CARDIO PACKET 2 TX Flashcards
Ventricular tachycardia: > ___
When sustained vtach causes s/s of diminished perfusion EMERGENT TX is necessary
______ protocol
________ with 100-360 J, then ______ or lidocaine
100
ACLS
DC cardioversion
amiodarone
Ventricular fibrillation
Surviving patients need evaluation and intervention (recurrences are common)
__________
- Exclude coronary disease as underlying cause
- Revascularization may prevent recurrence
If __ hours after infarction –> manage as other MIs
_______ = treatment of choice if no MI or other correctable causes found
After MI –> ____ outcomes with ICDs
coronary arteriography
24
ICD
worse
sinus bradycardia:
_______ patients do not require treatment
______ for symptomatic bradycardia or sick sinus syndrome
In patients without evidence of AV nodal or bundle branch conduction abnormality, a ____ chamber atrial pacemaker is reasonable
asymptomatic
pacemaker
single
sinus tachycardia
_______ OR
______ (anti-arrhythmic) –> slows Na+ influx/prolongs action potential OR
Radiofrequency modification of SA node
beta blockers
flecainide
PVST
METHODS TO INTERRUPT ATTACKS:
_____ maneuver (doing a crunch and bearing down)
Stretching arms and body
Lower head between knees
Coughing
_________
Carotid sinus massage (one side at a time!!!)
MEDS:
1st line: IV _____ in bolus every 2 minutes prn
Effects: might have flushing and chest discomfort, can promote bronchospasm
2nd line: ____, IV _______, _____
Effect: potential to cause hypotension
____ (short acting beta blocker)
_____
_______ : if hemodynamically ____OR if you cannot use adenosine or verapamil or they don’t work
Synchronized electrical cardioversion beginning at 100 J almost always successful
PREVENTION: _________ radiofrequency –> the catheter tip delivers bursts of high-energy waves that destroy the abnormal areas
valsalva
breath holding
ADENOSINE CCB verapamil, diltiazem esmolol metoprolol
cardioversion
unstable
catheter ablation
Atrial Fibrillation:
Patients with atrial fibrillation may spontaneously revert to NSR (normal sinus rhythm)
In acute presentation of a hemodynamically UNSTABLE patients:
MEDS: Rate control with IV _______ (esmolol, propranolol, metoprolol) or ______ (diltiazem, verapamil)
URGENT_______________: only in patients with shock, severe hypotension, pulmonary edema, acute MI
SAVE FOR CRITICALLY ILL PATIENTS because use of cardioversion in a patient with atrial fibrillation > ___ hours increases the risk of thromboembolism
In acute presentation of a hemodynamically STABLE patients, treatment should be focused on ______ CONTROL and assessment for ________ anticoagulate patients at high risk of stroke
MEDS: Attempt rate control with _______ or _____
IF CARDIOVERSION IS CONSIDERED: obtain ___ first to rule out L atrial thrombus if thrombus present, cardioversion is _____ 4 weeks
ANTICOAGULATION:
Patients with lone atrial fibrillation (and no indications of cardiac disease) DO NOT NEED long term ________
Patients with paroxysmal, persistent, or permanent AF should be evaluated for long term anti-coagulation
______ to an INR target of 2.0-3.0 should be attained and maintained indefinitely (with at least 1 risk factor for stroke)
warfarin is not the best
Four direct-acting oral anticoagulants (DOAC) approved for stroke prevention in patients with atrial fibrillation:
Dabigatran (Pradaxa), Rivaroxaban (_____), Apixaban (______), Edoxaban (Lixiana)
ELECTIVE CARDIOVERSION:
Following appropriate anticoagulation –> still need months of anticoagulation
Recommended for:
_____ episode if AF of recent onset and there is a factor that appears to have initiated it
In patients who are still _____ from the rhythm despite aggressive rate control
Can be ELECTRIC or PHARMACOLOGIC
Pharmacologic examples:
IV ______: needs continuous monitoring by ECG for 3 hours
________: for both cardioversion and maintenance therapy
Can also use dofetilide, propafenone, felcainide, sotalol
