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RCE Guidelines Studying > Laflamme- Chapter 6 (Arrhythmias) > Flashcards

Laflamme- Chapter 6 (Arrhythmias) Flashcards

1
Q

What are the three Arrhythmic mechanisms?

A

1) Abnormal Automaticity: Increase phase 4 diastolic depolarization
2) Reentry

3) Triggered activity:
- Early Afterdepolarization: Torsades
- Delayed Afterdepolarization: Digoxin posioning, Idiopathic VT, CPVT

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2
Q

What is RP interval cut off?

A

90 msec

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3
Q

What is definition of POTS?

A

Orthostatic tolerance with significant increase of HR in the first 10 mins after standing (HR > 120 or increase by 30 bpm)

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4
Q

What is heart block rate in AVNRT ablation? Recurrence rate?

A
  • Heart block: 1%

- Recurrence: 5%

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5
Q

What does left lateral pathway look like on ECG?

A

+V1, AVF

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6
Q

Left septal/Posterior pathway on ECG?

A

+V1, AVF

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7
Q

Right Septal pathway on ECG?

A

-V1, +AVL

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8
Q

Anterior or right lateral pathway on ECG?

A
  • V1, + aVF, + aVL
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9
Q

What are the two properties of a malignant accessory pathway?

A
  • Refractory period < 250 msec

- Able to maintain effective anterograde conduction of possible AF

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10
Q

What is the Mahaim pathway? What does the associated arrhyhthmia look like?

A
  • Accessory pathway in the lateral wall of the RV or to the right branch
  • Associated arrhythmia is antidromic AVRT with LBBB
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11
Q

What can you consider in a young patient with Lone AF?

A

EP Study: To eliminate other SVT degenerating into AFib (can be target for ablation)

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12
Q

Resting and walking HR for Afib rate control?

A
  • Resting < 100 bpm

- Walking < 110 bpm

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13
Q

Efficacy of Class 1C, Sotalol and Amio for Afib rhythm control at one year? What trial?

A

30%, 50%, 70%

CTAF trial

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14
Q

Name 8 complications of AFib ablation? What is total quoted rate?

A
  • 5%
  • Vascular complication, Cardiac perforation/Tamponade, TE, PV stenosis, Atrio esophageal fistula, Phrenic nerve palsy, Atypical flutter, Death
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15
Q

Name all 8 HASBLED risk factors?

A

HTN, Abnormal LE (ALT > 3x ULN), Cr > 200, Stroke, Bleeding history, Labile INR, Elderly > 65, Drugs associated with bleeding or Alcohol

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16
Q

How does Dabigatran work?

A

-Direct thrombin inhibitor

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17
Q

When to dose reduce Dabigatran?

A
  • > 75 y.o -> 110 mg BID
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18
Q

How to renally dose Rivaroxaban?

A

15mg if 15-50 crcl

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19
Q

How to renally dose Edoxaban?

A

30mg daily if CrCl 15-50

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20
Q

What is the reversal agent for Dabigatran?

A

-Idarucizumab

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21
Q

How to switch from INR to DOAC?

A
  • If INR < 2 -> switch right away

- If INR 2-3 -> start DOAC following day

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22
Q

How to switch from LMWH to DOAC? What about visa versa?

A

-Next schedule dose (for both)

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23
Q

How to switch from DOAC to Warfarin?

A

Stop doac when INR > 2.0

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24
Q

When to stop Apix, Riva and Dabigatran prior to surgery with high bleeding risk?

A
  • Apixaban and Rivaroxaban: 48h prior

- Dabigatran: >48h if CrCl > 80, >72h if CrCl > 50, >96h if CrCl >30

25
Q

What did the ASSERT Trial show?

A

Detection of SCAF (HR > 190 and duration > 6min) associated with increased TE risk

Espisodes > 17.7 significantly increased stroke risk (5x)

26
Q

What did the TRENDS trial show?

A

SCAF > 5.5h associated with increased TE risk

27
Q

What are the 4 brugada criteria?

A
  1. Structural heart disease
  2. Precordial concordance, absence of RS complexes
  3. RS interval > 100msec in 1 of more precordial lead
  4. AV dissociation
  5. Morphological criteria V1-V2 and V6
28
Q

What are the ECG criteria of the Schwartz score?

A
  • QTC > 480 (3), QTC > 460 (2), > 450 (males, 1)
  • Tdp (2)
  • Alternating T wave (1)
  • Notched T wave on 3 leads (1)
29
Q

What are two clinical criteria of Schwartz score?

A
  • Syncope on exercise

- Syncope without stress

30
Q

What are other components of Schwartz score?

A
  • QTc ( >480, 460-470, 450)
  • TDP
  • T wave alternans
  • Notched T wave in 3 leads
  • Low heart rate for age
  • Syncope (With stress or without)
  • Congenital deafness
  • Family members with LQTs
  • Unexplained SCD below age 30
31
Q

What is Gene mutation in LQT1, LQT2 and 3

A
  • KCNQ1 (Loss of function)
  • KCNH2 (Loss of function)
  • SCN5a (Gain of function)
32
Q

What are triggers for LQT1, 2 and 3?

A

1) Exercise, swimming, stress
2) Alarms, noise
3) Rest or sleep

33
Q

Describe ECG morophology in LQT1 2 and 3

A
  • Wide based T wave
  • Notched or biphasic T wave
  • Long isoelectric line with narrow based T wave
34
Q

What are three RF for SCD in LQT?

