Palpitations Flashcards
Perhaps the commonest arrhythmia causing a
patient to visit the family doctor is the _____
symptomatic
premature ventricular beat/complex (ventricular
ectopic).
The commonest cause of an apparent pause on the
ECG is a_______`
blocked premature atrial beat/complex
(atrial ectopic
Consider drugs as a cause, including prescribed
drugs and non-prescribed drugs such as ____, _____ and ______`
alcohol,
caffeine and cigarettes
Common triggers of paroxysmal supraventricular
tachycardia (PSVT) include _____ and _____
anxiety and cigarette
smoking
The commonest mechanism of any arrhythmia is
_____
re-entry
If the palpitations are not caused by anxiety or
fever, the common causes are____ and _____
sinus tachycardia and premature complexes/ectopics (atrial or ventricula
If the palpitations are not caused by anxiety or
fever, the common causes are _____ and _____
sinus tachycardia and
premature complexes/ectopics (atrial or ventricular
Sinus tachycardia can be differentiated clinically
from PSVT in that it starts and stops more gradually
than PSVT (abrupt) and has a ________
lower rate of 100–150
compared with 160–220
Sinister life-threatening arrhythmias are
- ventricular tachycardia
- atypical ventricular tachycardia (torsade de pointes)
- sick sinus syndrome (SSS)
- complete heart block
The rare tumour,________ presents with
palpitations and the interesting characteristic of
postural tachycardia (a change of more than 20 beats/
min).
phaeochromocytoma,
As a working guide, a rate estimated to be about
________ suggests PSVT, atrial flutter/
fibrillation or ventricular tachycardia
150 beats/minute
MC cause of palpitations in children
exercise, fever or anxiety
Palpitations needing special attention in children
PSVT, heart block and ventricular arrhythmias
________ is characterised by beats at 200–300 per
minute, the fastest rates occurring in infants
PSVT
The recommended firstline
treatment of PSVT is________ via the
application of ice packs to the upper face (forehead,
eyes and nose) of the affected infant
vagal stimulation
Medical Tx of PSVT
Intravenous
adenosine will usually terminate the episode.
They are prone to develop
ventricular tachyarrhythmias, which may lead to
sudden death. Consider it in children developing
syncope on exertion.
familial long QT syndrome
Occasional atrial
and ventricular arrhythmias, especially___________, occur in 40% of old people
premature
complexes (ectopics)
A ____________ is the
only indication for digoxin in the elderly but beware
of _______, especially if dizziness or syncope accompanies
the fibrillation.
rapid ventricular rate with symptoms
SSS
In the elderly, thyrotoxicosis may present as sinus
tachycardia or atrial fibrillation with only minimal
signs—the so-called________—so it is
easy to overlook it
‘masked thyrotoxicosis’
Avoid digoxin in cases with an _______
accessory pathway
The two main indications for permanent
pacemaking are_____ and ______
SSS (only if symptomatic) and
complete heart block
When to Tx sinus bradycardia
Treatment is required only if symptomatic, which is uncommon at rates >40–45 beats/min.
• Sudden onset without warning • Patient falls to ground • Collapse with loss of consciousness • Pallor and still as if dead with slow or absent pulse
Stokes–Adams attack
• These are usually asymptomatic.
• Management is based on reassurance.
• Check lifestyle factors such as excess alcohol,
caffeine, stress and smoking; avoid precipitating
factors
Premature (ectopic) atrial
complexes
Medical Mx of PACs
atenolol or metoprolol 25–100 mg (o) daily
or
verapamil SR 160–480 mg (o) daily
• These are also usually asymptomatic (90%).
• They occur in 20% of people with ‘normal’ hearts.
• Symptoms are usually noticed at rest in bed at
night
Premature (ectopic) ventricular
complexes
Approximately 60% of SVT are due to____ and _______
atrioventricular (AV) node re-entry and 35% due to accessory pathway tachycardia (e.g. WPW).
The structural basis for the arrhythmia of SVT
in WPW syndrome is an ______
accessory pathway that bypasses the AV node.
