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pre reg afsha CV > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

what is ectopic heartbeat

A
  • type of of arrhythmia (irregular heartbeat)
  • happens when your heart contracts (beats) too soon
  • heart can also skip a beat or feel like it’s racing or fluttering
  • usually harmless and doesn’t result from an underlying heart problem or health condition
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2
Q

treatment ectopic heartbeat

A
  • rarely needed if ectopic beats are spontaneous and pt has normal HR
  • otherwise, BB are sometimes effective and may be safer than others
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3
Q

2 classifications of arrhythmias

A
  • supra ventricular - occur above ventricles, in atria
  • ventricular
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4
Q

Name the supra ventricular arrhythmias

A
  • AF
  • atrial flutter
  • paroxysmal SV tachycardia
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5
Q

name the ventricular arrhythmias

A
  • ventricular tachycardia
  • ventricular fibrillation
  • torsade de pointes
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6
Q

is an ECG needed to manage arrhythmias

A

Always , helps diagnosis

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7
Q

what is the most common type of arrhythmia

A

AF

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8
Q

how does AF occur

A
  • fast and irregular heart rhythm originates in atria, overriding the SAN which is the hearts natural pacemaker
  • leads to irregular ventricular rhythm
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9
Q

ventricular rate of untreated AF

A

160-180bpm, typically slower in elderly

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10
Q

Pt with AF presents acutely, with suspected concomitant decompensated HF - considerations about drug treatment (2)

A

AVOID CCBS!
Seek specialist advice on use of BB

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11
Q

what is rate control

A
  • preferred 1st line for AF (with some exceptions)
  • reduces the ventricular rate (aka HR)
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12
Q

what is rhythm control

A

attempts to restore normal sinus rhythm of heart

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13
Q

Rate control is first line in AF, except in patients…

A
  • new onset AF
  • atrial flutter suitable for ablation strategy
  • AF with reversible cause (eg chest infection)
  • HF primarily caused by AF
  • rhythm control suitable based on clinical judgement
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14
Q

What does rate control consist of

A

Step 1: mono therapy with any of the following
Step 2: combination therapy with two of the following
Step 3: rhythm control

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15
Q

When would you consider rate control treatment of AF with digoxin

A
  • non-paroxysmal AF who are predominantly sedentary
  • other rate control unsuitable
  • AF accompanied with congestive HF
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16
Q

What is the rate control treatment of AF in pt who have diminished ventricular function (LVEF<40%)

A
  • BB licensed in HF (bisop, carvedilol, nebivolol) + digoxin
  • AVOID CCBS - worsen HF!!
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17
Q

A patient has new onset AF and has had symptoms for <48h, and doesn’t have life threatening haemodynamic instability. What treatment do you offer.

A

Rhythm control

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18
Q

What does rhythm control treatment consist of?

A
  • using an anti-arrhythmic drug e.g. amiodarone, flecainide, propafenone
  • using BB as they help reduce sympathomimetic activity which can contribute to arrhythmias
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19
Q

What would you give if drug treatment is required to maintain sinus rhythm (rhythm control) post cardioversion

A

1st line: standard BB, NOT SOTALOL
- if inappropriate of ineffective, give an anti-arrhythmic e.g. amiodarone, flecainide, propafenone

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20
Q

You are giving rhythm control to a pt with LV impairment & AF - which drug is preferred?

A

amiodarone

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21
Q

In which patients should you not give flecainide & propafenone

A

avoid in known ischaemic (e.g. PAD, angina, atherosclerosis, CAD) or structural heart disease

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22
Q

Verapamil and BB

A
  • Significant drug interaction
  • Caution/AVOID
  • Increases the risk of cardiovascular adverse effects when given with BB
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23
Q

What is cardioversion

A

Uses either electrical current or a drug to put heart back into rhythm

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24
Q

Which drugs would you use for cardioversion

A

Anti-arrhythmic: flecainide, amiodarone

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25
Q

When is electrical cardioversion preferred to pharmacological cardioversion for AF?

A

AF >48h

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26
Q

What to do if you have to give emergency cardioversion, and the patient has not been anti coagulated for at least 3 weeks?

