Lecture 10; Arrythmias Flashcards
sawtooth pattern
atrial flutter
where does atrial flutter originate
cavo-tricuspid isthmus counterclockwise between IVC and tricuspid
treatment of atrial flutter
same as afib
- rate and anticoagulation
- most need to be ablated because they are hard to control with medicaitons
unstable atrial arrythmia tx
cardioversion
stable atrial arrhythmia
- vagal/ AV manuevers
- BB, diltiazem
goal HR in atrial fibrillation
HR < 80 at rest
HR < 110 with exercize
Medications for rate control in afib
BB (proponalol, metoprolol, esmolol)
non-hydropyradime (diltiazem, verapamil)
digoxin
amioadorane
AV blockers (allow the conduction from the atrium to be conducted to the ventricle
Amiodarone toxicity
What A BITCH
B: bradycardia, Blue man sydnrome
I: interstitial lung disease, increased QTC
T: thyrdoid
C: - corneal micro
- cytochrome P450
- Increase Warfarin/Simvitastatin/digoxin levels - needs dose reduction
H: Hepatic, Hypotension
which rhythm control is used if structural heart disease
amiodarone
which rhythm control if no structural heart disease
flecanide
dofetilide
propafenone
ibutilide
lone a fib tx
nothing or ASA
CHADS2VASC 0-1
valvular afib tx
wafarin
tx non-valvular afib
CHA2DS2-VASc
Condition Points
C Congestive heart failure (or Left ventricular systolic dysfunction) 1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1
A2 Age ≥75 years 2
D Diabetes Mellitus 1
S2 Prior Stroke or TIA or thromboembolism 2
V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1
A Age 65–74 years 1
Sc Sex category (i.e. female sex) 1
HAS BLED
> 3
caution
Condition Points
H Hypertension: (uncontrolled, >160 mmHg systolic) 1
A Abnormal renal function: Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L ==> 1
Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal 1
S Stroke: Prior history of stroke 1
B Bleeding: Prior Major Bleeding or Predisposition to Bleeding 1
L Labile INR: (Unstable/high INR), Time in Therapeutic Range 65 years
1
D Prior Alcohol or Drug Usage History (≥ 8 drinks/week) == >1
Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs)
1
goal for INR afib
2-3
direct thrombin inhibitor
2 things to remember
digatraban
- renally adjusted
- no bridge needed
RAEF
rivoraxaban
Apixiban
Endoxaban
Factor XA inhibitors
which NOAC can be used in dialysis patients
apixiban - acting up kidneys
timing of anticoagulation around cardioversion
If cardioversion is planned, anticoagulation therapy is based on the duration of atrial fibrillation. For patients who are known to have been in atrial fibrillation for less than 48 hours, preprocedural anticoagulation is not necessary as the risk of thrombus formation is low. Patients with atrial fibrillation of unclear duration or those with atrial fibrillation for more than 48 hours require preprocedural anticoagulation. These patients should receive 3 weeks of therapeutic anticoagulation prior to cardioversion. Alternatively, transesophageal echocardiography (TEE) can be performed to look for an intracardiac thrombus. If TEE is negative for thrombus, acute cardioversion can be performed immediately
minimum of 4 weeks owing to an increased risk of thromboembolic events after restoration of sinus rhythm.
CAD + afib triple therapy management
if < 12 mo + stent ==> triple therapy
if < 12 mo, no stent = ASA + anticoagulation
if > 12 mo –> anticoagulation only
what are the contraindictations to ablation
- cannot be anticoagulated
wpw with afib
procainamide
best med post op afib
sotolal
when are PVC required to be treat
symtomatic/frequent (> 10,000 in 24 hours)
(>10% of all beat
tx symptomatic pvc
BB, NDP-C
definition non=sustained v-tach vs. sustained
> 3 PVC sequential running at 100 bpm vs. no association + 30 seconds
stable Vt tx
amio
Pacemaker indications
Symptomatic bradycardia without reversible cause
Asymptomatic bradycardia with significant pauses (>3 seconds in sinus rhythm) or persistent heart rate <40/min
Atrial fibrillation with 5-second pauses
Asymptomatic complete heart block or Mobitz type 2 second-degree atrioventricular block
Alternating bundle branch block
CRT
Patients with left ventricular ejection fraction (LVEF) of less than or equal to 35%, sinus rhythm, LBBB (left bundle branch block), New York Heart Association (NYHA) Class II, III or IV symptoms while on optimal medical therapy with a QRS duration of greater than or equal to 150 ms
DOC Brugada
quinidine
DOC SVT
Adenosine
common 2/2 causes of bradycardia
elevated intracranial pressure, hypothyroidism, hyperkalemia, Lyme disease, and medication effects
DOC HF and afib
digoxin
AC despite CHADS
left atrial appendage thrombus, and hypertrophic cardiomyopathy require oral anticoagulation regardless of risk score
NOAC reversal
The FDA recently approved idarucizumab, a monoclonal antibody that can be used in emergency situations to reverse the anticoagulant effects of dabigatran.
