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JL Cardiovascular > Cardiac Arrhythmias > Flashcards

Cardiac Arrhythmias Flashcards

1
Q

Where is the origin in a supraventricular arrythmia?

A

Above ventricle i.e. SA, atrial muscle, AV node or HIS node

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2
Q

What are ectopic beats?

A

Beats or rhythms that originate in places other than the SA node

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3
Q

Whta may cause single beats or take over and pace the heart, dictating its entire rhythm?

A

Ectopic focus

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4
Q

Name three supraventricular tachycardias?

A
  1. Atrial fibrillation
  2. Atrial flutter
  3. Ectopic atrial tachycardia
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5
Q

Name two bradycardia (supraventricular arrhythmias)?

A
  1. Sinus bradycardia

2. Sinus pauses

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6
Q

Name three atrio-ventricular node arrythmias?

A
  1. AVN re-entry
  2. Acessory pathway (e.g. WPW)
  3. AV block - 1st, 2nd and 3rd degree
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7
Q

Name 4 ventricular arrythmias?

A
  1. Premature ventricular complex (PVC)
  2. Ventricular tachycardia
  3. Ventricular fibrillation
  4. Asystole
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8
Q

What can abnormal anatomy e.g. left ventricular hypertrophy, accessory pathways and congenital HD cause?

A

Arrythmias

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9
Q

What are two autonomic causes of arrythmias?

A
  1. Sympathetic stimulation - nervousness, exercise, CHF, hyperthyroid
  2. Increased vagal tone (bradycardia, heart block)
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10
Q

What are three metabolic causes of arrythmias?

A
  1. Hypoxic myocardium: chronic pulmonary disease, PE
  2. Ischaemic myocardium: acute MI, angina
  3. Electrolye imbalances: imbalances of K, Ca, Mg
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11
Q

What inflammation cause is there of arrythmias?

A

Viral myocarditis

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12
Q

Name a mutation of cardiac ion channels that can cause arrythmias?

A

The congenital long QT syndrome

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13
Q

What two conditions can alter automacitiy?

A

Ischaemia and catecholamines

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14
Q

What two things can cause re-entry?

A

WPW syndrome - accessory pathway tachycardia

Previous MI

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15
Q

What does hypothermia do to phase 4 slope?

A

Decreases it

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16
Q

What do hypoxia and hypercapnia do to phase 4 slope?

A

Increase it

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17
Q

What does cardiac dilatation do to phase 4 slope?

A

Increases it

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18
Q

What increases automaticity of neighbouring cells?

A

Local areas of ischaemia or necrosis

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19
Q

Whay does hypokalaemia do to phase 4 slope?

A

Increases it and also increases ectopics, prolongs repolarisation

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20
Q

What is the term for: in the terminal phase of AP (phase 3), a small depolarisation may occur (called an after depolarisation), and if of sufficient magnitute may reach threshold and lead to a sustained train of depolarisations

A

Triggered activity

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21
Q

What mechanism underlyes digoxin toxicity, Torsades de Pointes in long QT syndrome and hypokalaemia?

A

Triggered activity

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22
Q

What requires available circuit, unidirectional block, and different conduction speed in limbs of circuit?

A

Re-entry

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23
Q

Where is the origin in a ventricular arrhythmia?

A

Ventricle

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24
Q

What type of conditions promote functional block?

A

Conditions that depress conduction velocity or shorten refractory period promote functional block

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25
Q

What are four main investigations you would do for arrythmias?

A
  1. 12 lead ECG
  2. CXR
  3. Echocardiogram
  4. Stress ECG
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26
Q

What are signs on an ECG of a previous MI?

A

Q waves

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27
Q

What does pre-excitation suggest, when seen on an ECG?

A

Wolf Parkinson White syndrome

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28
Q

What investigation can assess for ischaemia and excersise induced arrythmias?

A

Exercise ECG

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29
Q

What investigation is used to assess for paroxysmal arrythmia?

A

24hr Holter ECG

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30
Q

What investigation can assess for structural disease? (e.g. enlarged atria ain AF, LV dilatation or previous MI scar, aneurysm)

A

Echo

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31
Q

What study triggers arrythmia to study its mechanism and gives an opportunity to treat the arrythmia by radiofrequency ablation?

A

Electrophysiological study

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32
Q

What condition can be asymptomatic, palpitations, there is generally no treatment, b-adrenergic blockers may help and you need to avoid stimulants like caffeine?

A

Atrial ectopic beats

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33
Q

What type of STEMI is bradycardia related ischaemia common in?

A

Inferior STEMIs

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34
Q

What are the two treatment options for sinus bradycardia?

A
  1. Atropine (if acute)

2. Pacing if: haemodynamic compromise such as hypotension, CHF, angina or collapse

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35
Q

What drugs can be used to treat sinus tachycardia?

