1/9: Arrhythmia

Question 1

What is an Ectopic Beat, and how do you treat it?

Answer 1

An Ectopic Beat is a Heartbeat that is Premature. Reassure the patient but treat with Beta-Blockers if they’re troublesome. This Slows the heart down.

Question 2

What do we check for initially when someone presents with new onset AF?

Answer 2

Initial Stoke Assessment and Thromboemolism needs to be done in AF.

Using tools such as: CHA₂DS₂-VASc Assessment Tool.

A score of 0 for Men or 1 for women means we do not initiaite prophylaxis.

Question 3

Discuss how we manage AF

Answer 3

Managed by either controlling 1: ventricular rate or by attempting to 2: restore sinus rhythm. If this doesnt work for 4 weeks or is reocurring, patient should be referred

Ventricular rate can be controlled by a standard ß-Blocker Or a Rate Limiting CCB such as Verapamil [unlicensed] or Diltiazem as monotherapy.

Question 4

When do we give Ablation therapies

Answer 4

Ablation therapies are given if Drugs and other therapies fail to control AF

Question 5

If AF is not Life threatening, how do we treat it?

Answer 5

Rate or Rhythm control given if the Arrhythmia is within two days. After 48 hours, try Rate is preferred, and an oral anticoagulant is started

Based on the Circumstances, consider elcectrical or pharmacological cardioversion with Amiodarone or Flecanide (avoid in structural heart disease).

Question 6

Discuss Cardioversion

Answer 6

Initiated when the Sinus Rhythm needs to be Restored with Electrical / Pharmacological cardioversion.

Drug wise, we give either Amiodarone or Fleccanide.

But - we do not attempt electrical cardioversion unless the patient is fully anticoagulated for at least 3 weeks first. If that’s not possible give IV Anticoagulant . Rule out a left Atrial Thrombus, and continue Anticoag for 4 weeks +- Rate control as required.`

Question 7

First line Drug Treatment in AF?

Question 8

When can i give Digoxin

Answer 8

1. Digoxin is only good alone in the Monotherapy of controlling ventricular rate at rest, i.e if it is established Atrial Firbrillation.
2. It can also be given when Beta-Blocker Monottherapy is not good enough
3. It can be given when AF is accompanied by Heart Failure
4. When Ventricular Function is diminished: BB + Digoxin.

Question 9

When a single drug fails to treat AF, what’s next

Answer 9

When a single drug fails to control ventricular rate, a combination of drugs, including a ß-Blocker, Digoxin, or Diltiazem can be combined.

If these rate methods dont work. Try and control rhythm

Question 10

What do we give Post Cardioversion?

Answer 10

Post Cardioversion, to maintain sinus rhythm, we give

• Sotalol
• Flecanide Acetate
• Propafenone HCl

Amiodarone

Question 11

In any case, what drug do we avoid if stuctural heart disease is present in a patient? What can we give instead?

Answer 11

Flecanide and Propafenone. Give Amiodarone instead if patient has Left Ventricular Impairment or HF.

Question 12

Outline the guidance for Paroxysmal AF

Answer 12

In PAF – give :

1: Beta Blocker

2: Sotalol / Flecanide / Amiodarone (If ß Ineffective)

Question 13

What options do you have to give Oral Anticoags in AF?

Answer 13

• Vitamin K Antag (Warfarin)
• Apixaban
• Dabigatran
• Rivaroxaban

(All NOACs here given in non valvular AF)

Question 14

What do we not give in AF?

Answer 14

Aspirin is not given as monotherapy if the patient has AF

Question 15

Post an MI, if there is AF, what do we do and not do?

Answer 15

Dont give Anti-Arrhythmic until ECG obtained

Give Atropine IV as first line for Bradycardia and Hypotension

Give Adenosine/Epinephrine if there’s a risk of Asystole

Question 16

Outline Ventricular Tachycardia

Answer 16

For Pulseless VT / Ventricular Fibrillation:

• Treated with Immediate Defibrilation.

Patients with sustained Ventricular Tacchycardia and Hypotension + Reduced Cardiac Output

• DC Cardioversion to resore sinus rhythm
• IV Amiodarone + DC repeated to bring sinus rhythm back

Haemodynamically unstable patients with Ventricular Tacchycardia

1. Amiodarone
2. Fleccanide or Propafenone
3. Lidocaine
4. DC if sinus rhythm not resored
5. Catheter Ablation

In sutstained VT

• Specialist referal
• Implantable Defib
• ß-Blocker / Sotalol / Amiodarone may be used adjunct

Question 17

What the cause of Torsades the Pointes and what is the rescue?

Answer 17

Its a form of Ventricular Tachycardia and is associated witha prolonged QT syndrome, can be caused by hyperkalaemia and severe bradycardia.

Treated with IV magnesium sulfate or Standard ß-blockers

Avoid Giving AntiArrhythmics here as can further prolong the QT inerval.

Question 18

Outline the treatment of Paroxysmal Supraventricular Tachycardia and mention what to do if its recurrent

Answer 18

PSVT Normally terminates on its own or with Vagal Stimulation such as Valsalva Manouvre, Immersing the face in ice-cold water, or carodid sinus massage. Monitor the EGC for improvements.

No Change? Initiate IV Adenosine or if contraindicated (e.g COPD) give Verapamil. Avoid if already on BB.

If it doesnt work, it suggests the Arrhythmia of Atrial Origin.

If its recurrent. Give Catheter Ablation, or Prevent with Drugs such as Diltiazem, Verapamil, Sotalol, Flecanide, Propafenone.

Question 19

What does CHA₂DS₂-VASc Stand for? and What parameters do we give a score of 2?

Answer 19

C - Congestive Heart Failure

H - Hypertension

A - Age >70 (2)

A - Age > 65

D - Diabetes

S - Stroke/TIA (2)

Va - Vascular disease

S - Sex = Female.

Question 20

What Drug is given 4 months before and up to 12 months post cardioversion?

Answer 20

Amiodarone