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TCD Cardiology > Palpatations > Flashcards

Palpatations Flashcards

1
Q

Name the five phases of an action potential.

A

Phase 0 - rapid depolarisation
Phase 1 - early depolarisation
Phase 2 - plateau phase
Phase 3 - repolarisation
Phase 4 - resting membrane potential

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2
Q

Describe which channels are open/closed in each phase of a ventricular action potential.

A

Phase 0 - Na+ channels open
Phase 1 - Na+ channels close. K+ channels begin to open.
Phase 2 - Ca2+ channels open
Phase 3 - slow delayed-rectifier K+ channels open. Ca2+ channels close.

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3
Q

What is the most common cause of broad complex tachycardia?

A

Ventricular fibrillation.

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4
Q

What are the four main differentials for a narrow complex tachycardia?

A

Sinus tachycardia
Supraventricular tachycardia (SVT)
Atrial fibrillation
Atrial flutter

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5
Q

How can you distinguish supraventricular tachycardia from atrial fibrillation on an ECG?

A

Both will have narrow complex tachycardia, but in supraventricular tachycardia the QRS complexes will be regular, whilst in atrial fibrillation, they will be irregularly irregular.

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6
Q

What examination findings may indicate thyrotoxicosis? (3)

A

Goitre
Tremor
Exophthalmos (bulging of the eyes)

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7
Q

What are the three common descriptions of palpations?

A

Flip-flopping in chest
Rapid fluttering in chest
Pounding in neck

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8
Q

What are the indicated aetiologies for each of the common descriptions of palpations?

A

Flip-flopping in chest —> extra systoles (such as supraventricular or ventricular premature contractions)
Rapid fluttering in chest —> sustained ventricular or supraventricular arrhythmia (sudden cessation of this sensation can suggest paroxysmal SVT)
Pounding in neck —> if irregular, can indicate atrioventricular dissociation (atria contracting against closed AV valves produces cannon A waves)

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9
Q

What pathologies can palpitations induced by exercise be suggestive of? (3)

A

Cardiomyopathy
Ischaemia
Channelopathies

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10
Q

What are the three categories of palpitation causes?

A

High output states
Structural cardiac causes
Catecholamine excess

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11
Q

Describe the pathophysiology of a bradycardic arrhythmia.

A

Depolarisation fails to initiate or conduct properly, such as in
SA node disease or heart block.

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12
Q

Describe the pathophysiology of a tachycardic arrhythmia.

A

There is abnormal depolarisation occurring in the heart, such as in enhanced automaticity or reentry.

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13
Q

Name the three types of SA node disease.

A

Sinus bradycardia
Sinus pause
Sinoatrial exit block (heart block)

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14
Q

What is sinus pause?

A

A condition where the SA node fails to generate an electrical impulse for what is generally a brief period of time.

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15
Q

What is sinoatrial exit block?

A

A condition where the depolarizations that occur in the sinus node cannot leave the node towards the atria; they are blocked.

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16
Q

Describe the four types of heart block.

A

1st degree - slow conduction through AV node
2nd degree (Wenckebach or Mobitz Type I) - AV conduction becomes slower and slower until it misses a beat
2nd degree (Mobitz Type II) - fixed block (usually 2:1)
3rd degree - complete heart block; there is no conduction to the ventricles and an escape pacemaker takes over from the His-bundle / bundle branch

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17
Q

What is automaticity?

A

A condition where an area of myocardial cells depolarise faster than the SA node. This may be atrial or ventricular tissue; most occur at a single ‘focal’ site.

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18
Q

What is reentry?

A

Where there is an electrical pathway that is not supposed to be there, connecting two areas that should not be connected and forming an abnormal electrical circuit.

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19
Q

What is supraventricular tachycardia (SVT)?

A

A heart condition where the heart suddenly beats much faster than normal; originates from faulty electrical impulses in the upper part of the heart, rather than from the ventricles.

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20
Q

What is ventricular tachycardia (VT)?

A

A sequence of three or more ventricular beats; the frequency must by higher than 100 bpm, mostly it is 110-250 bpm.

21
Q

Name the five different types of supraventricular tachycardia (SVT).

A

Atrial fibrillation
Atrial flutter
AV nodal reentrant tachycardia (AVNRT)
Atrial tachycardia
Atrio-Ventricular Reentry Tachycardia (AVRT)

22
Q

Which type of SVT is grossly irregular?

A

Atrial fibrillation

23
Q

What are the two types of ventricular arrythmia?

A

Ventricular tachycardia
Ventricular fibrillation

24
Q

Which type of ventricular arrythmia is irregular?

A

Ventricular fibrillation

25
Q

What is Wolff-Parkinson-White (WPW) Syndrome?

A

A supraventricular tachycardia (SVT) that uses an atrioventricular (AV) accessory tract; the accessory pathway may also allow conduction during other supraventricular arrhythmias, such as atrial fibrillation or flutter.

