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Cardiology YR3 > Arrhythmias - booklet > Flashcards

Arrhythmias - booklet Flashcards

1
Q

Basic steps for interpreting ECG

A
  • Rate
  • Rhythm - regular, sinus arrhythmia, irregular
  • Axis - AVL most positive = left axis deviation, lead 3 most positive = right axis deviation
  • Intervals - PR, QRS, QT
  • ST/T wave changes
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2
Q

What to look for in intervals?

A
  • PR - 120-200ms, if short look for delta wave of WPW
  • QRS up to 120ms - if tall consider LVH
  • QT - 400-440ms or 2 large squares
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3
Q

Classification of bradycardia

A
  • Absolute - less than 40bpm
  • Relative - HR is inappropriately slow for haemodynamic state of pt
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4
Q

Sign of unstable bradycardia

A
  • Systolic BP less than 90
  • HR less than 40
  • Poor perfusion
  • Poor urine output
  • Ventrical arrhythmias requiring suppression
  • HF
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5
Q

What is sick sinus syndrome?

A

Sinus node dysfunction (aka tachy-brady)
Causing sinus bradycardia
Need pacemaker if persistent

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6
Q

Causes of sinus bradycardia

A
  • sick sinus syndrome
  • Medications
  • Hypothyroidism
  • Hypothermia
  • Sleep apnoea
  • Rheumatic fever
  • Viral myocarditis
  • Amyloidosis
  • Haemochromatosis
  • Pericarditis
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7
Q

AV node block types

A
  • First degree - prolonged PR interval more than 200ms
  • Second degree Mobitz Type 1 Wenckebach - progressively longer PR interval with dropped QRS
  • Second degree Mobitz type 2 - prolonged PR interval (fixed) with sudden drop of QRS
  • Third degree Complete heart block - disassociation between ventricles and atria
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8
Q

Management of AV heart block

A
  • First degree - monitor for further block, nothing
  • Second 1 - nothing, monitor for more severe eg if syncope/dizzy
  • Second 2 - Permanent pacing arranged in absence of recent coronary event and if drugs exlcuded
  • Third - Urgent pacing within 24hrs except those recent coronary event when likely to normalise
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9
Q

Mobitz type 1 vs 2

A
  • 1 - can be present in young fit patients with high vagal tone, can be seen during night, rarely progresses to complete block
  • 2 - indicates more serious involvement of conduction system, pacing should be arranged if no recent coronary event
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10
Q

Causes of complete heart block

A
  • Digoxin toxicity
  • Inferior STEMI - resolves within hours-days
  • Severe hyperkalaemia
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11
Q

Medical management of complete heart block

A
  • Atropine if haemodynamically unstable
  • Isoprenaline
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12
Q

Most common tachycardia in clinical practive

A

Atrial fibrillation

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13
Q

Natural course of AF

A
  • Initial brief paroxysmal attacks
  • Increasing duration of atatcks
  • Persistent and permanent AF - often have no or atypical symptoms
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14
Q

Complications of AF

A
  • Haemodynamic instability
  • ACS
  • CCF
  • Cardioembolic stroke
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15
Q

Diagnosis and assessement of AF

A
  • Manual pulse checks for irregularity
  • Assess for breathlessness, palpitations, syncope, dizziness, chest discomfort, previous TIA/stroke.
  • ECG

Esp common in obese pts with OSA

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16
Q

If AF paroxysmal, what is recommended?

A
  • Further cardiac monitoring
  • 24hr ECG
  • AliveCor app/cardiac monitor - repeated snapshots over time
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17
Q

When to refer paroxysmal attacks to cardiology?

A
  • If suspicion remains high in a patient you would anticoagulate
  • Unexplained syncope

Need more prolonged monitoring –> cardiology can have Holter monitor or implantable loop recorder

18
Q

When to perform echo in AF?

A
  • Suspect structural heart disease (symptoms or murmur or signs of HF)
  • Rhythm control strategy (cardioversion) is considered
  • Baseline echo needed for long term management
19
Q

Management aims for AF

A
  1. Anticoagulate to prevent stroke
  2. Rate control
  3. Rhythm control
20
Q

How to quantify risk in AF of stroke?

A

CHADSVASC score

21
Q

When to anticoag based on CHADSVASC?

A
  • Score 2 or more - significant risk - offer anticoag
  • Score 1 - intermediate - in men consider, keep bleed risk in mind
  • Score 0 - low risk, no anticoag offered
  • Score of 1 or 0 in women low risk, not advised
22
Q

How to reduce risk of bleeding if going on anticoag (from CHADVASC score advice)?

A
  • Control hypertension
  • Have good INR control
  • Minimise aspirin/NSAIDs use
  • Do not exceed recommended alcohol intake/week
23
Q

What does HAS-BLED score estimate?

A

Rate of major bleeds per 100 patient years

24
Q

Anticoag options AF

A
  • DOACs usually
25
Q

Criteria for rhythm control management

A
  • Reversible cause of AF
  • New onset of AF
  • Heart failure caused by AF
  • Symptoms despite rate control
26
Q

Criteria for rate control

A
  • Non-reversible cause
  • Not new onset of AF
  • No HF caused by AF
  • No symptoms when rate controlled adequately
27
Q

Options for rate control

A
  • Beta blocker
  • CCB
  • Digoxin
28
Q

Rhythm control options

A
  • Cardioversion - immediate or delayed
  • Long term control using medications
29
Q

When is immediate cardioversion used?

A
  • Presenting with AF for less than 48hrs
  • Causing life threatening haemdynamic instability
30
Q

Options for immediate cardioversion

A
  • Pharmacological - flecainide, amiodarone (if structural heart disease use ami)
  • Electrical - using defibrillator
31
Q

Long term rhythm control AF

A

Beta blockers
Dronedarone - 2nd line if had successful cardioversion
Amiodarone - HF/LVSD

32
Q

Management for paroxysmal AF

A

Pill in pocket - use when attack occurs, usually flecainide

33
Q

What is offered if rate, rhythm control not worked?

A

Ablation - left atrial or AV node with PPM

34
Q

SVT cause usually

A

AVNRT or AVRT
Depend on AV node conduction and therefore can be terminated by blocking AV node

35
Q

SVT initial management

A
  • Vagal manouvres if stable
  • eg Breath holding
  • Valsalva - bear down as if pooing or blow hard into syringe to move plunger
  • Carotid massage
36
Q

Management SVT not terminated by vagal maneuvures

A
  • IV adenosine or CCBs
  • Adenosine given as rapid IV bolus
  • If tachy continues despite this rhythm is probably atrial flutter or tachycardia
  • AVRT is excluded and AVNRT is very unlikely
37
Q

Management for hypotensive, pulmonary oedema, chest pain with ischaemia or unstable pts with SVT

A
  • Synchronised cardioversion following sedation at 150J
38
Q

Other medical management for SVT

A
  • Verapamil - but contraindicated in those on beta blockers or LV dysfunction
  • IV flecainide - best but avoid in patients with MI
39
Q

VT - when?

A
  • Broad complex tachycardia following STEMI is nearly always VT
40
Q

Management VT

A
  • Haemodynamically unstable - cardioversion with 150-200J shock
  • Suppression can be achieved with beta blockers but careful if hypotensive or LV is significantly impaired
  • Amiodarone can be tried
  • Lidocaine can be tried
41
Q
A

Cardiology YR3 (21 decks)

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