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Cardiology > Dysrhythmias 1, 2, and 3 > Flashcards

Dysrhythmias 1, 2, and 3 Flashcards

1
Q

How to differ a sinus arrhythmia from AFIB

A

Breathing in will increase the HR
Breathing out will decrease the HR

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2
Q

What is considered sinus bradycardia?

A

<60 BPM

really only worried if it is <45 BPM though

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3
Q

What can lead to sinus bradycardia?

A

Normal in healthy individuals
Should go up if they exert themselves

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4
Q

What if sinus bradycardia does not increase with exertion?

A

Sick sinus bradycardia

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5
Q

What drug can cause bradycardia?

A

Clonidine - lowers BP but decreases HR
lithium
methyldopa

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6
Q

Why can a stroke lead to bradycardia?

A

To compensate for increased ICP, the heart will pump softer

Scan the HEAD!

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7
Q

Why can an inferior wall MI cause bradycardia?

A

Problems of right coronary artery, which supplies the SA node, leads to a decreased HR

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8
Q

What is the treatment for obstructive sleep apnea bradycardia?

A

Treat the OSA!

CPAP

Don’t treat the bradycardia - it is just a result of the underlying cause, which is the OSA

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9
Q

How to diagnose sinus bradycardia sick sinus syndrome?

A

Put on treadmill and DO NOT see something close to predicted value (220 - age)

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10
Q

How to treat sick sinus syndrome?

A

Remove medications to see if this is the underlying cause of their bradycardia (do not remove amiodarone though). Otherwise:

Pacemaker - there HR will fluctuate like crazy, so you can more easily decrease an elevated HR

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11
Q

When do you treat sinus bradycardia?

A

If they are symptomatic

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12
Q

What shortens in sinus tach?

A

The T wave to the next Q wave

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13
Q

What underlying things can lead to sinus tachy?

A

hyperthyroidism, fever, sepsis, pain, anemia, volume depletion, pheochromocytoma, hypoxia, PE, heart failure, acute coronary ischemia, alcohol/alcohol withdrawal, stimulants

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14
Q

How do you treat sinus tachy?

A

RARELY
If they are in sinus tach, they are there for a reason

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15
Q

What can you do to try to slow down sinus tach?

A

Vagal maneuvers

even deep breathing

If no fluctuation, it is not sinus!!!

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16
Q

When is sinus tach a concern?

A

If there is an underlying heart problem

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17
Q

Where do we make up time for sinus tach?

A

Diastolic shortens, so we get less filling.

We still have the same systolic pump, but filling/relaxation may be compromised

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18
Q

When is sinus tach concerning?

A

If it is symptomatic and they have an underlying heart problem

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19
Q

What leads to inappropriate sinus tach?

A

Occurs in absence of heart disease or secondary causes
_ resting HR and/or exaggerated HR response to exercise
Exact cause unknown; possible exaggerated autonomic control

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20
Q

Difference between inappropriate sinus tachy and POTS

A

POTS is based on change in position while inappropriate sinus tach is based on things that would normally lead to increased HR, but it is an exaggerated response (may increase 2x compared to a normal, healthy patient).

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21
Q

Three different heart blocks

A

1st degree = PR interval greater than 0.2 seconds

2nd degree = sometimes it goes through

3rd degree = complete heart block; complete A-V dissociation, in which no supraventricular impulses are conducted to the ventricles

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22
Q

What causes first-degree heart block and Mobitz type 1?

A

May occur in normal individuals with heightened vagal tone
Drug effect - especially digitalis, calcium channel blockers, beta-blockers, or other sympatholytic agents
Electrolyte abnormalities
Organic disease - ischemia, infarction, inflammatory processes (including Lyme disease), fibrosis, calcification, or infiltration
May be transient or chronic

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23
Q

What can lead to a mobitz type II and third degree heartblock?

A

Almost always due to organic disease involving the infranodal conduction system
May be transient or permanent

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24
Q

What can be a normal heart block? What is not normal?

A

The first two heart blocks can be normal:
1st degree heart block and Mobitz type 1

The last 2 are almost ALWAYS pathologic:
Mobitz type 2 and type 3 heart block

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25
Q

What is a more exhaustive list of mobitz type II and III block?

