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MD2 Foundation > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What are the main presentations of arrhythmias?

A

Tachyarrhythmias present as palpitations
Bradyarrhythmias present as pre-syncope/syncope
Combination

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2
Q

Why might a severe tachyarrhythmia present as pre-syncope?

A

Decreased ventricular filling time (shorter diastole) > decreased cardiac output

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3
Q

What is the most common cause of rhythm disorders?

A

Ischaemic injury

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4
Q

What characteristics of palpitations is it important to clarify with the patient?

A

Fast heartbeat
Missed beats
Irregular beats
Awareness of forceful beats

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5
Q

Why do palpitations occur in ventricular ectopics?

A 
Heart pauses to compensate for extra heartbeat
Increased diastolic filling time
More blood in ventricle
More force to push blood out
Can feel that force
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6
Q

What does the term cardiac origin mean?

A

Pathology limited to heart

Usually present with all symptoms of cardiac disease

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7
Q

How do people with a systemic origin of arrhythmias present?

A

Don’t have classical symptoms of cardiac disease

Have symptoms of other systemic disease; eg: thyrotoxicosis

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8
Q

How do you elicit a history of palpitations?

A 
Character
How rapid
Ask patient to tap out rhythm
Onset and offset
Precipitants and relieving factors
Associated symptoms
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9
Q

What are possible precipitants of palpitations?

A

Caffeine
Stressful situation
Lying in quiet room on left side

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10
Q

What does having palpitations when lying in a quiet room on your left side suggest?

A

Ectopics

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11
Q

What relieving factors works classically in supraventricular tachycardia?

A

Valsalva manoeuvre > increases parasympathetic activity

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12
Q

What are the possible associated symptoms with palpitations?

A

Chest pain
Dyspnoea
Syncope/pre-syncope

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13
Q

What specific things should you look out for in a cardiovascular exam when a patient presents with palpitations?

A

Heart rate and blood pressure
Apex beat
Murmurs
Signs of heart failure

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14
Q

How can blood pressure indicate management in a patient presenting with palpitations?

A

Tachycardia with low blood pressure > more acute

Tachycardia with high blood pressure > have more time

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15
Q

If a patient presents with increased heart rate at rest, palmar erythema, and a hot and sweaty palm, what does this indicate?

A

Probably stressed

Uncommonly, thyrotoxicosis

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16
Q

If a patient presents with increased heart rate at rest, and sweaty and cold palms, what does this indicate?

A

Probably serious cardiac problem

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17
Q

What does a regularly irregular heart rhythm indicate?

A

Unifocal ectopic

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18
Q

What does an irregularly irregular heart rhythm indicate?

A

Atrial fibrillation

Multifocal ectopic

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19
Q

What can you gather from an apex beat?

A

If in expected place but very forceful > left ventricular hypertrophy
If displaced > dilated heart

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20
Q

How does aortic stenosis cause arrhythmia?

A

Because of left ventricular hypertrophy

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21
Q

How does mitral stenosis cause atrial fibrillation?

A

Dilates atrium > stretched cardiomyocytes > disrupts electrochemical signal

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22
Q

What are the investigations for palpitations?

A

ECG in all patients
- Aim to document exact cardiac rhythm at time of palpitations
Echocardiogram
- Look for underlying structural heart disease
Stress testing/coronary angigography
- If suspicion of ischaemia
- Chest pain with palpitations
- To help determine coronary artery stenosis
Electrophysiology study
- If still can’t find cause of symptoms

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23
Q

What are the devices available for prolonged ECG monitoring?

A

Holter monitor - 24 hours
Event recorder - 7 days
Loop recorder - months-years

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24
Q

If the morphology of the QRS complexes is different in an ECG of a person with ectopics, what does that suggest?

A

Multifocal ventricular ectopic

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25
Q

How do you managed premature ventricular/atrial complexes (ectopics)?

A

Usually benign
Reassurance to patient
Cut down on caffeine intake
Occasionally need to treat with beta blockers/calcium channel blockers if very frequent and symptomatic

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26
Q

What does atrial fibrillation look like on an ECG?

A

No P waves
QRS complexes narrowed
Varied R-R interval > irregularly irregular rhythm

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27
Q

What type of arrhythmia is atrial flutter?

A

Supraventricular tachycardia

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28
Q

What causes atrial flutter?

A

Really irritable automaticity focus in atrium
Fires at 250-300 bpm
Causes atria to contract at 250-300 bpm
AV node acts as gatekeeper
- Ventricles contract at slower rate; eg: 150 bpm, because of refractory period of AV node

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29
Q

What does atrial flutter look like on an ECG?

A

Multiple P waves - not each one followed by QRS complex
- Represent irritable automaticity focus
- In “saw tooth” pattern
Regular R-R interval

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30
Q

What does 3:1 conduction in atrial flutter mean?

A

For every 3 P waves, there’s 1 QRS complex

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31
Q

Where is atrial fibrillation common?

A

Older age groups
Known cardiac disease
Cardiovascular disease factors

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32
Q

What happens in atrial fibrillation?