A
  1. B-adrenergic blockers
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36
Q

16 year old girl, fast palpitations, alert, no distress, good colour, HR very fast and normal physical exam?

A

Narrow complex tachycardia, SVT

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37
Q

What three things may supra-ventricular tachycardia be due to?

A
  1. AV nodal re-entrant tachycardia
  2. Accessory pathway tachycardia i.e. Wolff Parkinson White syndrome
  3. Ectopic atrial tachycardia
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38
Q

What would you do as initial emergency treatment for an infant with SVT?

A

Peds vagal maneovres

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39
Q

What emergency initial step would you do for a child with SVT?

A

Blow through straw or carotid massage

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40
Q

What emergency step would you do for an adult with AVT?

A

Carotid sinus massage

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41
Q

For management of supra-ventricular tachycardia, what would you give after you have performed vagal manoeuvres, carotid massage?

A

IV adenosine

IV verapamil

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42
Q

What 3 steps of chronic management for SVTs are there?

A
  1. Avoid stimulants
  2. Radiofrequency ablation
  3. Antiarrythmic drugs (Class II or IV)
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43
Q

What is selective cautery of cardiac tissue to prevent tachycardia, targeting either an automatic focus or part of a re-entry circuit?

A

Ablation

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44
Q

What three steps are involved in ablation?

A
  1. Catheters placed in heart via femoral veins
  2. Intracardiac ECG recorded during sinus rhythm, tachycardia and during pacing manoeuvres
  3. Catheter placed over focus/pathway and tip heated to 55-65C
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45
Q

What investigation shows the activation sequence of the heart and has more detail than a surface ECG?

A

Intracardiac ECG

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46
Q

What type of arrythmic disease can ageing, acute MIs, myocarditis and infiltrative disease (amyloid) cause?

A

AVN conduction disease

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47
Q

What two classes of drugs cause AVN conduction disease?

A

B-blockers

Calcium channel blockers

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48
Q

What two genetic causes are there of AVN conduction disease?

A

Lenergre’s disease

Myotonic dystrophy

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49
Q

Can calcific aortic valve disease and post-aortic valve surgery lead to AVN conduction disease?

A

Yes

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50
Q

In first degree AV block, what is the PR interval like?

A

Longer than >0.2 seconds

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51
Q

What is the treatment for first degree AV block?

A

None

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52
Q

What degree of block is an intermittent block at the AVN (dropped beats)?

A

2nd degree AV block

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53
Q

What are the two types of 2nd degree AV block?

A

Mobitz I

Mobitz II

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54
Q

Give two features of Mobitz type I 2nd degree AV block?

A
  1. Progressive lengthening of the PR interval, eventually resulting in a dropped beat
  2. Usually vagal in tone
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55
Q

Give three features of Mobitz II, 2nd degree AV block?

A
  1. Pathological, may progress to complete heart block (3rd degree HB)
  2. Usually 2:1, or 3:1, but may be variable
  3. Permanent pacemaker indicated
56
Q

In 2nd degree AV block, Mobitz II what do some action potentials fail to do?

A

Get through the AV node

57
Q

What is the treatment for 2nd degree AV block Mobitz type II?

A

Ventricular pacing

58
Q

What can be said about hte action potentials in 3rd degree AV block?

A

No action potentials from the SA node/atria get through the AV node

59
Q

What is the treatment for 3rd degree AV block?

A

Ventricular pacing

60
Q

What are two options for acute pacing?

A
  1. Transcutaneous pacer

2. Transvenous pacer

61
Q

What two types of pacemakers are there?

A
  1. Single chamber (paces the right atria or right ventricle only)
  2. Dual chamber (paces the RA and RV)
62
Q

When are atrial pacemakers used?

A

In isolated SA node disease but normal AV node

63
Q

When are ventricular pacemakers used?

A

In AF with slow ventricualr rate

64
Q

What pacemakers maintain AV synchrony and are used for AVN dsiease?

A

Dual chamber

65
Q

What might premature ventricular ectopics be a marker for?

A

Inherited arrhythmia syndromes e.g. cardiomyopathy

66
Q

What happens to the atrial pressure in ventricular tachycardia?

A

Large, sustained reduction

67
Q

What two conditions do most patients have before getting ventricular tachycardia?

A

Coronary artery disease and previous MI

68
Q

What are two inherited/familial arrhythmia syndromes that can cause ventricular tachycardia?

A
  1. Long QT

2. Brugada syndrome

69
Q

What can rates range from in ventricular tachycardia?