A

ischemia
idiopathic
neuromuscular diseases
trauma
aortic valve problems/infections/surgery

Get an echo

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26
Q

What are the s/s of 1st degree AV block?

A

No symptoms, cannot hear on stethescope because everything goes through

just incidental on EKG

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27
Q

Mobitz type 1 s/s

A

Most commonly asymptomatic; however, may note palpitations, DOE, or dizziness

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28
Q

Mobitz type 2 s/s

A

Mainly exertional symptoms

palpitations, DOE, weakness, or dizziness

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29
Q

Third-degree block s/s

A

Symptoms vary, and are worse with exertion; palpitations, DOE, weakness, near syncope, syncope, and/or heart failure

Physical exam findings include bradycardia and possibly signs of heart failure

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30
Q

What are the diagnostic studies for heart blocks?

A

ECHOOOOOOOO
EKG
Ischemic, go to heart cath or CTA

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31
Q

What can we not do for heart block patients that is a common work block?

A

Exercise and chemical stress test

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32
Q

What labs do ALL heart block patients get?

A

Labs: CBC, CMP, TSH

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33
Q

Management of First degree AV block?

A

Nothing, just avoid PR prolongation medications

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34
Q

Management of mobitz type I?

A

Nothing, just avoid PR prolongation medications

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35
Q

Mobitz Type II and Third-degree AV Blocks

A

Unstable rhythms and majority require permanent pacemaker implantation
However, if transient due to acute organic process, then temporary pacing may be sufficient

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36
Q

If you have symptoms for premature atrial contractions, do you treat?

A

None!

BB if significant

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37
Q

Premature ventricular contraction - are they concerning? What should patients do?

A

Normally in normal hearts (60-80% of the time)
-concerning if EXERTIONAL - normal if they rest and lay down at night

should keep a log of when they notice them

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38
Q

What can cause premature ventricular contraction

A

Caffeine, stress, alcohol
Structural heart disease – CAD, Valvular disease, LVH
Electrolyte abnormalities
Thyroid disease

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39
Q

What electrolyte should we order in addition to BMP?

A

Mg levels - not included

go hand and hand with K+

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40
Q

What are the s/s of premature ventricular contractions?

A

reentry circuit
Typically initiated by a PAC or PVC

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41
Q

What is the MC pathophys of supraventricular contractions

A

reentry circuit
Typically initiated by a PAC or PVC

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42
Q

What are the two reentry types that lead to supraventricular

A

AVNRT (AV nodal reentrant tachycardia) – most common form
AVRT (AV reciprocating tachycardia)
WPW – Accessory pathway

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43
Q

fast pathway

A

short green light, long red light

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44
Q

MC form of SVT reentry

A

AVNRT

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45
Q

When is a reentry a problem?

A

When there is a PAC, which can lead to a circuit

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46
Q

how to tell the difference between WPW and AVNRT

A

need resting EKG to show delta waves on Wolff-parkinsons

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47
Q

what is the clinical presentation of SVT

A

Rapid onset and offset of rapid heart rate and awareness of symptoms

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48
Q

patient management of SVT

A

Valsalva (push down on abdomen with crossed fingers around the umbilical and have patient press abdomen against fingers for 5-10 seconds PREFERRED)

Stretching the arms and body, lowering the head between the knees
Coughing, breath holding
Splashing cold water on the face, placing ice or frozen peas on the face

All to increase intrathoracic pressure

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49
Q

What can be done by a provider to reduce symptoms of SVT?

A

Carotid sinus massage – SHOULD ONLY BE DONE BY A PROVIDER
-firm pressure, deep tissue, for 5-10 seconds

much more intense vagal response

ONE CAROTID AT A TIME
need telemetry and crash cart

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50
Q

What is the first line pharm treatment for acute SVT

A

Adenosine

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51
Q

What are some other pharm treatment of acute SVT?

A

CCB – Diltiazem, Verapamil
Beta-Blocker – Esmolol, Lopressor

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52
Q

What is used for refractory SVT

A

Amiodarone
Procainamide (anti-dromic wide complex tach)

53
Q

What is the first-line treatment of hemodynamically unstable tach

A

SHOCK (Synchronized electrical cardioversion)

if hypotensive

54
Q

First-line treatment of long-term SVT

A

catheter ablation
First line therapy for recurrent, symptomatic PSVT
curative

can cause complete heart block if they ablate too much

55
Q

First-line meds if not a surgical candidate for SVT

A

BB or CCB

56
Q

when do you refer to EP for SVT?

A

WPW -should go to cath lab

57
Q

What can lead to ectopic atrial arrythmias?

A

Results from an ectopic atrial focus creates an action potential at a rate faster than the sinus rate, therefore becoming the pacemaker
Onset and termination occur abruptly
P wave morphology varies from sinus node P wave
Atrial rate can range between 50 and 180 bpm
Most commonly between 100 to 160 bpm – Atrial Tachycardia
May be unifocal or multifocal

58
Q

How to tell if something is atrial tach?

A

Everything normal, except abnormal p waves and tachy

59
Q

What can cause ectopic atrial rhythm?

A

Mostly normal
-2-6%

get an ECHO!

60
Q

What are some electrolyte disturbances that can lead to atrial tach

A

Electrolyte disturbances (especially hypokalemia), chronic lung disease or pulmonary infection, acutealcoholingestion, hypoxia, and use of cardiac stimulants (theophylline,cocaine)

61
Q

treatment of atrial tach

A

only symptoms
BBs and CCB first-line
then EP

62
Q

what likely causes atrial fib?

A

Likely left atrium, but don’t know

left atrium fire around the same time, fire off at 350-400, go to AV node or accessory pathways

leads to irregularly irregular rhythm

63
Q

What are the different phases of afib?

A

Paroxysmal (<48 hours) - normally short-lived. MC

Persistent - short burst do not fix themselves >7 days - we need to convert them to sinus (patients that do not seek treatment) success rates to maintain sinus decrease if you get to this stage

Long-standing persistent >1 year

Permanent: livable rhythm (majority of patients get here) - if you live long enough

64
Q

Is there a cure to Afib?

A

NO

all patients will have permanent afib

65
Q

what is the goal of treatment of paroxysmal vs permanent afib

A

paroxysmal = we want to keep them in sinus

permanent = we want to manage symptoms

66
Q

What are the risk factors for afib?

A

CHF
HTN
Advanced age
CAD
Valvular heart disease (can affect that component of the heart)

because these risk factors are so common, afib is so common

67
Q

What is a very common underlying cause of afib?

A

OSA very common

also underlying lung problems, leading to increased heart pressure

also cardiac surgery, pericarditis, and other underlying causes

68
Q

Is afib alone common?

A

No, typically just one episode in otherwise healthy young patients and then it goes away.

Still risk of recurrence

69
Q

what are the symptoms of afib?

A

May be completely asymptomatic
Palpitations, heart racing sensation, SOB, chest pain, fatigue, dizziness, near syncope – all possible
May cause hypotension, especially if underlying heart disease and HR elevated
Persistent tachycardia may lead to cardiomyopathy
May also present due to thromboembolic event – CVA, acute limb arterial occlusion

70
Q

what are the PE of afib

A

Irregularly irregular rhythm
May have signs of CHF
Distal pulses may be difficult to obtain, especially if vent. rate is rapid

71
Q

how to tell if afib or heart failure came first?

A

Treat afib, if heart failure goes away, it was the problem. If the heart failure persists, then the afib came from the heart failure - not the other way around

72
Q

What do you treat, the pulse or electrically what they see on the monitor for afib>

A

The monitor - the HR on a pulse ox may not be accurate in afib

73
Q

What do you order for diagnostic studies for afub?

A

ECHO
BMP +Mg
TSH

74
Q

What is the three-fold management of afib?

A
  1. Thromboembolic event prevention to prevent stroke, ischemic bowel, and ischemic limb
    2 and 3: Rate control vs rhythm control
75
Q

What is interesting about frequency of afib and mortality?

A

Frequency and symptoms are NOT correlated to mortality

if they feel fine in afib, you keep in afib

if they feel bad in afib, you try to convert to sinus

76
Q

What are the rate control meds for afib?

A

CCBs
Beta blockers
Digoxin

77
Q

What is the long term management of afib?

A

AV node ablation with pacemaker implantation

78
Q

What class of drugs can you not use for heart problems?

A

class 1c

79
Q

normal heart afib

A

class 1c, then

80
Q

sotalol use

A

if you have CAD

81
Q

what are our 2 meds we use for heart failure

A

amiodarone dofetilide

82
Q

management of hemodynamically unstable afib with KNOWN afib with <48 hours

A

shock

83
Q

what patients get shocked

A
84
Q

CHADS2 -VASc score

A

Congestive HF
Hypertension
Age => 75
DM
S2 prior TIA or stroke
Vascular disease (MI, aortic plaque, etc, AAA)
Age 65-74
Sc sex category (female = 1 pt)

85
Q

What chads2-vasc score is typically treated?

A

typically 2 or more

86
Q

CHA2DS2-VASc score = 0

A

no treatment

87
Q

CHA2DS2-VASc score = 1

A

recommend antithrombotic therapy with oral anticoagulation or antiplatelet therapy (ASA 81 mg) but preferably oral anticoagulation

88
Q

CHA2DS2-VASc score = 2

A

recommend oral anticoagulation

89
Q

What is the HAS-BLED used for?

A

To see if they would be at a higher risk of bleeding rather than stroke

If Has-bled is greater than CHADS2 VASc score, then talk to patient about whether or not they wanna be on Anti-coagulants

90
Q

What is the initial anticoagulant used for afib

A

LMWH
Heparin

91
Q

Treatment of valvular AFIB

A

ONLY Warfarin

this is also the only time you should use warfarin!!!!

92
Q

treatment of any other AFIB

A

a DOAC!

Eliquis (superior)
Xarelto (not-inferior)
Pradaxa (not-inferior)
Savaysa (not-inferior)

93
Q

what is the maintenance of afib

A

Tell patients it changes with time, no cure.
Deal with it long term
see every 6 months for drug monitoring
CBC, BMP
Avoid alcohol (cardiotoxic)
Control underlying RF

94
Q

What is atrial flutter?

A

An ORGANIZED afib

right or left sided
saw-tooth pattern
see atrial activity

95
Q

What is the ONLY difference between atrial flutter and AFIB management?

A

MAY be curative with ablation on it’s own

otherwise the EXACT same treatment

96
Q

A 23-year-old female presents for an annual evaluation and reports no problems. On exam, cardiac rhythm is slightly irregular, with an increase in her heart rate with inspiration and a decrease during expiration. Which of the following is the recommended management for this patient?

A

No treatment

97
Q

A 31-year-old female presents complaining of a racing heart. Electrocardiogram demonstrates a supraventricular tachycardia, likely due to AV nodal reentry. Mechanical measures fail to convert the rhythm. Which of the following medications should be initiated?

Amiodarone (Pacerone)
Adenosine
Flecainide (Tambocor)
Disopyramide (Norpace)
Lidocaine

A

Adenosine

which works on the AV node, first-line treatment

only time we ever use this med!!!

98
Q

A 70-year-old woman is brought to the Emergency Department by ambulance because she has had nausea, shortness of breath, and diaphoresis for the past 2 hours. Medical history includes type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications include metformin and HCTZ. Temperature is 98.7 F, pulse rate is 38 bpm, respirations are 20/min, and BP is 90/60 mmHg. Oxygen saturation is 90% on room air. The patient is alert and oriented to person only. Physical examination shows pallor, diaphoresis, and cool skin.

Which of the following diagnostics is most important to obtain initially in this patient?

Chest CT without contrast
12-lead EKG
CBC, PT, PTT
CMP
Urinalysis

A

12-lead EKG, because we wanna see what is coming from it

99
Q

A 71-year-old male presents with fever, cough, shortness of breath and mild lethargy. Chest x-ray demonstrates an area of consolidation of the right middle lobe. Telemetry demonstrates a sinus tachycardia of 115 bpm. Which of the following is the most appropriate management of this patient’s dysrhythmia?

IV administration of metoprolol (Lopressor)
manage underlying pneumonia
IV administration of adenosine
carotid sinus massage

A

Manage underlying pneumonia, the HR will improve as a result

100
Q

What is the typical presentation of junctional arrhythmias and treatment

A

stable
find reversible cause
does not require anything

101
Q

what is the worst type of arrhythmia

A

ventricular

102
Q

What are the two mechanisms of accelerated idioventricular rhythm?

A

(1) an escape rhythm due to suppression of higher pacemakers resulting from sinoatrial and AV block or from depressed sinus node function
(2) slow ventricular tachycardia due to increased automaticity

103
Q

treatment of accelerated idioventricular rhythm?

A

ONLY if there is hemodynamic instability

104
Q

Non-sustained V tach

A

less than 30 seconds, terminates spontaneously

NOT concerning

160–240 bpm

105
Q

Sustained V tach

A

greater than 30 seconds

WORRIED

160–240 bpm

106
Q

what can cause v tach

A

acute MI
CAD
Cardiomyopathy

107
Q

What is Catecholaminergic Polymorphic VT?

A

you get scared, release NE, Epinephrine, and then get V tach and pass out

108
Q

what should be on your differential if a kid passes out in reaction to fear or exertion?

A

NOT EPILEPSY

worried about congenital abnormalities

109
Q

What type of PVCs are concerning?

A

Multifocal
Unifocal not as concerning

110
Q

What most likely causes Torsades?

A

Prolonged QT

check drugs!

111
Q

What normally causes prolonged QT?

A

Drug induced by far

if not, refer

112
Q

What is congenital long QT syndrome?

A

Three different syndromes

113
Q

MCC of death of long QT II

A

The most common forms of congenital LQTS are caused by ion channel defects.
LQT1and LQT2are K+channel abnormalities
LQT3is an Na+channel mutation.
Proposed as one of the causes of sudden infant death syndrome
Most patients have the first event around 9 to 12 years of age.
LQT1and LQT2account for 80% of the cases.
Exercise and sudden auditory stimuli are triggers
LQT3is only seen in 10% of the cases, but it accounts for most of the lethal cases of LQTS.
Most of the events occur during sleep at slower heart rates

114
Q

what is brugada syndrome

A

RBBB with ST segment elevation that does not return to baseline

If it does not return to baseline than refer to EP (preferred) or cardiology

115
Q

What is the treatment of brugada

A

Propranolol and Nadolol are preferred

116
Q

What is the treatment of hemodynamically unstable V tach?

A

shock and sedation

117
Q

What is the acute treatment of hemodynamically stable V tach?

A

IV amidodarone to convert to sinus

IV lidocaine if refractory
IV Mg possible

118
Q

What is the long term treatment of V tach?

A

ICD
Beta blockers
Amiodarone, Sotalol (Class III AAD)
Catheter ablation

seen by EP

119
Q

what is the treatment of nonsustained VTach?

A

Nothing if they are asymptomatic and have no underlying heart disease

BB if symptomatic

120
Q

What can stable V tach lead to?

A

unstable V fib
leading cause of sudden death

121
Q

what is the management of V fib?

A

SHOCK, unsynchronized

122
Q

What is more concerning LBBB or RBBB and why?

A

LBBB, because it is often d/t underlying heart disease. Also it involves the LAD that is the primary blood supply.

still sometimes seen in normal hearts

123
Q

What can lead to LBBB

A

LBBB is not usually the result of a single clinical entity, except in acute MIs.
Several chronic conditions which contribute to myocardial fibrosis (hypertension, coronary artery disease, cardiomyopathies) can contribute to the development of LBBB.
LBBB may result following acute myocardial insult, and if occurs is associated with worse prognosis

Functional LBBB
Rate-related aberrancy

124
Q

How do you evaluate LBBB?

A
  1. Chest pain with acute ischemia = treat as if it is an anterior STEMI
  2. Asymptomatic with baseline EKG that has LBBB, do not send to ER but look for RF and work them up with an echo
  3. If they have risk factors for ischemia, then work up according to heart score
125
Q

Management of LBBB

A

treat underlying problemo

126
Q

What should be on your differential for a RBBB

A

lung disease etiologies

127
Q

Patients with RBBB workup

A

Based on symptoms
not concerning

do not even need an echo

128
Q

Bifasicular block management

A

Benign
do not need to do anything for it

129
Q

When would you consider a pacemaker for bifascular bock?

A

Syncope w/ bifascular block
Get an echo
Get EP

otherwise no treatment

Cardiology (22 decks)

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