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ACCSAP > Arrhythmia > Flashcards

Arrhythmia Flashcards

1
Q

Reverse use dependence

A 
Increased effect at slow heart rates 
All class III drugs including dofetilide

III: block outward potassium channel activity (IKs) and prolong refractoriness

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2
Q

Dofetilide side effects

A

Hypomagnesemia, hypokalemia, QT prolongation

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3
Q

Pacemaker cardiomyopathy

A

12% of patients who are paced >20% of the time-> change or upgrade to biventricular

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4
Q

Ventricular pacing alone (without atrial pacing) increases

A

Afib

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5
Q

Management of LQTS

A 
Genetic testing of index patient 
Beta blockers 
ICDs if strong personal risk factors for SCD 
QTC > 480ms more definitive 
Polymorphic VT
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6
Q

Persistent afib
Paroxysmal
Long-standing persistent
Permanent

A

> 7 days
<7 days
12 months
We have stopped attempts to control and accepted it

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7
Q

Primary prevention ICD (MADIT-II trial)

A

Just EF and GDMT?

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8
Q

CRT (biventricular ICD) indication

A

EF <35%, QRS> 150, LBBB, sinus rhythm, class II-IV despite GDMT

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9
Q

Palpitations work up

24 hour holter vs event monitor

A

If risk factors for cardiac disease, attempt to correlate with monitor

Event monitor generally shown to be better

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10
Q

Palpitations and lightheaded ness with exercise and emotion in young person, positive family history

A

CPVT

Ryanodine receptor mutation more common

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11
Q

Transforming growth factor-beta (TGF-β) mutations

A

Familial thoracic aortic aneurysms

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12
Q

Fibrillin mutation

A

Marfan

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13
Q

Myosin heavy chain mutation

A

HCOM and dilated cardiomyopathy

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14
Q

Plakophilin mutation

A

ARVC

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15
Q

Monomorphiv VT that originates in RVOT

Differential

A

LBBB morphology (down in V1) with inferior axis, can ablate / BB/ CCB/ class 1C

idiopathic VT and arrhythmogenic right ventricular cardiomyopathy (ARVC)

RVOT VT is usually not ischemia driven

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16
Q

ARVC

A

Epsilon wave after QRS and TWIs in V1-V3

Get CT/MRI

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17
Q

Arrhythmias in Brugada

A

Beta blockers CI- increase ST elevation
Amiodarone is pro arrhythmic

Treat fever, avoid drugs and alcohol

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18
Q

Quinidine for

A

ICD w/ multiple shocks for VT

ICD is CI

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19
Q

LVOT VT

A

LBBB, inferior axis, early R wave progression

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20
Q

VT in structurally normal heart

VT in abnormal heart

A

Meds or ablate

ICD

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21
Q

Most common cause of VT (wise complex, positive concordance, monophasic R in V1) in CAD

A

Scar-mediated, re-entrant

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22
Q

Torsades in LQTS mechanism

A

Early afterdepolarizations

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23
Q

Mobitz type II vs complete heart block

A

Fixed PR interval

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24
Q

Brugada

A

Sodium channel blockers (flecainide, propafenone) can exacerbate the transient ECG abnormalities that occur in patients with Brugada syndrome who commonly have normal ECGs.

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25
Q

AF with aberrancy, WPW

Do not give

A

Beta blocker, adenosine, dig.

Use ibitulide and procainamide

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26
Q

AF with WPW vs plain AF

A

Wide complex vs narrow complex

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27
Q

2:1 block, differentiate between Mobitz I and II

A

I may be due to increased vagal tone in athletes- improves with exercise

II is due to His disease- worsens with exercise

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28
Q

atrial tachycardia, atrial flutter, or atrial fibrillation in adult congenital heart disease patients

A

progressive hemodynamic deterioration of the underlying disease
Obtain TTE and address arrhythmia

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29
Q

Marked first degree AV block can cause fatigue

A

> 300, cannon a waves
Due to AV dyssynchrony- atrium contracts before complete filling-> decreased ventricular filling
May benefit from pacing

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30
Q

Cardio inhibitory syncope

A

Vagally mediated

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31
Q

Sotalol side effect

A

Non sustained torsades

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32
Q

Sotalol

A

Class III
Blocks inward potassium channel, prolongs QT

Risk is higher in bradycardia, female sex, pre-existing QT prolongation, history of heart failure, history of ventricular tachycardia/ventricular fibrillation, or hypokalemia.

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33
Q

Sustained torsades treatment

A

If unstable- shock
If stable- IV mag

IV isoproterenol (increases HR, decreases QT) 
No beta blockers or amiodarone
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34
Q

Underlying causes of afib

A

hypertension, obstructive sleep apnea, and obesity

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35
Q

AV block (complete heart block) vs AV dissociation (AIVR)

A

Atrial rate is faster

Ventricular rate is faster

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36
Q

Tachy Brady syndrome

A

Post AF conversion pause - sinus node dysfunction + afib

Avoid sodium channel blockers like flecainide

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37
Q

ARVC lifestyle

A

high risk of ventricular arrhythmias and sudden death

avoid competitive sports and endurance training
Can do billiards, bowling, cricket, curling, golf, and riflery
Consider family screening, may need ICD

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38
Q

Polymorphic (multiple QRS morphology) tachy risk factors

Drugs

Ischemia is a common cause

A

baseline QT prolongation, bradycardia, and electrolyte disturbances (especially hypokalemia and hypomagnesemia, and less often hypocalcemia).

