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PDAT5 CV > 35 - Premature Ventricular Contractions and Ventricular Tachycardia/Fibrillation > Flashcards

35 - Premature Ventricular Contractions and Ventricular Tachycardia/Fibrillation Flashcards

1
Q

Which PVCs are we concerned about?
Premature Ventricular Contractions

A

NOT always a problem, can occur ANYWHERE in heart

  • *COMPLEX PVCs**
  • *Frequent > 5/min**
  • *Multiform**
  • *COUPLET / TRIPLET**
  • *R on T**

Patients with complex PVCs + heart disease
are at an INCREASED risk for DEATH

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2
Q
  • *CAST Trial**
  • *Purpose / Conclusions**
A

Use of 1c Agents to suppress PVCs
Flecainide / Encainide / Moricizine / Imipramine
in patients that are:
Post MI** with **Complex PVCs

Conclusion:

  • *INCREASE IN MORTALITY**
  • even though they DID suppress PVC*
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3
Q

Morals of CAST Trial

Drugs to use / not use

A

Do NOT use AADs / 1c agents for PVC supression
in patients with
Post-MI** or **Heart Disease

only drugs with mortality NEUTRAL in Heart Failure:
Amiodarone** & **Dofetilide

BETA BLOCKERS
are the preffered treatment if necessary

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4
Q

Sudden Cardiac Death
death due to cardiac issues, heralded by abrupt loss of conciousness within 1 hour of onset of symptoms

Causes for <35 y/o and >35y/o

A
  • *SCD in <35yo:**
  • *HYPERtrophic CM** (Cardiac Myopathy) + Idiopathic LVH
  • *SCD in > 35yo:**
  • *CORONARY HEART DISEASE >>>**
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5
Q

Sudden Cardiac Death
death due to cardiac issues, heralded by abrupt loss of conciousness within 1 hour of onset of symptoms

Etiology / Causes

A

Accounts for 50% of ALL deaths

  • *80-90%** are due to VT
  • *Ventricular Tachyarrhythmias**

Rest:

  • *VF** = V. Fibrillation = no PULSE
  • *Asystole_ + _EMD**
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6
Q

VT = Ventricular Tachycardia

S/Sx + Types

A

HR** > **100bpm
Mortality Risk correlates with degree of structural heart disease
Symptoms:
Dypsnea / Syncope / Palpitations

  • *NSVT** = Non-Sustained
  • *< 30 seconds** + terminates spontaneously

Sustained VT
>30sec or
<30 but requires termination due to hemodynamic compromise

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7
Q

Ventricular Tachycardia

RISK FACTORS

A

Idiopathic - no cause

Sleep Apnea

CAD / NIDCM / Myocardial Scarring

Electrolyte Abnormalities

R.Ventricular Dysplasia

HYPERtrophic CM (Cardiomyopathy)

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8
Q
  • *Monomorphic_ vs _Polymorphic**
  • *VT = Ventricular Tachycardia**

Impulse is generated from increased automaticity of a single point in either the left or right ventricle, triggered or caused by a re-entry circuit within the ventricle

A

Monomorphic VT
every QRS complex looks IDENTICAL
SINGLE discharging focus

Polymorphic VT
every QRS complex VARIES in amplitude & duration
MULTIPLE discharging foci

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9
Q

Torsades De Pointes

Definition + Presentation

A
  • *POLYMORPHIC VT_ with a _PROLONGED Qtc**
  • *>470ms** in MEN // >480ms in WOMEN
  • *QTC > 500msec** = ↑↑TDP Risk

TDP:
Waxing + Waning of QRS aplitude
TWISTING of points
caused primarily by
R on T phenomena

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10
Q

RISK FACTORS

  • *Torsades De Pointes**
  • *POLYMORPHIC VT_ with a _PROLONGED Qtc**
  • *>470ms** in MEN // >480ms in WOMEN
  • *QTC > 500msec** = ↑↑TDP Risk
A

K+ blockade –> Delayed V.Repolarization –> Prolonged QTc

Genetics
Congenital Long QT syndrome

Conditions:
Myocarditis / MI / HF
hypoKalemia - hypoMAGnesemia
starvation / SAH
severe bradycardia / hypoTHERMia