A

Lose organised signal in atria > atrial spasming

Signal AV node erratically > irregularly irregular rhythm

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33
Q

What are the risk factors for atrial fibrillation?

A 
Diseased atrial tissue
- Age
- Inflammation; eg: from surgery
- Enlarged atria
   - Hypertension
   - Valve disease; eg: mitral stenosis
   - Some lung diseases
- Previous atrial fibrillation
Hormonal abnormalities; specifically thyroid
Alcoholism
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34
Q

What is the natural history of atrial fibrillation?

A 
Silent
Paroxysmal
- First detection
- Without treatment, stops within 48 hours
Persistent
- Last >48 hours
Long-standing persistent
- 1+ year
Permanent
- Normal rhythm now atrial fibrillation
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35
Q

What causes the symptoms in atrial fibrillation?

A

Rapid heart rate

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36
Q

What are the symptoms of atrial fibrillation?

A

Palpitations
Shortness of breath
Chest pain, especially during exertion
May be symptomatic

37
Q

What condition(s) are you at an increased risk of having if you have atrial fibrillation?

A

Stroke

Peripheral embolus

38
Q

How is atrial fibrillation managed?

A

Rule out precipitant; eg:
- Hyperthyroidism
- Infection
Look for cause
Decide whether to control heart rate or maintain sinus rhythm
Evaluate risk of stroke and how best to manage - balance against risk of bleeding

39
Q

What does rhythm control in atrial fibrillation mean?

A

Put back into sinus rhythm

40
Q

Why may you choose rate control over rhythm control in atrial fibrillation?

A

If atrial fibrillation has been going on for >48 hours, don’t want to reinstate atrial kick because probable thrombus will embolise

41
Q

What are possible antiarrhythmic drugs that can be used to control the rhythm in atrial fibrillation?

A

Sotalol
Flecainide
- Contraindicated in structural heart disease
Amiodarone

42
Q

What are possible drugs that can be used to control the rate in atrial fibrillation?

A

Beta blockers
Calcium channel blockers
Digoxin

43
Q

Why is rate control usually safer than rhythm control in atrial fibrillation?

A

Rhythm controlling agents can sometimes cause other significant arrhythmias

44
Q

What does catheter ablation aim to do in atrial fibrillation?

A

Maintain sinus rhythm by preventing signals propagating from atrial fibrillation origin sites

45
Q

Where are common ablation sites for atrial fibrillation?

A

Around pulmonary veins

46
Q

What is supraventricular tachycardia?

A

Abnormally high heart rate at rest

Abnormal heartbeat starts at/above AV node

47
Q

What are the signs and symptoms of supraventricular tachycardia?

A 
Can be asymptomatic
Palpitations
Chest pain
Anxiety
Shortness of breath
Dizzy
- Due to decreased cardiac output > decreased cerebral perfusion
48
Q

What causes 90% of supraventricular tachycardias?

A

Re-entrant circuits within heart

49
Q

What is the most common re-entrant supraventricular tachycardia?

A

AV nodal re-entry tachycardia

50
Q

What is Wolff-Parkinson White syndrome?

A

2 electrical pathways instead of 1
Example of accessory pathway
- Usually connects atria directly to ventricles
- Due to short refractory period, electrical signal goes in loop: atria > ventricles > atria

51
Q

Why is the AV node targeted in treatment for supraventricular tachycardia?

A

Almost all involve AV node in pathway

Treatments aim to interrupt circuit

52
Q

What is postural orthostatic tachycardia syndrome?

A

Increase in heart rate when moving from supine to erect position

53
Q

What are the risk factors for supraventricular tachycardias?

A 
Inherited conditions
Structural abnormalities
Coronary artery disease
Heart failure
COPD
Pulmonary embolism
Alcoholism
Hypertension
Some medications
54
Q

How is supraventricular tachycardia treated acutely?

A

Similar to atrial fibrillation
Vagal manoeuvres
Adenosine
IV verapamil

55
Q

What should you warn your patient about before administering adenosine?

A

Flushing/feeling terrible for few seconds

56
Q

How does adenosine work in treating supraventricular tachycardia?

A

Induces transient AV block

57
Q

Why don’t you need to anticoagulate in supraventricular tachycardia?

A

No risk of thromboembolism

58
Q

What is the longer-term treatment for supraventricular tachycardia?

A 
If symptoms rare/isolated episode - no pharmacological intervention
"Pill in pocket" approach
Pharmacological interventions
- Beta blockers OR
- Calcium channel blockers
Catheter ablation
59
Q

What is ventricular tachycardia?

A

Arises from ventricles
Can reach up to 250 bpm
Decreased filling time > decreased cardiac output
Can lose pulse sometimes

60
Q

What happens when the cause of ventricular tachycardia is focal?

A 
Cells in ventricles irritated
Irritation caused by
- Hormones
   - Stress
   - Thyroid
- Hypoxia
- Stretch; eg: left ventricular hypertrophy
Cells overfire
61
Q

What happens when the cause of ventricular tachycardia is re-entrant?

