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Pre-reg revision > Arrhythmias > Flashcards

Arrhythmias Flashcards

1
Q

What are ectopic beats?

A

Spontaneous extra heart beats causing heart palpitations when the heart rhythm is otherwise normal.

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2
Q

How are ectopic beats treated?

A

Treatment rarely required. Can use beta-blockers if particularly troublesome.

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3
Q

How can AF be managed?

A

Rate control (controlling ventricular rate) or rhythm control (restoring and maintaining sinus rhythm).

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4
Q

If rate or rhythm control fails, or symptoms recur in AF, what treatment would you provide next?

A

Cardioversion and specialist management.

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5
Q

How often should anticoagulation, stroke and bleeding risk be reviewed in AF?

A

At least annually

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6
Q

How would you treat an acute presentation of life-threatening, haemodynamic instability caused by new onset AF?

A

Emergency electrical cardioversion (to achieve anticoagulation).

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7
Q

How would you treat an acute presentation of AF without life-threatening haemodynamic instability?

A

Rate or rhythm control if onset <48 hours.

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8
Q

If a patient presents with an acute presentation of non life-threatening AF, more than 48 hours after the onset, what treatment is preferred?

A

Rate control

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9
Q

What drugs do you use for pharmacological cardioversion?

A

IV antiarrhythmic: amiodarone or flecanide

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10
Q

What drugs can be used if urgent rate control is required?

A

IV beta-blocker or verapamil

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11
Q

What is cardioversion?

A

Restoration of sinus heart rhythm

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12
Q

What types of cardioversion are there?

A

Electrical or pharmacological

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13
Q

What type of cardioversion is preferred if AF has been present for more than 48 hours?

A

Electrical cardioversion

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14
Q

How long should a patient be anticoagulated for before electrical cardioversion is attempted?

A

At least 3 weeks.

Parental anticoagulation must be commenced if this is not possible.

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15
Q

What needs to be ruled out immediately before cardioversion?

A

Left atrial thromus

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16
Q

How long should oral anticoagulation be given for after cardioversion?

A

At least 4 weeks

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17
Q

What is the preferred first-line treatment for AF (except in new-onset AF, atrial flutter suitable for ablation, or AF with a reversible cause) ?

A

Rate control

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18
Q

When is rate control not first-line drug treatment for AF?

A
  • New-onset AF
  • Atrial flutter suitable for ablation
  • AF with a reversible cause
  • If rhythm control is more suitable based on clinical judgement
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19
Q

What drugs can be used for rate control?

A

Beta-blocker (not sotalol)

Rate-limiting CCB such as diltiazem (unlicensed) or verapamil.

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20
Q

Which beta-blocker should not be used for rate control?

A

Sotalol

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21
Q

When is digoxin effective?

A

At rest. It should only be used as monotherapy in predominantly sedentary patients with non-paroxysmal AF.

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22
Q

What is the next step when a single drug fails to adequately control ventricular rate?

A

Combination of 2 drugs: beta-blocker, diltiazem or digoxin.

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23
Q

What is the preferred combination for rate control if ventricular function is diminished?

A

Beta-blocker and digoxin

24
Q

If AF is accompanied by congestive heart failure what can be used?

A

Digoxin

25
Q

What drug treatment can be used for rhythm control post-cardioversion?

A

Beta-blocker

If not effective, consider oral anti-arrhythmic such as: sotalol, flecanide, propafenone or amiodarone.

Dronedarone may be considered in paroxysmal or persistent AF.

26
Q

What drug would you consider for rhythm control in patients with left ventricular impairment or HF?

A

Amiodarone

27
Q

When should amiodarone be used to increase the success of electrical cardioversion and maintain sinus rhythm?

A

4 weeks before procedure, and continuing for up to 12 months after.

28
Q

What drugs should not be used for rhythm control if there is known ischaemic or structural heart disease?

A

Flecanide or propafenone

29
Q

How do you treat paroxysmal AF?

A
  1. Beta-blocker
  2. Dronedarone, sotalol, flecanide, propafenone or amiodarone.

Pil-in-the-pocket approach using flecanide or propafenone to treat and episode of AF when it occurs.

30
Q

How do you assess the need for thromboporphylaxis in AF?

A

CHA2DS2VASc for stroke risk and HAS-BLED for bleeding risk.

CHA2DS2VASc 0 for men or 1 for women = no anticoagulation

31
Q

When should anticoagulation be offered in AF?

