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Cardiology finals > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

Define atrial fibrillation and atrial flutter

A

AF: disorganised, chaotic atrial activity with random ventricular conduction
Flutter: organised atrial activity with variable conduction to ventricles, often in 2:1, 3:1, 4:1 pattern

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2
Q

Describe the presentation of AF

A
  • Usually older patients
  • May be asymptomatic or symptomatic
  • Presents w palpitations, SOB, chest discomfort, dizziness, syncope, HD unstable
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3
Q

Name the causes of AF

A 
Idiopathic: Lone AF
Cardiac: valve disease, IHD 
Pulmonary causes: PE, pneumothorax 
Metabolic: alcohol use, thyrotoxicosis, electrolytes
Infection: sepsis
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4
Q

Describe the ECG findings in AF

A

-Irregularly irregular (rhythm)
-Narrow complex (QRS)
-Tachycardia (rate)- not always
+ absent p waves

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5
Q

Describe the assessment and initial management of acute AF

A
  1. A to E approach if HD unstable
  2. Investigations:
    - ECG
    - Bloods: FBC, CRP, U+Es, TFTs, glucose, troponins, clotting
    - Imaging: CXR
  3. Acute Management:
    - If started within 48 hours: rate/rhythm control + anticoagulate w LMWH
    - If HD unstable: DC cardioversion + anticoagulate (LMWH)
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6
Q

What are the options for rate and rhythm control in AF?

A

Rate control:

  • Beta-blockers (bisoprolol, metoprolol): avoid in asthma
  • CCBs (diltiazem, verapamil): avoid in HF
  • Digoxin

Rhythm control:

  • Pharm: flecainide, amiodarone (structural heart disease, IHD)
  • Non-pharm: DC cardioversion
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7
Q

Describe the long term management of AF

A

ABCs of AF:
A: Avoid stroke/Anticoagulation
-CHADS-VASc vs ORBIT for decision making
*Offer if 2+ score or consider if male and 1+
-Non-valvular AF: DOACs (apixaban, rivaroxaban)
-Valvular AF: warfarin

B: Better symptom control
-Rate control or rhythm control

C: CVS risk reduction

  • Diet + exercise, smoking cessation, alcohol reduction
  • Statin
  • BP control, DM control
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8
Q

When would you consider rhythm control in management of AF?

A
  • Acute AF (started within 48 hours)
  • HD unstable -> DCCV
  • Symptomatic on/refractory to rate control
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9
Q

Describe the management of AF presenting over 48 hours after onset

A
  1. Consider cardioversion if suitable
    - Anticoagulate for 3 weeks prior and continue after
    - Elective TOE guided DCCV > pharm
    - Consider amiodarone prior to and following DCCV to maintain
  2. Rate control for permanent AF/unsuitable for CV
  3. Pill-in-pocket for infrequent paroxysmal AF
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10
Q

Describe the CHADS-Vasc score

A 
CCF (1)
HTN (1)
Age >65 (1), >75 (2)
Diabetes (1)
Sex F (1)
Stroke or TIA (2) 
Vascular disease (1)
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11
Q

Name some complications of AF

A
  • Stroke
  • Heart failure
  • Death
  • Complications of treatment
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12
Q

Describe the management of atrial flutter

A

Similar to AF

  • If HD unstable: DCCV
  • If acute onset (48 hours): rate or rhythm control. Best is electrical rhythm control. Anticoagulate.
  • If >48 hours: rate control, anticoagulate. Consider long term rhythm control.
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13
Q

What are the signs of HD instability?

A

Shock
MI
Acute heart failure
Syncope

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14
Q

Describe atrial flutter on ECG

A
  • Regular
  • Narrow complex
  • Tachycardia (ventricular rate about 150bpm)
  • 2:1/3:1 etc AV block
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15
Q

Define SVT

A

Any tachycardia in which the electrical activity arises from above the ventricles (narrow complex tachy)

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16
Q

What are the types of SVT?

A
  1. Sinus tachycardia
  2. Atrial: AF, flutter, atrial tachycardia
  3. AVNRT
  4. AVRT
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17
Q

What is the difference between AVNRT and AVRT?

