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EP and Fetal Arrhythmias Flashcards

1
Q

Most common pediatric dysrhythmia

A

Paroxysmal SVT

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2
Q

Antibody associated with congenital lupus

A
  • Anti Ro/SSA
  • Anti La/SSB
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3
Q

Location of bundle of His in truncus arteriosus

A

Left aspect of the posterior/inferior rim of the VSD

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4
Q

Location of conduction fibers in ccTGA

A

Anterior superior rim

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5
Q

Most common fetal presentation of long QT

A

Sinus bradycardia with bursts of SVT

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6
Q

Incidence of fetal arrhythmias

A

1-3% but only 10% of these cause morbidity

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7
Q

Definition of fetal bradycardia

A
  • Rate < 110/min
  • If abnormal AV conduction have 50% risk of CHD
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8
Q

Definition of fetal tachycardia

A
  • Rate > 180/min
  • Baseline risk of CHD (1%)
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9
Q

Follow-up needed for fetal PACs

A
  • If frequent (every 3-5 beats) then weekly OB assessment
  • If infrequent, nothing special
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10
Q

Things to exclude for fetal PVCs

A

Myocarditis, cardiac tumors, maternal drug exposures

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11
Q

What types of CHD are at increased risk with fetal tachycardia

A
  • Ebsteins
  • Complete AV canal
  • HLHS
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12
Q

Fetal echo signs of tachyarrythmias

A
  • Early: atrial enlargement or AVV regurgitation
  • Late: ventricular dysfunction, effusion, hydrops, cardiomegayl
  • TACHY PLUS HYDROS = 50% mortality
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13
Q

1st and 2nd most common fetal tachyarrhythmias

A
  • AV reciprocating SVT with accessory pathway (70-90%)
  • Atrial flutter (10-30%)
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14
Q

1st line drug for fetal SVT

A

Digoxin - 50% termination
Oral load and higher doses
Direct IM is an option if hydrops
Check maternal levels and ECGs

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15
Q

2nd line drugs for fetal tachyarrhythmias

A
  • Sotalol: B blocker and K channel - daily ECG, some say better for A flutter
  • Flecainide - Na channel - daily ECG, some say better for SVT and not flutter
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16
Q

Things to rule out for fetal VT and treatment of fetal VT

A
  • Tumors, myocarditis, channelopathies, AV block
  • Tx: maternal IV mag or lido, oral propanolol or mexilitene
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17
Q

Percentage of congenital complete AV block that have CHD vs immune mediated

A
  • 50-55% have complex CHD (heterotaxy or L looping)
  • 40% are immune mediated with anti-Ro/SSA or anti-La/SSB antibodies
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18
Q

Percent risk of CCHB with known maternal antibodies

A
  • 3-5%
  • If prior then risk increases to 11-20%
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19
Q

Risks for death with CCHB

A

Structural CHD
HR < 55 at presentation
Hydrops
Decreased function

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20
Q

Difference between ORT vs ART

A
  • ORT has narrow QRS
  • ART has wide QRS with preexcitation
  • Both are accessory pathway mediated reentrant tachycardias with HR 200-250
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21
Q

Accessory pathway tachycardia associated with which CHD

A
  • Ebsteins
  • LTGA
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22
Q

Definition of PJRT

A
  • Permanent junctional reciprocating tachycardia
  • No preexcitation at baseline
  • Long VA during tachycardia, slower rates during SVT
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23
Q

Acute treatment of SVT

A
  • B block or CCB If normal EF and no preexcitation at baseline
  • Dig if no preescitation at baseline
  • DCCV
  • Amio if decreased EFC
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24
Q

