Mehl. arrhytmias: Afib, flut., VT, SVT Flashcards
M. Afib. pattern?
“irregularly irregular” rhythm with absent p-waves.
M. Afib.
AF is hugely important because it can cause turbulence/stasis within the left atrium that leads to a LA mural thrombus formation. This thrombus can launch off (i.e., become an embolus) and go to brain (stroke, TIA, retinal artery occlusion), SMA/IMA (acute mesenteric ischemia), and legs (acute limb ischemia).
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M. Afib. AF HY in older patients, especially over what age?
75
M. Afib.
Vignette will usually be an older patient with a stroke, TIA, or retinal artery occlusion, who has normal blood pressure (this implies carotid stenosis is not the etiology for the embolus).
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M. Afib. AF usually is paroxysmal, which means it comes and goes. The vignette might say the patient is 75 + had a TIA + BP normal + ECG shows sinus rhythm with no abnormalities -> next best step is??
Holter monitor (24-hour ambulatory ECG monitor) to pick up the paroxysmal AF (e.g., when the patient goes home and has dinner).
M. Afib. After AF is diagnosed with regular ECG OR Holter –> next step in 2CK?
echocardiography as the next best step to visualize the LA mural thrombus.
M. Afib. Dx arba paprastoj ECG, arba holteriu!!!
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M. Afib.Patient who has severe abdominal pain in setting of AF or hyperthyroidism (which can cause AF), diagnosis is ???? best next step??
acute mesenteric ischemia; next best step is mesenteric angiography; Tx is laparotomy if unstable (answer on NBME).
M. Afib. Patient who has severe abdominal pain in setting of AF or hyperthyroidism (which can cause AF). If patient unstable, what Tx?
Tx is laparotomy if unstable (answer on NBME).
M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm, Dx?
acute limb ischemia;
M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm, Tx?
USMLE wants “embolectomy” as answer.
M. Afib. Severe pain in a leg + absent pulses in patient with irregularly irregular rhythm. Buvo nbme 10 ar 11 panasi situacija su ranka, kad dingo pulsas. Buvo teisingas ats cardioecho (kad surasti embola) vs angiography (wrong)
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M. Afib. Any structural abnormality of the heart, either due to LV hypertrophy, ischemia, growth hormone/anabolic steroid use, prior MI, etc., can lead to AF.
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M. Afib. You need to know AF patient will get either??2 possible drugs
aspirin or warfarin.
M. Afib. You need to know AF patient will get drugs (aspirin or warfarin). how to know which drug?
This is determined by the CHADS2 score. There are variations of the score, but the simple CHADS2 suffices for USMLE: CHF, HTN, Age 75+, Diabetes, Stroke/TIA/emboli.
Each component is 1 point, but stroke/TIA/emboli is 2 points. If a patient has 0 or 1 points, give aspirin; if 2+ points, give warfarin.
nu siaip yra chads-vas, bet jis paminejo tik chads
M. Afib.
“Emboli” refers to Hx of AF leading to stroke, TIA, acute, mesenteric ischemia, or acute limb ischemia – i.e., any Hx of embolic event.
2CK IM form gives short vignette of 67F with chronic AF + Hx of acute limb ischemia + no other info relating to CHADS, and answer is warfarin to prevent recurrence; aspirin is wrong.
M. Afib. CHADS-VAS - kazkodel mehl rase tik apie chads, bet kad pagal situacijas su chads-vas geriau suskaiciuoti ir nuspresti gydyma.
CHA2DS2-VASc
Congestive Heart
Failure/LV dysfunction
Hypertension
Age >= 75 y.o (2points)
Diabetes Mellitus
Stroke/TIA/TE (2 points)
Vascular disease
Age 65-74
Sex category (female
gender)
Afib. CHA2DS2-VASc
Congestive Heart
Failure/LV dysfunction
Hypertension
Age >= 75 y.o (2points)
Diabetes Mellitus
Stroke/TIA/TE (2 points)
Vascular disease
Age 65-74
Sex category (female
gender)
Jeigu <65 - 0 points
Male 0/female 1 = no drug
Male 1/female 2 = anticoagulation needed
female visada tures uz lyti bent 1 taska.
Where the CHADS2 score is 1 (moderate risk) then either aspirin or anti-coagulants can be offered
Patients with 2 or more points should receive full anticoagulation with warfarin, dabigatran, rivaroxaban or apixaban.
M. Afib.
M. Afib.
Some students will ask about NOACs, e.g., apixaban, etc., for non-valvular AF àI’ve never seen NBME care about this stuff. They seem to be pretty old- school and just have warfarin as the answer, probably because there isn’t debate around whether it can be used; use of NOACs is less textbook.
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M. Afib. AF patient should also be on rate control before rhythm control.
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AF patient should also be on rate control before rhythm control.
The USMLE actually doesn’t give a fuck about this component of management, although in theory metoprolol or verapamil is standard. You could be aware for Step 3 that flecainide is first-line for rhythm control if patients fail rate-control and have a structurally normal heart and no coronary artery disease.
M. Afib. NBME for 2CK AF who has hemodynamic instability (i.e., low BP). , Mx?
NBME for 2CK has “electrical cardioversion”
M. Afib. What you need to know is: sometimes AF can trigger “rapid ventricular response,” where HR goes >150 and low BP can occur.
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M. Atrial flutter. Low yield.
nebuvo pas mehlman nieko. bet tooth-wave ecg. Mx kaip afib.
M. Ventricular tachycardia (VT). HIGH YIELD!!!.
Causes wide-complex QRS complexes (>120 ms; normal is 80-120 ms).
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M. Ventricular tachycardia (VT).
Exceedingly HY for 2CK that you know VT is wide-complex, whereas SVT is narrow-complex.
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M. Ventricular tachycardia (VT).
complexes look wide like mountains.
Tx? stable
VT is treated with anti-arrhythmics – i.e., amiodarone.
M. Ventricular tachycardia (VT).
Tx? UNstable
If patient has coma or hemodynamic instability (low BP), the NBME answer is direct current countershock or cardioversion (same thing).
M. Ventricular tachycardia (VT).
Premature ventricular complex (PVC) is asked on 2CK.
Wide complex (meaning ventricular in origin) that occurs earlier (hence premature). What they do on the NBME is show you this strip and ask where this abnormality originates from, then the answer is just “ventricle.”
Tx?
Don’t treat PVCs on USMLE.
M. Supraventricular tachycardia (SVT).
Causes narrow / needle-shaped complexes. Make sure you’re able to contrast this with VT above, which is wide-complex.
Notice the complexes are narrow / look like needles. This means the tachy originates above the ventricles (hence SVT).
M. Supraventricular tachycardia (SVT).
Treatment of SVT exceedingly HY on 2CK.
First step is????
is carotid massage (aka vagal maneuvers).
M. Supraventricular tachycardia (SVT)
Treatment of SVT exceedingly HY on 2CK.
First step is (IN PEDS WHAT CAN WE DO)????
In pediatrics, they can do icepack to the face.
M. Supraventricular tachycardia (SVT)
If carotic massage/ice pack doesnt work, next step in Tx?
If the above doesn’t work, the next step is give adenosine (not amiodarone).
M. Supraventricular tachycardia (SVT)
Same as with VT, if the patient has coma or low BP,Tx?
Shocking the patient is the first step.
In other words, for both SVT and VT, you must shock first in the setting of coma or hemodynamic instability.
It’s for stable SVT and VT that the treatments differ on USMLE.