A
  • rule out left atrial thrombus
  • give parenteral AC (heparin) immediately before cardioversion
  • oral AC to be given after cardioversion and continued for at least 4 weeks
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27
Q

Which class of anti arrhythmic drugs should not be given to pt with ischaemic or structural heart disease

A

class 1c: e.g. flecainide, propafenone

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28
Q

If drug treatment for long term rhythm control is needed, consider…

A

standard BB (not sotalol) as 1st line

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29
Q

what is paroxysmal SV tachycardia

A
  • causes heart to suddenly beat faster than normal for a short while
  • occurs in atria
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30
Q

treatment of paroxysmal SV tachycardia

A
  • often stops spontaneously
  • or use reflex vagal simulation e.g. VALSALVA manoeuvre, immerse face in ice cold water, carotid sinus massage
  • these manoeuvres should be perfumed with ECG monitoring
  • if these are ineffective, give IV adenosine
  • if ineffective, IV verapamil (avoid in pt recently treated with BB)
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31
Q

how to treat and prevent recurrent episodes of paroxysmal SV tachycardia

A
  • treat: catheter ablation
  • prevent: dilt, verap, BB including sotalol, flecainide, propafenone
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32
Q

failure to terminate paroxysmal SV tachycardia with reflex vagal stimulation of drug treatment may suggest…

A

… may suggest arrhythmia of atrial origin e.g. focal atrial tachycardia or atrial flutter

33
Q

paroxysmal tachycardia or rapid irregularity after MI - when to treat

A

only administer an anti-arrhthmyic until an ECG has been obtained

34
Q

treating bradycardia, particularly if complicated by hypotension, after MI should be treated with ….

A
  • IV dose of atropine, repeat if necessary
  • if risk of systole, or if pt unstable and has failed to respond to atropine, give IV adrenaline and adjust dose according to response
35
Q

pulseless ventricular tachycardia or ventricular fibrillation requires

A
  • resuscitation
  • IV injection of amiodarone is given in cardiopulmonary resuscitation for VF or pulseless VT refractory to defibrillation
36
Q

Patients with unstable sustained ventricular tachycardia who continue to deteriorate with signs of hypotension or reduced CO should receive

A
  • direct current cardioversion to restore sinus rhythm
  • if this fails, IV amiodarone and repeat direct current cardioversion
37
Q

treatment of pt with sustained ventricular tachycardia who are haemodynamically stable

A
  • IV antiarrhythmics
  • amiodarone preferred
    others include flecainide, propafenone, lidocaine (less effective)
  • if sinus rhythm not restored, direct current cardioversion or pacing should be considered
  • catheter ablation is alternative if cessation of arrhythmia is not urgent
38
Q

treatment of non sustained ventricular tachycardia

A

BB

39
Q

all pt presenting with ventricular tachycardia

A

refer to specialist

40
Q

long term treatment of ventricular tachycardia following restoration of sinus rhythm

A
  • pt who remain at high risk of cardiac arrest will need maintenance therapy
  • most pt treated with implantable cardioverter defibrillator
  • BB or sotalol or amiodarone (in combo with standard BB) can be used in addition to the device in some pt; or be used alone with implantable defibrillator not appropriate
41
Q

what is torsade de pointes

A

ventricular tachycardia associated with long QT interval - usually drug induced, but other factors are implicated e.g. hypokalaemia, severe bradycardia, genetic predisposition

42
Q

episodes of TDP are usually…

A

self limiting but are frequently recurrent and can cause impairment or loss of consciousness

43
Q

what can happen if TDP is not controlled

A

arrhythmia can progress to ventricular fibrillation and sometimes death

44
Q

treatment TDP

A
  • IV magnesium sulphate is usually effective
  • can consider a BB (not totally) and atrial (or ventricular) pacing
45
Q

are anti-arrhythmic drugs used for TDP and why

A

non because they can further prolong QT interval, thus worsening condition

46
Q

clinical classification of anti-arrhythmic drugs according to where they act - provide examples of each

A
  • act on SV arrhythmias e.g. verapamil
  • act on both SV and V arrhythmias e.g. amiodarone
  • act on V arrhythmias e.g. lidocaine
47
Q

vaughan williams classification of anti-arrhythmic drugs is based on

A

the effects of the drugs on the electrical behaviour of myocardial cells during activity

48
Q

what are the 4 classes of the Vaughan Williams classification

A
  1. membrane stabilising drugs e.g. lidocaine, flecainide

2: BB

  1. amiodarone, sotalol (also class 2)
  2. CCBs (incl verapamil but not dihydropyridines)
49
Q

what to do if 2 or more anti-arrhythmic drugs are prescribed

A
  • negative inotropic effects are usually additive - aka weakens contractions and slows HR
  • therefore special care is required, esp if impaired myocardial function
50
Q

SV arrhythmias - treatment to terminate paroxysmal SV tachycardia

A
  • adenosine
  • short duration of action (half life ~8-10seconds, but prolonged if taking dipyrimadole) so most SE short lived
  • can be used after a BB (unlike verapamil)
  • verapamil may be preferable to adenosine in asthma
51
Q

in which arrhythmias are cardiac glycosides contraindicated

A

SV arrhythmias associated with accessory conducting pathways (e.g. Wolff Parkinson White syndrome)

52
Q

oral administration of a cardiac glycoside e.g. digoxin slows the …. rate in cases of AF and atrial flutter

A

ventricular

53
Q

IV infusion digoxin is …. ……. for rapid control of ventricular rate

A

rarely effective

54
Q

which CCB is usually effective for SV tachycardias

A
  • verapamil
  • initial IV dose may be followed by oral treatment
  • hypotension can occur with large doses
55
Q

verapamil and BB interaction

A

verapamil contraindicated if BB - risk of reduced CO and HF!!