A

Scar formation
Disrupts normal electrical conduction
Forms loop
Excites ventricles

62
Q

What are the signs and symptoms of ventricular tachycardia?

A

Shorthness of breath > hypoxia
Chest pain > decreased myocardial perfusion
Palpitations
Lightheaded and dizzy > decreased cerebral perfusion
- Can sometimes lose consciousness

63
Q

Why is ventricular tachycardia a medical emergency?

A

Can become ventricular fibrillation

64
Q

What happens in ventricular fibrillation?

A

Ventricular walls spasm > no blood circulating

65
Q

What are the features of ventricular tachycardia on an ECG?

A

Wide QRS complexes

Tachycardia

66
Q

What are the risk factors for ventricular tachycardia?

A 
Coronary artery disease
Electrolyte imbalance; eg: hyperkalaemia
Myocardial infarction
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
67
Q

When should you worry about palpitations?

A 
Documented cardiac arrhythmia at time of symptoms
Past history of cardiac disease
Evidence of cardiac disease on baseline tests
Family history of sudden cardiac death
Severe symptoms
High risk work enviro
High level sporting activities
Before/during pregnancy
68
Q

What are the most common types of syncope?

A

Neurocardiogenic (vasovagal)
Cardiac
Postural hypotension

69
Q

What is syncope?

A 
Transient
Loss of consciousness, self-limited
Onset relatively rapid
Leads to fall
Recovery complete, rapid, spontaneous
70
Q

What questions should you focus on in a syncope history?

A 
Prodrome
Situation
Collateral history = witnesses
- Specific length of loss of consciousness
- Pallor
Recovery
History of previous episodes
71
Q

What are the common symptoms of neurocardiogenic syncope?

A

Pre-syncope symptoms

  • Diaphoresis
  • Headache
  • Nausea
  • Visual changes
72
Q

What are the common signs of neurocardiogenic syncope?

A

Facial pallor
Yawning
Pupillary dilatation

73
Q

What are the common precipitating events of neurocardiogenic syncope?

A

Fear
Emotional distress
Instrumentation
Prolonged standing

74
Q

What are the common symptoms of cardiac syncope?

A 
May be no warning symptoms
Rapid loss of consciousness
Often associated injury
May be exertional or occur when supine
Associated with chest pain/palpitations
Family history of sudden cardiac death
Background of known cardiac disease
75
Q

What is a significant orthostatic drop in blood pressure?

A

Between supine and erect

  • Difference of >20 mmHg in systolic OR
  • Difference of >10 mmHg in diastolic
76
Q

What is heart block?

A

Arrhythmia where signal delayed/blocked

77
Q

What is AV conduction block?

A

Signal delayed/blocked when trying to move from atria to ventricles

78
Q

What is first degree AV conduction block?

A

Delayed… but still makes it

PR interval >0.2 s (5 small boxes)

79
Q

What are the symptoms of first degree AV conduction block?

A

Asymptomatic

80
Q

What is the treatment for first degree AV conduction block?

A

Identify electrolyte imbalances/causes from medications

Usually no further treatment

81
Q

What is type 1 second degree AV conduction block?

A

Also called
- Mobitz I
- Wenckebach
PR interval becomes progressively longer until blocked completely > “dropped beat”
Eventually ventricles contract = ventricular escape beat

82
Q

What are the symptoms of type 1 second degree AV conduction block?

A 
Usually asymptomatic
Sometimes
- Lightheaded
- Dizzy
- Syncope
83
Q

What is type 2 second degree AV conduction block?

A

Also called Mobitz II
Intermittent dropped beats
No progressive lengthening of PR interval
Each time atria do conduct, PR interval stays same length
Written as ratio of conducted:dropped; eg: 2:1 Mobitz II AV block
Can’t predict when next beat dropped

84
Q

What are the symptoms of type 2 second degree AV conduction block?

A

Fatigue
Dyspnoea
Chest pain
Syncope

85
Q

What is third degree AV conduction block?

A

Signal completely blocked

Ventricles struggle along with escape beats at very slow rates

86
Q

What are the symptoms of third degree AV conduction block?

A 
Syncope
Confusion
Dyspnoea
Severe chest pain
Risk of death
87
Q

What is the treatment of third degree AV conduction block?

A

Medication to increase heart rate; eg: atropine
Transcutaneous pacing
- Through electrodes on skin
Permanent pacemaker

88
Q

What are the indications for a permanent pacemaker?

A 
Sinus node dysfunction
- Symptomatic sinus bradycardia
- Sinus pauses >2 sec (day) or >2.5 sec (night)
Symptomatic 2nd/3rd degree AV block
Intermittent 3rd degree AV block
89
Q

How do you treat tachy-brady syndrome?

A

Difficult to treat without pacemaker
- Can’t control tachycardias without worsening bradycardias
Once pacemaker implanted, use AV node blocking agents to control rapid heart rates

MD2 Foundation (42 decks)

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