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Cardiology > 1: Narrow Complex Tachyarrhytmias > Flashcards

1: Narrow Complex Tachyarrhytmias Flashcards

1
Q

If the arrhythmia is atrial in origin, how will the QRS complex appear

A

Narrow complex tachycardia

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2
Q

What defines a narrow complex tachycardia

A

Rate >100bpm

QRS <120ms

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3
Q

Define atrial fibrillation

A

Where un-coordinated atrial activity results in irregular ventricular response

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4
Q

How common is AF

A

Commonest arrhythmia

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5
Q

How does the incidence of AF change

A

Increases with age

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6
Q

What is paroxysmal AF

A

AF that lasts <7 days

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7
Q

What is persistent AF

A

AF that lasts >7days

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8
Q

What is permanent AF

A

continuous AF that cannot be cardioverted - therefore management focuses on rate control and anti-coagulation

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9
Q

What are 5 common cardiac causes of AF

A 
HF
IHD
HTN
Mitral Regurgitation
PE
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10
Q

What are 7 non cardiac causes of AF

A 
Hyperthyroidism 
Hypomagnesaemia
Hypokalaemia
Caffeine
Alcohol
Post-operatively
Pneumonia
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11
Q

What is lone AF

A

AF where no underlying cause can be identified

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12
Q

What are 6 CV risk factors for AF

A 
HTN
IHD
HF
Age
DM
Smoking
Obesity
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13
Q

What are 5 intrinsic cardiac disorders increasing risk of AF

A 
Mitral regurgitation 
Coronary artery disease
Congestive HF 
WPW
Sick sinus syndrome
Cardiomyopathy
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14
Q

What are 5 non-cardiac RF for AF

A 
COPD
Hyperthyroidism
Holiday Heart syndrome
Stress: sepsis or post-op 
Adenosine
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15
Q

What is holiday heart syndrome

A

Individual develops an arrhythmia following alcohol consumption

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16
Q

How do the majority of patients with AF present

A

Asymptomatic

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17
Q

What are the other symptoms of AF

A

Dizziness
Syncope
Palpitations
Fatigue

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18
Q

Describe the pathophysiology of AF

A
  • AF is caused by automatic foci adjacent to the pulmonary veins or fibrosed tissue
  • AF is sustained by re-entry circuits which is more likely if the atria are enlarged
  • Un-cordinated contraction of the atria leads to turbulent blood flow and increased risk of thrombosis
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19
Q

What is first line Ix for AF

A

ECG

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20
Q

What will be seen on ECG in AF

A
  • No p waves

- Irregularly Irregular rhythm

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21
Q

What other investigations should be performed in AF to look for reversible causes

A 
FBC (sepsis or anaemia)
TFT (hyperthyroidism)
Mg (hypomagnesaemia)
U+E (hypokalaemia)
Calcium
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22
Q

When should a trans thoracic ECHO be performed in AF

A

If suspected valve disease causing AF

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23
Q

When should a transoeseophageal ECHO be performed in AF

A

If checking for a thrombus. As thrombus most commonly occurs at left atrial appendage which is difficult to visualise on TTE

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24
Q

In acute AF, if a patient is harm-dynamically compromised how should they be treated

A
  1. A-E approach

2. Syncronised DC cardioversion (120-150J)

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25
Q

If cardioversion is unsuccessful what should be given

A

Amiodarone

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26
Q

How should a stable patient with AF be managed if symptoms started <48h ago

A

Rhythm control is preferred.

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27
Q

How is rhythm control achieved

A

DC cardioversion (or IV Flecainide)

Heparin should be started in case cardioversion is delayed

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28
Q

How should a patient with AF be managed if symptoms started >48h ago

A

Rate control

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29
Q

How should a patient undergoing rhythm control >48h be managed

A
  1. Anti-coagulate for 3W before elective cardioversion
    OR
  2. ECHO to check for mural thrombus before cardioversion
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30
Q

How is chronic AF managed

A

Rate or Rhythm Control

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31
Q

In which patients is rhythm control preferred

A
  1. Young patients
  2. HF patients
  3. New-Onset AF
  4. AF with a reversible cause
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32
Q

In which patients is rate control preferred

A

Majority of AF patients

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33
Q

What is first line rate control

A

B-blocker or non-dihydropyridine calcium channel blocker

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34
Q

What is second line rate control

A

digoxin

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35
Q

When should digoxin only be considered

A

Monotherapy for individuals with a sedentary lifestyle

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36
Q

What is 3rd line for rate control

A

Amiodarone

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37
Q

How is a patient rhythm controlled if symptoms <48h

A

Heparin (in case CV delayed)

DC Cardioversion

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38
Q

How is a patient rhythm controlled if symptoms >48h or unsure of onset

A

Rate control.