  • *DRUGS**:
  • *Class 1a** / Class 3 / Abx
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11
Q

DRUG INDUCED RISK FACTORS

  • *Torsades De Pointes**
  • *POLYMORPHIC VT_ with a _PROLONGED Qtc**
  • *>470ms** in MEN // >480ms in WOMEN
  • *QTC > 500msec** = ↑↑TDP Risk
A
  • *HIGH DOSE** / concentration
  • *CONCURRANT USE** of qt-prolongating drugs

Prolonged QT Interval @ BASELINE
>440 for dofetilitde // >450 sotolol
ANY increase in QTc > 500 after drug initiation

  • *ELECTROLYTE DISTURBANCES**
  • *K < 4** // Mg < 2
  • *Structural Heart Disease** / Bradycardia / adv age
  • *FEMALE > male**
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12
Q

QT Interval Prolonging DRUGS

concurrant use increases RISK for:

  • *Torsades De Pointes**
  • *POLYMORPHIC VT_ with a _PROLONGED Qtc**
  • *>470ms** in MEN // >480ms in WOMEN
  • *QTC > 500msec** = ↑↑TDP Risk
A

METHADONE + AMANTADINE** + **RANOLAZINE

AntiEMETICS:

  • *Dopamine Antagonist + Serotonin Antagonist**
  • *ARSENIC**

TCAs** + **AntiPsychotics** + **SSRI/SNRIs

-AZOLES
Antibiotics:
FQs** + **Macrolides** + **Trimethoprim
-floxacins + -mycins

AntiArrhythmics:

  • *Class 1a​** = Quinidine + Procainamide + Disopyramide
  • *Class 3** = Amio/Dronedarone + Sotolol + Dofetilide
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13
Q

Which ANTIARRHYTHMICS can cause
QT INTERVAL PROLONGATION?

↑TDP Risk

A
  • *Class 1a​**
  • *Quinidine + Procainamide + Disopyramide**
  • *Class 3**
  • *Amio/Dronedarone + Sotolol + Dofetilide**
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14
Q

Which ANTIBIOTICS can cause
QT INTERVAL PROLONGATION?

↑TDP risk

A

-AZOLES
antifungals

  • *Fluoroquinolones**
  • floxacin
  • *Macrolides**
  • mycins

Trimethoprim

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15
Q

Electrical Storm VT/VF
vs
Incessant VT

A
  • *Electrical Storm VT/VF**
  • *>3 seperate episodes of VT** within 24 hours

Incessant VT
Multiple recurrences over a short period of time
AFTER conversion to SR

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16
Q

Electrical Storm VT/VF & Incessant VT

Risk / Triggers / Treatment

A

Risk:
Structural Heart Disease > Class 1c / Electrolyte Abn / HF-Ischemia

Symptoms:
palpitations / syncope / repeated ICD shocks / cardiac arrest

Treatment:
IV AMIODARONE** / **IV B-Blocker** / **ABLATIOn

Prevention:
ICD for decondary prevention / reprogramed ICD

17
Q

Ventricular Fibrillation = VF

Etiology / Definition

A

Etiology:
Secondary to MI, usually PRE-ceeded by VT

NO coordinated beating** = **QUIVERING Ventricles

Vetricular Rate > 300 BMP

RHYTHM HAS
NO PULSE

18
Q
  • *VENTRICULAR TACHYCARDIA**
  • *Treatment Strategies**

Sustained VT
+NO PULSE+
>30 seconds or:
<30 seconds but requires termination due to:
hemodynamic compromise
unconcious / dizzy / SOB

A

Sustained VT + NO PULSE
VVV
ACLS ALGORHYTHM
S-C-R-E-A-M

Start CPR –> SHOCKING –> EPINEPHRINE
VV
AMIODARONE** OR **LIDOCAINE
repeated / complicated
Mag for TDP

19
Q
  • *VENTRICULAR TACHYCARDIA**
  • *Treatment Strategies**

Sustained VT
+PULSE PRESENT+
and
HEMODYNAMICALLY STABLE
concious / not dizzy or SOB

A

PULSE + Hemodynamically STABLE

  • *VAGAL MANEUVERS**
  • *Bear Down** + Cold Water + Carotid Massage

Antiarrhythmic Drugs:
AMIODARONE IV/IO
alternatives if NO structural HD:
Procainamide or Flecainade

