Exam 2: Tisdale Flashcards
What does a normal ECG look like? What are the characteristics?
- there is a p wave before every QRS complex
- there is a QRS complex after every p wave
- the QRS heights are equal
- HR btwn 60-100 bpm
How can we determine what the HR is on an ecg?
- can start with a complex on a box and count down from 300,150,100,75,60
- can also count the amount of peaks and multiply by 10
- can also count individual boxes inside
what is a normal ECG measurement for a PR interval?
0.12-0.20
what is a normal ECG measurement for a QRS interval?
0.08-0.12
what is a normal ECG measurement for a QT interval?
0.38-0.46
what is a normal ECG measurement for a QTc interval for men?
0.36-0.45
what is a normal ECG measurement for a QTc interval for women?
0.36-0.46
what is classified as torsades de pointes on an ECG? What is it?
- it is a life threatening condition that can lead to sudden cardiac death
- When the QTc interval is 500 ms, there is
increased risk of the drug-induced arrhythmia known as torsades de pointes
what drug classes can cause Torsades?
- antiarrythmics
- antidepressants
- antimicrobials (macrolides, fluoroquinolones)
- antipsychs
- opiods
- anticancer
what drugs cause torsades for each class?
- antiarrythmics –> amiodarone, flecanide, ibutilide, dofetilide, sotolol, dronedarone, prcainamide
- antidepressants –> citalopram, escitalopram, clomipramine, desipramine, lithium, mirtazapine, venlafaxine
- antimicrobials (macrolides (azithromycin, clarithromycin, erythromycin) fluoroquinolones (levofloxacin, ciprofloxacin, moxifloxacin)
- antipsychs –> Chlorpromazine, haloperidol, pimozide, thioridazine, aripiprazole, clozapine, iloperidone, olanzapine, paloperidone, quetiapine, risperidone, sertindole, ziprasidone
- opioids –> methadone
- anticancer –> Arsenic trioxide, eribulin, vandetanib (and most drugs ending in “nib”)
What are some superventricular arryhtmias?
sinus bradycardia, superventricular tachycardia, sinus tachycardia, afib, AV block
what are some ventricular arrythmias?
PVCs, VT, Vfib
What are the characteristics for bradycardia?
- HR < 60
- impulse originating in SA node
what is the mechanism of sinus bradycardia?
decreased automaticity in the SA node
what are some risk factors/ etiologies of how sinus bradycardia occurs?
- MI/Ischemia
- abnormal sns/psns tone
- electrolyte imbalances (increased k and mg)
- drugs (dig, bbs, ccbs, amio, droned, ivabradine)
- no reason (idiopathic)
what are symtpoms of sinus bradycardia?
hypotension, dizzy, syncope (passing out)
when do we treat sinus bradycardia and how do we treat it?
- only treat if symptomatic
- atropine 0.5-1mg q3-5min max 3mg
- can give other things (epi, dopa, ect. if not responsive)
what are some AEs of atropine?
tachycardia, blurred vision, dry mouth, urinary retention, mydriasis
what do you give patients for sinus bradycardia after a spinal cord injury or heart transplant?
aminophylline or theophylline
what is the LT treatment for sinus bradycardia?
pacemaker
what are the features of afib on an ecg?
- chaotic and disorganized (no atrial depolarizations)
- 120-180 bpm
- irregularly irregular rhythm
- no p waves
what are the stages of afib?
1,2,3,4
what is stage 1 afib?
there are modifiable and nonmodifiable risk factors associated with HF
what is stage 2 HF?
this is pre-afib
- there is evidence of structural or electrical findings that further lead to afib or enhance risk such as atrial flutter, enlargements, or premature beats
what are the 4 stages of stage 3?
a,b,c,d
what is stage 3a afib?
This is paroxysmal afib
- this means that the patient has intermittent afib that terminates < or equal to 7 days of onset
what is stage 3b afib?
this is persistent afib
- this means that af continues and sustains >7 days and needs intervention
what is stage 3c afib?
this means it is long-standing persistent af
- this means it has lasted longer than 12m
what is stage 3d afib?
this means successful ablation
- this means they have freedom af after undergoing ablation to eliminate af
what is stage 4 afib?
this means it is permanent and there are no further attempts at rhythm control after discussion between patient and clinician
what is the mechanism for afib?
- it has abnormal atrial/pulmonary vein automaticity
- trouble with atrial reentry
what are some risk factors/etiologies for afib?