A

AVRT occurs when there is an anatomical accessory pathway allowing electrical impulses to re-enter the atria.
AVNRT: functional re-entry circuit within the AV node

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18
Q

Describe the presentation of AVNRT

A

-Common demographic is young women w normal hearts
-Causes paroxysmal rapid regular palpitations, syncope, chest pain, SOB, anxiety
-

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19
Q

Describe the pathophysiology of AVNRT (slow-fast)

A
  • AV node has fast and slow pathways
  • Electrical impulse enters node and travels down fast pathway. This pathway then has to repolarise
  • If a new impulse enters the node (PAC), this will travel down the slow pathway bc fast is busy repolarising
  • By the time the impulse has travelled the slow path, the fast is done repolarising -> impulse travels the wrong direction up the fast.
  • Continual re-entry occurs
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20
Q

Describe the ECG in AVRT and AVNRT

A

AVNRT:

  • Narrow complex tachycardia (140-280bpm)
  • Absent (slow-fast) or inverse p waves after the QRS (fast-slow)
  • May have widespread ST depression

AVRT:

  • Narrow complex tachycardia (200-300bpm)
  • Buried p waves
  • Possible ST depression, T wave inversion
  • When controlled, may reveal WPW

BASICALLY THE SAME

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21
Q

What is WPW?

A

The presence of an accessory pathway between the atria and ventricles (Bundle of Kent) that can result in SVT (AVRT)

22
Q

Describe the management of acute SVT

A
  1. HD unstable: DCCV
  2. Vagal manoeuvres (carotid massage, Valsalva, ice cube)
  3. Adenosine 6mg IV bolus -> 12mg -> 12mg
  4. Digoxin, amiodarone, beta-block, CCB
23
Q

Describe the long term management of SVT

A

Conservative: avoid stimulants, alcohol
Pharmacological: flecainide, beta-blockers
Surgical: ablation

24
Q

Describe VT on ECG

A
  • Regular, broad complex tachycardia

- Monomorphic or polymorphic (Torsade des Pointes)

25
Q

Describe VF on ECG

A

Chaotic activity, no organised complexes

26
Q

Name the causes of VT/VF

A
  • Ischaemic heart disease
  • Structural heart disease
  • Electrolyte abnormality
  • Drugs/toxins
  • Congenital heart disease
27
Q

Describe the presentation of VT/VF

A
  1. Non-sustained VT: paroxysmal palpitations, syncope, chest pain, SOB, etc
  2. Cardiac arrest
  3. Sudden cardiac death
28
Q

Describe the management of in hospital cardiac arrest

A

Put out a 2222 cardiac arrest call

  1. Start CPR- 30:2 at 100-120/s
  2. Protect airway and give high flow O2
  3. Gain IV access and take bloods
    - FBC, CRP, U+Es, clotting, troponin, glucose
  4. Defibrillate when available if shockable rhythm (pulseless VT/VF)
    - Administer shock, continue CPR for 2 mins. Repeat 3x
    - Adrenaline 1mg of 1:10,000 after 3rd shock and then every alternate shock (3-5 mins)
    - Amiodarone 300mg after the 3rd shock
  5. If non-shockable rhythm, continue CPR and reassess
    - Give adrenaline and amiodarone as per shockable
29
Q

What are some causes of cardiac arrest?

A 
4 Hs and 4Ts
Hypoxia
Hypothermia
Hypovolaemia
Hypo/hyperkalaemia/metabolic

Thrombosis
Tamponade
Toxins
Tension pneumothorax

30
Q

Describe the acute management of sustained VT (not cardiac arrest)

A

A to E approach

  • IV access and bloods
  • Continuous cardiac monitor
    1. If HD unstable: sedate and DCCV with amiodarone
    2. If HD stable: amiodarone loading dose (300mg over 20-60 min, then 900mg over 23 hours)
    3. Correct any hypokalaemia or hypomagnesaemia
    4. Consider need for ICD
31
Q

What are the types of bradycardia? How do they appear on ECG?