Anticoagulate for 3W then cardiovert electively

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39
Q

How is the risk of an embolic stroke in AF assessed

A

CHADSVASC

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40
Q

What is the CHADSVASC score

A 
C ongestive HF
H TN (>140/90) 
A ge >75 (2 points)
D iabetes mellitus
S troke or TIA (2 points)
V ascular abnormalities `(PAD or prior MI) 
A ge 65-74
Sc sex category female
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41
Q

If CHADVASC >2 what does this mean

A

Offer anticoagulation to ALL individuals

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42
Q

If CHADVASC >1 what dose this mean

A

Consider anti-coagulation for males

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43
Q

If individual has AF secondary to valve disease what does this mean

A

You do not need to calculate the CHAD VASc score - they should automatically receive anticoagulation

44
Q

What is used to anti-coagulate in AF

A

DOAC or warfarin

45
Q

What should risk of anticoagulation be compared against

A

Risk of bleeding

46
Q

What score is used to predict the risk of bleeding

A

HAS BLED

47
Q

What does HAS BLED stand for

A 
H TN Uncontrolled (Systolic >160)
A bnormal liver, renal function or alcohol consumption harmful 
S troke
B leeding
L abile INR
E lderly >65
D rugs (NSAIDs, antiplatelets)
48
Q

What score in HAS BLED indicates a high risk of bleeding

A

> 1

49
Q

What are 3 complications of AF

A

Stroke
Left-sided HF
VT

50
Q

Where is the most common site of thrombus formation

A

left atrial appendage

51
Q

What is atrial flutter

A

formation of a re-entry circuit within the right atrium

52
Q

What is ventricular rate in atrial flutter determined by

A

AV conduction ratio

53
Q

What is the commonest conduction ratio in atrial flutter and what rate is this

A

2:1 block (2 P waves for one QRS) = 150bpm

54
Q

What are the types of re-entry circuit in atrial flutter

A

clockwise

anti-clockwise

55
Q

What is the most common re-entry circuit in atrial flutter

A

anti-clockwise (90%)

56
Q

In what gender is atrial flutter more common

A

males (5:1)

57
Q

How does the incidence of atrial flutter vary

A

increases with age

58
Q

How do the majority of patients with atrial flutter present clinically

A

asymptomatic

59
Q

How can patients with atrial flutter present

A

dyspneoa
syncope
palpitations

60
Q

How can atrial flutter be differentiated from atrial fibrillation by pulse alone

A

in atrial flutter the pulse is regular

61
Q

What is first line Ix for atrial flutter

A

ECG

62
Q

What are 3 ECG findings of atrial flutter

A
  • sawtooth baseline (particularly leads II, III, aVF)
  • regular
  • narrow complex tachycardia
63
Q

What does a a:b block stand for

A

number of p waves to QRS

64
Q

What rate is a 2:1 block

A

150bpm

65
Q

What rate is a 3:1 block

A

100bpm

66
Q

What rate is a 4:1 block

A

75bpm

67
Q

When will patients with atrial flutter undergo an ECHO

A

if suspected underlying valve disease

68
Q

Why may a trans-oesophageal ECHO be performed in atrial flutter

A

if suspect a thrombus (as TTE are poor for viewing the left atrial appendage - most common site)

69
Q

How is atrial flutter managed

A

Similar to AF

70
Q

Describe management in atrial flutter

A

Flutter is less sensitive to rate control and more sensitive to rhythm control

71
Q

What is curative management of atrial flutter

A

radio frequency ablation of the tricuspid isthmus

72
Q

What are 2 complications of atrial flutter

A

Atrial fibrillation

1:1 block - can quickly lead to VT

73
Q

What is atrio-ventricular re-entry tachycardia

A

There is an accessory pathway between the atria and the ventricles

74
Q

How will AVRT present clinically

A

palpitations
dyspnoea
dizziness

syncope (rare)

