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General Medicine > Arrhythmia > Flashcards

Arrhythmia Flashcards

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

A

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

21
Q

What are causes of arrhythmias

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

A

Telemetry (inpatient)
Holter monitor
Pacemakers, ICD

23
Q

What is focal atrial tachycardia

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

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
Q

What is atrial flutter

A

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
Q

What is atrioventricular nodal reentry tachycardia

A

Reentry circus forms within AVN
Due to presence of two pathways: fast conducting/long ERP + slow conducting/short ERP

Type of Junctional tachycardia

27
Q

What is atrioventricular re entrant tachycardia

A

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
Q

What are types of broad complex tachycardias

A 
VT
VF
Torsades de Pointes 
SVT with aberrant conduction (BBB) 
Antidromic AVRT
29
Q

How do you distinguish VT from SVT with aberrancy

A 
AV dissociation 
Left axis deviation 
QRS >160ms 
Fusion beats - normal WRS fuses with VT
Capture beats - normal QRS amongst VT
30
Q

What are ventricular extrasystoles

A

Beat due to early depolarisation from ectopic focus in ventricle
Common
ECG: broad QRS, compensatory pause, discordant ST

31
Q

What are types of ventricular extrasystoles

A

Unifocal
Multifocal - multiple foci, multiple morphology

Bigeminy - ectopics every other normal beat
Trigeminy

Couplet - two consecutive ectopics
Triplet

32
Q

What is clinical significance of extrasystoles

A

Normal and common
Sense of “skipping a beat”
Indications of underlying disease: frequent, couplets/triplets, post MI

33
Q

What are features of presentation of arrhythmias

A 
Asymptomatic
Palpitations
Chest pain
Syncope 
Hypotension
Pulmonary oedema
34
Q

What are causes of AF

A

IHD
Hypertension
Heart failure
Mitral valve disease

Pneumonia
PE

Hyperthyroidism 
Hypokalaemia, hypomagnesaemia 
Alcohol
Caffeine 
(Often non-cardiac)
35
Q

What are features of presentation of atrial fibrillation

A 
Asymptomatic 
Palpitations
Chest pain
Dyspnoea
Dizziness

Irregularly irregular pulse

36
Q

What shows on ecg with AF

A

Rate 300-600bpm
Irregularly irregular
Absent P waves
Fibrillation waves

37
Q

What is acute management of AF

A

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
Q

How do you manage chronic af

A

Rate control
Anticoagulation
Rhythm control if: young, first episode, precipitant treated

39
Q

What is used for rhythm control

A

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
Q

What is used for rate control

A

Beta blocker: bisoprolol
Rate limiting ccb: diltiazem
Digoxin: if above fails

41
Q

How do you manage paroxysmal AF

A

Pill in pocket
PRN sotalol, Flecainide
Anticoagulation

42
Q

What is anticoagulation management in acute af

A

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
Q

How do you manage anticoagulation in chronic AF

A

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
Q

What are types of pacing

A

Percussion pacing
Transcutaneous pacing (defibrillator pads)
Transvenous pacing
Subcutaneously implanted permanent pacemaker

45
Q

What are indications for temporary pacing

A

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
Q

What are indications for permanent pacemaker

A

Complete HB
Mobitz Type II
Persistent AV block post anterior MI
Symptomatic bradycardia
Heart failure (cardiac resynchronisation)
Drug resistant tachycardia (overdrive pacing)

47
Q

What is cardiac resynchronisation therapy

A

Pacing of both ventricles (biventricular pacing) to improve synchronisation of cardiac contraction
Improves mortality
Can be combined with defibrillator

48
Q

What are types of congenital arrhythmogenic conditions

A

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

General Medicine (6 decks)

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