A
  1. Sinus bradycardia
  2. Heart block
    - 1˚: prolonged PR interval
    - 2˚ Type 1: prolongingly prolonged PR interval with dropped QRS
    - 2˚ Type 2: prolonged PR interval with dropped QRS
    - 3˚/complete: no assoc between ps and QRSs
  3. Bundle branch block:
    - LBBB: W in V1, M in V6
    - RBBB: M in V1, W in V6
    - Trifascicular block: 1st degree heart block, RBBB, LAD
32
Q

How are pacemakers described?

A

3 letters:

1st: paced chamber (A/V/D)
2nd: sensing chamber (A/V/D)
3rd: response to sensed event (Inhibit/Trigger/Dual)

33
Q

What are the indications for permanent pacing?

A
  • Persistent bradycardia without correctable cause
  • High degree blocks: Type 2 2nd˚ block, 3˚ block
  • Symptomatic AV block (any degree)
  • Various others: NMJ diseases, cardiomyopathy, etc
34
Q

Describe a system for interpreting ECGs

A
  1. Rate: fast or slow?
  2. Rhythm: regular or irregular?
  3. Axis: LAD, RAD
  4. p waves: present? Assoc w each QRS?
  5. PR interval: prolonged or shortened?
  6. QRS: narrow or broad?
  7. ST segment: elevated or depressed?
  8. T wave: inversion?
  9. QTc: prolonged?
35
Q

Name some causes of QTc prolongation

A 
Toxins:
-TCAs
-Amiodarone
Ischaemia
Mitral valve prolapse
Electrolyte abnormality (low K, Mg, Ca)
36
Q

What is a normal axis? RAD? LAD?

A

-30 to 90
LAD: -30 to -90
RAD: 90 to 180

37
Q

How do you assess the axis?

A

Look at leads I and II:

  • If both +: normal
  • If I is - and II is +: RAD
  • I + and II -: LAD
38
Q

What is a normal PR interval?

A

0.12-0.2s OR 3-4 small squares

39
Q

What is a normal QRS width?

A

<0.12s or 3 small squares

40
Q

What is a normal QTc?

A

0.38-0.42s

41
Q

What are the signs of LVH on ECG?

A

Tall R wave in V1, deep S wave in V6

42
Q

What is electrical alternans a sign of?

A

Cardiac tamponade

43
Q

How do you distinguish pacemakers and ICDs on CXR?

A

ICD will have a thick wire, pacemaker wires are thin
Pacemakers often sit in the RA and RV
ICDs often sit in the LV

44
Q

What 4 factors will make you concerned in a patient with arrhythmia?

A

New onset:

  • Heart failure
  • Myocardial ischaemia
  • Shock
  • Syncope
45
Q

Describe the management of severe bradycardia (resus)

A
  1. Atropine 500mcg IV repeat to max 3mg (6 doses)
  2. Transcutaneous pacing
    OR Isoprenaline 5mcg/min IV
    OR adrenaline 2-10mcg/min IV
  3. Transvenous pacing
46
Q

Describe how transcutaneous pacing works

A

Using the defibrillator machine
Apply the pads as in defibrillation: R sternal edge, Apex
Adjust the machine to pacing, choose rate eg. 50-80
Check for electrical capture (on trace) and mechanical capture (pulse)

47
Q

Define syncope and describe the types

A

Syncope is a transient loss of consciousness due to impaired cerebral perfusion.

  • Vasovagal: most common. Assoc w emotions, prolonged standing, etc. Prodrome -> LOC -> recovery
  • Cardiac: caused by structural or electrical problem that impairs blood flow eg. outflow obstruction, arrhythmia
  • Orthostatic: caused by postural drop
48
Q

Describe cardiac syncope

A
  • Usually no prodrome eg. sudden
  • Rapid recovery
  • May have associated CP, SOB, palpitations
49
Q

Describe the diagnostic process for syncope

A
  • History
  • Examination: cardio, neuro
  • ECG
  • Lying + standing BP
  • Bloods: FBC, CRP, U+Es, glucose, TFTs, ?trop
  • Consider: cardiac monitor, echo, CTH, etc
50
Q

Describe the management of vasovagal syncope

A

Conservative:

  • Trigger avoidance, education
  • Hydration, rest

Medical:

  • Fludrocortisone
  • Midodrine (orthostatic)

Cardiology finals (4 decks)

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