Levo and albuterol

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39
Q

Non–isthmus-dependent (atypical) atrial flutter mechanism

Underlying etiology

Treatment

A

macro–re-entrant circuits elsewhere in the RA or LA

congenital heart disease, after cardiac surgery, and after catheter ablation of AF.

Rate control-> EPS

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40
Q

Afib mechanism

AVNRT mechanism

A

Rapid focal ectopic activity (pulmonary veins)

Re-entry within triangle of Koch

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41
Q

Type 1 Brugada, sudden death in family member

A

ICD is not indicated

Indicated in personal history of cardiac arrest or syncope (at rest, not vasovagal)

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42
Q

Typical atrial flutter vs atypical

A

Sawtooth in inferior leads, positive in V1: cavotricuspid, can be ablated

Fossa ovalis or SVC

43
Q

Acute renal failure, stop

A

Atenolol, accumulates

44
Q

ARVC VT

Idiopathic RVOT VT

A

Beta blocker -> ablation

Ablation

45
Q

Afib underlying causes

A

hyperthyroidism, pericarditis, pulmonary embolism, and electrolyte abnormalities (r/o)

46
Q

AVNRT

A

Most frequent SVT, Cannon a waves (neck discomfort)

AVRT
Atrial tachycardia

47
Q

Narrow complex regular tachycardia

A 
SVT: 
AVNRT (dual pathway)
AVRT (accessory pathway) 
AT (ectopic Ps, organized atrial activity with adenosine)
Sinus tachycardia 
Junctional tachycardia
48
Q

Narrow complex irregularly irregular tachycardia

A

AF
MAT
Sinus arrhythmia

Any pattern= regularly irregular

49
Q

Flutter or fib for less than 48 hours

A

Can be DC cardioverted without TEE

  • Rate control is difficult in flutter, aim for rhythm control if possible* (cardioversion preferred)
50
Q

Brugada type 2 (saddle back)/ 3

A

ECG with superior placement of V1 and V2/ block sodium channels with flecainide to unmask

Provocative testing such as drug challenge with procainamide or flecainide or programmed electrical stimulation during electrophysiology testing

51
Q

Prolonged QT-> PMVT-> vfib mechanism

A

Early after depolarizations

Hydroxychloroquine

52
Q

PMVT due to acute ischemia mechanism

A

causes re-entry due to loss of the epicardial action-potential dome in phase II.

53
Q

Treatment of recurrent symptomatic SVT

A

Ablation

54
Q

Fever, alcohol and cocaine unmask Brugada

Gene mutation

A

SCN5A

55
Q

PVC ablation

Work up

A

> 25%

Holter monitor-> implantable loop recorder

56
Q

Inappropriate sinus tachy treatment

A

Ivabradine (if current in SA node, drives sinus rate)

Beta blockers not effective

57
Q

Sinus node dysfunction

A

persistent sinus bradycardia , chronotropic incompetence, paroxysmal or persistent sinus arrest with replacement by subsidiary escape rhythms in the atrium, atrioventricular (AV) junction, or ventricular myocardium

58
Q

Chronotropic incompetence

Deconditioning

A

peak heart rate <100 bpm and <70% age-predicted maximum heart rate.

Exaggerated HR response during exercise

59
Q

First degree vs Mobitz I vs Mobitz II

A

No dropped ps vs increased PR, narrow complex vs normal PR, sometimes wide qrs

60
Q

Mobitz I vs Mobitz II

A

AV nodal block vs His

Carotid sinus massage worsens AV block, improve His conduction

Exercise improves AV conduction, worsens His

61
Q

Flecainide/ propafenone

Sotalol

A

Class Ic, Na blocker
Dissociate slowly during diastole-> use dependence
Effective for pill in pocket SVT
can exacerbate underlying conduction system disease, unmasking sinus node dysfunction (post conversion pause), atrioventricular block, or infrahisian block, and increases in the P-R and QRS intervals of ≤25%

Class III, potassium channel blocker
Reverse use dependence, effective at slower heart rates, use daily

62
Q

Afib > 48 hours

Post cardioversion anticoagulation (there is risk with cardioversion)

A 
Anticoagulate and TEE before cardioversion
4 weeks (Long term AC is determined by CV score)
63
Q

VT/ NSVT/ PVCs:
Negative in V1( left bundle morphology)
Positive in V1( right bundle morphology)

A

Differentiate normal heart from structural heart disease

RVOT (idiopathic vs ARVC) 
Left ventricle (different morphologies= cardiomyopathy)

ICD if there is structural heart disease

64
Q

Bidirectional VT

A

Digoxin toxicity (dronaderone increases, so does amiodarone)

Amiodarone and warfarin also = drug interaction

65
Q

WPW EKG

EKG+ symptoms

If uninterested in ablation

A

Noninvasive exercise testing to risk stratify
Disappearance of delta wave = low risk
Persistent, gradual shortening= high risk

Straight to ablation, no need for stress test

If no SHD, beta blocker / CCB, flecainide or propafenone

66
Q

Afib+ asymptomatic, normal EF

Target HR

A

Rate control and AC
Can consider ablation if symptomatic or decreases EF

<110 (RACE-II)

67
Q

Rate control = rhythm control

Factors to consider

A

age (rate in older), symptoms (rhythm?), duration of AF (>48 hrs- rate) evidence of tachycardia-mediated cardiomyopathy (rhythm), or difficulty in achieving adequate rate control.???

