Case 3 - Arrhytmia Flashcards
Difference between SVT and VT?
- SVT - narrow complex tachycardia, linked to atrial activation of ventricles via accessory pathway or re-entrant circuit, less CO threatening, can be managed with valsalva etc
- VT - broad complex tachycardia, originates from ventricles, can significantly compromise CO, need urgent shocking
Management of SVT - if stable (no hypotension or tachycardia)
- Valsalva manoeuvre - blow into syringe while lying down
- Carotid sinus massage
If unsuccessful:
* IV adenosine challenge
* Then IV metoprolol or IV verapamil if unsuccessful
* Then cardioversion if unsuccessful
Management of SVT if haemodynamically unstable
Cardioversion
Management of AF
- Rate or rhythm control - rate beta blocker or rate control CCB
- Anticoagulate with DOAC (warfarin 2nd line) when CHADVASC is 2 or more, and consider in men who score is 1 with
- Take into account bleed risk with ORBIT score
CHADVASC meaning
- CHF
- HTN
- Age older 75 (score 2)
- Diabetes
- Vascular disease
- Age 65-74
- Sex - female
- Cerebrovascular event - stroke/tia (2)
ORBIT score bleed risk
- Older - 75 or more
- Renal impairement (less than 60)
- Bleeding (GI or intracranial bleed history)
- Iron (low Hb/Ht)
- Taking antiplatelets
HASBLED score bleed risk
- HTN
- Abnormal liver/renal function
- Stroke
- Bleeding
- Labile INR (unstable/high)
- Elderly (older 65)
- Drugs/alcohol
Indications for electrical DC cardioversion for AF
- Life threatening haemodynamic instability caused by new onset AF
Management AF guidelines
- Offer rate or rhythm control if onset is less than 48hrs
- Offer rate control if onset is more than 48hrs or uncertain
- Rhythm control is pharmacological or electrical cardioversion
Pharmacological cardioversion options
- Flecainide or
- Amiodarone
If no evidence of structural heart disease
Amiodarone if heart disease
When is rhythm control recommended in AF? (ie not rate control)
- atrial fibrillation has a reversible cause
- heart failure thought to be primarily caused by atrial fibrillation
- new-onset atrial fibrillation
- atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
- for whom a rhythm-control strategy would be more suitable based on clinical judgement
Rate control medications AF
- Beta blocker
- CCB - rate (eg verapamil or diltiazem)
5 commonest causes of AF
- Sepsis
- Mitral valve pathology (stenosis/regurge)
- IHD
- Thyrotoxicosis
- HTN
Also alcohol and caffeine
SMITH AC
What is Wolff-Parkinson-White syndrome?
- Abnormal electrical pathway (accessory pathway) that bypasses AV node
- Congenital
Drugs used long term AF
- Rate - beta blockers, diltiazem, verapamil, digoxin
- Rhythm - amiodarone
- DOAC
- Statin if needed
- BP management
Scoring system used to determine if someone with AF should be taking long term anticoagulation
- CHADSVASC - clot risk
- ORBIT/HAS-BLED - bleed risk
Adult ALS guidelines for tachycardia
Pathway for AF treatment
- Decide for rate or rhythm control
- Decide if need anticoag (using CHADVASC)
- If rhythm control - is this long term pharmacological or cardioversion?
- If cardioversion - is this immediate or delayed? If delayed need to be anticoagulated for 3 weeks prior
- If immediate - can have pharmacological (flecainide or amiodarone) or electrical
- If none of this works or is tolerated they can have ablation.
(immediate is done if onset is within last 48hrs or life threatening haemodynamically unstable, delayed often uses electrical or maybe amiodarone and is done if AF has lasted more than 48hrs. Need anticoag as returning to sinus rhythm could mobilse a clot that has formed in atria
What long term rhythm control medications are used for AF?
- Beta blockers - 1st line
- Dronedarone - 2nd line for pts who had successful cardioversion
- Amiodarone - used in pts with HF or LV dysfunction
Management of paroxysmal AF
- Pill in pocket approach
- Take flecainide when episode occurs
Pts must be anticoagulated if CHADVASC says so, not have any structural HD and have infrequent episodes
