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Y4 Cardiology > 6. Cardiac Arrhythmias > Flashcards

6. Cardiac Arrhythmias Flashcards

1
Q

What can trigger torsades

A

Electrolyte imbalances or prolonged QT interval

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2
Q

Three types of AF

A

Paroxysmal - spontaneous termination
Persistent - longer than 7 days, plan to restore sinus rhythm
Permanent - longer than 7 days but no plan to restore sinus rhythm

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3
Q

Flutter vs fib

A

Flutter- Electrical activity arises almost solely in right atrium and occurs as a more coordinated cycle of electrical activity that passes around the RA in a very fast cycle
FIb has fib waves vs sawtooth pattern in flutter

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4
Q

Causes of AF

A

Idiopathic, hyperT, CHD, alcohol, thyroid, MVD, LVSD, Cardiomyopathy etc.

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5
Q

Main complications of AF

A

Stroke- due to left atrium embolism
Peripheral embolism
HF due to LVSD if vent response is poorly controlled
MR and TR long term due to remodelling of atrium

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6
Q

Common presenting Sx and signs of AF

A

Asymptomatic or
Breathlessness/dyspnoea , palps, syncope, dizziness, chest discomfort, stroke, TIA, irregular pulse

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7
Q

Bloods for AF

A

U and E, glucose, FBC, TFTs!!

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8
Q

Ix for AF apart from bloods

A

ECG, ambulatory ECG (24 hour tape) if paroxysmal AF is suspected, TTE for structural HD if AF confirmed, or TOE if thrombus in LA needs to be excluded

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9
Q

Complications of rate control vs rhythm control

A

Rate control may lead to MR and TR due to remodelling of atria, cardiac fx may be affected, long term anticoag is required

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10
Q

Benefits of rhythm control

A

Restores AV synchrony, improves CO

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11
Q

When should rhythm control be used instead of rate control

A

Younger pts less than 60, athletic/fit, pts with Sx or HF due to AF and normal heart structure and LA size. Short duration of AF, euthyroid, no previous DCCV

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12
Q

What is used for pharmacological cardioversion

A

IV flecanide or amiodarone in pts with no evidence of streuctural or ischaemic heart disease. Amiodarone if evidence of SHD

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13
Q

Risk of rhythm control in AF

A

Embolism, esp if >48 hrs in AF

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14
Q

If pt has been in AF for >48 hrs, what should be done before cardioversion

A

Anticoagulation for >4 weeks before cardioversion

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15
Q

Procedure for rhythm control

A

If AF<48 hrs, short term anticoag with heparin (IV or SC)
Pharmalogical or electrical cardioversion, and start drug to reduce AF risk for <12 weeks eg, BB or verapamil or dilitazem or amiodarone in pt with LVSD. No need for long term anticoag

If AF>48 hrs, delay cardioversion for min 3 weeks: anticoag with warfarin or DOAC, rate control while waiting to cardiovert ( digoxin, BB, rate limiting calcium antagonist like verapamil or diltiazem)
Continue anticoag after cardioversion for 6-12 weeks and use a drug that reduces recurrent AF risk .

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16
Q

What is the ideal ventricular rate for AF pt on rate control

A

Make vent rate <90bpm, ideally<80

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17
Q

Mx of pt on rate control

A

Use Cha2ds2-vasc score to assess stroke risk and need for anticoag, and HASBLED score for long term bleeding risk.
Use rate limiting medication ( BB eg, bisoprolol, rate limiting calcium antagonist like verapamil or diltiazem, digoxin, amiodarone)
Use long term anticoag like warfarin ( weekly then 4-6 weekly INR), doacs- usually Apixaban

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18
Q

Second line drug for rate control

A

Digoxin

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19
Q

What rate limiting meds are good for patients with hyper T, and when should it be contraindicated

A

Verapamil and diltiazem, verapamil cannot be used with BB but dilitazem can be used

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20
Q

Major worldwide cause of AF

A

Hypertension

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21
Q

Which drug is not suitable to control poorly controlled AF in pt with severe chronic lung disease

