INTRODUCTION TO ARRHYTHMIAS Flashcards
Electrocardiography is esential in managing arrhythmias T/F
True
Management of an arrhythmia requires precise diagnosis of the type of arrhythmia T/F
True
If a patient had ectopic beats abdominal normal heart, what is the general management
Treatment is rarely required and reassurance will suffice
Beta blockers are safer than suppressant drugs
Treatment aims for atrial fibrillation
Reduce symptoms
Prevent complications especially stroke
Two approaches to managing atrial fibrillation
Rhythm control (restore and maintain sinus rhythm)
Rate control (controlling ventricular rate)
Ablation strategies are considered in atrial fibrillation when……
Drug treatment has failed
In A. Fib, referral is made within how many weeks when cardioversion and drug treatment fails
Within 4 weeks
All patients with life- threatening haemodynamic instability caused by new onset atrial fibrillation should undergo…….
Emergency cardioversion without delaying to achieve anticoagulation
In A. Fib patients without life- threatening haemodynamic instability, what approach is preferred when onset is less than 48 hours and when onset is nore than 48 hours
<48 hours - rate or rhythm control
>48 hours or uncertain - rate control
Drugs used when urgent rate control is needed in A. Fib acute presentation
IV Beta blockers
Rate limiting -CCB( eg. Verapamil if LVEF is 40 or more)
Methods of cardioversion
Pharmacological
Electrical
Is cardioversion a rhythm or rate control strategy
Rhythm control strategy
Drugs for pharmacological cardioversion
Flecainide
Amiodarone
Among amiodarone and flecainide, which cannot be used in structural or ischemic heart disease patients
Flecainide is not used but Amiodarone is used
When is electrical cardioversion preferred to chemical
When atrial fibrillation has been present for more than 48 hours
How long should a patient be anticoagulated before electrical cardioversion
At least 3 weeks
How long is anticoagulation done after cardioversion
Right after cardioversion and continued for at least 4 weeks
If anticoagulation for 3 weeks before electrical cardioversion isn’t possible, what should be done
Rule out a left thrombus
Give a parenteral anticoagulation (heparin) immediately before cardioversion
Prior to cardioversion, patients should not be on rate control therapy. T/F
False
What is the regimen for amiodarone as a rate control therapy before and after cardioversion
Amiodarone HCl 4 weeks before and continued for 12 months after electrical cardioversion to maintain sinus rhythm
When is rate control not preferred as a first line treatment strategy in atrial fibrillation
- New-onset atrial fibrillation
- Atrial flutter suitable for ablation strategy
- Atrial fibrillation with reversible cause
- Heart failure caused by atrial fibrillation
- Rhythm control more suitable based on clinical judgement
Sotalol is used to control ventricular rate in atrial fibrillation
False
Drugs for controlling ventricular rate in atrial fibrillation
Beta blockers
Non-DHP- CCB
Digoxin
Factors that’ll affect choice of rate control drug in atrial fibrillation
Symptoms
Heart rate
Comorbidities
Patient preference
When is Digoxin monotherapy considered for ijitial rate control
Patients with non-paroxysmal atrial fibrillation who are predominantly sedentary or when other rate limiting drugs are unsuitable
Combination therapy for atrial fibrillation and when it is indicated
Combination of any 2 of digoxin, beta blocker and Non-DHP CCB
Used when monotherapy is ineffective
What is the next option when combination rate control drugs is not effective in A fib
Rhythm control
Preferred rate control combination therapy in heat failure (LVEF < 40%) patientd with A fib
Beta blocker and Digoxin
Rhythm control regimen post cardioversion
Beta blocker except sotalol as first line
Alternative drugs
Amiodarone
Flecainide
Propafenone
Sotalol
Anti arrhythmic drugs avoided in structural heart disease or ischemic heart disease
Flecainide
Propafenone
Amiodarone can be used in heart failure or left ventricular impairment T/F
True
Dronedarone is considered as a second line rhythm control drug in……
Persistent or paroxysmal atrial fibrillation
Pill-in-the-pocket approach can be used in patients with…….