26
Q

What are the two types of Wolff-Parkinson-White (WPW) Syndrome classified based off of ECG results?

A

Type A: delta wave and QRS complex are predominantly upright in the precordial leads. (May be mistaken for RBBB.)
Type B: delta wave and QRS complex are predominantly negative in leads V1 and V2 and positive in the other precordial leads (may be mistaken for LBBB).

27
Q

What are vagal manoeuvres?

A

Physical actions that stimulate your vagus nerve to act on the heart’s natural pacemaker, slowing down the electrical impulses there.

28
Q

What are the diagnostic indications for use of vagal manoeuvres? (2)

A

-Valsalva manoeuvre can be used to distinguish between ventricular tachycardia and supraventricular tachycardia by slowing the rate of conduction at the SA or AV nodes.
-Carotid sinus massage can be used to diagnose carotid sinus hypersensitivity.

29
Q

What are the therapeutic indications for use of vagal manoeuvres?

A

They are first-line treatment of hemodynamically stable supraventricular tachycardia, serving to slow down or terminate the arrhythmia.

30
Q

How do you perform the valsalva manoeuvre?

A

While lying on your back, take a deep breath and act like you’re exhaling but with your nose and mouth closed for 10 to 30 seconds. It should feel like trying to breathe air out into a blocked straw.

31
Q

When is it unsafe to perform vagal manoeuvres?

A

When the patient is haemodynamically unstable - they may have low BP, chest pain, SOB, oxygen deficit or perfusion deficit.

32
Q

What is ectopy (in a cardiology context)?

A

One of the commonest causes of palpitations - the origination of cardiac electrical impulses in the myocardium outside of the sinoatrial (SA) node.

33
Q

What is the only way atrial fibrillation can be confirmed?

A

An ECG demonstrating an irregularly irregular R-R interval and absent or abnormal p waves for more than 30 seconds.

34
Q

What features should you ask about when taking a palpitations history? (11)

A

-Nature
-Rate
-Regularity (“can you tap out the rhythm?”)
-Duration
-Onset/offset
-Frequency

-Associated symptoms
-Red flags (syncope!)
-PMH of structural heart disease
-FMH of sudden cardiac/premature death
-Drug and medication history

35
Q

Why is there usually a degree of AV block during atrial fibrillation?

A

The atrioventricular (AV) node is usually unable to conduct at the rapid rates of disorganised depolarisation occurring in the atria. This makes ventricular conduction random and irregular.

36
Q

What is the difference between paroxysmal and persistent atrial fibrillation (AF)?

A

Paroxysmal AF lasts between 30 seconds and 1 week, whilst persistent AF lasts over 1 week.

37
Q

What are three potential major adverse consequences of atrial fibrillation (AF)?

A

Stroke
Heart failure
Anxiety/depression

38
Q

What is the HASBLED score?

A

A useful means of identifying risk factors associated with a high bleeding risk - patients with a HASBLED score of 3 or more are deemed high risk and require close monitoring.

39
Q

Which DOAC is licensed for use in patients with Chronic Kidney Disease (CKD)?

A

Apixaban

40
Q

Give four available treatment options for atrial fibrillation (AF).

A

-Medications for rate control (i.e beta blockers)
-Medications to maintain sinus rhythm
-Catheter ablation to maintain sinus rhythm
-Permanent pacemaker to allow use of medications +/- an AV node ablation (i.e., pace and ablate)

41
Q

What should patients with mechanical heart valves or moderate to severe rheumatic mitral stenosis be offered for anticoagulation instead of DOACs?

A

Warfarin

42
Q

What is the aim for heart rate control in atrial fibrillation (AF) patients?

A

An average HR<100 bpm or <110 bpm in older patients over 70 years.

43
Q

What are the four rate control treatments available for atrial fibrillation (AF), in order of first-line to ‘last resort’?

A

Beta blockers (1st line)
Calcium channel blockers (2nd line)
Digoxin (can be added as adjunct if rate poorly controlled despite first line or second line)
Permanent pacemaker

44
Q

What are the six types of rhythm control available for treatment of atrial fibrillation (AF)?

A

Flecainide
Sotalol
Amiodarone
Dronedarone
Catheter ablation
DC cardioversion

45
Q

When should calcium channel blockers for atrial fibrillation (AF) be avoided?

A

In patients with left ventricular systolic dysfunction.

46
Q

What is flecainide?

A

A cardiac sodium channel blocker - the most commonly used antiarrhythmic drug for AF in the UK.

47
Q

When should flecainide be avoided?

A

In patients with coronary artery disease and structural heart disease.

48
Q

What needs to be monitored in patients taking sotalol or amiodarone?

A

QTc interval should be measured prior to starting and after any dose adjustments, because sotalol can cause QTc prolongation.

49
Q

Which rhythm control treatment available for atrial fibrillation (AF) can be given to patients with structural heart disease?

A

Amiodarone

TCD Cardiology (4 decks)

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