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Arrhythmias Flashcards

1
Q

Cardiac arrest rhythms

A

Shockable:
Ventricular tachycardia
Ventricular fibrillation

Non-shockable:
Pulseless electrical activity (all activity except VF/VT including sinus rhythm without a pulse)
Asystole

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2
Q

Tachycardia treatment in unstable pt

A

3 synchronised shocks
Amiodarone infusion

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3
Q

Tachycardia with narrow complex

A

AF
Atrial flutter
Supraventricular tachycardia

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4
Q

Tachycardia with broad complex

A

Ventricular tachycardia
SVT with bundle branch block
AF variation?

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5
Q

Atrial flutter pathophysiology

A

Reentrant rhythm
Electrical signal recirculates atrium in self-perpetuating loop
Atrial contraction at 300bpm
Passess through AVN every 2nd lap due to long refractory period
Ventricular contraction at 150bpm

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6
Q

Atrial flutter associated conditions

A

Hypertension
Ischaemia heart disease
Cardiomyopathy
thyrotoxicosis

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7
Q

Atrial flutter ECG

A

sawtooth appearance of p waves

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8
Q

Atrial flutter treatment

A

Rate/rhythm control - beta blockers / cardioversion
Treat reversible cause
Radiofrequency ablation of reentrant rhythm
Anticoagulation based on CHA2DS2VASc score
No flecanide - 1:1 AV conduction - tachycardia

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9
Q

Atrial fibrillation pathophysiology

A

Disorganised electrical activity overrides SAN
Atrial contraction uncoordinated rapid and irregular
Irregular conduction of electrical impulses to ventricles
Irregularly irregular ventricular contractions
Tachycardia
Heart failure (poor filling duirng diastole)
Risk of stroke

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10
Q

AF presentation

A

Palpitations
SOB
Syncope
Associated conditions - stroke, sepsis, thyrotoxicosis

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11
Q

Irregularly irregular pulse differentials

A

AF
Ventricular ectopics - disappear when HR increases - exercise test

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12
Q

AF on ECG

A

Absent p waves
Narrow QRS tachycardia
Irregularly irregular ventricular rhythm

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13
Q

AF - valvular vs non-valvular

A

Valvular - moderate/severe mitral stenosis or mechanical heart valve - lead to AF
Non-valvular - any other valve pathology, and non-valve pathology

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14
Q

Causes of AF

A

mrs SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension

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15
Q

AF principles of treatment

A

Rate / rhythm control
Anticoagulation to prevent stroke

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16
Q

AF rate control pathophysiology

A

Ventricles fill up by suction/gravity not atrial contraction
Heart rate below 100bpm = more time to fill up
First line

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17
Q

AF rate control options

A
  1. Beta blocker (atenolol 50-100mg OD)
  2. CCB (diltiazem) (not in heart failure)
  3. Digoxin (monitoring, risk of toxicity, only in sedentary people)
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18
Q

AF rhythm control indications

A

Reversible cause
New onset AF
Heart failure
Remain symptomatic despite rate control

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19
Q

AF immediate cardioversion indications

A

AF present for less than 48 hours
Haemodynamically unstable

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20
Q

AF delayed cardioversion indications

A

AF present for more than 48 hours
Stable

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21
Q

AF delayed cardioversion waiting

A

Anticoagulation for minimum of 3 weeks before
Otherwise clot mobilised - stroke
Rate control

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22
Q

AF pharmacological cardioversion

A

Flecanide
Amiodarone (if structural heart disease)