(alot)
1. age, smoking, alcohol, obese, diabete, htn, cad, hf,osa, valvular hd, ckd, genetic, or unkown cause
what are some etiologies with reversible afib?
- hyperthyroidism
- thoracic surgery such as CABG, lung resection, esophagectomy
what are the symtpoms of afib?
- can be asymptomatic
- palpitations, dizzy, fatique, lightheaded, sob, hypotension, syncope, angina, HF exacerbation
what is the mortality rate for having a stroke and ebolism?
5x increased risk
what is the mortality rate for having HF?
3x increased risk
what is the mortality rate for dementia in afib?
2x increased risk
what is the mortality rate for having death in afib?
2 x increased risk
how can we prevent afib from happening?
- lifestyle and risk factor modification such as losing weight if BMI > 27
- targeting 210 minutes each week of exercise
- smoking cessation
- limit alcohol
- BP control if HTn
- diabetes control if diabetic
what are the goals of therapy for afib?
- prevent stroke
- slow ventricular rate response
- convert to sinus rhythm and stay there
when do we anticoagulate someone with afib? when do we not?
Recommended if score 2 or more in men and 3 or more in women
- reasonable if score of 1 in men and 2 in women
- if score is 0 or 0-1 then do not
what is the preffered anticoag in afib?
DOACs in most patients
when is warfarin preferred over doacs ?
- if mechanical valve inr goal 2.5-3.5
- if severe mitral valve stenosis inr goal 2-3
what is preferred in pateitns with CrCl < 15 (severe ckd) or dialysis?
apixaban or warfarin
How do we define is a person is hemodynamically stable or not?
UNSTABLE MEANING
1. loss of consciousness
2. ischemic chest pain
3. HR > 150 bpm
4. SBP < 90
- any one of these things
If someone is having afib and is hemodynamically unstable what do we do in terms of ventricular rate control treatment?
shock to the chest (DCC)
If someone is having afib and is hemodynamically stable and DOES NOT HAVE decompensated HF what do we do in terms of ventricular rate control treatment?
- BB, verapamil, diltiazem
- digoxin
- amiodarone
If someone is having afib and is hemodynamically stable and DOES HAVE decompensated HF what do we do in terms of ventricular rate control treatment?
amiodarone
If we are talking now about long term ventricular rate control for someone with afib and does not have a HFrEF (LVEF > 40%) what do we give them?
BB, diltiazem or verapamil
2. digoxin if that doesnt work
If we are talking now about long term ventricular rate control for someone with afib and does have a HFrEF (LVEF < or equal to 40%) what do we give them?
beta blocker
2. digoxin if bb does not work
what are drug interactions and adverse effects of diltiaem?
AEs: hypotension, bradycardia, HF exacerbation, AV block
INT: CYP 3A4 (statins and cyclosporine)
what are the drug interactions and AEs of verapamil?
AEs: hypotension, bradycardia, HF exacerbation, AV block
INT: CYP 3A4 and PGP (dig and dofetilide)
what are the AEs of BBs?
hypotension, bradycardia, HF exacerbation, AV block, masked hypoglycemia, fatique
what are the AEs and interactions with digoxin?
AEs: N/V, anorexia, ventricular arrythmias
INT: amio, verapamil (dec. by 50%)
what are the AEs and drug interactions with amiodarone?
AEs: hypotension, bradycardia, blue/grey skin, pulmonary edema, corneal microdeposits, heptotoxicity, thyroid issues, QTc prolongation
INT: warfarin, statin, digoxin ( dec. doses by 50%)
what is the rule of thumb hen trying to convert to sinus rhythm for afib?
- if afib present less than or equal to 48 hours then okay toconvert
- if afib > 48hrs then wait until on coag for 3 weeks or do a Tee to determine if clot is present
what are the drugs used for conversion to sinus rhythm?
amiodarone, ibutilide, procainamide, flecainide, propafenone
what are the adverse effects of ibutilide?
Torsades de pointes
what are the adverse effects of procainamide?
QT prolongation, torsades de pointes, hypotension, HFrEF exacerbation, agranulocytosis, neutropenia
what are the adverse effects of flecainide and propafenone?
dizzy, blurred vision, HFrEF exacerbation
if someone has afib and has normal LV function, what do we use to convert them to sinus rhythm?
IV amiodarone or ibutilide then procainamide (only if have not given the other two)
if someone has afib and has HFrEF, what do we use to convert them to sinus rhythm?