_____ is the first treatment of choice for PSVT
Carotid sinus massage
Other methods of vagal stimulation
- Valsalva manoeuvre (easiest for patient)
- self-induced vomiting
- ocular pressure (avoid)
- cold (ice) water to face or swallowing ice
- immersion of the face in water
How to give Adenosine if vagal stim does not work
give adenosine IV (try 6 mg first over
5–10 seconds, then 12 mg in 2 minutes if
unsuccessful, then 18 mg in 2 minutes if
necessary and well tolerated
2nd line of Tx if vagal stim does not work
Second-line treatment is verapamil IV 1 mg/min up to
10–15 mg (provided patient is not taking a beta
blocker).
Adenosine causes less hypotension than
verapamil but may cause ______ in
asthmatics
bronchospasm
When to avoid Verapamil
AVOID verapamil if taking β -blockers
and
persistent tachycardia with QRS complexes
>0.14 s (suggests ventricular tachycardia
In the rare event of failure of medical treatment in SVT,
consider ____ and ____
DC cardioversion or overdrive pacing.
Meds to prevent recurrences of SVT
To prevent recurrences (frequent episodes) use
atenolol or metoprolol, flecainide (only if no structural
heart damage) or sotalol
In SVT,
_______, which is usually curative, is indicated for
frequent attacks not responding to medical therapy
Radiofrequency catheter
ablation
_________ causes vagal stimulation and
its effect on SVT is all or nothing
Carotid sinus massage
T or F,
Carotid sinus massage has no effect on
ventricular tachycardia
T
How does carotid massage work?
It slows the sinus rate and
breaks the SVT by blocking AV nodal conduction.
In general, right carotid pressure tends to________and left carotid pressure tends to ____
slow the sinus rate
impair AV nodal conduction
Wc pts to avoid carotid massage?
Avoid in the elderly (risk of embolism or bradycardia
No cause is found in ________—isolated atrial
fibrillation
12%
With sustained atrial fibrillation there is a______
chance per annum of embolic episodes. There is a
fivefold risk of CVA overall
5%
in Af, _______ controls the ventricular rate but does not
terminate or prevent attacks
Digoxin
______, ________, _______are used
for conversion of atrial fibrillation and
maintenance of sinus rhythm
Sotalol, flecainide and amiodarone
in AF,________ should
never be prescribed in patients with reduced LV
function
Flecainide
Beta blockers and calciumchannel
antagonists benefited rate control
but ________ was much less effective than
amiodarone at restoring cardiac rhythm
verapamil
The ECG of _________has a regular saw-tooth
baseline ventricular rate of 150 with narrow
QRS complexes. This is a 2:1 AV block
atrial flutter
The _______study confirmed that there was no
statistically significant difference between the rate
and rhythm of control groups. However, patients
fare marginally better (in terms of mortality) with
just rate control rather than trying to get them back
into sinus rhythm if they are asymptomatic in atrial
fibrillation.
AFFIRM
Mx of Rapid, urgent control of ventricular rate:
verapamil 1 mg/min IV up to maximum 15 mg then orally
or
metoprolol 5 mg (1 mg/min) IV to max 20 mg (provided no evidence of heart failure and wellmonitored BP)
Routine control and maintenance of AF
verapamil SR 160–480 mg (o) daily or diltiazem CR 180–360 mg (o) daily or atenolol or metoprolol 25–100 mg (o) bd
In AF Tx, when do we consider rhythm control?
This should be considered if the patient is
symptomatic and the arrhythmia is of recent onset—
less than 6 months
If the rate cannot be well controlled despite
maximal medical therapy, consider _____ and ______
AV node ablation
and a permanent pacemaker
What surgical procedure?
Specific abnormal foci in the conducting pathways
can be ablated using direct current electrical surgery
or radiofrequency ‘burns’ via a catheter electrode
Catheter electrode ablation
_________which will probably
supplant surgery as a form of treatment, is indicated
for recurrent episodes of supraventricular tachycardia
Radiofrequency ablation,
This expensive implant is the most effective therapy
yet devised for the prevention of sudden cardiac death
in patients with documented sustained ventricular
tachycardia or fibrillation
Automatic implantable cardiac
defibrillator (AICD)
IACD
Operative mortality should be less than ______, after which survival at 1 year is over _____
10%
90%.
T or F
A normal ECG in sinus rhythm does not exclude an
accessory pathway
t
Consider conduction disorders such as the WPW
syndrome in PSVT. Avoid ______ in WPW
syndrome.
digoxin
