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CARDIOLOGY > ARRHYTHMIAS > Flashcards

ARRHYTHMIAS Flashcards

1
Q

Normal QRS

A

Rate = 60-100
Regularity = R-R interval is same

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2
Q

Wide QRS

A

Ventricular Tachycardia

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3
Q

Normal sinus Rhythm

A

Normal P wave before every QRS
Upright P wave in Lead II
Biphasic P wave in V1

Every P wave followed by QRS

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4
Q

Normal Intervals

A

PR interval = 0.12-0.21 s
QT interval = <0.4 s

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5
Q

Sinus Tachycardia (5)

A

> 100 bpm
Normal p wave followed by QRS
Regular R-R interval
Narrow QRS
Camel hump (P merge with T)

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6
Q

Sinus Tachycardia- Pathophysiology

A

Sympathetic activation or vagal withdrawl on SA node

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7
Q

Sinus Tachycardia- Causes (3)

A

1- Increased sympathetic tone e.g. exercise, anxiety, pain, pregnancy
2- Alcohol, caffeine, drugs e.g. B-adrenergic agonists, anticholinergic drugs
3- Systemic etiology: fever, hypotension, hypovolemia, anemia, thyrotoxicosis, CHF, MI, shock, pulmonary embolism

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8
Q

Sinus Tachycardia- Treatment

A

Treat underlying cause
Consider beta blockers if symptomatic (if beta blocker is contraindicated use CCB)

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9
Q

Respiratory Sinus Arrhythmia

A

Change in sinus rhythm during respiration
Inspiration —> Faster
Expiration —> Slower

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10
Q

Supraventricular Tachycardias (2)

A

Arising above the level of the Bundle of His

Narrow QRS

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11
Q

Paroxysmal Supraventricular Tachycardia- Overview (2)

A

1- In young patients with no structural heart disease, abrupt onset and offset
2- Seen with re-entry tachycardia

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12
Q

Paroxysmal Supraventricular Tachycardia- Types (2)

A

1- AVRT (Atrioventricular)
- Anatomical reentry; accessory pathway (extra piece of conducting tissue between atria and ventricles)
- e.g. Wolf-Parkinson-White (WPW) syndrome: short PR interval, delta wave

2- AVNRT (AV node) (more common)
- Functional reentry within AV node (fast and slow pathways in AV node)

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13
Q

Paroxysmal Supraventricular Tachycardia- ECG (4)

A

1- Regular, 250bpm (fast)
2- Narrow QRS
3- P-wave sometimes hidden in QRS (bc it’s very fast)
4- ST depression

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14
Q

Paroxysmal Supraventricular Tachycardia- Treatment (3)

A

1- Termination by acutely blocking AV nodal conduction
- 1st line —> vagal manuevers, carotid massage. If not terminated —> IV Adenosine
- 2nd line —> IV BB, Diltiazem (CCB), Verapamil (CCB)
2- Preferred to cure: ablation of accessory pathway
3- Unstable patient: emergency cardioversion

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15
Q

Atrial Fibrillation- Overview (3)

A

1- Irregularly irregular, no p-waves (only fine oscillations), narrow QRS
2- Can be fast or slow depending on AV conduction
3- Tachycardia with an irregularly irregular pulse

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16
Q

Atrial Fibrillation- Most feared complications (3)

A

V. Fib, Embolism, Stroke

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17
Q

Atrial Fibrillation- Symptoms (5)

A

Palpitations, Fatigue, Dyspnea, Syncope, may precipitate or worsen heart failure

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18
Q

Atrial Fibrillation- Causes (7)

A

Cardiac (most common):
- MI
- Mitral stenosis
- HTN

Non-cardiac:
- Thyrotoxicosis
- Pulmonary embolism
- Alcohol
- Hypokalemia

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19
Q

Atrial Fibrillation- Diagnostic Approach (4)

A

1- Suspected A.Fib —> obtain an ECG
2- Confirmed A.Fib (new diagnosis) —> echo to assess cardiac function and rule out underlying structural cardiac disease (MS)
3- If A.Fib is not confirmed on ECG but strong clinical suspicion —> Holter monitor
4- Investigate for underlying cause

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20
Q

Atrial Fibrillation- Treatment (5)

A
  • If patient is hemodynamically unstable —> DC cardioversion
  • If patient is stable:
    1- Rate control (to decrease heart rate):
    - BB, CCB
    - Digoxin
    2- Rhythm control:
    - Electrical —> DC cardioversion
    - Pharmacological:
    - If structural heart disease —> amiodarone
    - If no heart disease —> flecianide, or propafenone
    3- Anticoagulation
    - Valvular A.Fib (prosthetic or moderate-severe MS) —> anticoagulate all with warfarin or NOACs
    - Non-valvular A.Fib —> decide on anticoagulation using the CHA2DS2VASc score
    4- Treatment of underlying cause
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21
Q

