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Cardiology > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What is an arrhythmia?

A

Irregular rhythm of the heart

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2
Q

What is a bradyarrhythmia?

A

Heart rhythms with a rate of < 60 bpm

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3
Q

What are the risks associated with a bradyarrhythmia?

A

Risk of:
sudden cardiac death due to slowing or stopping of the heart

falls - especially in elderly people (due to fainting)

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4
Q

How could patients with bradyarrhythmia present?

A

Lethargy

SOB

Chest pain

Dizziness

Fainting (due to reduced cardiac output and cardiac and cerebral hypoperfusion)

Syncope - episodic and often infrequent (20-40% of patients report and episode of syncope with bradycardia, and this may recur in 10-15% of patients)

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5
Q

What is the aetiology of bradycardia?

A

Sinus node dysfunction
- sinus bradycardia
- sinoatrial nodal pauses/arrests
- sinoatrial nodal exit bock

AV conduction disturbances
- 1st degree AV-block
- 2nd degree AV block (Mobitz I, II, 2:1 block, high degree AV block)
- 3rd degree AV block

AV dissociation
- isorhythmic dissociation
- interference dissociation

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6
Q

What are the common causes of bradyarrhythmias?

A

More common in older people due to degeneration and fibrosis of the conducting system e.g.,
- sinus node disease
- AV block

Ischaemic heart disease

HTN

Thyroid dysfunction

AV blocking drugs e.g., β blockers, CCBs, digoxin

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7
Q

What investigations would you do for bradyarrhythmias?

A

Bedside
- 12-lead ECG : can be performed in primary care if patient is clinically stable

Bloods
- TFT : to exclude thyroid causes
- U&E : to check for electrolyte imbalance

Imaging
- ECHO : once bradyarrhythmia is diagnosed esp. in the presence of symptoms to assess LVEF as this will influence the choice of pacemaker
- MRI : in < 55 years old to exclude cardiomyopathy

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8
Q

What are the red flags that should prompt referral of a bradyarrhythmic patient to secondary care?

A

Patient clinically unstable (e.g., hypotension, impaired consciousness or chest pain)

Ongoing pre-syncope or syncope associated with any bradyarrhythmia

Syncope with the following features:
- abnormal ECG
- HF
- new or unexplained breathlessness
- syncope on exertion
- syncope without prodrome in a patient > 65 years old
- FHx of inherited arrhythmia or sudden cardiac death

Persistent (i.e., continuous and not intermitted) type 2 second-degree heart block or complete heart block whether asymptomatic or not

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9
Q

How is bradyarrhythmia managed?

A

Correct reversible causes e.g., bradyarrhythmia

Chest pain - after ischaemia is treated do further observation on a coronary care unit until bradyarrhythmia resolves

Don’t delay Tx of bradyarrhythmia even if the patient has metabolic derangement

No long term medical therapy (but isoprenaline or adrenaline is sometimes given in high dependency units)

If bradyarrhythmia persists discuss pacemaker treatment with patient

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10
Q

What are the rarer causes of bradyarrhythmias?

A

Inflammatory cardiac disease e.g., sarcoidosis

Infectious diseases e.g., Lyme disease, acute rheumatic fever, infectious mononucleosis

Cardiomyopathies e.g., Leiden dilated cardiomyopathy, amyloidosis

Neurological diseases e.g. myotonic dystrophy, limb girdle muscular dystrophy

Catheter ablation

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11
Q

What are the common pacemaker types, their indications and long-term complications?

A
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12
Q

What are the common bradyarrhythmias, their ECG features, risk factors, symptoms and Mx?

A
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13
Q

How can you classify tachyarrhythmias?

A

Narrow complex

Broad complex

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14
Q

How do you further classify narrow and broad complex tachyarrhythmias?

A

Regular

Irregular

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15
Q

Name the causes of regular narrow complex tachyarrhythmias

A

Sinus tachycardia

AVNRT

AVRT

Atrial flutter

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16
Q

What is AVNRT? What causes it?

A

AV nodal re-entry tachycardia

Two pathways i.e., dual conduction pathways that can pass impulses to and from the AV node

Usually starts following an early beat (ectopic)

Electrical short circuit then occurs where the electrical impulses rotates around the circuit and with each cycle pass to the ventricles

Results in a very fast heartbeat

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17
Q

What is AVRT/WPW?

A

AV re-entry tachycardia

Extra electrical pathway that bypasses the AV node i.e., accessory pathway

This pathway directly connects the atria to the ventricles

Electrical impulses reach ventricles before the normal electrical impulse i.e., pre-excitation

18
Q

What does an ECG of a patient with WPW show?

A

Delta wave

19
Q

What is an atrial flutter?

A

Occurs in atria

Similar to AF as electrical impulses are fired rapidly but the rhythm is regular and organised

Rhythm is due to a re-entry circuit within the atria, where the electrical impulse travels in circles leaving and arriving back at the same point

Atria can beat at 300bpm

20
Q

Name the causes of irregular narrow complex tachyarrhythmias

A

Atrial fibrillation

Multifocal atrial tachycardia

21
Q

What is AF?

A

One of the most common types of arrhythmias

Occurs in the atria

Electrical impulse originates in SA nodes, but many impulses are fired rapidly and at random throughout the atria down to the ventricles

Resulting heartbeat is irregular and usually fast

22
Q

How does AF increase the risk of thrombus formation?