A
  • New onset
  • When sinus rhythm has not been successfully restored within 48 hours of onset
  • Patients who have high risk of AF recurrence e.g. those with structural heart disease, prolonged history of AF (>12 months), failed cardioversion, and risk of stroke outweighs bleeding risk.
32
Q

Should anticoagulation be held if the patient has a risk of falls?

A

No

33
Q

Can aspirin be offered as monotherapy for stroke prevention in Af?

A

No

34
Q

What is atrial flutter?

A

Arrhythmia where the atria and ventricles beat at different speeds - the atria beats much faster than it should.

35
Q

What are the treatment options for atrial flutter?

A

Rate control of rhythm control - however, generally responds less well to drug treatment than AF.

36
Q

How do you achieve sinus rhythm in atrial flutter?

A

Rate control can be used as an interim measure prior to:

  • Pharmacological cardioversion
  • Electrical cardioversion
  • Catheter ablation

Direct current cardioversion is usually the treatment of choice when rapid conversion to sinus rhythm is necessary.

37
Q

Does the patient need to be anticoagulated for 3 week prior to cardioversion for atrial flutter?

A

Only if the duration of the atrial flutter is unknown or has laster for more than 48 hours.

38
Q

Does the patient need anticoagulation when they have atrial flutter?

A

Risk should be assessed the same as with AF.

39
Q

what is paroxysmal supraventricular tachycardia (PSVT)?

A

Episode of rapid heart rate starting at the part of the heart above the ventricles.

Paroxysmal = from time to time.

40
Q

How can you terminate PSVT?

A

They will terminate spontaneously, or with reflex vagal stimulation such as a Valsalva manoeuvre, immersing the face in cold water, or a carotid sinus massage. These manoeuvres should be performed with ECG monitoring.

41
Q

What if PSVT does not resolve with vagal stimulation?

A

IV adenosine
First choice as has short half-life (8-10 seconds) so SEs are short lived. Can also be used after a beta-blocker.

or

IV verapamil if adenosine ineffective or contraindicated.
Verapamil cannot be given after a beta-blocker. But preferable to adenosine in asthma.

42
Q

How do you treat arrhythmias after an MI?

A
  1. Do not administer anti-arrhythmic until and ECG has been obtained.
  2. Bradycardia should be treated with an IV atropine dose, repeated if necessary.
  3. If risk of asystole, pt is unstable, or failed to respond to atropine, adrenaline should be given.
43
Q

What is ventricular tachycardia?

A

Fast HR starting in ventricles HR>100 bpm.

44
Q

How do you treat pulseless ventricular tachycardia or ventricular fibrilation?

A

Immediate defibrillation.

45
Q

How do you treat unstable ventricular tachycardia?

A

Patients with unstable VT, with signs of hypotension or reduced cardiac output should receive direct cardioversion. If this fails, IV amiodarone should be administered.

46
Q

How do you treat haemodynamically stable patients with VT?

A

IV amiodarone as first choice

Flecanide, propafenone and lidocaine (less effective) can also be used.

47
Q

What is torsade de pointes?

A

A form of ventricular tachycardia associated with long QT syndrome.

Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness.

If not controlled, the arrhythmia can process to ventricular fibrillation and result in death.

48
Q

How do you treat torsade de pointes?

A

IV magnesium

Beta-blocker (not sotalol) can be considered.

Anti-arrhythmics can further prolong QT, worsening condition, so not used.

49
Q

Which anti-arrhythmic drug acts on supraventricular arrhythmias?

A

Verapamil

50
Q

Which anti-arrhythmic drug acts on both supra-ventricular and ventricular arrhythmias?

A

Amiodarone, beta-blockers, disopyramide, flecanide, procainamide and propafenone.

51
Q

Which anti-arrhythmic drug acts on ventricular arrhythmias?

A

Lidocaine

52
Q

When are cardiac glycosides (digoxin) and verapamil contraindicated?

A

Supraventricular arrhythmias associated with accessory conducting pathways e.g. Wolff-Parkinson-White syndrome.

53
Q

When does sotalol have a role in arrhythmias?

A

Can be used in the management of ventricular arrhythmias.

54
Q

When can disopryamide be given?

When is is contraindicated?

A

To control arrhythmias after an MI, however, it impairs cardiac contractility.

Antimuscarinic so CI/caution in patients susceptible to angle-closure glaucoma or with prostatic hyperplasia.

55
Q

When can mexiletine be used?

A

Life-threatening ventricular arrhythmias.

Pre-reg revision (5 decks)

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