FOR RECURRENT PAROXYSMAL A FIB (episodes of A Fib begin suddenly and usually stop spontaneously):
_______ pharmacologic cardioversion = “pill in the pocket treatment”
Without CAD or structural heart disease: flecainide or propafenone in addition to beta blocker or non-dihydropyridine CCB
Give first dose in a controlled environment
FOR REFRACTORY (UNMANAGEABLE) A FIB: If it causes persistent symptoms or limits activity --> \_\_\_\_\_\_\_ of foci in and around the pulmonary veins
beta blockers
CCBs
ELECTRO CARDIOVERSION
48
RATE
ANTICOAGULATION
beta blockers
CCBs
TEE
delayed
anticoagulation
warfarin
xaralto
eliquis
initial
symptomatic
ibutilide
amiodarone
on demand
catheter ablation
WPW
RADIOFREQUENCY ________ is the procedure of choice in patients with accessory pathways
Complications: AV block, cardiac tamponade, and thromboembolic events
________: if hemodynamically compromised
PHARMACOLOGIC THERAPY
Meds:
Class IA: _______ (IV)
Class III: _______
Avoid ______ and _____
Afib with concomitant antegrade conducting bypass tract presents as irregular, wide complex arrhythmia and must be managed differently
CATHETER ABLATION
cardioversion
procainamide
ibutilide
beta blockers
ccbs
pre. mature ventricular complexes
no ____ needed
tx
atrial flutter ___ - ___ bpm
NON-CHRONIC ATRIAL FLUTTER
Meds:
Class III anti-arrhythmic: IV _______
50-70% of patients return to sinus rhythm within 60-90 minutes*
AVOID class I and III agents (ex. _______) in the ______ setting because of possible induction of 1:1 conduction (collapse)
_______ cardioversion – 90% convert after 25-50J
CHRONIC ATRIAL FLUTTER - Harder to control rate than atrial fibrillation
Meds:
Anticoagulation (stroke risk IN chronic a fib)
Antiarrhythmics: ______and dofetilide (with AV nodal blocker, not verapamil)
_________
250-350
ibutilide
procainamide
prehospital
electrical
anticoagulation
amiodarone
catheter ablation
heart block
1st degree: no ___ is generally needed
2nd degree
Mobitz type I: good prognosis – _________ pacemaker if symptomatic
Mobitz type 2: _________ pacing required if it progresses to complete heart block
3rd degree:
Requires ____ pacing (if delayed, use temporary pacing)
INTRAVENTRICULAR CONDUCTION BLOCK - Common and may be transient
RBBB (right bundle branch block): often seen in patients with normal structural hearts
LBBB (left bundle branch block): two components (anterior and posterior); more often a marker of underlying disease including ischemic heart disease
New LBBB indicative of acute MI
TREATMENT:
Treatment of any potentially ______ cause (myocardial ischemia, medication effect)
Asymptomatic patients: NO specific treatment
Symptomatic patients: IV _____
Patients with cardiac syncope with normal heart rates and rhythm but bifascular or trifasicular block on ECG should also be considered for pacing
tx
AV alternative
prophylactic ventricular
permanent
reversible
atropine
TREATMENT OF ACUTE PERICARDITIS:
- Restrict _____ until symptoms subside (~3 months for athletes)
o Symptoms subside in several days to weeks - ___ 750-1000 mg q 8 hours for 1-2 wks w/ a taper (↓ the dose 250-400 mg every 1-2 wks)
OR
- ______. 600 mg q 8 hours for 1-2 wks w/ a taper (↓ the dose by 200-400 mg every 1-2 wks)
- _______ should be added to NSAIDs to prevent recurrences
o 0.5-0.6 mg once or twice daily and continued for at least 3 months – no need to taper
o Last week of treatment – the dosage can be reduced every other day for patients < 70 kg or one a day for patients > 70 kg
o If colchicine can’t be tolerated:
§ More significant _________: cyclophosphamide, azathioprine, IV human immunoglobulins, interleukin-1 receptor antagonists (anakinra), or methotrexate these can be treatments for some of the causes (cancer, CT disease)
§ Pericardial stripping (________
– surgical removal of pericardium) may be considered
- Major early complication = tamponade (occurs in less than 5% of pts)
