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Cardiology > Arrhythmia > Flashcards

Arrhythmia Flashcards

1
Q

Cardiac causes [6]

A

Ischemic heart disease
Structural changes
Cardiomyopathy
Pericarditis
Myocarditis
Aberrant conduction pathways (WPW syndrome)

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2
Q

Non cardiac causes [5]

A 
Electrolyte imbalance
Metabolic - hypoxia/acidosis/thyroid
Caffeine, Smoking, Alcohol 
Pneumonia, phaeochromocytoma
Drugs
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3
Q

Drugs that cause arrhythmia [5]

A 
Levodopa
Digoxin 
Beta 2 agonists (asthma drugs)
Tricyclic antidepressants 
Doxorubicin
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4
Q

Presentation [7]

A 
Palpitations 
Dyspnoea 
Chest pain 
Fatigue 
syncope/presyncope 
Pulmonary oedema 
Can be asymptomatic
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5
Q

Initial mx of arrhythmias [6]

A

ABCDE
Oxygen
Gain IV access
12 lead ECG
Correct metabolic abnormalities
Classify patient as stable or unstable

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6
Q

Stable vs unstable arrhythmia patient [6]

A 
Signs of shock: 
Hypotension, Tachycardia 
Pallor, Peripheral cyanosis
Cold, clammy hands and feet, Sweating 
Confusion 
Syncope 
Myocardial ischemia, Heart failure, Pulmonary oedema (fine crackles), Raised JVP
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7
Q

What is a sinus arrhythmia? [3]

Management?

A

Normal conduction at faster frequency
HR increases inspiration
Decreases expiration

No Rx needed

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8
Q

Causes of sinus arrhythmia [7]

A

Infection, fever
dehydration, hypovolaemia
pain / exercise
drugs, salbutamol
adrenaline
PE
hypothyroid
MI

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9
Q

What type of tachycardias are there [2]

A

Supraventricular - narrow complex
Ventricular - broad complex
Sinus

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10
Q

What is sinus arrest? [2]

Management [2]

A

SA node fails to generate an impulse
No pulse

Mx:
CPR pathway
Adrenaline

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11
Q

What is a narrow complex tachycardia and why? [4]

A

> 100BPM
QRS <120
Short P wave
Ventricles depolarised via normal pathway so QRS normal

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12
Q

Types of narrow complex tachycardias [5]

A

Sinus tachycardia
Atrial tachycardia - due to abnormal signal in atria other than SA node
Atrial flutter
AV re-entry tachycardia
(WPW)
AV nodal re-entrant tachycardia = most common cause of paroxysmal (re-entrant point through AV node)

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13
Q

What is WPW [2]

ECG [2]

A

AV re-entrant tachycardia - another pathway through atrial and ventricle not AV node
As the accessory pathway does not slow conduction AF can degenerate rapidly to VF
ECG:
- short PR interval
- wide QRS complexes with a slurred upstroke - ‘delta wave’

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14
Q

What causes irregular narrow complex [3]

A

Atrial fibrillation
Ectopic
Atrial flutter with variable block

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15
Q

What is atrial tachycardia [2]

What can cause an atrial tachycardia?

A

Group of atrial cells act as pacemaker
P wave different (more pointy) but everything else same
Cause: digoxin toxicity

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16
Q

How does WPW present [8]

A 
SVT - associated AF / flutter or tachy 
Palpitations
SOB
Dizzy
Chest pain
Sweating 
Anxious
Syncope
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17
Q

What is associated with WPW [4]

How do you treat WPW [2]

A

HOCM
Mitral valve prolapse
Ebstein
Thyrotoxicosis

Radiofrequency Ablation = definite
Amiadarone / fliecanide if AF (rhythm control)

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18
Q

What is type A WPW

Type B WPW

A

Type A: L pathway so RAD
Dominant R in V1

Type B: R pathway so LAD
No dominant R wave

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19
Q

What are adverse signs of supra ventricular tachy which you should assess for [5]

A 
Chest pain (MI) 
Syncope
Shock 
Heart failure 
Can be peri-arrest and go into VF or systole = emergency
20
Q

In a patient with SVT…
What do you do if rate is regular [3]
If rate is irregular what is the most likely problem?

A

Continuous ECG
Valsalva manœuvre
Carotid sinus massage

If irregular, most likely the diagnosis is AF

21
Q

What do you do when someone presents in SVT [6]

A 
ABCDE 
O2 if low sats
IV access
Bloods 
Monitor ECG (narrrow/broad QRS) and BP 
Identify and treat reversible cause e.g. electrolyte
22
Q

What should you do if someone has adverse signs? [8]

A 
Treat as VT rater than SVT
Put out crash call 
DC shock up to 3 times under sedation  
Seek expert help
Correct electrolyte imbalance
IV Amiadarone after shock, 300mg over 10-20 mins
Repeat shock 
IV amiadarone infusion over 24 hours
23
Q

What do you do for sinus tachy

A

Not an arrhythmia so no cardio version
Rx = treat cause
If no cause can be found = BB

24
Q

What do you do if suspect AVRT / AVNRT?

2nd line: [5]
Contraindications of 2nd line [5] (what would you give instead to these patients)

What to do if 2nd line management fails [1]

A

Block AV node by performing Valsalva or carotid sinus massage (will stop tachy)

IV adenosine (chemical cardioversion) 6mg then 12mg then 12mg if no response

  • Need continuous ECG monitoring
  • Given as rapid bolus into large proximal vein
  • Can cause Brady which is scary but transient - warn patient
  • Do ECG during infusion
  • CI in asthma / COPD / HF / heart block / severe hypo so give verapamil
  • May need to direct cardiovert if doesn’t work
25
Q

What is the Valsalva manoeuvre [5]

A 
Forced expiration against closed glottis
Increases intrathoracic pressure
Reduced venous return due to increased atrial pressure
Reduced preload 
Reduced CO
26
Q

If sinus rhythm after Valsalva is restored what does this suggest?