A

Amiodarone as contraindicated in PF patients

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22
Q

When is cathether ablation considered for AF

A

If pt has not responded to antiarrhymic, use 4 weeks anticoag before procedue but patient still needs anticoag after based on CHADSVASC

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23
Q

Which drug is particularly considered in rhythm control to maintain sinus rhythm esp if coexisting heart failure

A

Amiodarone

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24
Q

How to mx pt with paroxysmal AF on routine ECG pre-operation

A

Start low dose oral BB and proceed with operation, arrange 24 hr ambulatory heart monitor post-op

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25
What is usual HR in SVT
>140-150 bpm
26
Diff between AVNRT and AVRT
Functional second pathway within AV node vs extra accessory pathway separate to AV node- Allows electrical conduction to travel back up from ventricle to atrium and form circuit
27
Sx of SVT
Palp, SOB or chest pain
28
Which SVT is most common in young women and how do Sx differ from VT
AVNRT, syncope is unusual Shorter refractory period in AVRT and can conduct rhythms much faster, if AF occurs and is conducted 1:1 without AV block it may be fatal
29
What are the clinical signs of SVT
Regular, narrow complex tachycardia, P wave may be seen after QRS or not seen (retrograde P wave esp in V1 ) May be dignificantly tachy or hypoT, evidence of HF if tachycardic for prolonged periods Peri oedema or increased JVP
30
Where is delta wave evident and what is it
WPW syndrome Upsloping entry into QRS complex - some of the heart's electrical conduction is transmitted from atria to ventricle via accessory pathway / extra cardiac conductive tissue
31
What does WPW predispose a patient to
AVRT
32
What does a short PR interval suggest
signal btw A and V transmitted faster than normal ( indication of accessory pathway, which do not have same refractory period of AV node)
33
what is the bpm of 1 to 1 AF
300bpm
34
Main Ix for SVT
ECG primary Ix Can do echo- For evidence of struct. HD, devoplement of LVF, or tachycardic myopathy if tachycardic for long period of time 24 hr tape if have frequent palpitation
35
Tx for SVT
Vagal manoeuvres should be first line - Return of venous blood to RA, profound vagal response produced. Includes carotid sinus massage or REVERT manouever Adenosine second line- causes AV block. Verapamil for asthma pts BB, amiodarone flecanide- may block accessory pathway DC cardioversion - For pts with evidence of haemodynamic instability eg. SOB with HF, persistest hypoT, MI with ST depression or chest discomfort or syncope EP study and ablation for pts - Potientially curative treatment- cathether ablation where tissue can be burnt or frozen
36
What is the size of the QRS complex
>120ms
37
What is non sustained VT
Less than 30s
38
Most common type of VT
Re-entry, caused by scar/fibrosis
39
What conditions can cause Re- entry VT
Fibrosis, structural disease eg. Dilated cardiomyopathy, ischaemic cardiomyopathy, HOCM PVC BBB
40
What can cause automatic VT
Ischaemia, metabolic disturbance, sympathetic tone --- Cells that can't normally depolarise spontaneously suddenly get triggered due to neural hormonal imbalance (eg. Enhance sympathetic drive)
41
What causes triggered VT
Metabolic dist., drug toxocity
42
Sx of VT
May be asx, but may have palpitations, malaise, dyspnea, chest pain (refelects ischaemia due to reduced CO), pre-syncope, syncope Tachycardia, reduced BP and GCS Fluctuating BP, cannon A waves and varying S1 intensity if there is variable cardiac filling and AV dissoc
43
Early ix for VT and later IX
ECG, bloods ( as electrolyte disturbance can predispose to VT), angiography if STEMI pts in cath lab --- Echo or MRI for fx / struct, ischaemia assessment, EP study or provocative testing
44
What pattern is seen on ECG for VT
Broad complex tachycardia
45
Ddx for VT
SVRT with abberant conduction, avrt
46
What kind of axis deviation is very suggestive of VT and what leads show this
