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Cardiac Arrythmias Flashcards

1
Q

From where do supraventricular tachycardias arise?

A

From the the atria or from the atrioventricular junction

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2
Q

What is the rate of sinus node discharge modulated by?

A

The autonomic nervous system

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3
Q

What does the parasympathetic system do to heart rate?

A

It decreases.

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4
Q

What part (or parts) of the nervous system lead to tachycardia?

A

Reduction of the parasympathetic system or increase in the sympathetic nervous system.

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5
Q

What are the components of the ‘Electrical System’ of the heart?

A

SA node, AV node, Bachmann’s Bundle, Bundle of His, L + R Bundles, Left posterior fascicle, Left Anterior Fascicle and Purkinje Fibres

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6
Q

What are the mechanisms of arrhythmogenesis?

A

1 - The Phase 4 slope is steeper or the threshold is reduced
2 - There can be another depolarisation after the initial one. this can be early (during phase 3) or delayed (after phase 3 is below the threshold)
3 - Scar tissue can cause depolarisation to move in rings causing re-entry or circus movements.

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7
Q

Bradycardia causes can be split into two categories, what are they?

A

Extrinsic and Intrinsic

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8
Q

What are the causes of extrinsic Bradycardias?

A

Hypothermia, hypothyroid, beta-blockers and Neurally Mediated Syndromes

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9
Q

What are the causes of intrinsic Bradycardias?

A

Acute Ischaemia of the SA node (from MI), Chronic degenerative fibrosis of the atrium (sick sinus syndrome)

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10
Q

Neurally mediated syndromes are due to a reflex called what?

A

Bezold-Jarisch

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11
Q

How to patients with with neurally mediated syndromes present?

A

Syncope and pre-syncope

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12
Q

What are the three neurally mediated syndromes? (Think about what happens)

A

Carotid Sinus Syndrome
Vasovagal Syncope
Postural orthostatic tachycardia syndrome (POTS)

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13
Q

How do we treat patients with bradycardia? (5)

A

If there an extrinsic cause this should be removed

Temporary pacemakers can be useful for reversible causes

If there is chronic SA nod disease a permanent pacemaker should be inserted

In patients with Brady-Tachy syndrome anti-coagulants should be used

Patients with vasovagal causes should avoid the stimulants or do a valsalva manoeuvre, beta-blockers can be considered

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14
Q

Where are heart blocks found and what are they called?

A

AV Node - AV Block
His Bundle - AV Block
Lower Bundles - Bundle branch block

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15
Q

What are the three forms of AV block?

A

1st degree, 2nd degree and 3rd degree (complete) AV block

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16
Q

What does 1st degree heart block mean?

A

That there is a delay of more than 0.22s in the PR interval

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17
Q

What are forms of 2nd degree heart block? (3)

A

Mobitz type I (wenckebach Phenomenon)
Mobitz type II
2:1 or 3:1 block

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18
Q

What Does Mobitz type I involve?

A

A progressively long PR interval followed by a dropped QRS complex

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19
Q

What does Mobitz type II involve?

A

A QRS complex is dropped with out a progressively prolonged PR interval

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20
Q

A Mobitz type I implies that the block is where?

A

The AV node

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21
Q

A Mobitz type II implies that the block is where?

A

The bundle of His

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22
Q

Which type of 2nd degree heart block is more likely to progress to complete heart block?

A

Mobitz type II

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23
Q

What is the leading cause of Mobitz type II?

