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Cardio > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

Arrhythmia cardiac causes

A

IHD
Cardiomyopathy
Myo/pericarditis

Aberrant conduction pathways
Structural changes

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2
Q

Arrhythmia non-cardiac causes

A

Caffeine, smoking, alcohol
Drugs (beta2-agonists, digoxin, l-dopa, tricyclics)

Metabolic imbalance
Phaeochromocytoma

Pneumonia

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3
Q

Arrhythmia history qs

A

Detailed history of palpitations (speed, rate, precipitating factors)

Drug Hx
Family Hx of cardiac disease + sudden death

Syncope during exercise

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4
Q

Continuous ECG monitoring options

A

Telemetry - in hospital for high risk (e.g. post STEMI)
Exercise ECGs
Holter monitors (worn during daily life)
Loop recorders - pt clicks button to save, following event
Pacemakers + ICDs store data of activity

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5
Q

What is sick sinus syndrome

A

Usually caused by SAN fibrosis, typically in elderly

Variable dysfunction, can be tachy or brady, or both

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6
Q

Sick sinus syndrome management

A

VTE prophylaxis if AF episodes

Permanent pacemakers for symptomatic bradycardia/ sinus pauses

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7
Q

Narrow complex tachycardia definition

A

ECG shows rate >100bpm and QRS <120ms

Ventricles depolarised via normal conduction pathways

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8
Q

Irregular narrow complex tachycardias

A

Sinus arrhythmia/ sinus rhythm + ectopic beats
AF
Atrial flutter with variable block, irregular ventricular rhythm
Multifocal atrial tachycardia (usually associated with COPD)

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9
Q

Regular narrow complex tachycardias

A

Sinus tachycardia from SAN

Focal atrial tachycardia (Atrial cell group outpaces SAN)
Atrial flutter (sawtooth baseline, ventricular rate is factor of 300)

AVRT - atria->AVN->ventricles->atria via accessory pathway
AVNRT (circuits within AVN)

Junctional tachycardia - AVN cells pace
Bundle branch block

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10
Q

All tachycardia initial emergency management

A

Check pulse -> arrest protocol if not present, otherwise:
O2 if sats<90, IV access + 12 lead ECG
Check for adverse signs then get expert help if present

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11
Q

Narrow complex tachycardia emergency management with adverse signs

A

Expert help
Sedation

Up to 3 DC shocks:
70-120J for first (120-150 in AF)
then 120-360J for subsequent

Correct K, Mg, Ca abnormalities

Amiodarone 300mg IV over 20mins, consider repeat shock then 900mg/24h IVI via central line

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12
Q

Tachycardia adverse signs

A

Shock
Chest pain/ Ischaemia on ECG
Heart failure
Syncope

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13
Q

Narrow complex tachycardia emergency management no adverse signs

A

No regular rhythm then treat as AF

Start continuous ECG trace if regular rhythm, vagal manoeuvres (carotid sinus massage, Valsalva)

If failed then adenosine 6mg bolus IV, then 12mg, further 12mg if necessary

Verapamil 2.5-5mg over 2 mins if adenosine CI/ fails
If sinus rhythm achieved, assess ECG and consider referral

If sinus not achieved, potential atrial flutter so rate control with beta-blocker + expert help

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14
Q

Acute AF treatment

A

If onset <48h or effectively anti-coagulated >3wk, consider cardioversion with shock or flecanide 300mg PO (if no structural damage) or amiodarone 300mg IVI over 20-60mins

Rate control
Anticoagulation with warfarin NOAC

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15
Q

Acute AF treatment - rate control

A

Rate control:

Beta-blocker (bisoprolol 1-10mg IV) or
Rate-limiting Ca channel blocker e.g. Verapamil 5-10mg IV (not with bb)

Digoxin 500µg PO in heart failure

Amiodarone (may also control rhythm)

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16
Q

Broad complex tachycardia definition

A

ECG shows rate >100 and QRS >120ms

If no clear QRS then VF or asystole

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17
Q

Broad complex tachycardia differentials

A

VF
VT
Torsade de pointes (polymorphic VT, VT with varying axis)
Antidromic AVRT
Narrow complex tachycardia combined with BBB or metabolic broad QRS

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18
Q

ECG making VT more likely than SVT

A

+ve/-ve concordance in all chest leads

QRS>160ms

LAD
AV dissociation

Fusion/capture beats
RSR’ pattern where R is taller than R’

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19
Q

Ventricular ectopic beat types

A

Bigeminy - ectopic alternate beats
Trigeminy - every 3rd beat is ectopic
Couplet - 2 ectopic beats together
Triplet - 3 ectopic beats together

20
Q

When to investigate ventricular ectopics

A

> 60/hour
Couplets/triplets
Post-MI

21
Q

Broad complex tachycardia emergency management with adverse signs

A

Expert help
Sedation

Up to 3 DC shocks, 120-150J for first then 150-360J for subsequent

Correct K, Mg, Ca abnormalities

Amiodarone 300mg IV over 20mins, consider repeat shock then 900mg/24h IVI via central line