Extreme RAD, +ve QRS in AVR and -ve in AVF
47
What is a trigger for Torsades
Long QT, antiarrhytmics like amiodarone, sotalol, class 1a antiarrhtymics, TCA, antipsychotics etc.
48
How to Mx Torsade's
IV mg so4
49
Acute VT Tx
ALS, directed therapy like electrolytes or coronary angiography depending on cause
50
Drugs that can cause VT
Hydroxychloroquine, antidepressants
51
Prevention meds for VT and Tx for chronic VT
BB Cathether ablation for VT, ICD
52
What electrolyte abnormalities may lead to VT
Hypercal,hypokal
53
Common causes of pathological bradycardai
Problem with SA and AV node
54
What infiltrative disorders can cause bradycardias
Cardicac amyloidosis, sarcoidosis or haemachromatosis
55
What can cause direct damage to conducting system
AV surgery/TAVI, aortic valve endocarditis, cardiac ablation
56
Where does ischaemia commonly cause bradycardias
RCA
57
What electrolyte abnormalities can cause bradycardias
Hyper or hypokal
58
What is sick sinus sx
Sino atrial disease causing bradycardia. Normal sinus beats but long pause after. No non-conducted P wave, just sinus arrest
59
What are the four types of AV block and how to diff
1st degree - PR > 200ms 2nd, Mobitz 1- progressive PR until QRS is dropped 2nd, Mobitz 2 - Fixed ratio, 2:1, 3:1 etc and no progressive PR. Non-conducted p waves according to the ratio 3rd- complete disassoc of AV, CHB
60
Sx of bradycardia
Asx in 1st degree May have pre-syncope, collapse and syncope, Sx of HF esp in CHB eg, breathlessness Reduced ET, fatigue, CA
61
SIgns of bradycardia
Low pulse rate, hypoT esp acutely, peripheral oedema and pulm oedema, Cannon A waves which can be seen classically in CHB, when atria contract against closed AV valve as blood reguirgitates back into internal jugular vein
62
What Ix should be done for bradycardia
12 lead Echo for AV disease, hypertensive heart disease, cradiomyopathy MRI if sarcoidosis or amyloidosis is suspected Bloods for endocarditis, lyme seology if approp, ferritin levels
63
Mx of sinus bradycardia or 1st degree AV block
not required
64
What are rate limting meds that should be stopped in bradycardia
BB, digoxin and amiodarone
65
What treatment should be used for bradycardia ( short and long term)
NO long term Short term- first line is Atropine 500mcg, max 3mg Next transcutanoeus pacing or Isoprenaline, adrenaline/NA Inotropic agents like dobutamine
66
MOA of Atropine
Anticholinergic, blocks parasymp to heart
67
MOA of isoprenaline
B agonist, may precipitate tachyarrhythmia
68
Non drug treatment for bradycardias
Pacemaker
69
How to identify atrial and ventricularectopics
Atrial - diff shape of P wave and PR interval Vent- abnormal QRS complex
70
Indication for temporary pacemake
symptomatic/haemodynamically unstable bradycardia, not responding to atropine post-ANTERIOR MI: type 2 or complete heart block trifascicular block prior to surgery
71
ALS- what are life threatening features and what should be done
Life threatening features are shock, syncope, MI and severe HF Sync DC shock up to 3 attemps, amiodarone 300mg IV if unsuccessful
72
What to do if adenosine 18mg given to SVT pt but still ineffective
Give verapamil or BB
73
Ix for venous leg ulcers and where are they usually seen
ABPI- to assess for poor arterial flow which could impair healing Seen above middle malleolus
74
Mx of venous leg ulcers
Compression leg bandaging oral pentoxifylline, a peripheral vasodilator,
75
Shockable vs non shockable rhythm
'shockable' rhythms: ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT) 'non-shockable' rhythms: asystole/pulseless-electrical activity (asystole/PEA)
76
What is ALS algorithm
If unresponsive and not breathing normally Call resusc and ambulance CPR 30:2 attach defib Assess rhythm- if shockable then 1 shock and resume CPR for 2 min If non-shockable resume CPR for 2 min If PEA- 1mg adrenaline IV asap for non-shockable rythms in CA, if VF/VT CA only give after third shock amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
77

Y4 Cardiology (6 decks)

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