A

110-250bpm

70
Q

What are these ECG findings characteristic of: QRS complexes are rapid, wide and distorted, T waves are large with deflections opposite the QRS complexes, ventricular rhythm is usually regular, P waves are usually not visible, PR interval is not measurable, AV dissociation may be present, VA condution may or may not be present?

A

Ventricular Tachycardia

71
Q

What arrythmia is chaotic ventricular electrical activity which causes the heart to lose the ability to function as a pump?

A

Ventricular fibrillation

72
Q

What are the two treatment methods for ventricular fibrillation?

A

Defibrillation

Cardiopulmonary resuscitation

73
Q

What are two acute treatment options for VT?

A
  1. DC cardioversion if unstable

2. If stable consider pharmacologic cardioversion with AAD

74
Q

What do sotalol, quinidine, terfenadine and erythromycin do to the QT interval?

A

Prolong it

75
Q

What are three causes of VT?

A
  1. Hypokalaemia, hypomagnesaemia
  2. Ischaemia
  3. Hypoxia
76
Q

For a monomorphic stable VT, what 4 drugs would you administer?

A
  1. IV procainamide
  2. IV sotalol
  3. IV amiodarone
  4. IV beta blockers
77
Q

What can you implant if life threatening VT is there long term?

A

Implantable cardiovertor defibrillator (ICD)

78
Q

What two arrythmias are life threatening?

A

VT and VF

79
Q

What do most ventricular arrythmias occur in the setting of?

A

Structural heart disease

80
Q

60 female, hypertension for years, palpitations, SOB, fatigue, on enalapril, irregularly irregular pulse?

A

Atrial fibrillation & LVH

81
Q

What is the atrial activity like in AF?

A

Chaotic and disorganised

82
Q

What three things can AF be defined as either?

A
  1. Paroxysmal
  2. Persistnet
  3. Permanent
83
Q

Give two features of paroxysmal AF?

A
  1. Paroxysmal and lasting less than 48 hours

2. Often recurrent

84
Q

Give two features of persistent AF?

A
  1. An episode of AF lasting greater than 48 hours, which can still be cardioverted to NSR
  2. Unlikely to spontaneously revert to NSR
85
Q

Give one feature of permanent AF?

A

Inability of pharmacological or non-pharmacologic methods to restore NSR

86
Q

What are hypertension, congestive heart failure, sick sinus syndrome, coronary heart disease, thyroid disease, familial and valvular heart disease all causes of?

A

AF

87
Q

What are COPD, pneumonia, septicaemia, pericarditis and tumours all causes of?

A

AF

88
Q

What occurs in the absence of any heart disease and no evidence of ventricular dysfunction, a diagnosis of exclusion?

A

Lone/idiopathic AF

89
Q

Give 5 symptoms of AF?

A
  1. Palpitations and chest pain
  2. Pre-syncope dizziness and syncope
  3. Dyspnea
  4. Sweatiness
  5. Fatigue
90
Q

Give two features of the mechanism of AF?

A
  1. Multiple wavelets of reentry

2. Ectopic focus around the pulmonary veins

91
Q

Give three terminations of AF?

A
  1. Pharmacologic cardioversion with anti-arrythmic drugs
  2. Electrical cardioversion
  3. Spontaneous reversion to sinus rhythm
92
Q

What three drugs can terminate and prevent AF?

A
  1. Flecainide
  2. Sotalol
  3. Amiodarone
93
Q

What is the atrial rate and rythm of an ECG in AF?

A
  1. Atrial rate > 300bpm

2. Rhythm: irregularly irregular

94
Q

What three things is the ventricular rate on ECG in AF dependent upon?

A
  1. AV node conduction properties
  2. Sympahtetic and parasympathetic tone
  3. Presence of drugs with act on the AV node
95
Q

What is there the absence of P waves and the presence of “f” waves in?

A

AF

96
Q

What two classes of drugs decrease conduction in the AV node and are useful in controlling ventricular rate during AF?

A

Beta-blockers

Calcium channel blockers

97
Q

For patients with hypertrophic cardiomyopathy, what can loss of atrial kick and decreased filling times result in?

A

Congestive heart failure

98
Q

What can patients with pre-excitation (Wolff-Parkinson-White Syndrome) result in?

A

Ventricular fibrillation and sudden cardiac death

99
Q

What in AF does lost ‘atrial kick’ and decreased filling times (reduced diastole) lead to?

A

Reduced cardiac output

100
Q

What two approaches of management are there for AF?

A

Rhythm control - maintain SR predominantly

Rate control - accept AF but control ventricular rate

101
Q

If there is a high risk for thromboembolism for both rhythm control and rate control, what should be done?

A

Anticoagulation

102
Q

During rate control in AF, what 4 pharmacological therapies are there to slow down AVN conduction?