Infrequent episodes of symptomatic paroxysmal atrial fibrillation
What is the pill-in-the-pocket approach
Patient takes an oral antiarrhythmic drug to self-treat an episode of atrial fibrillation
Factors the determine when to stop anticoagulation in atrial fibrillation
Patient preference
Stroke and bleeding risk
Arrhythmia
Score for assessing stroke risk in A fib
CHA2DS2VASc score
Score for assessing bleeding risk in atrial fibrillation before anticoagulation
ORBIT risk tool
CHA2- DS2- VASc risk tool parameters
C - Congestive heart failure - 1
H - Hypertension - 1
A- Age of 75 or more - 1
D- Diabetes - 1
S- Stroke/TIA/Thromboembolism - 2
V- Vascular disease - 1
A- Age - 65- 75 - 1
S - Sex (female)- 1
CHA2- DS2- VASc risk tool interpretation
Give anticoagulation if score is 2 or more
Consider anticoagulation in men if score is 1
When is Parenteral anticoagulation with heparin given in atrial fibrillation
New-onset atrial fibrillation who are receiving subtherapeutic or no anticoagulation therapy, until
assessment is made and appropriate anticoagulation is
started
When is oral anticoagulation given in confirmed atrial fibrillation
- Stable sinus rhythm has not been successfully restored within 48 hours of onset
- Risk of stroke outweighs risk of bleeding
- Have had, or are at high risk of, recurrence of atrial fibrillation such as those with structural heart disease, a prolonged history of atrial fibrillation (more than 12 months), or a history of failed attempts at cardioversion
When is oral anticoagulation given in confirmed atrial fibrillation
- Stable sinus rhythm has not been successfully restored within 48 hours of onset
- Risk of stroke outweighs risk of bleeding
- Have had, or are at high risk of, recurrence of atrial fibrillation such as those with structural heart disease, a prolonged history of atrial fibrillation (more than 12 months), or a history of failed attempts at cardioversion
Recommended oral anticoagulation in non-valvular atrial fibrillation
Direct acting oral anticoagulants
Apixaban
Edoxaban
Rivaroxaban
Dabigatran
If DAOC are contraindicated in a patient with atrial fibrillation, what anticoagulant can be given
Warfarin
Aspirin can be used as monotherapy for stroke prevention in patients with atrial fibrillation
False
Role of left atrial appendage ovclusion in atrial fibrillation
For stroke prevention if anticoagulant treatment is contra-indicated or not tolerated
Role of left atrial appendage ovclusion in atrial fibrillation
For stroke prevention if anticoagulant treatment is contra-indicated or not tolerated
Treatment approaches for atrial flutter
Controlling the ventricular rate
Attempting to restore and maintain sinus rhythm
Rate control drugs used in atrial flutter
Beta blockers
Non-DHP CCBs
Digoxin
Rate control drugs used in atrial flutter
Beta blockers
Non-DHP CCBs
Digoxin
Preferred drugs for rapid rate control in atrial fibrillation
IV Beta blockers
IV Verapamil
Conversion to sinus rhythm in atrial flutter can be achieved with
Electrical cardioversion
Pharmacological Cardioversion
Catheter ablation
How long should anticoagulation be done for in patients with atrial flutter for more than 48 hours or unknow duration before cardioversion and if patient cannot wait what should be done
3 weeks
If not possible, parenteral anticoagulation should be given and a left atrial thrombus ruled out before cardioversion
How long should anticoagulation be done for in patients with atrial flutter for more than 48 hours or unknow duration before cardioversion and if patient cannot wait what should be done
3 weeks
If not possible, parenteral anticoagulation should be given and a left atrial thrombus ruled out before cardioversion
How long should oral anticoagulation be done after cardioversion in atrial flutter
For at least 4 weeks
How long should oral anticoagulation be done after cardioversion in atrial flutter
For at least 4 weeks