75
Q

Explain the pathophysiology of AVRT

A

there is an accessory pathway that runs between the atria and the ventricles. This bypasses the AV node (that usually delays electrical transmission) and can lead to pre-mature ventricular activation

76
Q

What is first Ix for AVRT

A

ECG

77
Q

How will AVRT present on ECG

A 
narrow complex (<120ms) tachycardia
p waves may be embedded in QRS
78
Q

What is first-line management for AVRT

A

valsava manoueveres

79
Q

What is second line management of AVRT

A

IV adenosine 6mg

80
Q

In which individuals is adenosine contraindicated

A

Asthmatics

81
Q

What is used as an alternative to adenosine in asthmatics

A

Verapamil

82
Q

What is used to treat AVRT in a haemodynamically unstable individual

A

DC Cardioversion

83
Q

What is the only curative treatment for AVRT

A

Radiofrequency ablation of the accessory pathway

84
Q

What is Wolff Parkinson white

A

Presence of a congenital accessory pathway that connects the atria to the ventricles and causes ventricular pre-excitation

85
Q

What is Wolff Parkinson White syndrome

A

When the accessory pathway leads to ventricular pre-excitation. As the pathway does not slow conduction it can degenerate into AF.

86
Q

What is the most common type of AVRT

A

WPW

87
Q

How does Wolff Parkinson White present

A

Asymptomatic

88
Q

How does Wolff Parkinson White Syndrome present

A

Palpitations
Dizziness
Syncope

89
Q

What is the accessory pathway called in WPW

A

Bundle Of Kent

90
Q

Explain the pathophysiology of WPW

A

In WPW there is an accessory pathway (bundle of Kent) from the atria to the ventricles which does not delay impulses. This leads to pre-excitation of the ventricles

91
Q

Explain the pathophysiology of WPW syndrome

A

If the individual is in AF that accessory pathway cannot delay impulses as it has no AV node. This means all signals from the atria are transmitted to the ventricles causing a rapid ventricular response and cariogenic shock as the heart does not have time to gill. It forms a re-entry circuit leading to rapid ventricular rate

92
Q

What are 3 features of WPW on ECG

A
  1. Shortened PR interval
  2. Broad QRS
  3. Delta wave = slurred upstroke of QRS
93
Q

If individuals have type A WPW (left sided pathway) how will it present

A

right bundle branch block

dominant R wave in V1

94
Q

If individuals have type B WPW (right sided pathway, how will it present)

A

left bundle branch block

no dominant R wave in V1

95
Q

What is the definitive management for WPW

A

radio frequency ablation of the accessory pathway

96
Q

What is AVNRT

A

generation of re-entry circuit close to the AV node

97
Q

How will AVNRT present clinically

A

Dizziness
Palpitations
Dyspneoa
Syncope

98
Q

Explain the pathophysiology of AVNRT

A
  • electrical pathway is close to AV node
  • There are 2 pathways in the AV node. Alpha = slow conduction, fast refractory
    Beta = fast conduction, slow refractory
  • Signal passess from AV node down the A and B pathway. As B pathway is quicker is passes down here and up the A pathway where it meets to signal + slows.
  • both A and B are in refractory. As A comes out of refractory first. Signal passes down A (from SA node) and to B (which then comes out of refractory) which then passes again to A = forming a re-entry loop
99
Q

What is first-line Ix for AVNRT

A

ECG

100
Q

How will AVNRT present on ECG

A
  1. No P waves

2. Narrow complex tachycardia

101
Q

How is a haemodynamically unstable individual with AVNRT be managed

A

DC cardioversion

102
Q

How is a haemodynamically stable individual with AVNRT managed

A

Valsava manœuvres

103
Q

What is second-line management for AVNRT

A

IV adenosine (6mg)

104
Q

In which individuals is adenosine contraindicated

A

Asthmatics - verapamil should be used as an alternative

105
Q

How are episodes prevented in AVNRT

A

B blocker

106
Q

What is the definitive management of AVNRT

A

Radio-frequency ablation of the accessory pathway

Cardiology (13 decks)

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