Arrhythmias

Question 1

The Three main types of Arrhythmias are:

Answer 1

1)Atrial Fibrillation
2)Ventricular Arrhythmias (or ventricular fibrillation) - MOST dangerous and requires resuscitation
3)Paroxysmal supra-ventricular arrhythmias

Question 2

Difference between Af and ectopic beats?

Answer 2

• Ectopic beats: spontaneous and go away alone - no treatment
  
  • If treatment needed, use a beta blocker

Question 3

ATRIAL FIBRILLATION

Answer 3

more serious, Abnormal disorganised signals-fired casing the atria to quiver or fibrillate = rapid and irregular heart beat

Question 4

Symptoms

Answer 4

• Heart Palpitations = pounding/fluttering
  
  • SOB and dizziness,tiredness

Question 5

Complications

Answer 5

Stroke and heart failure

Question 6

Types of AF

Answer 6

• Paroxysmal AF: episodes stop within 48 hours without treatment
  
  • Persistent AF :Episodes last more than 7 days
  • Permanent AF: present all the time

Question 7

AF could ….

Answer 7

• Can lead to stroke, values are not emptying as they should - blood doesn’t fully eject = clots
  
  • Patients should be assess for strokes
  • Manage through ventricular rate or rhythm control

Question 8

There are two treatment pathways for Atrial fibrillation:

Answer 8

1) Rate control - controls ventricular rate
Rhythm - control restores and maintains sinus rhythm

Question 9

Cardio version

Answer 9

• 1)electrical - using direct current
  2)Pharmacological - Using an anti - arrhythmic

Question 10

Can’t give if symptoms

Answer 10

have lasted more than 48 hours- increased risk of stroke

Question 11

Electrical

Answer 11

• Electrical is preferred if it has lasted more than 48 hours
  
  • Need to wait until the patient is fully coagulated for 3 weeks before cardio version can be used and continue this for 4 weeks after
  • If haemdynamically unstable, then emergency electrical cardio version - give a parenteral anticoagulant and rule out left atrial thrombus immediately before the procedure - this needs to be done ASAP to ensure that anti coagulation is not delayed

Question 12

Acute NEW onset presentation:

Answer 12

• As discussed, if life threatening haemodynamic instability - electrical cardioversion
  
  • If no life threatening haemodynaic instability …..
    . Less than 48 hours = Rate or rhythm control(electrical or aminodarone/flecainide)
    .More than 48 hours = rate control (verapamil, beta blocker but not sotalol)

Question 13

Maintenance Drug treatment:
1st line:

Answer 13

• RATE control: Beta blocker (not sotalol), rate limiting calcium Chanel blocker( eg, verapamil, diltiazem), digoxinMono therapy -Dual Therapy - Rhythm controlMono therapy used in patients that are specific and predominantly sedentary patients with non specific paroxysmal AFRate control Dual therapy CCB used is diltiazem only

Question 14

2nd line: RHYTHM CONTROL

Answer 14

• Beta Blocker or Oral Anti -arrhythmic drug
  (eg,sotalol,amiodarone,flecanide,propafenone,dronedarone)

Or ELECTRICAL

If over 48 hours we go for electrical cardio version but there is always a risk of clotting so patient must be sully anti-coagulated for at least 3 weeks
Or / and give oral anticoagulation - continued for at Lear 4 weeks after cardio version

Question 15

Paroxysmal (SUDDEN) OR Symptomatic Atrial fibrillation:

Answer 15

• Ventricular rhythm is controlled with standard beta blocker
  
  • If symptoms persist use SPAF
  • Patients with episodes of paroxysmal AF
  • Sinus rhythm can be restored using ‘pill in the pocket approach - flecainide/propafenone when required on symptoms

Question 16

We have to keep treating clots; STROKE Prevention - CHADsVASc

Answer 16

Only Men with score of 0 and women with score of 1 do not require any thromboprophylaxis!!

Thromboprophylaxis Options: Warfarin or NOACs in non valvular AF)

New onset of AF: Parenteral anti- coagulant

Question 17

Atrial Flutters:

Answer 17

Treated using rhythm or Rate but usually reacts less effectively with drug treatment.
Rate control is usually temporary and used until sinus rhythm is restored
Using beta blockers or rate limiting calcium Channel blockers

Rhythm control uses Cardioversion - direct current, Pharmacological cardioversion BUT catheter catheter ablation is more suitable

Patient needs to be assessed for stroke still and need to be put on an anticoagulant IV 3 weeks before and 4 weeks after

Tachycardia= Fast heart Rate
Bradycardia = Slower heart rate

Question 18

Ventricular Arrhythmias:

Answer 18

The most dangerous!!!!!!!!!!!!!!

- Pulseless or fibrillation = immediate defibrillation and CPR (IV amiodarone is given refractory to defibrillation)
- Unstable sustained ventricular tachycardia = direct current cardioversion. If fails give IV amiodarone and repeat direct current 
- Stable - Sustained ventricular tachycardia - IV anti arrhythmic drug(amiodarone is preferred)
- Non sustained ventricular tachycardia -Beta blocker 

Maintenance treatment:
For patients at risk of a cardiac arrest;
- Most pts have a cardioverter defibrillator implant
- Some patients also require a drug:solatol, beta blocker alone or beta blocker and amiodarone

Torsdae De Pointes (Prolonged QT interval)
- Treatment: magnesium Sulphate (+beta blocker) (not sotalol) - consider atrial and ventricular pacing)- NEVER USE ANTI- ARRHTHMICS - they prolong QT interval further - symptoms are worse
Causes:
- Sotalol and other drugs that prolong QT interval , hypOKalaemia and bradycardia
- This can be caused by drugs, especially ones that cause hypokalaemia and severe bradycardia - Amiodarone,amiodarone,sotalol,macroloids,haloperidol,SSRI’s,TCA’s and anti fungal

Question 19

Amiodarone

Answer 19

This is used to treat Supra-ventricular tachycardia (heart beating faster than normal)

The effects of adenosine are enhanced by dipyridamole(anti-platelet) and blocked by theophylline’s.Should be avoided with asthmatic patients, can cause bronchospasm.

Mechanism of action:
- Causes transient heart block in the AV node
- Agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyper polarisation by increasing outward potassium flux
- Adenosine has a very short half life 8-10 seconds

Adenosine should be ideally given as an infusion via a large calibre cannula due to its short half life

Adverse effects -
- Chest pain
- Bronchospasm
- Transient flushing
- Can enhance conduction down accessory pathways resulting in increased ventricular rate - (WPW syndrome)- wolf Parkinson white syndrome