Approach to the patient with Suspected Dysrhythmia

Question 1

What are the 4 mechanisms of dysrhythmias

Answer 1

Disorders of impulse formation or automaticity
Abnormalities of impulse conduction
Reentry
Triggered activity

Premature / Ectopic / Escape beats or rhythms
Bradyarrhythmias
Tachyarrhythmias

Question 2

what can lead to arrhythmias?

Answer 2

Genetic abnormalities
Acquired structural heart disease
Electrolyte abnormalities
Hormonal imbalances (thyrotoxicosis, hypercatecholaminergic states)
Hypoxia
Drug effects (such as QT interval prolongation or changes in automaticity, conduction, and refractoriness)
Myocardial ischemia

Question 3

What are ways that palpations can present

Answer 3

Palpitations are defined as an unpleasant awareness of the beating of the heart

Forceful
Rapid
Irregular

can ask patients if they can beat

Question 4

What are most of palpitations?

Answer 4

benign :)

Question 5

What are the 4 goals of evaluation of palpitation

Answer 5

1. an arrhythmia that is minor and transient
2. significant cardiovascular disease
3. a cardiac manifestation of a systemic disease, such as thyrotoxicosis
4. a benign somatic symptom that is amplified by underlying psychosocial characteristics of the patient

should get TSH because most other systemic diseases do not present with palpitations and it is pretty easy to r/o

Question 6

What are historical risk factors that are red flags for palpitations?

Answer 6

Family history of young onset of cardiac
Passing out (history of syncope)
sudden death
History of MI

Question 7

What are some red flags of PE findings of palpitations?

Answer 7

Structural heart disease such as dilated or hypertrophic cardiomyopathies
Valvular disease (stenotic or regurgitant)

Question 8

What are red flags of ECG findings for palpitations?

Answer 8

Prolonged QTC
Bradycardia
Second- or third-degree heart block
Sustained ventricular arrhythmias

Question 9

What are some common descriptions of palpatations

Answer 9

“Flip-flopping” (or “stop and start” or “skipped beats”)
Often a result of premature contractions
Rapid “fluttering in the chest”
Is the fluttering regular (SVT, sinus tach, VT)
Or irregular (afib)
“Pounding in the neck”
Commonly occur with afib and aflutter, as well as PACs

Question 10

What symptoms do you check for, for atrial flutter?

Answer 10

Age at first episode
The rate, duration, and degree of regularity of the heart beat
The circumstances associated with onset and termination
Abrupt onset and termination vs gradual
Setting in which they occur

Question 11

SVT presentation

Answer 11

Abrupt change from normal to like 180

Question 12

What are some associated symptoms of palpitations

Answer 12

Chest pain, shortness of breath
Dizziness, near syncope or syncope

Question 13

What is a concerning onset of arrhythmias?

Answer 13

associated with exercise or syncope

Question 14

What are some red fag social history for palpitations

Answer 14

alcohol
illicit drug use

Question 15

What medications can cause palpitations?

Answer 15

Stimulants, OTC cold medicine
AADs

Question 16

What diagnostic studies do you order for palpitations?

Answer 16

ALL patients get EKGs (even if you are not symptomatic)

Question 17

Ambulatory Monitoring Devices

Answer 17

Holter monitor
Event monitors
Real-time monitors
Patch recorders
Implantable loop recorders
When should each be used? Benefits of each? Concerns / costs?

Question 18

Holter monitor

Answer 18

24 hour - it will be normal

monitor every single heart beat over 24-48 hour period, patient gets diary so you can correlate symptoms with palpitations

longer monitoring is better

Question 19

Patch, real-time, and event monitor

Answer 19

Monitor for longer

patches come with a phone and record if they are having symptoms (and record time) and then say what their symptoms were when there was an episode

Question 20

Event monitors

Answer 20

Only record events or if a patient records it

Question 21

real-time monitors

Answer 21

Record the whole time

more useful

Question 22

If they have daily episodes, what is a good monitor

Answer 22

holter monitor (would see within that 24 hour period)

Question 23

If they only have epidoses every now and again, what do you use?

Answer 23

Event monitors
Real-time monitors
Patch recorders

Question 24

Loop recorder

Answer 24

clean skin
put over drape
make an incision under the skin to the left of the sternum
has an angled scapule that flattens out (so it does not go too deep)
Have a syringe

A couple syncope episodes that was not caught with other monitors

Question 25

Are electrophyisiology pros and cons

Answer 25

Pros: measures pathways, can induce rhythms
Cons: very invasive

Question 26

When is a good time to get an EKG exercise testing?

Answer 26

If their arrythmia is exerciseinduced

controlled environment

Question 27

Use of echo for palpitations?