CHA2DS2VASc score (8)

A
  • CHF or LVEF <= 40% (1) score of 0 —> no prophylaxis
  • Hypertension (1) score of 1 —> aspirin
  • Age > 75 (2) score of 2 or more —> warfarin or NOAC
  • Diabeties (1)
  • Stroke/TIA/Thromboembolism (2)
  • Vascular disease (1)
  • Age 65-74 (1)
  • Female (1)
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22
Q

Atrial Flutter - Overview (3)

A
  • No p-waves; saw-toothed flutter waves
  • Always some degree of AV block (2:1, 3:1, 4:1)
    • 150bpm, 2:1. After vagal maneuver goes to exactly 75 bpm (characteristic)
  • Often occurs with A.Fib
23
Q

Atrial Flutter - Associated with (5)

A
  • Underlying heart disease, cardiomyopathy, COPD, hyperthyroidism, hypertension
24
Q

Atrial Flutter - ECG

A

Sawtoothed waves better seen in inferior leads (II, III, aVF)

25
Q

Atrial Flutter - Treatment (4)

A
  • If unstable (e.g. hypotension, CHF, angina) —> electrical cardioversion
  • If stable:
    • Rate control: BB, Dilitiazem, Verapamil, or Digoxin
    • Chemical cardioversion: Sotalol, Amiodarone, Type I antiarrhythmatics, or electrical cardioversion
  • Anticoagulation (guidlines same as patients with A.Fib)
  • Treatment of long-term atrial flutter includes anti-arrhythmics (Amiodarone, Flecianide, Propafenone) and radiofrequency or catheter ablation
26
Q

Multifocal Atrial Tachycardia- Overview (6)

A
  • A rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria
  • Most commonly seen in patients with severe COPD or congestive heart failure
    • Characteristically commonly seen in COPD. Other hints to COPD: right axis deviation, tall R wave in V1 and deep S wave in V6 (due to right ventricular hypertrophy - cor pulmonale)
  • Usually a transitional rhythm between frequent premature atrial complexes (PACs) and atrial fibrillation (differentiate from A.Fib as both have irregular narrow complex tachycardia)
  • Heart rate >100bpm (usually 100-150bpm; may be as high as 250bpm)
  • Irregulary irregular rhythm with varying PP, PR, and RR intervals. No flutter waves
  • At least 3 distinct p-wave morphologies in the same lead
27
Q

Multifocal Atrial Tachycardia- Treatment

A

Resolves following treatment of the underlying disorder

28
Q

Multifocal Atrial Tachycardia- Progonisis

A

Considered by a poor prognostic sign when developing during an acute illness (—> increased mortality due to the underlying illness)

29
Q

Ventricular Tachycardia - Definition (2)

A
  • Arising below the level of the Bundle of His.
  • Wide QRS
30
Q

Ventricular Tachycardia - Overview (5)

A
  • 3 or more consecutive premature ventricular beats
  • Regular, Rate > 100 (usually 140-200)
  • Sustained if > 30 secs; non-sustained < 30 secs
  • Wide aberrant bizzare-shaped QRS
  • Capture beats and fusion beats
31
Q

Ventricular Tachycardia - Symptoms (6)

A
  • Dizziness, syncope, SOB, chest pain, palpitations, sudden death
32
Q

Ventricular Tachycardia - Causes (2)

A
  • IHD
  • Cardiomyopathy (hypertrophic/dilated)
33
Q

Ventricular Tachycardia - Types (2)

A
  • Monomorphic (more common)
  • Polymorphic (torsade’s)
34
Q

Ventricular Tachycardia - Treatment (3)

A
  • Hemodynamically unstable: electrical cardioversion (100J)
  • If hemodynamically stable: electrical cardioversion, amiodarone, Type I agents (procainamide, quinidine)
  • Correction of reversible causes (hypokalemia, ischemia, HF, hypotension)
35
Q

Torsade’s de points - Definition (4)

A

Polymorphic ventricular tachycardia (twisting of the axis: beat to beat variation in QRS shape), usually occurs in patients with a baseline of QT prolongation due to:
- Congenital Long QT syndrome
- Drugs: class IA (quinidine), class III (sotalol), phenothiazines (TCAs), erythromycin, quinolones, antihistamines
- Electrolyte disturbances: Hypokalemia, hypomagnesemia