68
Q

Permanent AF

Can prevent effective pacing

A

Can not restore sinus, so no need for antiarrhythmic drugs

Can ablate AV junction for rate control

69
Q

Pacing + LBBB

No response to CRT causes

A

RV pacing only

atrial fibrillation with rapid conduction, inappropriate device programming, and frequent ventricular ectopy, loss of LV lead capture or poor LV lead position

Response depends on >90% biv pacing

70
Q

CV risk of stroke

A

Corresponds till 4, then sequential increase 5_->7, 6-> 9, 7-> 10, 9-> 15

71
Q

SCD during swimming

LQTS syndrome treatment

A

Long QTS
Loss of function in potassium channel-> delay in membrane repolarization

Beta blocker -> ICD

72
Q

AF/flutter + HCOM

A

AC regardless of CV score

73
Q

1st / 2nd degree Brugada relative with normal ECG

A

Genetic testing

74
Q

PMVT-> acute ischemia

A

ongoing chest pain with a normal ECG canbe seen with an acute circumflex artery occlusio

75
Q

Monomorphic VT mechanism

A

Re-entry around a scar
Or
Single focus in structural heart disease

76
Q

BRUISE CONTROL

A

peridevice surgery anticoagulation

Warfarin better than lovenox

77
Q

Sinus node dysfunction types

A

symptomatic bradycardia, sinus pauses due to sinus arrest or sinoatrial exit block, and chronotropic incompetence.

78
Q

RVOT PVCs

A

LBBB with inferior axis and late R-wave progression, beyond V3
Ablate

79
Q

Irreversible symptomatic Brady due to SND or AV block (both types of second degree )

A

Pacemaker

80
Q

HCOM ICD

A

prior cardiac arrest/ sustained VT/ first degree SCD/ wall thickness >30 mm/ unexplained syncope

  • do not do dobutamine stress= increase LVOT gradient-dangerous*
81
Q

Unexplained syncope

A

Investigate with monitoring for arrhythmia and echo for LV dysfunction

82
Q

LQTS genetic testing

A

Strong clinical suspicion for LQTS and qt prolongation

Asymptomatic, idiopathic qtc >500/480 /460

83
Q

Prolonged qtc underlying causes

A

Bundle branch block, meds

84
Q

WPW treatment

A

Procainamide, ibutilide, cardioversion

No amiodarone or lidocaine

85
Q

Predicted max HR
Goal max HR
Chronotropic incompetence

A

220-Age
(220-Age)* 0.85
Inability to reach 80%

86
Q

Atrial tachycardia treatment

A

Ablate

If resistant, beta blockers, nondihydro

87
Q

MNVT mechanism

RVOT VT mechanism

Torsades mechanism

A

Scar mediated re-entry

Delayed and early afterdepolarization

Early afterdepolarization

88
Q

Timolol eye drops can cause

A

Brady arrhythmia in drug interactions with paroxetine for example

Rule out drugs before diagnosing SND

89
Q

VT
SHD
No SHD

A

ICD

Drugs or ablation

90
Q

Left ventricle fascicular VT

A

Re entrant tachy
Sensitive to verapamil
Can ablate

91
Q

Characteristic of wenckebach

A

Short PR after dropped P

92
Q

Hyperkalemia

A

Peaked T, wide QRS, prolonged PR

93
Q

Hypokalemia ECG

A

U wave

94
Q

bradycardia treatment

A 
hemodynamically unstable, third-degree AV block with escape rates <40 bpm: transcutaneous pacing
Infra nodal (wide qrs, Mobitz II onwards): isoproterenol, will need pacemaker eventually
AV nodal (narrow qrs, first degree, Mobitz I): atropine
dopamine?
95
Q

advanced degree AV block

A

2 or more consecutive ps are blocked

96
Q

1 second on ecg strip

infranodal block

A

5 large boxes

wide qrs, mobitz II onwards (can be mobitz I)

97
Q

posterior fascicular VT

anterior fascicular VT

A

RBBB+ LAD

RBBB+ RAD

98
Q

2:1 block

A

Differentiate b/w Mobitz I vs II with carotid sinus massage or ETT

99
Q

Regularization of QRS in afib

A

Complete heart block

100
Q

Indeterminate axis differential

A

LAFB+ RVH

101
Q

Regularization of QRS in afib

A

Complete heart block

102
Q

Indeterminate axis differential

A

LAFB+ RVH

103
Q

Electrical storm treatment

A

Propanol

ACCSAP (11 decks)

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