Preferred method of cardioversion in atrial flutter when rapid cardioversion is necessary
Direct current cardioversion
Preferred method of cardioversion in recurrent atrial flutter
Catheter ablation
Rhythm control drugs in atrial flutter
Flecainide
Propafenone
Amiodarone when other drugs are contraindicated or ineffective
Is thromboprohylaxis necessary in atrial flutter
Yes
Is thromboprohylaxis necessary in atrial flutter
Yes
Criteria for anticoagulation in atrial flutter is same as in atrial fibrillation. T/F
True
Why do antiarrhythmics have a limited role in atrial flutter
Not always effective
Initial management of paroxysmal supraventrivular tavhycardia
Spontaneous termination
Reflex vagal stimulation
Initial management of paroxysmal supraventrivular tavhycardia
Spontaneous termination
Reflex vagal stimulation
Reflex vagal stimulation techniques
Valsava maneuver
Immersing the face in ice cold water
Carotid sinus massage
Reflex vagal stimulation techniques
Valsava maneuver
Immersing the face in ice cold water
Carotid sinus massage
Drugs for PSVT when reflex vagal stimulation fails or severe symptoms are present
IV adenosine
Drugs for PSVT when reflex vagal stimulation fails or severe symptoms are present
IV adenosine
Drug to be given in PSVT when IV adenosine is contraindicated or ineffective
IV Verapamil
Direct cardioversion in PSVT is needed when…..
Patient is Hemodynamically unstable
Reflex vagal stimulation fails
Drugs such as IV adenosine and verapamil are ineffective in restoring sinus rhythm
Direct cardioversion in PSVT is needed when…..
Patient is Hemodynamically unstable
Reflex vagal stimulation fails
Drugs such as IV adenosine and verapamil are ineffective in restoring sinus rhythm
Treatment for recurrent episodes of PSVT
Catheter ablation
Prevention with drugs
Drugs for prevention of PSVT
Diltiazem
Verapamil
Beta blockers including sotalol
Flecainide
Propafenone
Drugs for bradycardia after myocardial infarction
Iv atropine
Drug for bradycardia after MI if atropine is ineffective or patient is at risk of asystole
Epinephrine by IV infusion
Treatment for pulseless ventricular tachycardia or ventricular tachycardia
Resuscitation
Patients with unstable sustained ventricular tachycardia,who continue to deteriorate with signs of hypotension or reduced cardiac output, should receive …………. to restore sinus rhythm
direct current
cardioversion
What should be done if direct current cardioversion fails in unstable sustained ventricular tachycardia
Give IV Amiodsrone and repeat direct current cardioversion
What should be done if direct current cardioversion fails in unstable sustained ventricular tachycardia
Give IV Amiodsrone and repeat direct current cardioversion
Treatment for hemodynamically stable ventricular tachycardia
Intravenousa antiarrhythmics
Amiodarone hydrochloride - preferred
Flecainide acetate
Propafenone hydrochloride
lidocaine hydrochloride - less effective
Treatment for hemodynamically stable sustained ventricular tachycardia if IV antiarrhythmics are ineffective
Direct current cardioversion
Pacing
Treatment for hemodynamically stable sustained ventricular tachycardia if IV antiarrhythmics are ineffective
Direct current cardioversion
Pacing
Catheter ablation if urgent cessation of arrhythmia is not needed
Maintenance treatment for ventricular tachycardia
Implantable cardioverter defibrillator plus beta blocker or sotalol or amiodarone
Or
Implantable cardioverter defibrillator plus amiodarone plus beta blocker
or
Beta blocker with or without amiodarone if Implantable cardioverter defibrillator is not appropriate
Torsades de pointes
Form of ventricular tachycardia associated with a long QT syndrome
Causes of Torsades de pointes
Drugs
Hypokalemia
Severe bradycardia
Genetics
Treatment of torsades de pointes
IV Magnesium sulphate
Beta blocker(not sotalol)
Atrial or ventricular pacing
Why are antiarrhythmics not advisable in Torsades de pointes
They prolong QT interval and worsen the condition