20
Q
  • *VENTRICULAR TACHYCARDIA**
  • *Treatment Strategies**

Sustained VT
+PULSE PRESENT+
&
HEMODYNAMICALLY UNSTABLE

A

Pulse + Hemodynamically UNSTABLE

SYNCHRONIZED DC CARDIOVERSION
VV
Shock DURING the QRS
avoid the T-interval

21
Q
  • *Epinephrine in ACLS**
  • *Function**

ACLS for Sustained VT (>30 sec) + NO PULSE

A

S-C-R-E-A-M

a-Peripheral Vascular Tone + +B-Inotrope + +B-Chronotropy
VV
↑Myocardial, coronary, cerebral and arterial blood flow during CPR
VV
↑likelyhood of achievingROSCduringCPR
Return of Spontaneous Circulation

22
Q

Torsades MANAGEMENT
VV
DC QTc Prolonging Drugs & Correct hypoK or hypoMg
VV
if Hemodynamically UNSTABLE?

A

Unstable:
DEFIBRILLATION

23
Q

Torsades MANAGEMENT
VV
DC QTc Prolonging Drugs & Correct hypoK or hypoMg
VV
if Hemodynamically STABLE?

A

STABLE:
Mag Sulfate
1-2g IV admin over 15 min
VVV
TdP + BRADYCARDIA** => **DEFIBRILATION

if NO bradycardia:
ISOPROTERENOL** or **Rapid Pacing via Tem. Pacemaker
2-10mcg/min IV infusion

24
Q

CHRONIC MANAGEMENT
of
NSVT = Non-Sustained VT
<30 sec
Depends if:
heart disease or NO HEART DISEASE

A

NSVT + NO HEART DISEASE

ASYMPTOMATIC = no treatment

SYMPTOMATIC:
BETA BLOCKER >>
CCB or Class 1C (+BB) or Ablation
1C = Propafenone + Flecanide

25
Q

CHRONIC MANAGEMENT
of
NSVT = Non-Sustained VT
<30 sec
Depends if:
HEART DISEASE or no heat disease

A

NSVT + HEART DISEASE

Post-MI or LVEF < 40%
VV
if POSITIVE - EP STUDY
VVV
ICD for PRIMARY prevention
Implantable Cardioverter Defibrillator

26
Q

CHRONIC MANAGEMENT of VT

When would we recommend a
ICD = Implantable Cardioverter Defibrillator?
for
SECONDARY PREVENTION

A

SECONDARY PREVENTION of SCD
ICD for all patients with:
H/o Sustained VF
or
Hemodynamically did NOT tolerate VT
or
RECURRENT
or
Optimal Therapy + LVEF > 50%

27
Q

CHRONIC MANAGEMENT of VT

When would we NOT RECOMMEND a
ICD = Implantable Cardioverter Defibrillator?
for
SECONDARY PREVENTION

A

do NOT recommend ICD

REVERSIBLE cause of VT
Or
conditions LIMITING
Life Expectancy 1-2 years

28
Q

PRIMARY PREVENTION
of SCD & VT
ISCHEMIC HEART DISEASE** + **NSVT
Non Sustained VT <30 sec

A
  • *LVEF > 40%**
  • -> BETA BLOCKERS

LVEF < 40%
Electrophysiology Study with inducible VT** –> **ICD**” **without inducible VT** –> **GDMT

29
Q

PRIMARY PREVENTION
of SCD & VT
ISCHEMIC HEART DISEASE** + **NICM
Non-Ischemic CardioMyopathy

A

Ischemic Disease + NICM
w/ NO ARRHYTHMIA

  • *LVEF > 35%**
  • *Optimize post-MI** + HF DRUG therapies
  • *LVEF <35%_ + _Class2-3 HF**
  • *GDMT > 3 months FIRST** –> ICD
30
Q

Treatment of
Sustained VT
if
VT RECURRS AFTER placement** or if **ICD is NOT an option

A

AMIODARONE
added to Beta Blocker

Sotalol

Correct underlying cause : Electrolytes / CAD

Ablation

PDAT5 CV (30 decks)

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