56
Q

when should verapamil not be used (3)

A
  • do not use for tachyarrhythmias where QRS complex is wide (broad complex) unless SV origin has been established
  • contraindicated in AF or atrial flutter associated with accessory conducting pathways (e.g. Wolff Parkinson White syndrome)
  • do not use in children with arrhythmias w/o specialist advice as some SV arrhythmias in children can be accelerated by verapamil with dangerous consequences
57
Q

IV administration of … can be used to achieved rapid control of ventricular rate

A

BB e.g. esmolol or propranolol

58
Q

drugs for both SV and V arrhythmias

A
  • amiodarone
  • BBs
  • diopyramide
  • flecainide
  • procainamide (special)
  • propafenone
59
Q

for which arrhythmias can amiodarone be used for

A
  • PSV
  • nodal and ventricular tachycardia
  • AF and flutter
  • ventricular fibrillation
  • tachyarrhythmias associated with Wolff Parkinson White syndrome
60
Q

who can initiate amiodarone

A

only under hospital or specialist supervision

61
Q

advantage of amiodarone

A

causes little or no myocardial depression

62
Q

oral vs IV amiodarone

A

unlike oral, IV acts relatively rapidly

63
Q

half life and dosing of amiodarone

A
  • very long half life (several weeks) and only needs to be given OD
  • high doses can cause nausea unless divided
  • many weeks or months may be needed to achieve steady-state plasma-amiodarone conc
  • this is particularly important when drug interactions are likely
64
Q

explain how BBs act as anti-arrhythmic drugs

A
  • attenuate effects of sympathetic system on automaticity and conductivity within the heart
65
Q

sotalol can be used for…

A

management of ventricular arrhythmias

66
Q

use of disopyramide

A
  • can be given via IV injection to control arrhythmias after MI, including those not responding to lidocaine
  • but it impaired cardiac contractility
  • oral administration is useful but has antimuscarinic effect which limits its use in pt susceptible to CAG or with prostatic hyperplasia
67
Q

dose for flecainide when concurrent use of amiodarone

A

reduce dose by half with concurrent use of amiodarone

68
Q

use of propafenone

A

used for prophylaxis and treatment of ventricular arrhythmias and also for some SV arrhythmias

69
Q

use of propafenone in obstructive airways disease and why

A

has weak beta-blocking activity to caution in obstructive airways disease, contraindicated if severe

70
Q

name 3 drugs for SV arrhythmias

A

adenosine, cardiac glycosides, veramapil

71
Q

name a drug used for ventricular arrhythmias

A

lidocaine

72
Q

pt presenting with acutely w/o haemodynamic instability with new onset AF

A
  • Offer rate or rhythm control if onset <48 hours
  • Rate control preferred if onset >48h/uncertain
73
Q

pt acutely presents with life-threatening haemodynamic instability caused by new onset AF

A

pt to undergo emergency cardioversion without delaying to achieve anticoagulation

74
Q

what are some symptoms of haemodynamic instability

A
  • rapid pulse (>150bpm)
  • low BP (systolic <90)
  • unconscious
  • severe dizziness/syncope
  • ongoing chest pain
  • increasing breathlessness
75
Q

4 most common causes of AF

A
  • ischaemic heart disease
  • valvular heart disease
  • hypertension
  • hyperthyroidism
76
Q

complications of AF

A
  • stroke: atria do not have enough time to fully contract and empty blood, leading to blood pools, clot formation, and embolus
  • TIA
  • heart failure: heart cannot pump blood efficiently around body
77
Q

symptoms of AF

A
  • palpitations
  • floppy fish in chest (pounding or fluttering)
  • dyspnoea
  • dizzy, syncope
  • tired
  • polyuria
  • reduced exercise tolerance
  • irregular pulse!
78
Q

describe an ECG of a pt with AF

A

No p waves, chaotic baseline, irregular ventricular rate

79
Q

when to suspect AF - pulse

A

irregular pulse
absence of irregular pulse = unlikely!

pre reg afsha CV (37 decks)

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