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23
Q

AF electrical cardioversion

A

Sedation/GA
Cardiac defibrillator

24
Q

AF LT rhythm control

A
  1. Beta blockers
  2. Dronedarone (if successful cardioversion)
  3. Amiodarone (heart failure of LV dysfunction)
25
Paroxysmal AF
Intermittent No longer than 48 hours 'Pill in pocket' approach if not underlying structural disease - flecanide Anticoagulation
26
AF anticoagulation
Blood stagnation in atrial appendage Thrombus - embolus - ischaemic stroke Reduces risk of stroke by 2/3rds 3% risk of bleeds
27
Warfarin
Vitamin K antagonist Prolongs prothrombin time International normalised ratio (INR) = prothrombin time of normal adult vs prothrombin time of pt Target INR = 2-3 INR affected by many antibiotics - influence P450 system in liver - influence warfarin INR affected by diet (vit K / P450) - leafy green veg, cranberry juice, alcohol Reversible with vitamin K Half life of 1-3 days
28
DOACs
7-15 hour half life No monitoring No major interactions Equal at preventing strokes / bleed risks Reverse: Andexanet alfa (apixiban and rivaroxaban) Indarucizumab (dabigatran)
29
CHADSVASC
> 1 = consider anticoagiulation Risk of stroke /TIA in pts with AF Congestive heart failure Hypertension A2 = age>75 = 2 Diabetes S2 = stroke/Tia = 2 Vascular disease Age 65-74 Sex (female)
30
ORBIT
Risk of major bleeding while on anticoagulations Low Hb/haemocrit Age 75+ Previous GI / intracranial bleeding Renal function (GFR<60) Antiplatelet medications
31
HAS-BLED
Assess risk of bleeding Hypertension Abnormal renal and liver function stroke Bleeding Labile INRs Elderly Drugs/alcohol
32
Supra-ventricular tachycardias definiton
electrical signal reenters atria from ventricles Self-perpetuating electrical loop Narrow complex tachycardia
33
SVT types
AVN reentrant tachycardia (through AVN) AV reentrant tachycardia (accessory pathway - Wolff-parkinson-white syndrome) Atrial tachycardia - other than SAN
34
SVT acute management
Continuous ECG monitering Valsalva manoeuvre - blow against resistance Carotid sinus massage Adenosine Verapamil Direct current cardioversion
35
Adenosine
Slows cardiac conduction Interrupts AVN / accessory pathway Resets sinus rhythm Rapid bolus into large proximal cannula Asystole/bradycardia Avoid if asthma, COPD, heart failure, heart block, hypotension Warn pt about feeling of dying 6mg then 12mg then 12mg again
36
SVT LT management
Beta blockers CCB Amiodarone Radiofrequency ablation
37
Wolff-Parkinson White Syndrome
Accessory pathway (bundle of Kent) Radio frequency ablation of this = definitive treatment ECG: Short PR interval Wide QRS complex Delta wave If AF/atrial flutter - electrical activity can pass onto ventricles via accessory pathway - polymorphic wide complex tachycardia (do not give antiarrhythmic medication in this case)
38
Radiofrequency ablation
Catheter ablation Heat applied to abnormal area AF Atrial flutter SVT WPW syndrome
39
Torsades de pointes pathophysiology
Polymorphic ventricluar tachycardia Prolonged QT interval (prolonged repolarisation) Random spontaneous depolarisation (afterdepolarisations) Ventricles stimulate recurrent contractions without normal repolarisation Terminate or progress to VT - cardiac arrest
40
Torsades de pointes ecg
QRS height gets progressively smaller, then progressively larger
41
Causes of prolonged QT
Long QT syndrome Antipsychotics Citalopram Flecanide Sotalol Amiodarone Macrolide antibiotics Hypokalaemia Hypomagnesaemia Hypocalaemia
42
Torsades de pointes acute management
Correct cause Magnesium infusion Defibrillation if VT occurs
43
Prolonged QT LT management
Avoid medications Correct electrolyte disturbances Beta blockers (not sotalol) Pacemaker / implantable defibrillator
44
Ventricular ectopics definition
Premature ventricular beats Random electrical discharges outside of atria
45
Ventricular ectopics ECG
individual, random, abnormal broad QRS complexes
46
Bigeminy
Ventricluar ectopics occur after every sinus beat
47
Ventricular ectopics management
Check for anaemia, electrolytes and thyroid abnormalitites reassurance to healthy people Seek expert advice if heart condition or symptoms other than palpitations
48
First degree heart block
Delayed AV conduction Every atrial impulse leads to ventricular contraction PR interval > 0.2s
49
Second degree heart block
Some atrial impulses do not make it to the ventricles Wenckebach's phenomenon (Mobitz type I): Increasing PR interval Until p wave no longer conducts to ventricles - absent QRS PR interval then returns to normal Mobitz type II: Intermittent failure of AV conduction Missing QRS complexes 3:1 block = every 3 p waves, a missing QRS Risk of asystole
50
Third degree heart block
Complete No observable relationship between p waves and QRS Risk of asystole
51
AVN block/bradycardia treatment if unstable/risk of asystole
1. Atropine 500mcg IV (anti-muscarinic - inhibit PNS - pupil dilation, urinary retention, dry eyes, constipation) 2. Atropine repeated (up to 6 doses) 3. Other inotropes (noradrenalin) 4. Transcutaneous cardiac pacing 5. Transvenous cardiac pacing 6. Permanent implantable pacemaker when available
52
Pacemaker indications
Symptomatic bradycardia Mobitz type to AV block Third degree heart block Severe heart failure (biventricular pacemaker) Hypertrophic obstructive cardiomyopathy (ICD)
53
Pacemaker types
Single chamber - RA or RV Dual chamber - RA and RV Biventricular / triple chamber - RA, RV and LV - heart failure - cardiac resynchronisation therapy Implantable cardioverter defibrillators - monitor and deliver shock if detect shockable arrythmia
54
Pacemaker ECG
Sharp vertical line on all leads Before p or QRS = single Before both = dual
55
Pacemaker info
Pulse generator and pacing leads Implanted under left anterior chest wall / axilla 5 years MRI compatible

Cardiology (15 decks)

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