Answer 27

Pretty much every patient

See if their are structural/valvular issues

Question 28

What labs should you always order for palpitations

Answer 28

Thyroid
Electrolytes

Question 29

Goal of dysrhythmia management

Answer 29

Goal #1: prevent sudden death
Goal #2: reduce symptoms improve QOL
Goal #3: reduce hospitalization

Weigh benefits/harms based on patient

Question 30

What are the management for dysrhythmias (read don’t memorize)

Answer 30

Antiarrhythmic drugs
Cardioversion
Electrical or chemical
Synchronized or unsynchronized (defibrillation)
Catheter ablation
Pacemaker
Temporary – transcutaneous or transvenous
Permanent/implanted
Cardioverter-defibrillator
Portable AED
Wearable – Life Vest
Permanent/implanted

Question 31

Cardioversion use

Answer 31

Patches placed rather than paddles

only for tachyarrythmias (SVT, AF, VT, VF)

Atrial fibrillation / flutter
SVT
Ventricular tachycardia

Question 32

What is the range of Jouels for cardioversion?

Answer 32

50-360 J

Question 33

Preparation of cardioversion?

Answer 33

Pads placed or conduction gel applied to paddles
ALL staff/personnel must be clear of touching patient
Requires informed consent, except in unstable emergency / cardiac arrest
Requires sedation, except in unconscious unstable patient

Question 34

Risk/complications of cardioversion

Answer 34

VT/VF due to general anesthesia or lack of synchronization between the DC shock and the QRS complex
Thromboembolus due to insufficient anticoagulant therapy
Arrhythmias: non-sustained VT, atrial arrhythmia, heart block, bradycardia, transient left bundle branch block
Myocardial necrosis, myocardial dysfunction (every shock causes death of tissue)
Transient hypotension
Pulmonary edema (pressure no long moves into the heart)
Skin burn

Question 35

catheter ablation

Answer 35

laser or cryo (freezing) can map a PVC cell and burn it

invasive
pricy
First-line for some arrhythmias
need sedation because it hurts and is long

Question 36

What conditions are catheter ablation first-line

Answer 36

AV nodal reentrant tachycardia
Paroxysmal atrial tachycardia
Atrial flutter

Question 37

How do we get to the left atrium?

Answer 37

Through the right, which is why a catheter ablation is CI in people with a congental defect

Question 38

Complications of catheter ablation

Answer 38

Generally fairly safe

Major vascular damage during catheter insertion occurs in < 2% of patients.
There is a low incidence of perforation of the myocardial wall resulting in pericardial tamponade.
Sufficient damage to the AV node to require permanent cardiac pacing occurs in < 1% of patients.
A rare but potentially fatal complication after catheter ablation of atrial fibrillation is the development of an atrio-esophageal fistula resulting from ablation on the posterior wall of the LA just overlying the esophagus.

Question 39

Pacemakers are indicated for

Answer 39

Bradyarrythmias

can ONLY speed up the heart - kicks in with a small impulse if <60 BPM

Question 40

Implantable cardioverter-defibrillator (ICD)

Answer 40

are indicated to prevent SCD, and ALL include pacemakers

lower power and internal

Question 41

Indications for pacemakers

Answer 41

Symptomatic bradycardia
High-grade AV Block
Sinus pauses or afib pauses with symptoms
No reversible causes identified – this is important (treat the reversible cause first - whether it is meds or something else)

Question 42

ICD Indications

Answer 42

Primary prevention of Sudden Cardiac Arrest (VT/VF)
EF < 35% or other at-risk population (Long QT, Brugada, Hypertrophic Cardiomyopathy - no waiting period)
Secondary prevention of Sudden Cardiac Arrest (VT/VF)

40 days after MI
90 days if others

Question 43

where do you put an ICD

Answer 43

non-dominant side that is less active (so that there is less tearing)

normally on left side because most people are right handed

Question 44

What are the different types of ICD

Answer 44

All devices include the can and leads (wires)

Question 45

What lead is always included

Answer 45

Right ventricular lead

depending on the indication, it can be:

Single chamber pacemaker
RV lead only
Dual Chamber ICD
RA and RV leads
Bi-Ventricular ICD (CRT-D)
RV and LV leads +/- RA lead

Question 46

How to know that leads are placed correctly?

Answer 46

Fish hook in right atrium

heal arch toes of apex of RV

Question 47

How to know if there is a pacemaker?

Answer 47

Tiny thickness on end

Shock coil is larger and is seen in defibrillator

Question 48

Patient education for shocks?

Answer 48

Pacing should not be detectable by the patient
ICD shocks are substantial!!!
The devices are METAL and are affected by MAGNETS
Therefore, patients will set off metal detectors
MRIs may be contraindicated (for the most part – newer devices are MRI-safe)
Pacing is detectable on EKG and Telemetry, marked by “pacer spikes”
Patients with a pacemaker or ICD should be following with a cardiologist, electrophysiologist, or the surgeon who implanted the device
Home wireless monitoring has improved safety

if you get out of rythym, you have a 95% chance of dying with out it, if you have it, you have a 95% chance of surviving

Question 49

What do you see on pacemaker EKG

Answer 49

Pacemaker spikes followed by wide QRS complex

If it does not cause any EKG changes and it’s rhythm is independent to the patient’s EKG (random pacemaker spikes), then it is not working or is placed incorrectly

Question 50

What should a pacemaker spike cause

Answer 50

depolarization of atria or ventricles

otherwise it is not working

def don’t wanna see a spike at the T wave as it can cause torsades