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HPIM Cardio > Ch276 Supraventricular Tachyarrhythmias > Flashcards

Ch276 Supraventricular Tachyarrhythmias Flashcards

1
Q

T or F: Most supraventricular tachyarrhythmias produce wide QRS complex tachycardia (QRS duration >120 ms)

A

False

mostly narrow QRS-complex <120 ms

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2
Q

2 types of supraventricular tachyarrhythmia

A
  1. Physiologic sinus tachycardia

2. Pathologic tachycardia

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3
Q

T or F: Supraventricular arrhythmia usually precipitates cardiac arrest in patients with Wolff-Parkinson-White syndrome or severe heart disease such as hypertrophic cardiomyopathy

A

False

Rarely

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4
Q

Diagnostic of supraventricular arrhythmia

A

ECG

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5
Q

Normal sinus rhythm rate

A

60-100 beats/min

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6
Q

Sinus tachycardia rate

A

> 100 beats/min

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7
Q

Difference of sinus tachycardia vs atrial tachycardia

A

Sinus tach: GRADUAL increase and decrease in rate

Atrial tach: ABRUPT onset and offset

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8
Q

Treatment for physiologic sinus tachycardia

A

Treat the underlying condition

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9
Q

Uncommon condition in which sinus rate increases spontaneously at rest or out of proportion to physiologic stress or exertion

A

Inappropriate sinus tachycardia

Common: women, 3rd-4th decade

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10
Q

Defining feature of physiologic sinus tachycardia

A

Normal sinus mechanism precipitated by exertion, stress, concurrent illness

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11
Q

Drug that blocks the funny current (If) causing sinus node depolarization

A

Ivabradine

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12
Q

Syndrome wherein symptomatic sinus tachycardia occurs with postural hypotension

A

Postural orthostatic tachycardia syndrome (POTS)

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13
Q

Condition due to autonomic dysfunction following a viral illness and resolve spontaneously over 3-12 months

A

Postural orthostatic tachycardia syndrome (POTS)

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14
Q

Treatment for POTS that can be helpful

A 
Volume expansion with salt supplementation
Oral Fludrocortisone
Compression stockings
a-agonist midodrine
Exercise training
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15
Q

Condition due to abnormal automaticity, triggered automaticity, or a small reentry circuit confined to the atrium or atrial tissue extending into a pulmonary vein, the coronary sinus, or vena cava

A

Focal atrial tachycardia (AT)

Sustained, nonsustained, paroxysmal, incessant

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16
Q

Type of focal atrial tachycardia that can cause tachycardia-induced cardiomyopathy

A

Incessant AT

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17
Q

Difference of AT from AV nodal-dependent SVTs

A

AT will not terminate with AV block and atrial rate will not be affected

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18
Q

Defining feature of Inappropriate sinus tachycardia

A

Tachycardia from normal sinus node area that occurs without an identifiable precipitating factor as a result of the dysfunctional autonomic regulation

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19
Q

Defining feature of Focal atrial tachycardia

A

Regular atrial tachycardia with defined P wave

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20
Q

In AT, P wave may fall on top of the T wave or coincident with QRS. What maneuvers can be done to expose the P wave?

A

Carotid sinus massage
Valsalva maneuver
Administration of AV nodal-blocking agents (Adenosine)

Maneuvers that increase AV block

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21
Q

Common causes of physiologic sinus tachycardia

A
  1. Exercise
  2. Acute illness with fever, infection, pain
  3. Hypovolemia, anemia
  4. Hyperthyroidism
  5. Pulmonary insufficiency
  6. Drugs that have sympathomimetic, vagolytic, or vasodilator properties
  7. Pheochromocytoma
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22
Q

Treatment for AT with recurrent episodes

A
  1. Beta blockers
  2. Calcium ch blockers (Diltiazem, Verapamil)
  3. Flecainide
  4. Propafenone
  5. Disopyramide
  6. Sotalol
  7. Amiodarone
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23
Q

Recommended treatment for recurrent symptomatic AT if unresponsive to drugs OR Incessant AT causing tachycardia-induced cardiomyopathy

A

Catheter ablation

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24
Q

The most common form of PSVT

A

AV nodal reentry tachycardia (AVNRT)

women>men, 2nd-4th decade

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25
Q

T or F: AVNRT is usually associated with structural heart disease.