- May have recurrences in the first few weeks or months
- In REFRACTORY CASES of acute pericarditis: ________ for 6 months
o _____ is used to assess the effectiveness of tx – once the levels are normal –> taper tx
o _______ in doses of 25-50 mg q 8 hours can be ADDED instead of ibuprofen
o Systemic _____ can be added in refractory cases or if there is autoimmune origin (like SLE or RA)
activities ASA ibuprofen colcichine immunosuppression pericardiectomy
colchichine
CRP
indomethacin
corticosteroids
constrictive pericarditis
TREATMENT: aimed at the specific ____ initially
If lab evidence of ongoing inflammation (↑ ___, ____, etc.): anti-inflammatories may be of benefit
Once hemodynamics are evident –> mainstay of therapy = _________
problems that appear to be like RHF (peripheral edema, ascites, etc.) so treat like other disorders of RHF (aggressive diuresis):
__________ (oral TORSEMIDE or BUMETANIDE if bowel edema is suspected OR IV FUROSEMIDE) AND ______ AND ALDOSTERONE ANTAGONISTS (especially in the presence of ascites & liver congestion)
Aquaphoresis may be of value to remove salt and water out of the body safely
If diuresis fails —> surgical ________ (with continued diuresis)
Morbidity & mortality are high (up to 15%)
Poor prognosis in: Prior radiation, renal dysfunction, higher pulmonary systolic pressures, abnormal LV systolic function lower serum sodium level, liver dysfunction and older age
etiology ESR, CRP dieuretics LOOP DIURETICS THIAZIDES pericardectomy
pericardial effusion (cardiac tamponade)
TREATMENT: treat _______ cause of the effusion!!!!!
______: for pain relief
If small effusion, can carefully observe ____ and changes in paradoxical pulse
If large effusion or there is cardiac tamponade present ——> _________
-fluid withdrawl from pericardial sac – can be diagnostic or therapeutic
If effusion reoccurs or becomes persistent —> pericardial ______ (cut a hole/window)
-create an opening in pericardial sac – ↓ risk for large effusions or pressure to develop
underlying NSAIDs JVP periocardiocentesis window
Dressler’s syndrome
Post MI
_____ and ______- 3 months
Don’t use ____ or steroids: can impair healing
Refractory
_______- 6 months
______ is used to assess effectiveness of tx; once normalized can taper
__________ instead of ibuprofen (recurrent pericarditis)
-Add colchicine for 3 months to prevent recurrence
ASA, colcichine
NSAIDs
colchichine
CRP
indomethacin
Myocarditis
Subacute disease
- Dilated cardiomyopathy
- _______ recovery
Chronic disease
- Mild dilation of the LV and eventually present with more restrictive cardiomyopathy
- ____ and _____ if LVEF is <40%
- ______ if myopericarditis related CP
- Colchicine if pericarditis predominates
- Arrhythmias should be suppressed
Fulminant myocarditis
Aggressive short-term support
Including an _____) or an LV assist device
_____ support may be temporarily required and has noted success
Giant cell myocarditis
May be responsive to _________ agents
2/3 in a study in 2013 reached at least partial remission
Freedom from severe heart failure and need for transplantation
Prone however to _______ arrhythmias
-Specific ______ indicated when infecting agent is identified
-Exercise limited during the recovery phase
______ should be avoided
-No benefit from steroids or intravenous immunoglobulin (IVIG)
-Interferon may have supportive role
-Overall, if improvement does not occur, many patients may be eventual candidates for cardiac transplantation or long term use of a newer LV assist device
-Patients in which myocarditis is suspected
-Should see a cardiologist at a tertiary care center where facilities are available for diagnosis and therapies available to treat a fulminant case
Facility should have support devices and transplantation options available.
incomplete
ACEI, beta blockers
NSAIDs
IABP
ECMO
immunosuppressive
ventricular
antibiotic
digoxin
