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Internal Medicine > JH IM Board Review - Arrhythmias II > Flashcards

JH IM Board Review - Arrhythmias II Flashcards

1
Q

What is the QRS morphology of VT?

A

Wide QRS complex.

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2
Q

What is the origin of the majority of wide-complex tachycardias?

A

85% ==> Ventricular.

***remainder are supraventricular w/ aberrant conduction.

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3
Q

What are the 4 types of VT?

A
  1. Non sustained (3 beats to 30sec).
  2. Sustained (>30sec).
  3. Monomorphic.
  4. Polymorphic.
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4
Q

What is the determinant of prognosis and Tx in VTs?

A

Dependent on presence of underlying structural heart disease.

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5
Q

What is the VT which may occur in otherwise healthy pts with structurally normal hearts?

A

Benign idiopathic VT.

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6
Q

What is the MC form of benign idiopathic VT?

A

RVOT VT.

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7
Q

What is the clinical presentation of nonsustained VT?

A

May be asx or cause occasional palpitations.

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8
Q

What is the clinical presentation of sustained VT?

A

More likely to cause palpitations, lightheadedness, near-syncope, syncope, cardiac arrest.

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9
Q

What is the 1st step in the diagnosis of VT?

A

Evaluation for structural heart disease.

==> Do echo.

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10
Q

What are the additional studies for the evaluation of structural heart disease besides echo in pts with VTs?

(3)

A
  1. Stress testing with imaging.
  2. CT or conventional coronary angio.
  3. Cardiac MRI.
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11
Q

What is the monitoring for a pt with VT?

A

Depending on sx frequency — May include 24-48h Holter monitor.

Or 30-day event monitor.

Or long-term implantable loop recorder (ILR).

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12
Q

What is the form of VT in which EPS is most useful?

A

In the evaluation of monomorphic VT.

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13
Q

What is the tx in an hemodynamically unstable pt with VT?

A

Emergent cardioversion/defibrillation.

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14
Q

What is the major determinant of chronic tx of most VTs?

A

The underlying presence of ischemic heart disease.

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15
Q

What is the prognosis in pts with monomorphic VT and no underlying structural heart disease (ie idiopathic VT)?

A

Good prognosis.

80-90% cure rates w/ ablation.

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16
Q

What are the target groups in which we should consider placing an ICD (shown to improve survival)?

(2)

A
  1. IHD w/ previous MI and LVEF 30% or less measured more than 3mo after revascularization + medical tx.
  2. Ischemic or non ischemic cardiomyopathy (LVEF <35%) and NYHA II or III despite at least 3mo of guideline-directed medical tx w/ beta-blockers and afterload-reducing agents.
17
Q

What is the role of EP study in some pts w/ milder forms of cardiomyopathy who have non sustained VT or sx possibly related to VT (palpitations, syncope)?

A

May be useful for risk stratification.

18
Q

What is a useful adjunctive therapy for recurrent VT in pts w/ ICDs that can help prevent sx and recurrent ICD shocks?

A

Catheter ablation.

19
Q

What is torsades?

A

A form of polymorphic VT a/w prolonged V-repolarization, manifesting on ECG as a prolonged QT interval.

20
Q

What are the main syndromes with which Torsades is a/w?

A

Both congenital + acquired long QT syndromes.

21
Q

What is the usual cause of congenital LQT syndrome?

A

Mutations in cardiac ion channels affecting ventricular repolarization (MC K or Na channels).

22
Q

What is the percentage of pts with congenital LQT syndrome in which a genetic mutation can be identified?

A

60-70%.

23
Q

What are the 2 MC associations of acquired LQTS?

A
  1. Drugs.

2. Electrolyte disturbances (ie hypokalemia, hypomagnesemia).

24
Q

What is the usual precipitant of torsades (Polymorphic VT)?

A

Premature ventricular contraction occurring on the preceding T wave (R-on-T wave).

25
Q

What is the acute management of torsades?

4

A
  1. IV Mg (2g IV push, repeat as necessary).
  2. Correct underlying metabolic abnormality or stop offending meds.
  3. Consider IB antiarrhythmics (IV lidocaine 1-1.5 mg/kg over 2min).
  4. Increase HR to decrease QT duration.
26
Q

What are the 2 ways by which you can increase HR therapeutically in order to decrease QT duration?

A
  1. IV isoproterenol.

2. Temporary pacer and overdrive pace to 90-100 beats/min.

27
Q

What is the chronic management of torsades?

A
  1. Avoid QT prolonging drugs.
  2. Avoid hypokalemia and hypomagnesemia.
  3. Beta blockers in pts with congenital LQTS.
  4. Consider ICD placement in selected pts.
28
Q

What are the high risk pts w/ congenital LQTS that may be helped by ICD placement?

A
  1. Pts w/ recurrent syncope.
  2. Torsades on beta blockers.
  3. Personal/FHx of cardiac arrest.
  4. Other high risk markers.
29
Q

What is the definition of syncope?

A

Transient + involuntary LOC and postural tone (lasting seconds to minutes) caused by cerebral hypoperfusion, followed by full spontaneous recovery.

30
Q

What is the percentage of syncopes in which the cause remains unknown?

A

25-40%.

31
Q

What is NOT included in the definition of syncope?

A

LOC caused by seizure, hypoglycemia, cataplexy etc.

32
Q

What is essential in all pts with syncope?

A

ECG.

33
Q

What is the management in a pt with a vasovagal syncope?

5

A
  1. Incr. Fluid intake + salt intake.
  2. Advise pts to stand slowly from a seated position.
  3. Eliminate offending meds.
  4. Consider midodrine or SSRIs in refractory cases.
  5. Consider pacemaker placement in exceptional cases a/w prolonged asystole.
34
Q

What is the definition of SCD?

A

Sudden, unexpected death that occurs within 1h of sx b/c of documented or presumed cardiac cause.

35
Q

What is the percentage of SCDs for which V-fib or pulseless VT is responsible?

A

30-60%.

36
Q

What is often the 1st manifestation of IHD?

A

SCD.

37
Q

What is the use of ECG in the evaluation of SCD?

4

A
  1. Evidence of MI or ischemia.
  2. WPW syndrome.
  3. Prolonged QT.
  4. Brugada.
38
Q

What are the indications for ICD implantation?

A
  1. Documented VT/VF cardiac arrest not caused by transient or reversible causes (ie MI, intoxication).
  2. Documented familial or inherited conditions w/ high risk of life-threatening arrhythmia, such as LQTS, HCM.
  3. Documented previous MI (>40 days), LVEF <40%, inducible sustained VT or VF at EPS (MADIT-1 criteria).
  4. Documented previous MI, LVEF<30% either 40 days following medically managed MI or 3mo following revascularization (PCI or bypass surgery).
  5. Pts w/ ischemic or nonischemic DCM, measured LVEF <35%, and NYHA II or III despite at least 3mo of guideline-directed medical tx.
  6. Pts w/ NYHA IV who meet other requirements for cardiac resync therapy.

Internal Medicine (107 decks)

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