A

False

NOT usually associated

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26
Q

T or F: In AVNRT, P wave can be difficult to discern

A

True

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27
Q

Is AVNRT responsive to Valsalva manuever?

A

Yes

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28
Q

Recommended treatment for recurrent or severe episodes or when drug therapy is ineffective, not tolerated, or not desired in patients with AVNRT

A

Catheter ablation of the slow AV nodal pathway

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29
Q

Condition due to automaticity within the AV node; Rare in adults and more frequently encountered as incessant tachycardia in children usually in perioperative period surgery for congenital heart disease

A

Junctional Ectopic Tachycardia (JET)

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30
Q

Is JET, a narrow or wide QRS tachycardia?

A

Narrow QRS tachycardia

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31
Q

A junctional automatic rhythm between 50 and 100 beats/min

A

Accelerated junctional rhythm

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32
Q

Defining feature of AV nodal reentry tachycardia

A
  1. Paroxysmal regular tachycardia with P waves visible at the end of the QRS complex or not visible at all
  2. Most common paroxysmal sustained tachycardia in healthy young adults
  3. More common in women
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33
Q

Conditions associated with accessory pathways

A
  1. Ebstein’s anomaly of tricuspid valve
  2. Forms of hypertrophic cardiomyopathy (PRKAG2 mutations)
  3. Danon’s disease (LAMP2, lysosomal membrane disorder)
  4. Fabry’s disease (lysosomal storage disease)
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34
Q

Location of accessory pathways

A

Across either an AV valve annulus or septum, most frequently between the left atrium and free wall of the left ventricle, followed by posteroseptal, right free wall, and anteroseptal locations

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35
Q

ECG findings associated with accessory pathways

A
  1. Short P-R interval (<0.12s)
  2. Slurred initial portion of the QRS (delta wave)
  3. Prolonged QRS duration (widened QRS complex)
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36
Q

Defined as preexcited QRS during sinus rhythm and episodes of PSVT

A

Wolff-Parkinson-White (WPW) syndrome

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37
Q

The most common tachycardia caused by an AP

A

PSVT (Orthodromic AV reentry)

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38
Q

Pathway of orthodromic AV reentry

A

Reentry wavefront propagates from atrium anterogradely over the AV node and His-Purkinje system to ventricles and then re enters atria via retrograde conduction over the AP

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39
Q

Most common preexcited tachycardia in which activation propagates from atrium to ventricle via the AP and then conducts retrogradely to the atria via the His-Purkinje system and the AV node

A

Antidromic AV reentry

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40
Q

T or F: Preexcitated tachycardia is associated with ventricular fibrillation and sudden death.

A

True

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41
Q

AV nodal-blocking agents that are contraindicated in preexcitated tachycardia

A 
Oral or IV verapamil
Diltiazem
Beta blockers
IV adenosine
IV amiodarone
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42
Q

Treatment for preexcited tachycardia

A

Electrical cardioversion
IV procainamide
Ibutilide

*slow ventricular rate

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43
Q

In focal atrial tachycardia, P wave morphology can be used to estimate the location of the ectopic focus

A
  1. Right atrium - positive P wave in lead I and biphasic in V1
  2. Atrial septum - narrower P wave duration than sinus rhythm
  3. Left atrium - monophasic, positive P wave in V1
  4. Superior atrial location (Superior vena cava/superior pulmo veins) - positive in inferior limb leads II, III, aVF
  5. Inferior location (Ostium of coronary sinus) - negative P waves in limb leads II, III, aVF
44
Q

Relationship of Focal Atrial Tachycardia on structural heart disease

A

Can occur in the absence of structural heart disease OR can be associated with any form of heart disease that affects the atrium

45
Q

Possible causes of Focal Atrial Tachycardia

A
  1. Sympathetic stimulation which can be a sign of an underlying illness
  2. Digitalis toxicity
46
Q

Frequent sites of origin of Focal Atrial Tachycardia

A
  1. valve annuli of left or right atrium
  2. pulmonary veins
  3. coronary sinus musculature
  4. superior vena cava
47
Q

P wave in Atrioventricular Nodal Reentry Tachycardia (AVNRT)

A
  1. No discernible P-waves (inscribed during the QRS) (80-90%*)
  2. Slightly after the QRS (10%*)
  3. Slightly before the QRS (1-5%*)

*accdg to life in the fast lane ;)

48
Q

Condition causing incessant tachycardia and tachycardia-induced cardiomyopathy due to slow conduction that facilitates reentry associated with accessory pathways

A

Paroxysmal junctional reciprocating tachycardia (PJRT)

49
Q

In a patient presenting narrow QRS PSVT together with hypotension, what is your next step?

A

QRS-synchronous direct current cardioversion

50
Q

In a patient presenting with narrow QRS PSVT and hemodynamically stable, what is the next step?

A

Vagal manuevers
IV adenosine
IV verapamil/diltiazem

Figure 276-9, p. 1483

51
Q

In a narrow QRS PSVT, hemodynamically stable patient, however did not respond to sympatholytic and vagotonic maneuvers and drugs, what is the next step?

A

IV ibutilide + AV nodal-blocking agent
IV procainamide + AV nodal-blocking agent
Cardioversion

Figure 276-9, p. 1483

52
Q

Defining feature of Atrial Flutter

A

Organized reentry creates organized atrial activity commonly seen as sawtooth flutter waves at rates typically faster than 200 beats/min

Table 276-1, p. 1477

53
Q

Condition due to a large reentry circuit and is often associated with areas of scar in the atria

A

Macroreentrant atrial tachycardia

54
Q

Condition due to a circuit that revolves around the tricuspid valve annulus, bounded anteriorly by the annulus and posteriorly by functional conduction block in the crista terminalis

A

Common or typical right atrial flutter

55
Q

Pathway of wavefront of common atrial flutter

A

Through an isthmus between the inferior vena cava and the tricuspid valve annulus (sub-Eustachian or cavotricuspid isthmus)

56
Q

Circuit most commonly revolves in a counterclockwise direction and produces negative sawtooth flutter waves in leads II, III, aVF and positive P waves in lead V1

A

Common atrial flutter

Rate: 240-300 beats/min

57
Q

T or F: Atrial flutter will respond to maneuvers that increase AV nodal block

A

True

58
Q

Common right atrial flutter often occur in association with what conditions?

A

Atrial fibrillation

Atrial scar from senescence or prior cardiac surgery

59
Q

Macroreentrant atrial tachycardia that are not dependent on conduction through the cavotricuspid isthmus

A

Atypical atrial flutters

60
Q

What condition does left atrial flutter and perimitral left atrial flutter more commonly seen?

A

After extensive left atrial ablation for atrial fibrillation or atrial surgery

61
Q

In a patient with atrial flutter and hemodynamically unstable, what is your next step?

A

Electrical cardioversion

62
Q

In a patient with atrial flutter and hemodynamically stable, what is the next step?

A

Administer AV nodal-blocking agents

63
Q

For patients with atrial flutter more than 48h or for patients at increased risk of thromboembolic stroke based on CHA2DS2-VASc scoring system, what should be given prior to conversion?

A

Anticoagulation

64
Q

Components of CHA2DS2-VASc scoring system

A 
Congestive heart failure 
Hypertension
Age>/= 75 y/o
Diabetes mellitus
Stroke or TIA, embolus
Vascular disease
Age 65-75 y
Sex - female
65
Q 
Give the mechanism for each anticoagulant:
Warfarin
Dabigatran
Rivaroxaban
Apixaban
A

Warfarin - Vitamin K antagonist
Dabigatran - Thrombin inhibitor
Rivaroxaban - Xa inhibitor
Apixaban - Xa inhibitor

Table 276-6, p. 1485

66
Q

Treatment for recurrent episodes of common atrial flutter that abolishes arrhythmia in over 90% of patients

A

Catheter ablation of cavotricuspid isthmus

67
Q

Anti arrhythmic drug therapy for atrial flutter

A

Sotalol
Dofetilide
Disopyramide
Amiodarone

> 70% have recurrence

68
Q

T or F: 50% of patients with atrial flutter will develop atrial fibrillation within the next 5 years

A

True

69
Q

Characterized by atleast three distinct P-wave morphologies with rates typically between 100 and 150 beats/min

A

Multifocal Atrial Tachycardia (MAT)

70
Q

What conditions do multifocal atrial tachycardia usually encountered?

A
  1. Chronic pulmonary disease

2. Acute illness

71
Q

Treatment for MAT

A

Treat the underlying disease and correct any metabolic abnormalities

72
Q

T or F: Electrical cardioversion if effective for MAT

A

False.

No effect.

73
Q

Drug therapy for MAT that can be considered

A

Verapamil or Diltiazem - may slow atrial and ventricular rate
Amiodarone - long term therapy avoided due to pulmonary fibrosis
Beta blocker - not tolerated in severe pulmonary disease

74
Q

Characterized by disorganized, rapid, and irregular atrial activation with loss of atrial contraction and with an irregular ventricular rate that is determined by AV nodal conduction

A

Atrial fibrillation (AF)

75
Q

Most common sustained arrhythmia

A

Atrial fibrillation

Men>women, white>black

76
Q

T or F: Prevalence of AF increases with age

A

True

77
Q

Risk factors for developing atrial fibrillation

A
  1. Age
  2. Hypertension
  3. Diabetes mellitus
  4. Cardiac disease
  5. Sleep apnea
78
Q

AF increases the risk of developing these conditions

A
  1. Heart failure
  2. Stroke (5x)
  3. Dementia
79
Q

Acute precipitating factors associated with AF

A
  1. Hyperthyroidism
  2. Acute alcohol intoxication
  3. Acute illness (MI, pulmo embolism, cardiac surgery)
80
Q

Clinical types of AF

A
  1. Paroxysmal AF (start and stop spontaneously)
  2. Persistent AF (>7 days)
  3. Long-standing persistent AF (>1 year)
81
Q

Treatment for paroxysmal AF

A

Catheter ablation that isolates these foci

82
Q

T or F: In high risk patients with AF, antiplatelets have equal effects as anticoagulants

A

False

Less effect

83
Q

New onset AF producing severe hypotension, pulmonary edema or angina : What is your next step?

A

Cardioversion with QRS synchronous shock of 200J

84
Q

In new onset AF that reinitiated after cardioversion : what is your next step?

A

Administer antiarrhythmic drug (Ibutilide)

Repeat cardioversion can be considered

85
Q

Goals of therapy for AF in a stable patient

A
  1. Rate control to alleviate or prevent symptoms
  2. Anticoagulation if appropriate
  3. Cardioversion to restore sinus rhythm if AF is persistent
86
Q

In the absence of contraindications, what systemic anticoagulation can you give in new onset AF?

A

Heparin (immediately)

87
Q

Patient at the ER came within 48h of the onset of AF and anticoagulation was never given. Upon probing, he is low risk for stroke. What should be done?

A
  1. Cardioversion

2. Anticoagulate based on CHA2DS2-VASc score

88
Q

Two approaches that can mitigate the risk of thromboemolism related to cardioversion in patients with AF exceeding 48h or with unknown duration

A
  1. Anticoagulate continously for 3 weeks before and minimum of 4 weeks after cardioversion
  2. Start anticoagulation and perform transesophageal echocardiogram to determine if thrombus is present in left atrial appendage. If absent, cardioversion can be performed and anticoagulation continued for a minimum of 4 weeks
89
Q

Drug therapy for acute rate control in patients with AF

A
  1. Beta blockers and/or
  2. Calcium channel blockers (Verapamil/Diltiazem, IV or PO)
  3. Digoxin may be added (esp in heart failure)

Goal: Reduce ventricular rate to less than 100/min or guided by clinical situation

90
Q

Goal of therapy for chronic AF

A

Rate control - to alleviate and prevent symptoms, prevent deterioration of ventricular function (beta adrenergic blockers, calcium ch blockers, digoxin)

Goal: Heart rate <80beats/min to less than 100 beats/min with light exertion

91
Q

Next step for chronic AF that can’t be controlled by medications:

A

Catheter ablation and permanent pacemaker

92
Q

Anticoagulation for patients with AF who have rheumatic mitral stenosis or mechanical heart valves

A

Vitamin K antagonist

93
Q

Patients that can be given vitamin K antagonist (warfarin) OR newer oral anticoagulants

A
  1. Had more than 48h of AF and are undergoing cardioversion
  2. Have prior history of stroke
  3. CHA2DS2-VASc score >/=2, but may be considered in patients with a risk score of 1
94
Q

Risk factors for bleeding as a major risk of anticoagulation

A
  1. Age >65-75 y/o
  2. Heart failure
  3. History of anemia
  4. Excessive alcohol
  5. NSAID use
  6. With coronary stents who require antiplatelet with aspirin and thienopyridine
95
Q

T or F: Newer anticoagulants are noninferior to warfarin but superior by 0.4-0.7% in reduction of mortality, stroke, major bleeding and intracranial hemorrhage.

A

True

96
Q

Reversing agents for warfarin anticoagulation

A

FFP

Vitamin K

97
Q

Time limit for newer anticoagulants to improve clotting once it is excreted

A

12 hours

98
Q

T or F: Antiplatelet agents aspirin and clopidogrel are noninferior to warfarin for stroke prevention in AF and do not reduce the risk of bleeding

A

False

ASA and clopidogrel are inferior to warfarin

99
Q

T or F: Aspirin alone is better than Clopidogrel combined with aspirin for stroke prevention in patients with AF

A

False

Clopidogrel combined with aspirin is better than aspirin alone

100
Q

T or F: Clopidogrel combined with aspirin is inferior to warfarin and has greater bleeding risk than aspirin alone for stroke prevention in patients with AF

A

True

101
Q

Goal of pharmacologic therapy in AF

A

Maintain sinus rhythm

Reduce episodes of AF

102
Q

Drugs that help control ventricular rate, improve symptoms and possess a low-risk profile, but have low efficacy for preventing AF episodes

A

Beta adrenergic blockers

Calcium channel blockers

103
Q

Indication and contraindication for Class I sodium channel-blocking agents (flecainide, propafenone, disopyramide)

A

For:
Subjects without significant structural heart disease

Against:

  1. Negative inotropic and proarrhythmic effects
  2. Avoided in patients with coronary artery disease or heart failure
104
Q

Indication and contraindication for Class III agents (Sotalol, Dofetilide, Dronedarone, Amiodarone)

A

For:
With coronary artery disease or structural heart disease
Amiodarone more effective in 2/3 of patients

Against:

  1. 3% risk of inducing excessive QT prolongation and torsades des pointes
  2. Dronedarone increases mortality in patients with heart failure
  3. 20% of patients on long-term amiodarone experience toxicities
105
Q

This procedure involves cardiac catheterization, transatrial septal puncture, and radiofrequency ablation or cryoablation

A

Catheter ablation

106
Q

Major complications of catheter ablation

2-7% risk

A

Stroke (0.5-1%)
Cardiac tamponade (1%)
Phrenic nerve paralysis
Bleeding from femoral access sites
Fluid overload with heart failure 1-3 days after procedure
Sinus node injury requiring pacemaker implantation

107
Q

T or F: Catheter ablation is less effective for persistent AF.

A

True

More extensive ablation is often required

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