IV amiodarone
if someone has afib and has normal LV function, what do we use to convert them to sinus rhythm if they are outside of the hospital?
Pill in pocket
- flecainide or propafenone
what drugs are used to maintain sinus rhythm in afib?
amiodarone, dofetilide, sotolol, dronedarone, propafenone, flecainide
what is the dofetilide dose if being based off of CrCl?
> 60 –> 500 mcg bid
40-60 –> 250 mcg bid
20-39 –> 125 mcg bid
< 20 –> Contraindicated
what is the recommended monitoring for the adverse effect of hypo and hyperthyroidism of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: TSH labs
Initial: 3-6m
Additional: 3-6m
what is the recommended monitoring for the adverse effect of hepatotoxicity of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: LFTs labs
Initial: 3-6m
Additional: 3-6m
what is the recommended monitoring for the adverse effect of QT interval prolongation of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: ecg
Initial: annually
Additional: no
what is the recommended monitoring for the adverse effect of pulmonary fibrosis of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: chest x-ray
Initial: if pt develops unexplained cough or dyspnea or develops other symtpoms of lung disease
Additional: none
what is the recommended monitoring for the adverse effect of corneal microdeposits of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: none
Initial: only if develops visual abnormalities
Additional: none
what is the recommended monitoring for the adverse effect of blue/grey skin discoloration of amiodarone? (for baseline, initial fu, and additional fu)
Baseline: none
Initial: annually
Additional: none
if a person has afib and is trying to get maintenance therapy for staying in sinus rhythm and has normal function with no prior MI or HD, what do you give them?
- dofetilide, dronederone, flecainide, propafenone
- amiodarone
- sotolol
if a person has afib and is trying to get maintenance therapy for staying in sinus rhythm and has had an mi or HD and has HFrEF, what do you give them?
amiodarone, dofetilide
2. sotolol
if a person has afib and is trying to get maintenance therapy for staying in sinus rhythm and has normal function with no prior MI or HD, what do you give them? If class 1 or 2 ?
dronedarone
if class 3 or 4 in HFrEF and need to stay in sinus rhythm, what med is contraindicated?
dronedarone
when is catheter ablation used in afib?
can be used as first ine therapy for pts with symptomatic paroxysmal afib
what is the algorithm for inpatient initiation of dofetilide?
- place on continuous ecg and proceed only if ATc < or equal to 440ms
- give dose based on CrCl
- post dose adjustment (2-3hrs) after 1st dose and check QTc interval
- if QTc increases 15% or less then continue current dose
- If QTc above 15% then decrease the dose currently on bu alf
- if after 2nd dose and QTc > 500ms, d/c dofetilide
what is the algorithm for inpatient initiation of sotolol?
- place on ECG, proceed only if QTc 450ms or less
- if Crcl > 60 give 80mg bid
- if Crcl 40-60 then give 80mg qd
- check QTc interval2-4hrs after each dose
- if QT < 500 after 3 days they can be discharged or given a dose of 120mg bid and be followed for 3 days
- if QTc > 500 or equal to it then d/c sotolol
what are the characteristics of supraventricular tachycardia on an ecg?
- regular rhythm
- narrow QRS complex
- HR 110- > 250 bpm
- spontaneous initiation and termination
what is a paroxysmal SVT (PSCVT)?
it is a subset of SVT
- intermittent episodes of SVT
- episodes start suddenly and spontaneously last for minutes to hours and terminate suddenly and spontaneously
what is the mechanism (main mechanisms) of supra-ventricular tachycardia?
reentry within
– av node (60%)
– accessory pathway
what are the etiologies and risk factors for supraventricular tachycardia?
- women have 2x higher risk than men
- age > 65 years: 5x greater risk than younger people
- often occurs in individuals with no underlying CVD
what are the symptoms of supraventricular tachycardia?
neckpounding, palpitations, dizziness, weakness, lightheadedness, syncope, polyuria
what are the goals of therapy for supraventricular tachycardia?
- terminate SVT, restore sinus rhythm
- prevent recurrence
what is the AEs and drug interactions for adenosine?
AEs: chest pain, flushing, SOB, sinus pauses, bronchospasm
INT: dipyridamole and carbamezapine response to adenosine (dec. dose by 50%)
what is the algorithm for termination of stable SVT?