Chronic treatment of SVT

A
  • If preexcitation: B blockers, Class Ia/Ic/III
  • No digoxin or verapamil due to risk for rapid anterograde conduction and VF if there is preexcitation
  • If no preexcitation can use digoxin, B blockers, Class Ia/Ic/III/IV
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25
Risk for SCD with WPW
- Risk is due to rapid conduction of AF - Risks are age < 30, male, CHD, hx syncope or arrest, familial WPW, shortest RR during AF < 220, shortest preexcited RR < 250, AP ERP < 250
26
Definition of AVNRT typical vs atypical and ECG findings
- Typical is slow-fast - Atypical is fast-slow and can look like PJRT - HR 150-250, p often buried in QRS, rate can vary some
27
Differential for long RP tachycardia
Atypical AVNRT PJRT AET Sinus tachy
28
Acute treatment of atrial tachycardia
- Treat underlying cause - CCB, B blocker, dig, proc, amio
29
Where does typical atrial flutter originate
Cavotricusipd isthmus
30
Acute treatment of atrial flutter or fib
- Rate control with B blocker or CCB if normal function, dig or amio if decreased function - Cardiovert pharm with ibutilide, amio or proc - DCCT if symptomatic but NOT IF DIG TOXICICTY - If > 48 hours have increased risk of clot so treat with rate control and anticoag for 3 weeks then DCCV with 4 weeks anticoag OR TEE plus anticoag bolus followed by DCCV immediately and then 4 weeks anticoag
31
Chronic treatment of atrial flutter or fib
B blocker CCB Class Ia/Ic/III Chronic anticoagulation Surgical maze
32
Acute treatment of WPW plus atrial fibrillation
- Proc plus AVN blocker - dont use AVN blocker as single agent - DCCV
33
ECG findings for RVOT VT
- LBBB morphology (bunny ears in V6) with inferior axis (positive QRS in 2, 3, aVF) - Occurs at rest or in recovery from exercise - Dx: AVRC, myocarditis, tumor
34
Treatment of RVOT VT
Verapamil Responds to adenosine or vagal (cAMP mediated) B blocker DCCV or ablation
35
ECG findings of idiopathic or fasicular LV tachycardia
- RBBB morphology (bunny ears in V1), superior axis (QRS negative in 2, 3, aVF) - Reeentrant from LV septum - Dx: myocarditis, tumor, CPVT
36
Treament of Fasicular VT
Verapamil B blocker Class Ia/Ic/III DCCV or ablation
37
3 meds and ways they work for vasovagal syncope
- Florinef (mineralocorticoid) - absorbs salt and volume expansion - B blocker - blocks B1/B2 - Midodrine - alpha agonist - activates receptors on vasculature to increase tone
38
Most common etiologies of SCD in athletes
Ventricular arrhythmias from: - HCM, LVH, coronary problem, commotio cordis
39
HCM risk factors for SCD
- Wall thickness > 30 mm - Hx arrhythmia leading to syncope - Family history
40
What does the murmur do in HCMD
- Systolic murmur that increases with standing
41
Genes associated with HCM
- Autosomal dominant - TTN, MYH7, TNNT2, ACTC, MYBPC3
42
What happens to the RV in ARVC
Myocardium gets replaced with fatty tissue which leads to electrical instability and risk for VT or SCD
43
ARVDVC1 gene and association
TGFB3 Progressive RV myopathy
44
ARVDVC2 gene and association
RYR2 Maybe associated with CPVT
45
ARVDVC5 gene and association
LAMR1 Seen in New Foundland
46
ARVDVC6 gene and association
Tyr phos Early onset
47
ARVDVC7 gene and association
DES A/w myofibril myopathy
48
ARVDVC8 gene and association
Desmolakin Keratoderma and wooly hair
49
Long QT type 1 gene, triggers and ECG finding
KCNQ1 - K channel loss of function Broad based T waves Triggers are exertion and swimming Adolescent males and post partum females
50
Long QT type 2 gene, triggers and ECG finding
KCNH2 - K channel loss of function Low amplitude T waves and can have double notch Triggers are startling (alarm clock) Females > 13
51
Long QT type 3 gene, triggers and ECG finding
SCN5A - Na channel gain of function Long ST segment and late peaking T waves Triggers are sleeping
52
Treatment in long QT
If QTc > 470 use beta blockers or if symptomatic Can use ICD if prior arrest or high risk
53
CPVT definition
- Catecholaminergic polymorphic VT - Polymorphic or bidirectional VT with sports or stimulus
54
CPVT genetic mutations
- AD RYR2 - AR CASQ2, TRDN, CALM 1/2/3
55
Brugada ECG apperance
RBBB with ST elevation in V1-V3 - Type 1 has downslowping ST segments and inverted T waves - Type 2 has saddle back ST/T wave complex and biphasic T waves
56
Mutation for Brugada
SCN5A Loss of function in Na channels Common in SE Asian males
57
Treatment for Brugada
ICD if hx of arrest or high risk Aggressive treatment of febrile illness Can use quinidine
58
How does vagal nerve regulate heart rate
- Acetylcholine release, increases K permeability, decreases Ca permeability, slows pacemaker cells, slows AV node conduction
59
How does sympathetic nerve regulate heart rate
- Norepi release, increases Ca permeability, facilitates AVN conduction, accelerates pacemaker cells
60
SA nodal artery origin
RCA in 60%, LCA in 40%
61
AV nodal artery origin
RCA in 55%, LCx in 45%
62
Right and left bundles get blood supply from where
Septal perforators of LAD
63
Why no atropine for transplant patients with sinus brady
- No response (denervated) - Risk for paradoxical response and leading to heart block
64
Use for glucagon with sinus brady
B blocker or CCB overdose
65
Causes of left axis deviation in infants
- AV septal defect - Tricuspid atresia
66
Is complete AV block more common in polysplenia or asplenia
Polysplenia due to underdevelopment of right sided structures
67
Common training related changes on ECG
- Sinus brady - First degree AV block - Incomplete RBBB - Early repolarization - Isolated QRS voltage criteria for LVH
68
Treatment for fetal VT with hydrops
Sotalol Digoxin is not good for hydropic fetus
69
Primary electrolyte driver of depolarization
Sodium
70
Primary electrolyte driver of repolarization
Potassium
71
Class IA anti-arrhythmics
- Sodium channel blockers - Delay depolarization and repolarization - Antivagal effects - Drugs: quinidine, procainamide, disopyramide
72
Indications for quinidine
Brugada syndrome
73
Side effect of class 1A anti-arrhythmics
Prolongs QT interval
74
Procainamide indications and side effects
- Indications: acute management of SVT and VT - Drug induced lupus but not an oral form anymore so less common - Prolonged QT
75
Class 1B anti-arrhythmic drugs
- Sodium channel blockers - Shorten action potential duration and repolarization - Drugs: lidocaine, mexiletine, phenytoin
76
Lidocaine uses and side effects
- Ventricular arrhythmias - SE: apnea and seizures (especially in infants)
77
Mexiletine uses and side effects
- PVCs or ventircular arrhythmias (oral lidocaine) - Long QT type III
78
Class 1C anti-arrhythmics
- Drugs: Flecainide, propafenone - Sodium channel blockers - Slow conduction - Minimal effect on repolarization
79
Side effects of class 1C anti-arrhythmics
QRS widening
80
Flecainide indications and side effects
- No in LV dysfunction - Indication: SVT and VT - Can widen QRS
81
Propafenone uses
- Use for SVT and VT - Does have some beta blocker effect (cautious in asthma)
82
Class 2 anti-arrhythmics
Beta blockers --> slow conduction Selective: atenolol, metoprolol, esmolol Non-selective: propranolol, nadolol
83
Metabolism of different beta blockers
Liver: propranolol, metoprolol Kidney: atenolol, nadolol
84
Side effects/contraindications of beta blockers
- Hypoglycemia (infants) - Contraindications: AV block, bradycardia, LV dysfunction - Cautious in asthma patients
85
Class 3 anti-arrhythmics
STRONGEST - Potassium channel blockers - Prolong AP duration and repolarization - Drugs: amio, sotalol, ibutilide, dofetilide
86
Amiodarone uses
- Has K, Na, Ca channel blocking - Also has beta and alpha blocker - Good for SVT and VT - LESS LV depression than others (so okay in dysfunction)
87
Amio adverse effects
- LFT dysfunction - Pulmonary interstitial fibrosis - Hypothyroidism - GI symptoms - Neurotoxicity - Hypotension with IV form - Photosensitivty - Corneal microdeposits
88
Sotalol uses/function
- K/Na channel blocker, non-selective beta blocker - Good for SVT and VT *** Pay close attention to QT interval with initiation
89
Uses of ibutilide
Very short acting IV form - acts in the atrium - Good for atrial flutter or fibrillation - Risk for QT prolongation and development of torsades
90
Class IV anti-arrhythmics
Calcium channel blockers - Affect slow response (in the atrium)
91
Uses/contraindications for verapamil
- Slows sinus/AV node, has some alpha effect - Good for SVT - Contraindicated for infants < 1 d/t calcium effects - Also no in WPW (can increase antegrade AP conduction)
92
Uses for diltiaze
- Calcium channel blocker - Very fast IV form for acute rate control of A fib or A flutter
93
Adenosine mechanism of action and contraindication
- K channel opener - Inhibits SA and AV node - Contraindication: asthma, heart transplant - Can cause acute onset of afib (hyperpolarizes the membrane potential)
94
Use of ivabradine
- Inhibits sinus node activity and decreases heart rate - Primary indication is to decrease heart rate in setting of heart failure - Slows down sinus rate
95
Digoxin has effects with what other anti-arrhythmics
Frank Ate Pizza Very Quickly - Flecainide - Amiodarone - Propafenone - Verapamil - Quinidine
96
Wide complex tachycardia that is regular - why would you give adenosine
Could be SVT with baseline bundle branch block - will look like VT
97
EKG for PJRT in tachycardia
Slower rates 150-200 P waves negative in II, III and aVF

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