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Arrhythmia Flashcards

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1
Q

What is Torsades de pointes

A

Type of VT with constantly varying axis, often occurring in setting of long QT syndromes

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2
Q

What are causes of Torsades de Pointes

A

Antimalarial: quinine
Antibiotic: erythromycin
Psychoactive: haloperidol, risperidone, SSRI, Tricyclics
Anti arrhythmics: quinidine, procainamide, amiodarone, sotalol
Congenital: K channelopathies - romano Ward, Jervell and Lange-Nielsen
Cardiac: MI
Metabolic: hypokalaemia, hypomagnesaemia, hypocalcaemia
Motility Drugs: domperidone

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3
Q

What are types of broad complex tachycardia

A

Ventricular tachycardia
SVT with aberrant conduction
Pre-excited tachycardias with accessory pathway

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4
Q

What is management of broad complex tachycardias

A

Pulseless: no synchronised DC shock

Haemodynamically unstable:
Synchronised DC shock
Correct electrolytes: Mg, K
IV amiodarone

Haemodynamically stable VT:
Correct electrolytes
IV amiodarone
SynchronisedDC shock if unsuccessful

If known SVT:
Treat as SVT

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5
Q

What are causes of narrow complex tachycardia

A 
Sinus tachycardia
Atrial: 
AF
Atrial Flutter 
focal atrial tachycardia 
multifocal atrial tachycardia 
Junctional: 
AVNRT 
AVRT
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6
Q

What is management of narrow complex tachycardia

A

Haemodynamic instability:
synchronised dc shock
Correct Mg, Ca, K
IV amiodarone

Stable 
Assess underlying rhythm + treat cause 
Irregular = AF: rate control 
Regular:
Vagal manoeuvre 
IV adenosine
Terminated: Junctional tachycardia 
Not terminated: Atrial flutter = rate control
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7
Q

How do you treat irregular narrow complex tachycardia

A

Treat as AF

Rate control:
beta blocker
Rate limiting CCB
Digoxin (if Heart failure)

Cardioversion if <48hr or anticoagulated:
DC cardioversion
Flecainide or amiodarone

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8
Q

How do you treat stable narrow complex tachycardia

A

Vagal manoeuvres - show atrial rhythm
IV adenosine - show atrial rhythm, terminate junctional tachycardias (diagnostic + therapeutic)
Verapamil - if above fails
DC cardioversion - if above fails

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9
Q

How do you treat focal atrial tachycardia

A

Occurs with digoxin toxicity
Stop digoxin
Correct electrolyte: hypokalaemia, hypomagnesaemia, hypercalcaemia
Digoxin specific antibody fragments

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10
Q

How do you treat multifocal atrial tachycardia

A

Occurs with COPD
Treat hypoxia and hypercapnia
Verapamil if refractory

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11
Q

How do you treat Junctional tachycardia

A

Vagal maneouvres: valsalva maneouvre, carotid sinus massage
IV adenosine
Bisoprolol or Verapamil
Radio frequency ablation

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12
Q

What is Wolff Parkinson White syndrome

A

Syndrome of palpitations + preexcited ECG

Caused by accessory pathway between atrium and ventricle - bundle of Kent
Associated with AVRT: macro reentry circuit involving accessory pathway

ECG: prolonged PR with wide QRS from slurred delta wave 
Type A (+ve delta on V1) type B (-ve delta on V1) s
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13
Q

What types of arrhythmias occur with WPW syndrome

A

AVRT
Pre excited AF
Pre excited A flutter
VF

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14
Q

What is Bradycardia

A

Heart rate <60bpm

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15
Q

What are symptoms of bradycardia

A

Asymptomatic (normal)
Dizziness, fatigue, faintness
Adverse signs: syncope, dyspnoea, chest pain, palpitations

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16
Q

What are types of bradycardia

A 
Sinus bradycardia
Heart block
AF with slow ventricular response
A flutter with high degree block 
Junctional bradycardia
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17
Q

What are causes of bradycardia

A

Physiological
Cardiac: inferior mi, fibrosis of conducting system, aortic valve disease (IE), myocarditis, cardiomyopathy, iatrogenic
Non-cardiac: vasovagal, hypothyroidism, Hyperkalaemia, cushings reflex
Drugs: beta blocker, verapamil, diltiazem, Digoxin, amiodarone

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18
Q

What is management of bradycardia

A

Correct reversible cause

If adverse signs + risk of asystole:
Atropine

If ineffective:
Transcutaneous pacing
Isoprenaline infusion
Adrenaline infusion

If ineffective:
Transvenous pacing

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19
Q

Who is at risk of asystole

A

Recent asystole
Mobitz type II HB
Complete HB with broad QRS
Ventricular pause >3s

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20
Q

What are characteristics of arrhythmias

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A

Common
Often benign
Occasionally cause cardiac compromise
Often intermittent - need continuous ECG monitoring

21
Q

What are causes of arrhythmias

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A 
IHD
Structural Changes 
Accessory pathway
Cardiomyopathy
Myocarditis 
Pericarditis 
Non cardiac: alcohol, cocaine, pneumonia, electrolytes, thyroid, phaeochromocytoma
22
Q

