. Therapy is chosen based on patient’s symptoms and preference. Rate control medications include BB, non-dihydropyridine CCB, and digoxin. And rhythm control includes dronedarone, flecainide, sotalol, and amiodarone. We will go over details of these medications in the next episode.

Catheter ablation is mainly for symptom control. It may be first line for highly selected patients,  is often considered 2nd line after multiple drug therapy, or for patients who failed on multiple antiarrhythmic therapy and maintenance of sinus rhythm is still desired.

  • Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

http://www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext

  • The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure

http://www.onlinecjc.ca/article/S0828-282X%2812%2901379-7/abstract

  • Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter

http://www.onlinecjc.ca/article/S0828-282X(10)00012-7/fulltext

A Fib 1: Etiology and Diagnosis

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Initial Investigations

CHADS2 Score

HAS-BLED Score

Mayo Clinic on A Fib

CHF 2: medications

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

  • Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone
  • Loop diuretic: furosemide
  • Digoxin
  • Vasodilators: hydralazine and isosorbite dinitrate

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

  • all asymptomatic patients with an EF < 35%
  • all symptomatic HF patients and EF < 40%

ARB:

  • if intolerant to ACEI
  • add to ACEI if intolerant or contraindicated for BB
  • add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events

BB:

  • all HF patients with an EF ≤ 40%
  • initiated at a low dose and titrated to the target dose or maximal tolerated dose

MRA:

  • patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or
  • with elevated BNP or NT-proBNP levels
  • after an MI with EF ≤ 30% and HF or
  • EF ≤ 30% alone in the presence of diabetes
  • EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments

Diuretics:

  • for congestive symptoms
  • When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms
  • persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium

Digoxin:

  • patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy
  • patients with chronic atrial fibrillation (AF) and poor control of ventricular rate

Isosorbide dinitrate and hydralazine:

  • black Canadians with HF-REF
  • non-black HF patients unable to tolerate an ACE inhibitor or ARB

Drug information from:

  • Drug monographs
  • CPS: http://www.e-therapeutics.ca/
  • Therapeutic Choices: http://www.e-therapeutics.ca/
  • Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx