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Conduction system disorders Flashcards

1
Q

symptoms of conduction system disorders

A

Palpitations: **
- “Extra beat”, “Fluttering”, “Heart beating out of chest”
SOB **
Chest pain **
Diaphoresis - excess sweating
-Dizziness(room spinning- rule out vertigo)/lightheadedness(sit to stand)
Syncope - fainting**
-Cough
-Fatigue
-Weakness

Arrhythmias become significant when disrupts cardiac output

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2
Q

Cryptogenic stroke and ILR

A
  • after stroke of unknown cause -> push for ILR to check for AFIB**
  • one stroke significantly increases risk for second stroke
    -Crystal AF study: 88% of pts who had afib would have been missed if they were only monitored for 30 days instead of loop
    -MRI safe
    -3 year monitor

Takes spontaneous recording of:
-Tachycardia
-Bradycardia
-Pauses
-Irregular rhythms

Triggered symptom events recorded

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3
Q

dx of conduction system

A

1) 12 lead Electrocardiogram (EKG)

2) Holter monitor- 24hrs – 30 days

3) Implantable Loop Recorder (ILR)
- Useful for cryptogenic CVA: check for afib

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4
Q

Palpitations sx/description

A

-“Extra beat”
-“Fluttering”
-“Heart beating out of chest”

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5
Q

paroxysmal supraventricular tachycardia definition

A

General term:
- rate 150-250 bpm/min
- NARROW QRS -> normal ventricular depolarization
- rapid heartbeat originating from atria

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6
Q

paroxysmal supraventricular tachycardia types

A

MC: AV node re-entry**
- P-wave hidden in T-wave
- narrow QRS
- short circuit around the AV node

Other types of PSVT:
-Atrial Tachycardia
-Multifocal Atrial Tachycardia
-Junctional Tachycardia- rapid firing from AV

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7
Q

causes of PSVT

A

-Excessive caffeine (stop at 2 8oz cups)
-Post myocardial infarction (MI) - ischemic ds
-Structural heart disease
-Chronic lung disease
-Amphetamines
-Myocarditis/pericarditis
-Pulmonary embolism- right heart typically affected
-Idiopathic

PSVT = Please Eat SCAMPI
-pulmonary embolism

-excess alc or caffeine
-structual heart ds
-chronic lung ds
-amphetamines
-myocarditis
-post MI
-idiopathic

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8
Q

SVT acute phase tx for hemodynamically unstable pt

A

Unstable = synchronized CARDIOVERSION to reset heart

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9
Q

SVT prevention and definitive tx

A

Prevention:
-Beta-blockers: atenolol, metoprolol, carvedilol
-Calcium cannel blockers: diltiazem, verapamil

Definitive treatment for SVT: radiofrequency ablation **

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10
Q

SVT acute phase tx for hemodynamically stable pt

A

*Carotid massage NOT RECOMMENDED in elderly -> CVA risk
DEFINITIVE TX: RADIOFREQUENCY ABLATION

first determine if stable vs unstable -> if stable:

1st line: Vagal maneuvers
-Bearing down (valsalva)
- cough
- holding breath
- moves that increase intrathoracic pressure -> stimulate vagus nerve -> slow HR

Pharmacological interventions:
Narrow QRS complex:
- Adenosine: 6mg IV then 12 mg IV push
- causes AV node arrest for 6s
- adenosine temporarily blocks conduction through AV node -> interrupts circuit

Wide QRS complex:
- Amiodarone (prof doesnt recommend)

-note: if you gave adenosine with afib it wouldnt do anything -> not coming from AV node

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11
Q

Amiodarone: description, half life and side effects

A

Class 3 antiarrhythmic drug - blocks K+ channels; but also Beta, Ca, Na+

Half life: 58 hours

Common side effects:
-Nausea
-Fatigue
-Tremors

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12
Q

Adenosine MOA and half life

A

MOA:
- causes vasodilation
- Transient heart block at AV node in hopes SA node resets on its own
- Half life <10 seconds

SVT medication for NARROW complex hemodynamically stable

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13
Q

Adenosine ADRs and Contraindications

A

Most common side effects:
-METALLIC taste*
-“IMPENDING DOOM”*
-Chest pain
-SOB
-Facial flushing
-Lightheadedness

Contraindications:
-Asthma
-Long QT syndrome
-2nd/3rd degree heart blocks

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14
Q

Amiodarone: ADR and contraindications

A

ADR:
-Hepatotoxicity
-Pulmonary fibrosis
-Optic neuritis
-Thyroid dysfunction- MC
-blue skin discoloration in the sun

Contraindications:
-2nd/3rd degree heart block
-Prolonged QT
-Pregnancy
-Sinus node dysfunction

-“<65 yo, ablation not this, this is a very toxic drug; not good for pts over 65 yrs; dr hates this drug”

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15
Q

atrial fibrillation definition + common cause of afib

A

Definition:
- rate 350 – 450 bpm
-Multiple foci in the atria rapidly firing - Irregularly irregular rhythm
-NO P-wave present
-Irregular QRS intervals

Common cause:
-“Holiday heart” syndrome: excessive alc or withdrawl*
-> pt young, having drinks, etc”

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16
Q

length categories of AFib

A

Paroxysmal- Less than 7 days
Persistent- Longer than 7 days
Chronic- Arrhythmias presents for at least 1 year without resolution

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17
Q

3 questions when looking at afib

A

-hows the rate
-hows the rhythm
-protected from stroke? are they on anticoagulants?

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18
Q

rate categories of afib

A

Based on ventricular rate:
-Rapid ventricular response: Rate ≥ 100
-Moderate ventricular response: Rate 60-100-
-Slow ventricular response: Rate < 60

“think regular HR”

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19
Q

causes of atrial fibrillation

A

-Ischemic heart disease *** -> need to r/o CAD first
-Structural heart disease: MC = mitral stenosis
-Alcohol consumption
—
-Hyperthyroidism
-Pheochromocytoma
-Embolism (Pulmonary)
-Sepsis
-Post-operative stress
-Anemia
-Cardiomyopathy
-Electrolyte disturbance

“ayyy ferb (AFib) -> I SHAPE SPACE”
-ischemic hd - CAD
- structural - MC mitral stenosis
- alcohol
- pheochromocytoma
- embolism

-sepsis
-post op stress
-anemia
-cardiomyopathy
-electrolyties

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20
Q

afib treatment acute phase: less than 48 hours

A

Less than 48 hours from onset -> Synchronized CARDIOVERSION

only do if you are sure about <48h

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21
Q

afib treatment acute phase: Greater than 48 hours

A

Greater than 48 hours tx:
1) Anticoagulation + rate control for 3 WKS
- clot breaks down in 3 weeks with medication
2) TEE BEFORE CARDIOVERSION:
- visualizes the left atrial appendage and check for clot*
3) Cardioversion
- > cardioversion causes an increased risk of thromboembolic events***

-Ablation therapy
-TEE** = visualizes left atrial appendage

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22
Q

AFib: rate and rhythm control meds

A

Rate control medication:
-Beta-blockers
-Calcium channel blockers
-Digoxin

Rhythm control medications:
- class 1 and 3 antiarrhythmic medications: amiodarone

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23
Q

Who do we anticoagulate??

A

based on CHADS2 score vs. CHADSVASC score

Score:
-0 points- none or ASA
-1 point- ASA or full anticoagulation
-2 or greater- full anticoagulation

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24
Q

CHA2DS2VASc score: how to calculate

A
  • C - Congestive heart failure (1 point)
  • H - Hypertension (1 point)
  • A2 - Age ≥75 years (2 points)
  • D - Diabetes Mellitus (1 point)
  • S2 - Prior Stroke or TIA or thromboembolism (2 points) -> retinal artery occlusion is a TIA
  • V - Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic atheroscleoris) (1 point)
  • A - Age 65–74 years (1 point)
  • Sc - Sex category (i.e., female gender) (1 point)
    If their score is 0 and female: DO not give a point

Score:
-0 points- none or ASA
-1 point- ASA or full anticoagulation
-2 or greater- full anticoagulation

CHA2DS2VASc = percentange risk for stroke in patients with AFib

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25
Warfarin MOA, metabolism, INR goal levels
MOA: -Blocks vitamin K dependent clotting factors in the liver - Factors II, VII, IX, and X + Protein C and S -Can be reversed with Vitamin K or fresh frozen plasma****** - Metabolism: Cytochrome P450 Monitor INR - Standard goal: 2-3 - pts with mechanical heart valves: 2.5 – 3.5 -> if even goes .1 under -> start over therapy
26
Warfarin: factors affecting INR
Decreasing INR: -Leafy green vegetables: spinach, broccoli, brussels sprouts - Phenytoin - phenobarbitol -St. Jonhs wart- OTC supplement Increasing INR: -Alcohol -ANTIBIOTICS: quinolones, amoxicillin, metronidazole -Amiodarone -Steroids INR too high: risk bleeding event INR too low: risk blood clotting
27
afib: direct oral anticoagulants (DOAC) indication and contraindications
Indication: - pts with NON-VALVULAR afib - valvular afib: mitral stenosis and mechanical heart valves -benefit: NO monitoring of INR - All metabolized through the kidneys Contraindication: - Warning in renal impairment patients - valvular afib: mitral stenosis and mechanical heart valves
28
afib: direct oral anticoagulants (DOAC) drug names
-Dabigatran (Pradaxa)- Direct thrombin (II) inhibitor -Rivaroxaban (Xarelto)- Factor Xa inhibitor -Apixaban (Eliquis)- Factor Xa inhibitor -> prof preferred drug
29
HASBLED score- bleed risk
Assess 1 year risk of major bleeding in pts taking anticoagulation Hypertension (uncontrolled) : 1 point Abnormal Liver/Renal Function: 1 or 2 - Cr > 2.26 - bili x2- - AST/ALT/AkP x3 Stroke: 1 point Bleeding: 1 point - major bleeding event - unpredictable INR Elderly > 65: 1 point Drugs or Alcohol : 1 or 2 - over 8 drinks/wk - Drugs that cause bleeding: ex - NSAIDS,
30
What is the watchmen procedure?
device placed inside left atrial appendage and creates endothelialization; left atrial appendage cant be accessed → prevents thrombus in that area
31
atrial flutter definition
Rate 250 – 350 bpm (rate of atrium not HR) -Reentry circuit in the atrium -*Produces a “SAW-TOOTH” pattern -Classified as atrial to ventricular conduction ratio - ex: 3 flutter waves and 1 QRS complex: 3:1 conduction
32
atrial flutter causes
Causes: -COPD** --- -Cardiomyopathy -Structural heart disease -Atrial septal defect -Myocarditis -Hyperthyroidism -Idiopathic -these things just exacerbate the deformity thats already there "you make my heart flutter i cant BREATHE bc of COPD"
33
atrial flutter tx
-More successful with ablation therapy -> ablation is tx for life -Anticoagulation -Treatment for atrial fibrillation atrial flutter = reentry circuit in the atrium "you make my heart flutter, i cant breathe (COPD) -> i need to cut you off (ablation tx) and heal (anticoagulants)"
34
ventricular tachycardia definition + sustained vs nonsustained
Definition: ventricular rate of 150-250 bpm -3 of more premature ventricular contractions in a row (PVC) -Unifocal (monomorphic) -Multifocal (polymorphic) Nonsustained vs. sustained -NSVT: < 30 seconds -Sustained VT: > 30 seconds -> Even if spontaneous resolution - if sustained VT -> need a deliberator
35
ventricular tachycardia causes
-MC: coronary artery disease -> especially post- MI -Cardiomyopathy -Congenital defects -Prolonged QT syndrome- can be candidate for defibrillator- sudden death -Illicit drug use -Medications VTach = CAD -> everyone in chis needs to calm down
36
ventricular tachycardia tx: pulseless and unstable VT
With sustained VT initiated ACLS protocol ** Pulseless VT: immediate defibrillation - unsynchronized cardioversion Unstable VT: synchronized cardioversion -5 mins of no BP/pulse -> brain damage -HR is so fast there is no CO and pulse > 200 usually (vfib is pulseless)
37
ventricular tachycardia tx: stable VT
Non-sustained Stable VT: -beta-blocker therapy Sustained Stable VT -Synchronized cardioversion - Antiarrhythmic drugs: ALP - Amiodarone* - Lidocaine (IV) - Procainamide (cant give to pts with CAD so not recommended) You TACH on ALP drugs after
38
ventricular tachycardia treating the underlying cause
Goal: treat underlying cause MI: Cardiac catheterization Cardiomyopathy: -Echocardiogram to assess ejection fraction and walls -Medical management of cardiomyopathy Electrolyte abnormalities (find the cause: diuretics, dialysis): K+, Mg2+, calcium STOP Anti-arrhythmic meds: Sotalol, Amiodarone, Mexiletine
39
torsades de pointes def and treatment
Polymorphic Vtach -“Twisting of the points” -QRS complex twists around axis -Torsades = Warning sign of VFIB Treatment: -First line: MAGNESIUM 1g IV push* -Defibrillation if no pulse
40
ventricular fibrillation definition
Definition: ventricular rate of 300 - 400bpm -Rapid firing of multiple foci leading to no uniform ventricular contraction -No CO -No BP -Irregular and shapeless QRS pattern on EKG -Most commonly caused by ischemic heart disease*** -MC event that leads to cardiac arrest
41
ventricular fibrillation causes
-Ischemic heart disease - MC* -Antiarrhythmics-Prolongation of the QT interval -Atrial fibrillation with rapid ventricular response -Drug toxicity -Sepsis -Hemorrhagic shock -Electrolyte abnormalities VFIb= Ischemic heart ds/mI VTAch = CAD - i goes w i and a goes with a
42
ventricular fibrillation treatment + prevention
Definitive treatment: defibrillation*** (ACLS protocol) - Defibrillation -> Epinephrine -->Defibrillation-->Epinephrine Amiodarone IV: given 24 to 48 hours post- conversion Treat the underlying cause: - do ischemic evaluation Prevention: AICD - AICD placement (Automatic Implantable Cardioverter Defibrillator)
43
cardiac arrest definition
Definition: sudden cessation of blood flow due to failure of the heart - heart CANNOT CONTRACT -Death within minutes MC cause is CAD*** MC rhythm is ventricular fibrillation ** Cardiac Arrest = CAd - arrest is bad and vfib is the worst arrhythmia
44
causes of cardiac arrest
-Coronary artery disease** -Heart failure -Genetics: pro-longed QT syndrome, -Brugada syndrome, Hypertrophic cardiomyopathy (thick septum obstructs- congenital) -Low magnesium, potassium -Anemia, hemorrhage -Trauma
45
brugada syndrome description and treatment
Description: - Genetic autosomal dominant disorder -60 + MUTATION of the Na+ channels in the cardiac muscle -Increased risk for sudden death for VFib -Onset occurs during adulthood Definitive treatment: ICD placement
46
Brugada Syndrome EKG
- ST elevations with negative T wave in leads V1-V3 appearance - with no structural cardiac abnormalities
47
defibrillator
-leads go into the subclavian vein -snake into right ventricle -dual chamber- RA lead -if they have left? bundle branch block they can snake it through coronary sinus (biventricular device)
48
sick sinus syndrome definition + MC presentation
Definition: CHRONIC dysfunction of the SA node -MC in the elderly** -MC asymptomatic** Syndrome includes: -Sinus bradycardia -Sinus tachycardia -Sinus pauses -Sinus arrest
49
causes of sick sinus syndrome
Myocardial scarring Medications: "BAD ML" -Beta-blockers, CCB -Antiarrhythmics -Digitalis -Methyldopa -Lithium Genetic: Familial sick sinus syndrome Sarcoidosis, amloydosis Lyme disease SS Syndrome -> MM + you are sick Myocardial scarring Meds: BADML Beta blockers anti arrhythmic digitalis methydopa lithium you are sick: sarcoidosis; amylodosis lyme
50
sick sinus syndrome treatment
-Definitive treatment: permanent pacemaker placement* -Discontinuation medication
51
Who needs a pacemaker?
Sick sinus syndrome Second degree Mobitz II: 3rd degree AV block --- also bifascicular block
52
bundle branch blocks
-Blocked conduction of the right or left bundle branch leading to delay in activation of correlating ventricle -Ventricular conduction is not in sync Measured by QRS complex: > 0.12 seconds (3 small boxes) -“Rabbit ears” = Overlapping of QRS complex Treatment- Rule out underlying cause
53
right bundle branch block (RBBB) description and ekg
Electrical impulses are delayed in the right bundle branch -delayed contraction in right ventricle "WiLLIAM MaRRoW" EKG: -leads V1 and V2* -RsR complex -T-wave inversions
54
right bundle branch block (RBBB) causes and treatment
Causes: -Increased RIGHT ventricular pressures: -Cor pulmonale -PE -Myocardial ischemia -Idiopathic Treatment- Rule out underlying cause
55
left bundle branch block (LBBB)
Delay occurs in the left bundle branch -delayed contraction in left ventricle - usually pathologic "WiLLIAM MaRRoW" EKG: -Leads V5 and V6 -Broadened R wave -T-wave inversions -Widened QRS in V1 and V2
56
left bundle branch block (LBBB) causes and treatment
Causes: Myocardial fibrosing -HTN -Myocardial ischemia: LAD ** -Cardiomyopathies Treatment- Rule out underlying disease; do an ischemic workup
57
atrioventricular (AV) block definition
-Intermittent or complete failure of the conduction system between the atria and ventricles Classifications of heart block: -First degree AV block -Second degree AV block: -1) Mobitz I (Wenckebach) -2) Mobitz II -Third degree AV block: complete heart block
58
AV block causes
-Aging -Coronary artery disease- MI -Rheumatic heart disease -Lyme disease -Sarcoidosis -Hematomachrosis -Hyperthyroidism -Congenital -Hyperkalemia
59
AV block treatment
-First degree: no tx -Second degree: -Type I: No tx required unless sx -Type II: permanent pacemaker -> could progress to third degree -Third degree: permanent pacemaker (PPM)
60
first degree heart block
-not a true block -> conduction delay -delay in the AV node -fix prolonged PR interval (> 200ms/5 small box) -Tx: none
61
second degree type 1 - wenkebach
-Intermittent block within the AV NODE -Progressive lengthening of PR interval with eventual non-conducting P wave* -Caused by conduction arriving at time when AV node is absolutely refectory "it gets longer and longer till you get a wenkebach" Tx: none required unless sx ---- - eventually there is a p wave with no QRS
62
second degree type 2
-Intermittent block within the HIS-PURKINJE system -Fixed PR interval with eventual non-conducting P-wave* -Wide QRS complex -Can progress to complete heart block Tx: - more likely to progress to third degree -> Requires permanent pacemaker
63
third degree heart block
-complete -dissociation of electrical activity between the atria and ventricles * Tx: requires permanent pacemaker (PPM)
64
ICD treatment
Brugada Syndrome (ICD) VFib prevention (AICD)
65
Radiofrequency ablation when do we use this
SVT - DEFINITIVE TX AFlutter - more sucessful tx compared to anticoagulation AFib (its an option)

Cardiology (6 decks)

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