pulmonary vein stenosis
Patients who develop dyspnea months to years after an atrial fibrillation ablation
high likelihood of familial arrhythmia issue
The presence of unexplained premature (younger than 35 years) death or sudden death in a first-degree family member should raise suspicion for the possible presence of an inherited arrhythmia syndrome and referral to a cardiovascular specialist
definition of long-QT syndrome
prolonged QTc interval (>440 msec in men and >460 msec in women) accompanied by unexplained syncope or ventricular arrhythmia
tx long QT syndrome
irst-line therapy for long QT syndrome is β-blocker therapy. Patients with cardiac arrest or those who have recurrent events (syncope or VT) despite β-blocker therapy should undergo ICD implantation.
definition and treatment of short QT syndrome
short QT interval, usually less than 340 msec (or QTc <350 msec).
high risk for SCD, and ICD placement is recommended for all patients.
ACS for asystole PEA
asystole or pulseless electrical activity (PEA), CPR is continued with reassessment of rhythm status for a shockable rhythm every 2 minutes. Epinephrine (1 mg intravenously) should be given every 3 to 5 minutes, although vasopressin (40 units intravenously) can replace the first or second dose of epinephrine.
ACS for VT/VF
In patients with VT/VF, a shock is advised with immediate resumption of CPR and reassessment of the rhythm in 2 minutes. Epinephrine should be given after the second shock and every 3 to 5 minutes thereafter. If VT/VF continues despite three shocks and epinephrine, amiodarone should be given as a bolus.
bradycardia symptomatic tx
ymptomatic bradycardia and hemodynamic distress should first be treated with atropine. If atropine is ineffective, dopamine or epinephrine infusions can be attempted until transcutaneous pacing or a temporary pacing wire (preferred) can be implemented
what should you not do in suspected device infecton
he device pocket should never be aspirated for diagnostic purposes because puncturing the pocket can damage the leads or introduce infection.
QTC in female and man considered prolonged
450 in women and 470 in men
treatment of congenital Long QT
- avoidance of Low MG/low K
- Antipsychotics/FQ/Anti-emetics/marcolides/antiarrythmics
- tx with BB
Cheyne-stoke breathing
creascendo-decrescendo osillation in tidal volume and intervals of hyponea and apena
- central sleep apnea
- advanced Hf
treatment atrial flutter
most effective and first line treatment is radiofrequency ablation
treatment of pericarditis
NSAIDS and cholchine
NOT STEROIDS
anticoagulation around cardioversion
3 weeks and then 4 weeks after
triple DAPT and AC therapy
ACS < 12 months - triple
> 12 months - only AC
when do you treat PVC with medication
BB
> 10,000 in 24 hours or > 10% of all beats are PVV
pacemaker indications
- symptomatic bradycardia
- 2nd degree type 2 or third degree heart block
- sinus pauses > 3 seconds with afib
- alternating bifisciular block
anticoagulation around surgery
low risk surgery - no interruption in warfarin without bridging
high risk surgery - temp interruption in wafarin
who requires bridging
CHADS2VASC > 6
QRS duration for BIV pacing
QRS > 150
risk stratification for WPW
exercize stress test with increased HR or procainimide challenge.
Intermittent loss of delta waves is a good prognostic factor and don’t have to do anything else
what medication need to be avoided in WPW
AV nodal blockers
tx high risk WPW
catheter ablation
INR goal mitral stenosis/afib
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