Arrythmias

Question 1

What is first degree heart block?

Answer 1

This is a conductivity block at the AV node which causes a PR interval of >0.2 seconds (>5 small squares)

Question 2

What is one thing you should check for in a patient with first degree heart block?

Answer 2

Digoxin toxicity which can occur as a result of too much being taken or a decline in renal function

Question 3

What is second degree AV block - Mobitz type I?

Answer 3

This is when there is a gradual prolonging of each PR interval and then a drop in a QRS complex.

Question 4

What is second degree AV block - Mobitz type II?

Answer 4

This is where there is no prolonging of a PR interval but then a sudden drop in a QRS complex.

Question 5

What is third degree heart block?

Answer 5

This is where there is no conduction from the atria to the ventricles and therefore AV dissociation. There is no relationship between the P waves and QRS complexes.

Question 6

What are some causes of third degree heart block?

Answer 6

Digoxin toxicity

Inferior or anterior STEMI

Severe hyperkalaemia

Question 7

What are the different types of AF?

Answer 7

Paroxysmal - AF that terminates spontaneously or with intervention within 7 days. Your symptoms can come and go.

Persistent - AF that lasts longer than 7 days

Permanent - Your symptoms last for more than a year

Question 8

What are some symptoms of Atrial Fibrillation?

Answer 8

Breathlessness

Palpitations

Syncope/dizziness

chest discomfort

stroke/TIA

Question 9

What is the first line investigation in a patient with suspected Paroxysmal AF?

Answer 9

24 hour ECG monitoring.

Question 10

When should an Echo be performed?

Answer 10

If the patient has suspected structural heart disease

Where cardioversion is being considered

Baseline echocardiogram required to inform long term management

Question 11

What is the core management of AF?

Answer 11

Anticoagulation

Rate control

Rhythm control

Question 12

How would you interpret a CHA2DS2VaSc?

Answer 12

2 or more - offer anticoagulation

1 or more in men - offer anticoagulation

Question 13

Recite the CHA2DS2VaSc?

Answer 13

Congestive heart failure or LVEF<40%

Hypertension

Age >75 - 2 points

Diabetes

Stroke/TIA - 2 points

Vascular disease - 1 point

Age 65-74 - 1 point

Sex female - 1 point

Question 14

How would you assess a bleeding risk in a patient when prescribing anticoagulation?

Answer 14

HASBLED score.

Question 15

Name some examples of factor Xa inhibitors?

Answer 15

Apixaban

Rivaroxaban

Question 16

Name an example of a direct thrombin inhibitor?

Answer 16

Dabigatran

Question 17

How would you manage a patient with AF who was harm-dynamically unstable?

Answer 17

Electrical cardioversion

Question 18

How would you manage a patient with AF who wasn’t harm-dynamically stable but had structural heart disease?

Answer 18

IV Amiodarone

Question 19

How would you manage a patient with AF who wasn’t harm-dynamically stable and didn’t have structural heart disease?

Answer 19

IV Flecainide

Question 20

What rate control is indicated in a patient who has a LVEF <40%?

Answer 20

First start a beta blocker and if therapeutic effect still not achieved add digoxin

Question 21

What rate control is indicated in a patient who has LVEF >40%?

Answer 21

First start a beta blocker

then if required add a calcium channel blocker

then if required add digoxin

Question 22

Name two different types of supra ventricular tachycardia?

Answer 22

AV nodal re-entry tachycardia

Atrio-ventricular re-entry tachycardia

Question 23

How would you manage a SVT in a harm-dynamically stable patient?

Answer 23

Valsalva manicures are first line treatment in harm-dynamically stable patients.

Carotid massage reserved for younger patients.

Short term management if the above fails is IV adenosine or CCB (eg. Verapamil)

Question 24

What is a side effect of Adenosine that you should warn patients about?

Answer 24

Chest discomfort
Hypotension
Flushing

Question 25

How should you manage SVT in a harm-dynamically unstable patient?

Answer 25

Synchronised cardioversion following sedation at 150J

Question 26

What kind of drugs do dihydropyridine CCB (eg. Verapamil) have a direct drug interaction with

Answer 26

Beta blockers. They should not be prescribed together!

Question 27

What is the management for ventricular tachycardia?

Answer 27

Haemodynamically compromised patients can be managed with cardioversion (150-200 joule shock) with a biphasic defibrillator Pharmacological management can be done with a beta blocker. Amiodarone can be tried or lidocaine.