36
Q

Torsade’s de points - Treatment

A

IV Magnesium sulfate. Correct the underlying cause of prolonged QT

37
Q

Ventricular Fibrillation - Definition

A

A very rapid and irregular ventricular activation with no mechanical effect and therefore no cardiac output

38
Q

Ventricular Fibrillation - Presentation

A

Patient pulseless and becomes rapidly unconscious, and respiration ceases (cardiac arrest)

39
Q

Ventricular Fibrillation - Treatment

A

Immediate defibrillation
Survivors at high risk of sudden death and treatment is with an ICD

40
Q

Cardioversion Vs Defibrillation (5)

A

Cardioversion:
- Shock in synchrony with QRS complex
- Has a pulse but hemodynamically unstable
- A.Fib, atrial flutter, SVT, VT with a pulse
- 50-200 Joules
- Elective, patient awake and frequently sedated

Defibrillation:
- Shock NOT in synchrony with QRS complex
- Patient is pulseless
- V.Fib, VT without pulse
- 200-360 Joules
- Emergency, patient is unconscious

41
Q

Sinus Bradycardia - Definition

A

< 60 bpm. Normal p-wave followed by QRS. Regular (regular R-R interval)

42
Q

Sinus Bradycardia - Causes (3)

A
  • Normal —> during sleep, athletes
  • Extrinsic to heart: BB intake, hypothyroidism, hypothermia
  • Intrinsic to heart:
    • Acute ischemia and infarction of the node (complication of MI)
    • Degenerative changes: fibrosis of atrium and node “sick sinus syndrome”
43
Q

Sinus Bradycardia - Treatment (2)

A
  • Could be normal/stop offending agent (BB, CCB)/Atropine
  • Patients with persistent symptomatic bradycardia treated with a permanent cardiac pacemaker
44
Q

Sick Sinus Syndrome- Definition

A

Failure of sinus node to depolarize (sinus arrest) or failure of the sinus impulse to propagate to the atria (sinoatrial block) —> BRADYCARDIA —> this will cause ectopic pacemaker activity and tachyarrhythmias (tachy-brady syndrome)

45
Q

Sick Sinus Syndrome- ECG

A

Severe sinus bradycardia or intermittent long pauses between consecutive P waves

46
Q

Sick Sinus Syndrome- Treatment (2)

A

Permanent pacemaker insertion and anti-coagulation

47
Q

AV Blocks - 1st Degree (2)

A
  • AV conduction excessively slowed (but all conducted)
  • Constant PR
48
Q

AV Blocks - 2nd Degree

A

AV conduction occasionally blocked
- Mobitz I: PR increases progressively until beat dropped
- Mobitz II: PR is constant then beat is dropped

49
Q

AV Blocks - 3rd Degree (complete heart block)

A

AV conduction is completely blocked
- P waves marching through
- QRSs without correlating P waves

50
Q

AV Blocks - Treatment (2)

A
  • Unstable: Atropine then percutaneous pacing
  • Mobitz II and 3rd degree: Pacemaker
51
Q

Bundle Branch Blocks - Left bundle branch block (4)

A
  • Wide QRS
  • Broad R with prolonged upstroke in the lateral leads (I, aVL, V5, V6)
  • ST depression and T wave inversion
  • Reciprocal changes in V1 and V2
52
Q

Bundle Branch Blocks - Right Bundle Branch Block (4)

A
  • Wide QRS
  • RSR’ in V1 and V2 (rabbit ears)
  • ST depression and T wave inversion
  • Reciprocal changes in the lateral leads (I, aVL, V5, V6)
53
Q

Anti-arrhythmics (4)

A

NO BODY KNOWS CARDIOLOGY

1- No —> Na channel blockers
- Increased AP —> quinidine procainamide
- Decreased AP —> lidocaine
- Same AP —> Flecianide

2- Body —> Beta blockers
- MOA: decreased HR, decreased force of contraction, decreased BP
- e.g. Propanolol, atenolol, bisoprolol
- side effects: bradycardia, increased intermittent claudication, decreased glucose tolerance

3- Knows —> K channel blockers
- e.g. Amiodarone, sotalol
- side effects: hypo/hyperthyroidism, skin, liver toxicity, corneal micro-deposits

4- Cardiology —> Ca channel blockers
- Non dihydro: verapamil, dilitazem

54
Q

Anti-arrhythmics - General rules

A

If hemodynamically stable:
- Bradycardia: Atropine
- Supraventricular tachycardia: ABCD (adenosine, BB, CCB, digoxin)
- Ventricular tachycardia: LAPS (Lidocaine, Amiodarone, Procainamide, Sotalol)

If hemodynamically unstable:
- Bradycardia: Pacemaker
- Tachycardia: DC shock

CARDIOLOGY (22 decks)

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