A
  1. Digoxin
  2. Betablockers
  3. Verapamol
  4. Diltiazem
103
Q

During rhythm control of AF, what two methods are there for restoring NSR?

A
  1. Pharmacologic cardioversion (anti-arrythmic drugs e.g. amiodarone)
  2. Direct current cardioversion (DCCV)
104
Q

What three methods are there for rhythm control - maintainence of NSR in AF?

A
  1. Anti-arrythmic drugs
  2. Catheter ablation of atrial focus/pulmonary veins
  3. Surgery (maze procedure)
105
Q

What do flecainid, sotalol and amiodarone do to AF rythm?

A

Maintain sinus rhythm

106
Q

During an episode of AF, what can immediatly restore normal sinus rhythm?

A

Electrical cardioversion

107
Q

How do anti-arrythmic drugs act?

A

Through electrophysiological mechanisms by blocking the ionic currents across cell membranes that create the action potentials

108
Q

What channel block, action potential phase and main use in AF are for Class I anti-arrythmic drugs?

A

Channel blocked: Na+
Action potential phase: 0
Main uses in AF: Rythm control

109
Q

What class of anti-arrythmic drugs are flecainide and propafenone?

A

Class I

110
Q

What are channels blocked, action potential phase and main uses in AF for class II anti-arrythmic drugs?

A

Channels blocked: beta-receptors
Action potential phase: 4
Main uses in AF: Rate control

111
Q

What are channels blocked, action potential phase and main uses in AF for class III anti-arrythmic drugs?

A

Channels blocked: K+
Action potential phase: 3
Main uses in AF: Rhythm control

112
Q

What are channels blocked, action potential phase and main uses in AF for class IV anti-arrythmic drugs?

A

Channels blocked: Ca2+
Action potential phase: 2
Main uses in AF: rate control

113
Q

Name 4 class I anti-arrythmic drugs?

A
  1. Lignocaine
  2. Quinidine
  3. Flecainide
  4. Propafenone
114
Q

Give 1 class II anti-arrythmic drug?

A

Propranalol

115
Q

Give three class III anti-arrythmic drugs?

A
  1. Amiodarone
  2. Sotalol
  3. Dronedarone
116
Q

Give one example of a class IV anti-arrythmic drug?

A

Verapamil

117
Q

What is a rapid, distinct VT with a twisting configuration of the QRS morphology and associated with prolonged repolarisation?

A

Torsades de Pointes

118
Q

What is the heart rate in Torsades de Pointes?

A

200 - 250bpm

119
Q

What is the rhythm like in Torosades de Pointes?

A

Irregular

120
Q

Give three features for ECG recognation of Torsades de Pointes?

A
  1. Long QT interval
  2. Wide QRS
  3. Continuously changing QRS morphology
121
Q

Give three events leading to TdP?

A
  1. Hypokalaemia
  2. Prolongation of the action potential duration (drug induced)
  3. Renal impairment (increased drug levels)
122
Q

What two valvular AF conditions would indicate for anti-coagulation?

A

Mitral stenosis

Mitral regurgitation

123
Q

What does CHA(2)DS(2)-VAS Score stand for?

A 
Congestive heart failure/LV dysfunction - 1
Hypertension - 1
Age>75 - 2
Diabetes mellitus - 1
Stroke (TIA/TE) - 2
Vascular disease - 1
Age 65-74 years - 1
Sex - 1
124
Q

What does HASBLED assess?

A

Bleeding risk

125
Q

What does HASBLED stand for? (>3 is high risk)

A 
Hypertension
Abnormal renal or liver function
Stroke
Bleeding
Labile INRs
Elderly > 65
Drugs or alcohol
126
Q

How does radiofrequency ablation in AF maintain SR?

A

By ablating AF focus (usually in the pulmonary veins)

127
Q

How does radiofrequency ablation in AF control rate?

A

Ablation of the AVN to stop fast conduction to the ventricles

128
Q

Name a rapid and regular form of atrial tachycardia?

A

Atrial flutter

129
Q

What is atrial flutter (paroxysmal) sustained by?

A

Macro-reentrant circuit

130
Q

Where is the atrial flutter circuit combined to?

A

Right atrium

131
Q

What does chronic atrial flutter usually progress to?

A

AF

132
Q

What is the rate usually in atrial flutter?

A

300bpm

133
Q

What is seen instead of a p-wave in atrial flutter?

A

Saw tooth ‘F’ wave

134
Q

Is atrial flutter clockwise or counterclockwise?

A

Counterclockwise

135
Q

What are the four treatment options for atrial flutter?

A
  1. RF ablation
  2. Pharmacologic therapy - slow the ventricular rate, restore SR, maintain SR
  3. Cardioversion
  4. Warfarin for prevention of thromboembolism

JL Cardiovascular (18 decks)

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