What are types of continuous ecg monitoring

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A

Telemetry (inpatient)
Holter monitor
Pacemakers, ICD

23
Q

What is focal atrial tachycardia

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A

Tachycardia due to group of atrial cells acting as pacemaker, out-pacing SAN
P waves abnormal morphology

24
Q

What is multifocal atrial tachycardia

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A

Tachycardia due to multiple groups of atrial cells acting as pacemaker
ECG: Multiple morphology P waves, irregular narrow complex tachycardia
Associated with COPD

25
What is atrial flutter
Tachycardia due to electrical activity around atria circulating at 300 bpm Re entrant atrial circuit set up around isthmus (bw tricuspid valve and IVC) ECG: flutter waves (sawtooth), with AV block/ventricular rate in factors of 300
26
What is atrioventricular nodal reentry tachycardia
Reentry circus forms within AVN Due to presence of two pathways: fast conducting/long ERP + slow conducting/short ERP Type of Junctional tachycardia
27
What is atrioventricular re entrant tachycardia
Re entry circuit forms between atria and ventricles by accessory pathway, allowing electrical activity to pass from ventricles to atria Orthodromic conduction: circuit V-A, narrow complex tachycardia Antidromic: circuit A-V by accessory pathway, broad complex tachycardia
28
What are types of broad complex tachycardias
``` VT VF Torsades de Pointes SVT with aberrant conduction (BBB) Antidromic AVRT ```
29
How do you distinguish VT from SVT with aberrancy
``` AV dissociation Left axis deviation QRS >160ms Fusion beats - normal WRS fuses with VT Capture beats - normal QRS amongst VT ```
30
What are ventricular extrasystoles
Beat due to early depolarisation from ectopic focus in ventricle Common ECG: broad QRS, compensatory pause, discordant ST
31
What are types of ventricular extrasystoles
Unifocal Multifocal - multiple foci, multiple morphology Bigeminy - ectopics every other normal beat Trigeminy Couplet - two consecutive ectopics Triplet
32
What is clinical significance of extrasystoles
Normal and common Sense of “skipping a beat” Indications of underlying disease: frequent, couplets/triplets, post MI
33
What are features of presentation of arrhythmias
``` Asymptomatic Palpitations Chest pain Syncope Hypotension Pulmonary oedema ```
34
What are causes of AF
IHD Hypertension Heart failure Mitral valve disease Pneumonia PE ``` Hyperthyroidism Hypokalaemia, hypomagnesaemia Alcohol Caffeine (Often non-cardiac) ```
35
What are features of presentation of atrial fibrillation
``` Asymptomatic Palpitations Chest pain Dyspnoea Dizziness ``` Irregularly irregular pulse
36
What shows on ecg with AF
Rate 300-600bpm Irregularly irregular Absent P waves Fibrillation waves
37
What is acute management of AF
Adverse signs DC cardioversion <48hr + Stable Rate or rhythm control Anticoagulate with heparin >48hr Rate control Elective rhythm control Anticoagulate 3wks w DOAC/warfarin
38
How do you manage chronic af
Rate control Anticoagulation Rhythm control if: young, first episode, precipitant treated
39
What is used for rhythm control
Elective DC cardioversion Give Amiodarone before/after if high risk of failure Flecainide (CI in structural heart disease) Amiodarone AVN ablation with pacing Pulmonary vein pacing
40
What is used for rate control
Beta blocker: bisoprolol Rate limiting ccb: diltiazem Digoxin: if above fails
41
How do you manage paroxysmal AF
Pill in pocket PRN sotalol, Flecainide Anticoagulation
42
What is anticoagulation management in acute af
Heparin if acute episode treated with DC cardioversion DOAC/warfarin for 3 wks if elective cardioversion No anticoagulation if low risk of emobolism + AF recurrence
43
How do you manage anticoagulation in chronic AF
Balance risk of embolism: CHA2DS2VASc with risk of anticoagulation: HASBLED ``` CCF Hypertension Age >65, >75 DM Stroke/TIA/thromboembolism Vascular disease Sex (F=1) ```
44
What are types of pacing
Percussion pacing Transcutaneous pacing (defibrillator pads) Transvenous pacing Subcutaneously implanted permanent pacemaker
45
What are indications for temporary pacing
Symptomatic bradycardia unresponsive to atropine Prophylactic pacing in anterior MI with HB or trifascicular block (not for inferior MI) Overdrive pacing in tachycardia unresponsive to medicine
46
What are indications for permanent pacemaker
Complete HB Mobitz Type II Persistent AV block post anterior MI Symptomatic bradycardia Heart failure (cardiac resynchronisation) Drug resistant tachycardia (overdrive pacing)
47
What is cardiac resynchronisation therapy
Pacing of both ventricles (biventricular pacing) to improve synchronisation of cardiac contraction Improves mortality Can be combined with defibrillator
48
What are types of congenital arrhythmogenic conditions
WPW syndrome: congenital accessory pathway between atria and ventricles, associated with AVRT, Pre excited AF/Flutter Long QT Syndrome: K channelopathy, causing prolonged repolarisation and predisposing to ventricular arrhythmias (esp TdP) Brugada: Na channelopathy

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