Further cardioversion if needed
For refractory, expert help + consider procainamide/ overdrive pacing

22
Q

Broad complex tachycardia emergency management no adverse signs

A

Correct electrolyte problems

If regular rhythm:
Give amiodarone 300mg IV over 20mins then 900mg/24h
If known SVT + BBB, treat as narrow complex

If irregular rhythm:
Expert help

If no success, sedation then synchronised DC shock 150-200J, 150-360J x2

23
Q

AF features

A

300-600bpm
Irregularly irregular
Apical pulse greater rate than radial
1st heart sound variable intensity

24
Q

AF causes

A

Heart failure
MI
PE

HT

Hyperthyroidism
Caffeine/alcohol

Post-op

25
Q

AF tests

A

ECG: absent P waves, irregular QRS

Echo for LA enlargement, mitral valve disease, poor LV function

26
Q

Chronic AF management

A

Anticoagulation
Beta-blocker/ Verapamil for rate control, digoxin added if needed

Rhythm control with elective DC cardioversion (echo first for thrombi) or Flecainide for pharm cardioversion
AVN ablation with pacing in refractory to rhythm control

Sotalol/ flecainide PRN for paroxysmal infrequent AF with BP>100 systolic + no LV dysfunction

27
Q

Atrial flutter treatment

A

Same as AF regarding rate + rhythm control

DC cardioversion preferred to pharm, start with 70-120J

28
Q

Anticoagulation in chronic AF

A

CHADSVASC score, balanced against risks for anticoagulation with HAS-BLED score

29
Q

Acute AF anticoagulation

A

Use heparin until full assessment

Apixaban or warfarin for 3wks before cardioversion if high risk of emboli

30
Q

Indications for temporary pacing

A

Symptomatic bradycardia unresponsive to atropine
Suppression of drug-resistant tachyarrhythmias

Post anterior MI with (complete AV block, Mobitz type I/II AV block, non-adjacent bi/tri fascicular block)
Post inferior MI unless rate >40-50 + narrow QRS

Special situation e.g. anaesthesia/ surgery

31
Q

Indications for PPM

A

Complete AV block
Mobitz II AV block
Persistent AV block after MI

Symptomatic bradycardias
Drug-resistant tachyarrhythmias

Heart failure

32
Q

Pacemaker letter codes

A

1 - Paced: (A)tria, (V)entricles, (D)ual chamber
2 - Sensed: (A)tria, (V)entricles, (D)ual chamber, n(O)ne
3 - Response: (T)riggered, (I)nhibited, (D)ual
4 - Pacemaker response: (R)ate modulation, (P)rogrammable, (M)ultiprogrammable
5 - will (P)ace pt in tachy; will (S)hock pt in tachy; (D)ual ability to do both; n(O)ne of these

33
Q

What is cardiac resynchronisation therapy

A

Improves sync of cardiac contraction in those with ejection fraction <35% and QRS>120ms
Involves septal and lateral AV wall pacing ± atrial lead ± defib

34
Q

What is a pacemaker fusion beat

A

Union of native depolarisation + pacemaker impulse

35
Q

What is a pacemaker pseudofusion beat

A

Pacemaker impulse just after native, so ineffective but distorts QRS morphology

36
Q

What is a pacemaker pseudopseudofusion beat

A

DVI pm gives atrial spike with native QRS complex, atrial output is ineffective

37
Q

What is pacemaker syndrome

A

Single-chamber pacing retrograde conduction to atria which contract during ventricular systole, retrograde flow into pulmonary veins

38
Q

What is pacemaker-mediated tachycardia

A

Retrograde conduction to atrium sensed by pm + ventricle shock given, causes retrograde atrial conduction again so loop

39
Q

Congenital arrythmogenic conditions

A

WPW
LQTS
Arrhytmogenic RV cardiomyopathy
Brugada

40
Q

What is WPW

A

Congenital accessory conduction pathway between atria + ventricles
Causes short PR, wide QRS with slurred upstroke (∂ wave) and ST-T changes on ECG

41
Q

WPW types

A

Type A: +ve ∂ wave on V1

Type B: -ve ∂ wave on V1

42
Q

What are Long QT syndromes

A

Channelopathies resulting in prolonged repolarisation

Predisposes pt to ventricular arrhythmias classically Torsades de pointes

43
Q

What is ARVC

A

RV myocardium replaced with fibro-fatty material

Causes epsilon wave, T inversion and broad QRS in V1-V3 on ECG

44
Q

What is Brugada

A

Sodium channelopathy

Causes coved ST elevation in V1-V3 + suggestive clinical hx

45
Q

Torsades de pointes treatment

A

IV MgSO4

46
Q

Bifascicular block conditions

A

RBBB

Left anterior/posterior hemiblock

47
Q

Trifascicular block conditions

A

RBBB
Left anterior/posterior hemiblock
1st ˚ heart block

Cardio (15 decks)

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