A

AVRT

Consider anti-arrhythmia prophylaxis if recurs

27
Q

What do you suspect if sinus rhythm not achieved with adenosine and what would you do in this case? [2]

A

Atrial flutter
AF if irregular
SEEK expert help and rate control with BB

28
Q

Atrial flutter [4]

A
  • characterised by a succession of rapid atrial depolarisation waves.
  • ECG: sawtooth appearance
  • as the underlying atrial rate is often around 300/min
  • the ventricular or heart rate is dependent on the degree of AV block.
    For example if there is 2:1 block the ventricular rate will be 150/min
29
Q

Atrial flutter [2]

A
  • cardioversion

- radiofrequency ablation of the tricuspid valve isthmus is curative for most patients

30
Q

Atrial fibrillation pathophysiology [3]

Types [3]

A
  1. SA node isn’t firing properly = disorganised signal
  2. Other sites as well as SA node initiate conduction
  3. CO drops as ventricles not primed reliably leading to HF / increased risk of stroke
    Paroxysmal - <7 days and self terminate
    Persistent
    Permanent - resistant to Rx
31
Q

What are cardiac causes of AF: valvular [1] and non-valvular [9]

A

Valvular = MS / prosthetic heart valve issue

Non-valvular
* Ischaemia = most common UK
* Rheumatic = common world wide
* HF
* Hypertension
* IHD
* Cardiomyopathy
* Myocarditis
* Endocarditis
* Surgery

32
Q

What are non-cardiac causes [8]

A 
Sepsis
PE, Bleed 
Pneumonia
Hyperthyroid
Alcohol, Caffiene, Drugs
Post op
Metabolic: Low K / Mg / Ca, Acidosis
33
Q

Most common causes of AF (SMITH)

A

SMITH
Sepsis
Mitral valve - S or R
IHD
Thyrotoxicosis
Hypertension

34
Q

Aetiology Bradycardia

split into extrinsic or intrinsic

A

Intrinsic
* Idiopathic degeneration - ageing
* Infiltrative disease - sarcoidosis, amyloidosis
* Infectious - endocarditis
* Autoimmune - SLE, RA, scleroderma
* Trauma - valve replacement
Extrinsic
* Increased vagal tone from Vasovagal syncope ir exercise training
* Electrolyte imbalancce - hypo/hyperkaelemia, hyponatremia
* Metabolic - hypothyroidism, hypothermia
* Neurological - raised ICP

35
Q

Heart block

Bundle branch block

A
  • RBBB
  • LBBB
  • LAFB
  • LPFB
  • Bifascicular block
  • Trifascicular block
36
Q

RBBB vs LBBB

A

One of the most common ways to remember the difference between LBBB and RBBB is WiLLiaM MaRRoW
in LBBB there is a ‘W’ in V1 and a ‘M’ in V6 in RBBB there is a ‘M’ in V1 and a ‘W’ in V6

37
Q

New LBBB is always pathological. Causes of new LBBB [6]

A

myocardial infarction
hypertension
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia

38
Q

What is the Sgarbossa criteria?

A

In patients with left bundle branch block (LBBB) or ventricular paced rhythm, infarct diagnosis based on the ECG can be difficult.
1. Concordant ST elevation ≥ 1 mm in ≥ 1 lead
2. Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
3. Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave

39
Q

ECG criteria for LAFB, LPFB

A

◆ Left anterior hemiblock: left axis deviation, rS pattern inferior leads.
◆ Left posterior hemiblock: right axis deviation, tall R wave in inferior leads.

40
Q

What is a bifascicular block?
What is a trifascicular block?

A
  • Bifascicular block:
    RBBB + left anterior or left posterior hemiblock.
    LBBB (due to involvement of both fascicles).
  • Trifascicular block:
    first degree heart block and RBBB
    AND
    either left anterior or left posterior hemiblock.
41
Q

Management of peri-arrest bradycardia

A

◆ IV atropine ± isoprenaline if symptomatic.
◆ Treat reversible causes (e.g. metabolic abnormality or stop offending drug).
◆ Consider pacemaker insertion.

42
Q

Indications for pacing [7]

A
  • Sinus node disease
  • Acquired AV Block
  • Congenital AV block
  • Neurocardiogenic syncope
  • Overdrive pacing for atrial tachyarrhythmias
  • Left ventricular outflow tract obstruction in HOCM
  • Acquired long QT syndrome e.g., amiodarone overdose
43
Q

What is considered persistent or permanent atrial fibrillation

A

persistent (>7 days, but ‘cardiovertable’) or permanent (>7 days + NSR not
possible).

44
Q

Annual stroke risk

CHA2DS2VASC score

A

Remember that if a CHA2DS2-VASc score suggests no need for anticoagulation it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.

Apixaban 5mg BD lifelong

45
Q

May be used in conjunction with the CHA₂DS₂-Vasc Score to risk stratify patients for clinically significant bleeding to help guide decisions on anticoagulation in patients with atrial fibrillation.
ORBIT score

A
  • Age >74 +1
  • Bleeding history - any history of GI bleed, intracranial bleeding/ haemorrhagic stroke +2
  • GFR<60 +1
  • Treatment with antiplatelet agents
46
Q

Management of atrial fibrillation, what factors do you have to consider?

A
  • Age: elderly > rate control. Young symptomatic patients, consider rhythm control
  • If young patient and adverse featurse > DC cardioversion
  • Onset of symptoms >48h: delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks (if considered for long term rhythm control). If elderly then just rate control

Cardiology (29 decks)

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