A

Myocardial Infarction

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24
Q

How do the treatment strategies compare between Mobitz I + II

A

Mobitz I should be monitored and Mobitz II will require a pacemaker

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25
How is life maintained during complete heart block?
With escape beats arising from the ventricles
26
In Complete heart block, what are the rhythms found in Narrow complex escape rhythm and broad complex escape rhythm?
Narrow complex - 50-60 bpm | Broad Complex - 15-40 bpm
27
How is Narrow complex complete heart block treated?
if it is acute then the underlying cause should be treated, temporary pacing or IV atropine can be useful If it is chronic then permanent pacing should be used
28
What is atropine, how does it work and when is it used?
It is a competitive antagonist to acetyl choline. It therefor counters parasympathetic nervous stimulus. It is used to acutely raise heart rate
29
What are the causes of Complete Heart Block (6)
Congenital - Structural heart disease Idiopathic Fibrosis - Lev's Disease Ischaemic Heart Disease Non-ischaemic heart disease - calcific aortic stenosis, infiltrations (amyloidosis, sarcoidosis, neoplasia) Cardiac Surgery - following valve replacement Iatrogenic - Following ablation or pacemaker Drug Induced - digoxin, beta blockers Infections - endocarditis, Rheumatic heart disease,
30
In cardiology what is Lev's Disease?
progressive fibrosis of the His-Purkije system in elderly patients
31
How does Digoxin work and when is it used?
it is a cardiac glycoside which inhibits the the sodium potassium pump, this stops sodium calcium exchange and increases contractility. It is used in AF when no other medications are effective
32
What is Bundle Branch Block?
A condition which stops the conduction below the level of His bundle inc left and right bundle and the anterior and posterior fascicles of the left bundle.
33
What are the different variations of bundle branch Block? (4)
Bundle Branch conduction delay, complete bundle branch block, hemiblock and bifascicular block.
34
What does bundle branch conduction delay show on an ECG?
Widening of the QRS complex up to 0.11s
35
What width would the QRS complex but in complete bundle branch block?
>0.12s
36
What ECG pattern would a right bundle branch block show?
An rsR' pattern in leads V1 and V2. The R' wave is wide and late, this shows that the activation of the right ventricle is delayed.
37
What ECG pattern would a left bundle branch block show?
In leads V1-V3 there will be a deep broad s wave, showing that there is early activation of the left ventricle (it is moving away from the right sided chest leads.
38
What is Hemiblock?
A blockage of one of the branches of the left bundle branch (left anterior fascicle or the left posterior fascicle)
39
What is the difference on ECG between left anterior and posterior division hemiblock?
Anterior will swing the axis to the left, posterior will swing it to the right. (QRS complexes are bigger on either the left or the right)
40
What is Bifascicular block?
More than one bundle branch block
41
Clinically, what would you find in a patient with bundle branch block? (signs and symptoms)
splitting of the second heart sound and syncope if there is intermittent complete block.
42
What are the causes of right bundle branch block? (6)
Congenital, Cor pulmonale, PE, MI, conduction system fibrosis
43
What are the causes of left bundle branch block? (3)
Aortic stenosis, Hypertension, MI
44
What determines a sinus tachycardia on an ECG?
the presence of P waves
45
What are the most common causes of inappropriate sinus tachycardia?
exercise, stress, pain, emotion, fever, hypovolaemia, hyperthyroid, catecholamine excess, anaemia
46
what is the pathophysiology involved in Atrioventricular reciprocating tachycardia?
There is an abnormal communication between the atria and ventricles which occurs in utero, the atria contract before and after the ventricles have contracted
47
What would be seen on an ECG in Atrioventricular reciprocating tachycardia?
Another P wave would be seen between the QRS and the T wave
48
What are the most common accessory pathways in atrioventricular reciprocating tachycardia?
Kent Bundles
49
If the p wave runs into the QRS complex and there is a history of palpitation what are these waves called and what is the name of the syndrome?
δ waves and it is called wolff-parkinson-white syndrome
50
What is the main symptom in SVTs?
palpitations with sudden onset and termination, sometimes with caffeine or other stimulus
51
Why might patients get polyuria with SVT?
Because of the release of atrial natriuretic peptide
52
Might might patients get pulsating jugulars with SVT?
Because the atria are pumping against closed tricuspid and mitral valves.
53
What is the difference between Atrioventricular Nodal Re-entry Tachycardia and Atrioventricular Reciprocating Tachycardia on an ECG?
In AVNRT there are no p waves | In AVRT the p waves can be part of the QRS (δ waves) or be after the QRS
54
What is the immediate treatment of a patient with an SVT who is haemodynamically unstable?
DC cardioversion
55
What is the immediate treatment of a patient with an SVT who is haemodynamically stable?
Emersion of face in cold water, Valsalva manoeuvre, carotid massage, if these do not work then 6mg of adenosine may be used
56
What are the side effects of adenosine?
``` Bronchospasm Flushing chest pain heaviness of the limbs sense of impending doom ```
57
What are the options for long term management of SVT?
Ablation, verapamil, Beta-blockers. | Amiodarone may also be used
58
What underlying pathologies of the atria lead to atrial fibrillation?
raised atrial pressure, increased atrial muscle mass, fibrosis and inflammation
59
What are the 'classic' causes of AF? (3)
Thyrotoxicosis, Rheumatic heart disease and Alcohol intoxication
60
What are the most common causes of AF?
Congestive Heart failure and Hypertension
61
What will an AF ECG show?
apparently random QRS complexes, f waves, no correlation between p waves and QRS complexes, sinus rhythm of 300-600 bpm
62
What are the options for immediate treatment of AF?
treat the underlying cause (Throid, Chest infection, Alcohol), Cardioversion, IV infusion of anti-arrhythimic drug
63
What should be considered before choosing treatment in AF? (3)
How well is AF tolerated? Is anticoagulation required before cardioversion? Will this patient resolve on their own? (has it happened before, is it a reversible cause?)
64
How are patients anti-coagulated for DC cardioversion?
with warfarin before and after treatment. Transoesophageal echo maybe be used to check for clots, if there are none then no warfarin needed
65
What are the two strategies for long term management of AF?
``` rate control rhythm control (both with warfarin) ```
66
What drugs are used in rate control?
Digoxin, Calcium-channel blockers and beta-blockers
67
What Calcium channel blocker may be used as an alternative to verapamil?
diltiazem
68
What is the target INR for patients with AF?
between 2.0 and 3.0
69
What drugs are used to anti-coagulate patients?
warfarin and rivaroxaban
70
What is the CHA2DS2-VASc score?
Congestive heart failure, Hypertension, Age (65-74), Diabetes Mellitus, Stroke, Vascular disease, Age (again), Sex. Anticoagulation is recommended in patients with a score of ≥2
71
How should patients be treated who have sustained VT and haemodynamic comprimise?
DC cardioversion
72
How should patients be treated who have sustained VT and no haemodynamic comprimise?
IV Lidocaine is first line (100mg over 5 minutes) followed by lidocaine infusion of 4mg/min Amiodarone 5mg/kg should be given for an hour. Cardioversion if this fails
73
What is Brugada Syndrome?
Inherited idiopathic VF
74
How does Brugada look on ECG?
ST segment elevation with apparent right bundle branch block

Cardiovascular Medicine (9 decks)

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