A

Rapid beating of atria means they are unable to empty all the blood they receive into the ventricles

This blood pooling can cause blood clot formation

Can cause embolus in brain (stroke)

Patients are placed on blood thinners to prevent this

23
Q

Name the causes of regular broad complex tachyarrhythmias

A

Ventricular tachycardia

Supraventricular tachycardia (e.g., AVRT, AVNRT) with BBB

24
Q

What is VT?

A

Electrical impulses arise in the ventricles

Ventricles start beating at an abnormally fast, irregular rate

25
Q

What are the symptoms of VT?

A

Weakness

Dizziness

Chest pain

SOB

Collapse

26
Q

What are the causes of VT?

A

Previous MI = scar tissues increases susceptibility to abnormal heart rhythms

Cardiomyopathy

Previous corrective congenital heart surgery

Inherited

N.B. small group of VT patients with structurally normal heart

27
Q

Name the causes of irregular broad complex tachyarrhythmias

A

AF with BBB

Polymorphic VT (i.e., Torsade de pointes)

Pre-excited AF

28
Q

What is the Mx of regular narrow complex tachyarrhythmias?

A

Vagal manoeuvres

Adenosine 6mg rapid IV bolus -> (if no effect) 12mg -> (if no effect) 12mg

Monitor/record ECG continuously

29
Q

What is the Mx of irregular narrow complex tachyarrhythmias?

A

Probable AF

Control rate with beta-blockers (class 2 antiarrhythmics), CCB (class 4 antiarrhythmics)

Heart failure = digoxin or amiodarone

Assess thromboembolic risk and consider anticoagulation

30
Q

If the Mx of regular narrow complex tachyarrhythmias works what should you do?

A

Probable re-entry paroxysmal SVT
- Record 12-lead ECG in sinus rhythm
- If SVT recurs treat again and consider anti-arrhythmic prophylaxis

31
Q

If the Mx of regular narrow complex tachyarrhythmias does not work what should you do?

A

Seek expert help

Possible AF
- control rate (e.g., with beta-blockers)

32
Q

What is the Mx of regular broad complex tachyarrhythmias?

A

VT
- Amiodarone 300mg IV over 20-60 min then 900mg over 24 h

SVT with BBB
- treat as for regular narrow complex tachycardia

33
Q

What is the Mx of irregular broad complex tachyarrhythmias?

A

Seek expert help

DDx include:
- AF with BBB = treat as for irregular narrow complex
- Pre-excited AF = consider amiodarone

34
Q

What is the Mx of irregular broad complex tachyarrhythmias?

A

Seek expert help

DDx include:
- AF with BBB = treat as for irregular narrow complex
- Pre-excited AF = consider amiodarone

35
Q

What are the different of AVRT?

A

ORTHODROMIC - down the AV node and up the accessory pathway

ANTIDROMIC - down the accessory pathway and up the normal AV conduction

36
Q

a) Which patients are given permanent pacemakers?

b) How is it inserted?

c) How does it work?

A

a) Patients with Tx resistant AF

b) implanted beneath the skin below the clavicle and connected to a pacing wire placed inside the heart. Done with AV node ablation

c) delivers a small electrical impulse to stimulate the heart to beat when it is going too slowly

37
Q

a) Which patients are given radiofrequency energy/cryo energy catheter ablation?

b) How is it done?

c) How does it work?

A

a) those with an extra electrical pathway or group of cells who may not have responded well to meds or who cannot/would rather not take meds

b) scar tissue created

c) blocks the area of extra electrical activity causing the arrhythmias. High % of success in treating many types of arrhythmia

38
Q

a) Which patients are given internal cardioversion?

b) How is it done?

c) How does it work?

A

a) patient in whom meds and external cardioversion have been unsuccessful in returning the heart’s rhythm back to a normal sinus rhythm

b) two catheter inserted into the vein in the groin and a small electrode pad is placed on the chest. Patient is sedated for the procedure

c) Low energy electrical shocks are delivered inside the heart.

39
Q

a) Which patients are given an implantable cardioverter defib (ICD)?

b) How is it inserted?

c) How does it work?

A

a) patients who have life-threatening arrythmias

b) larger device than a pacemaker. Placed under the skin below the clavicle. Connected via leads that are placed in the heart

c) determines and stops fast ventricular arrhythmias by using extra paced beats a.k.a ‘anti-tachycardia pacing’ (ATP) or by delivering an electric shock to the heart. Also capable of pacing the heart if it goes too slowly

40
Q

Tachyarrhythmia sources

A

https://www.bhf.org.uk/informationsupport/conditions/arrhythmias/atrial-flutter

https://www.youtube.com/watch?v=-enL5BclTUA&t=170s

https://geekymedics.com/narrow-complex-tachycardia/

https://www.resus.org.uk/sites/default/files/2020-05/G2015_Adult_tachycardia.pdf

https://www.uhs.nhs.uk/Media/UHS-website-2019/Patientinformation/Heartandlungs/Tachyarrhythmias-727-PIL.pdf

https://www.bhf.org.uk/informationsupport/conditions/arrhythmias/atrial-flutter

Cardiology (15 decks)

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