SVT – vagal maneuvers and/or IV adenosine – if not feasible – IV BB, IV dilt, IV verp – if not feasible. – synchronized DCC
what is the algorithm for prevention of recurrence SVT if asymptomatic?
no tx just follow up without treatment
what is the algorithm for prevention of recurrence SVT if symptomatic?
- Catheter ablation is first if candidate
- if no to candidate and have HFrEF what do we use?
–> amio, dig, dofet, or sotolol –> can end up in ablation - if no to candidate and no HFrEF what can they use?
–> bb, dilt, ver or flec/ propafenone (only use flec or prop if no cad) can also do ablation
what goes on in an ecg for PVCs? What are the characteristics?
- wide qrs complex
what are the types of PVCs that can occur?
- simple (isolated single)
- frequent
– pair (couplets)
– q2nd bt (bigemony)
– q3rd bt (trigemony)
– q4th bt (quadrigemony)
what is the meaning of a frequent PVC?
- at least 1 PVC in a 12 lead ECG
- > 30 PVCs per hour
what is the mechanism for PVCs?
increased automaticity of ventricular muscle cells/ purkinje fibers
what are the etiologies/risk factors for PVCs?
- ischemic heart disease
- MI
- anemia
- hypoxia
- cardiac surgery
what are the symptoms for PVCs?
- normally asymptomatic
- can lead to palpitations, dizzy, lightheaded
do we treat asymtomatic PVCs?
no
what do we treat PVCs with if do not have CAD or HF?
bb, dilt, ver
– not responsive then antiarrhythmic meds
what do we treat PVCs with if do have frequent PVCs and are unresponsive to bbs, ccbs, or antiarrhythmics??
catheter ablation
what do we treat PVCs with if do have CAD ?
bb, ver, dilt
– if unresponsive then give antiarrhythmic med
what do we treat PVCs with if do have HF?
bbs
what are the characteristics of ventricular tachycardia on an ecg?
- regular rhythm
- wide ARS complexes
- defined as series of 3 or more PVCs at rate of 100 bpm
what is nonsustained VT?
3 or more PVCs, terminating spontaneously
what is sustained VTs?
- VT lasts > 30 seconds or requires termination because of hemodynamic instability in < 30 seconds
what are the types of sustained monomorphic VT with no structural heart disease?
- verapamil sensitive
- outflow tract vt
what are the mechanisms for ventricular tachycardia?
- increased ventricular automaticity
- reentry
what are the etiologies/risk factors for VT?
CAD
MI
HFrEF
electrolyte abnormalities (low k and mg)
drugs (flec, prop, dig)
what are the symptoms of vt?
can be asymptomatic, palpitations, hypotension, dizzy, lightheadedness, syncope, angina
Can vt lead to vfib?
yes
what are the goals of therapy for VT?
- terminate VT, restore sinus rhythm
- prevent recurrence of VT
- reduce the risk of sudden cardiac death
if someone who has vt and has no structural heart disease and has verapamil sensitive vt, what doe we give them?
verapamil
If verapamil does not work for VSVT, what is next?
if works continue therapy and if not then shock them
if someone who has vt and has no structural heart disease and has outflow tract vt, what doe we give them?
bbs
If verapamil does not work for outflow tract vt, what is next?
if works continue therapy and if not then shock them
if someone has vt and has structural heart disease, what are the patients treatment options?
- shock
- IV procainamide
- IV sotolol or IV amiodarone
if vt is not terminated or is in structural heart disease what do we do?
if works then continue therapy and if not then shock them
what are recurrent treatments for vt?
- implant
- drugs to help implant (amiodarone and sotolol)
- ablation
what are the characteristics of vfib on an ecg?
no qrs complexes
1. irregular, disorganized, chaotic activity
what are the risk factors for vfib?
- mi
- HFrEF
- CAD
what are the symptoms for vfib?
syndrome of sudden cardiac death
what are the treatment goals for vfib?
- term vfib and restore sinus rhythm and circulation
- only effective treatment is shock and drugs just help the shock to work better
what is the treatment plan for someone with vfib?
cpr x2 & obtain IV/IO access –> shock –> cpr x2 –> epi 1mg –> shock –> cpr x2 –> amio (300mg) or lidocaine (1-1.5) –> shock –> cpr x2 –> epi 1mg –> shock –> cpr x2 –> amio (150mg) or lidocaine (0.5-0.75) –> shock –> cpr x2 –> epi 1mg
how long do you keep going for with vfib for tx?
until wakes up or the lead says no but continue to do it every 3-5min for epi continue shock and cpr x2 min