A
  • QTc > 500
  • Complex ventricular arrhythmia
  • Jervell and Lange Nielsen
35
Q

What is definition of Carotid Sinus Massage?

A

-Ventricular asystole > 3s

36
Q

What to monitor for quinidine?

A
  • QRS increase

- Increase QTc

37
Q

What are 5 adverse effects of Procainamide?

A
  • drug induced Lupus
  • Arrhyhtmogenic
  • Torsades/increased QTc
  • Negative inotropic agent with high doses
  • Hypotension
38
Q

3 adverse effects of Disopyramide?

A
  • Negative inotrope
  • Increased HR
  • Vagal tone: Urinary retention, constipation
39
Q

Amiodarone side effects and incidence?

A
  • Pulmonary toxicity (2%): BOOP, COP, ARDS, Restriction
  • GI toxicity (30%): Nausea, anorexia. AST, ALT 2x normal
  • Hypothyroidism (20%): Continue amiodarone, supplement levothyroxine.
  • Hyperthyroid (10%): Iodine load, destruction. Stop amiodarone, consider PTU.Methimazole or Prednisone
  • Skin: Photosensitivity (75%), blue discoloration
  • CNS: Ataxia
  • Opthalmic: Halo, Opti meuropathy
  • Cardiac: Bradycardia, increased defibrillation threshold.
40
Q

11 drugs that interact with Amiodarone?

A

-Warfarin (need to reduce warfarin by 30-40% when starting Amiodarone)

  • Digoxin
  • Procainamide
  • Disopyramide
  • Diltiazem
  • Flecaniade
  • Phenytoin
  • Cyclosporine
  • Simvastatin
  • Atorvastatin
41
Q

What is monitoring schedule for Amiodarone?

A
  • Baseline CXR
  • TSH and free T3+T4 -> q6 months
  • LFT -> q6 months
  • CXR -> annual
  • Optho exam
  • Renal function
  • ECG
42
Q

3 studies that show minimal RV pacing improves results?

A
  • MOST
  • DAVID
  • CTOPP
43
Q

What happens if P-P interval is less than upper rate limit?

A

-Electronic wenckebach

44
Q

What happens if PP interval is less than Total Atrial Refractory period?

A
  • 2:1 block

- The frequency of 2:1 block = 60 000 / TARP

45
Q

What is Hysteresis?

A

Lower rate limit drops after V sense event

46
Q

What is Dynamic AV delay and what is it used for>

A

-AV delay decreases at higher HR (Decreased TARP), useful in patients with AV block and 2:1 block on exercise

47
Q

What is mode switch?

A

-DDD more switches to DDI mode following atrial tachyarrhythmia to prevent tracking of this tachyarrhythmia

48
Q

What is ventricular safety pacing ?

A

-Following atrial pacing -> early ventricular pacing in the presence of a ventricular event detected inside the cross-talk detection window (Prevents asystole in the presence of cross-talk or preventing R on T in the presence of PVC)

49
Q

What are 8 causes of Capture failure?

A 
Lead migration 
Exit block 
Myocardial infarction/CMO/Metabolic (increased threshold) 
Lead fracture 
Lead insulation defect
Loose set screw  
Battery depletion 
Ineffective autocapture algorithm
50
Q

What are 10 causes of undersensing?

A
  • Inadequate intrinsic signal like PVC or APC
  • Signal modification due to same as capture issues
  • High sensitivity programming
  • Lead migration
  • Lead perforation
  • Lead fracture
  • Insulation defece
  • Noise response
  • Magnet
  • Functional undersensing
51
Q

What are 6 reasons for oversensing?

A
  • Cross talk
  • Far field oversensing (QRS detected as an atrial event)
  • Oversensing of T wave
  • Electromagnetic interference
  • Myopotentials (unipolar only)
  • Lead issues
52
Q

What are 4 risk factors for Pacemaker mediated tachycardia?

A
  • PVC with retrograde conduction
  • Atrial capture failure
  • Very long programmed AV delay
  • Atrial oversensing or undersensing
53
Q

What are three ways to prevent or terminate PMT?

A
  • Prolong PVARP
  • Extension of post-PVC PVARP
  • 1 cycle without V pace following A sense during PMT
54
Q

What is a class 1 and 4 class IIa indications for CRT?

A
  • (1): LVEF M 35% NYHA II-IV + SR + LBBB + QRS > 150 msec
  • IIa: As above but QRS 120-149msec, Anything other than LBBB > 150msec, BiV pacing after Afib AV ablation, LVEF <35% with VPace > 40% according to DAVID
55
Q

What does ECG look like in CRT pacing?

A
  • V1: Dominant R wave

- 1: Negative

56
Q

What are indications for ICD for primary prevention? (3)

A
  • LVEF < 35% II-III
  • LVEF < 30% I
  • LVEF < 40% + NSVT + Inducible VT
  • 40 days post MI and > 3 months post revascularization
57
Q

What are 7 reasons for Inappropriate ICD shock?

A
  • Lead issues
  • SVT
  • T wave oversensing
  • Atrial far field
  • Myopotentials
  • Electromagnetic interference
  • R wave double counting
58
Q

Indications to ablate an asymptomatic patient with WPW?

A

-High risk job that precludes employment (SVT 2015)

  • High risk findings on EPS:
    a) Induced Afib with R-R < 250 msec
    b) presence of multiple pathways
    c) refractory period < 240 msec
    d) the ability to provoke sustained AVRT
    e) the finding of AVRT precipitating Afib

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