Rhythm and Conduction abnormalities part 3 Flashcards
The most significant in left ventricular filling is
The shortening of diastole,
Because you fast ventricular rate and this means for the exactly same category of patients that depend on longer filling period they ill be more symptomatic
CHAD-VASc
2 in men or 3 in women
2 points without sex for anticoagulation
1 point - anticoagulation/nothing
when we decide to restore the sinus rhythm and when we try to control the ventricular rate
if no symptoms and esp in old pts -> rate control strategy
But if you are not completely sure ans esp the patient is young and there is subconsious adaptation to arrhythmia,pts sometimes unconsiously release the level of exercise and so on,you can try restore sinus rhythm and see if there is some improvement in exercise tolerance and if there is a case this means that the pt is not really asymptomatic
*IF SYMPTOMS ARE PRESENT WE MUST BE SURE THAT THEY ARE RELATED TO ARRHYTHMIA
if there are not related to arrhythmia then we should go for rate control especially in old pt,very dilated left atrium,very low propability of sinus rhythm
embolic risk seems to be related to
embolic burden
shorter episodes
less embolic risk
electrical cardioversion
IV sedation
midazolam
propofol
etomidate
Synchronous EEC/IEC
Anterior patch is placed in the right parasternal area and the posterior patch is placed in the left parasternal area
Amiodarone is
slow conversion drug
best drug for prophylaxis - atrial fibrillation recurrence
it takes more than 12 hrs to see cardioversion
you can use rate control temporarily until you decide if you will do cardioversion
or to gain sometime to facilitate spontaneous cardioversion or it could be
the first choice in pts with no symptoms
Early Ablation in pts that
- not very dilated left atrium with high propablility or propability of recurrence, usually these are young pts with no previous history of AFib,no significant comorbidities or mildly controled
- normal LA or mildly dilated
- HF in pts ->produced or aggravated by atrial fibrillation,they have cardiomyopathy as a cause for HF or aggravating factor for HF.
rhythm control
- try to restore sinus rhythm
- usually symptomatic pts
- cardioversion ,long term prophylaxy
- Antiarrhythmic drug
- PV isolation
rate control
- pts asymptomatic or local ability to restore or maintain
sinus rhythm on the pts very dilated left atrium and so on
post PVC pause is
compensatory
pre PVC interval and post PVC interval is
double RR or PP during sinus rhythm beats
The PVC usually doesnt
- reset the SA node so the next P wave will come to the right moment.
- can be one morphology or can be muultiple morphology
sometimes PVC or VT can be narrower than baseline rhythm.
ventricular arrhythmia provoke
wider QRS
interopolated beat
the beat that increases the most the heart rate
syncope more severe than
palpitations
arrhythmias that comes from right ventricular outflow tract are almost never
benign,associated with sturural heart disease.
arrhythmias that comes from left ventricular outflow tract
are not associated with structural heart diseases,if there associated is by chance
We avoid class___ medication in pts with ischemic heart disease,left ventricular dysfunction or severe hypertrophy
I
lidocaine associated
with increased mortality during acute phase of MI,you can use for e.g. in sustained VT to cardiovert a sustained VT with an intravenous bolus but prolonged perfusion to treat PVC is to be avoided because is associated with increased mortality
if its focal arrhythmia ablation can be
curative
VT : if it is < 30 sec (1)
if it is > 30 sec (2)
(1) it’s not sustained
(2) sustained VT
Monomorphic VT
- usually they are regular
- AV dissociation, atrium is slow - ventricle is fast
- Fusion beats
- Capture beats
- Morphological criteria
Fusion beats
- they have a morphology thats its inbetween tachycardia and sinus rhythm
- usually narrower than tachycardia beat
Capture beats
some of the P waves are able to go to go through AV nodal HIS and bundle branches and capture most of the myocardium and give rise to almost normal QRS complex
Monomorphic VT and vast majority of cases are generated by
the re-entrant circuits,so if you capture all the myocardium , if you depolarise all the myocardium the tachycardia it will be stopped.The circuit remains excitable and the tachycardia continues
when you BBB
somewhere depolarisation will be normal on the other side.
- If you have RBBB you will have normal left bundle conduction
-if you have LBBB you will have normal right bundle conduction
Somewhere in the endocardium depolarisation will start fast and only at the end of depolarisation will go through more specialised tissues
Wide QRS SVT
- SVT + pre-existent BBB
- TSV with aberrant conduction
- SVT + antidromic AVRT ( WPW )
ECG differentiation criteria VT - wide QRS SVT
- Fusion beats : ventricualr captures
- AV dissociation
- VA retrograde conduction ( retrograde P )
- QRS > 140 msec ( ESPECIALLY > 160 msec)
- Unique morphology of QRS in chest leads =VT
Most famous polymorphic VT : Torsades de points
long QT syndromes can be congenital but also can be acquired or both.
medication that induces hypokalemia
Diuretics or some antiarrhythmic drugs
congenital long QT syndrome is rare
Ventricular fibrillation
complelety chaotic activation of the ventricle,no significant mechanical activity.
- Polymorphic QRS that change continuously
- usually not compatible with life and in most instances isnt self- limited
- In 4-6 mins you have irreversible cerebral lesions
In acute ischemia is not a sign of
reperfusion
this can be appear even with closed coronary artery
Automatic idioventricular rhythm is a sign of reperfusion ?
NO ,there are other signs
Before and after cardioversion you need to provide
provide CPR,intrahaling incubation or chest comperssion for cardiac massage
implantable defribrillator works by
delivering high energy shock in an intracardiac lead
the lead has some small electrodes at the tip that are similar to pacing
the most effective position for the defibrillator is in
the left precordial space,good waveform for defibrillation
defibrillator
- this a device that can terminate ventricular arrhythmia
- can reduce the sudden cardiac death
implantable cardioverter defibrillator ICD
INDICATION
Secondary prevention
, the pt has already experianced
sudden cardiac arrest,sustained ventricular arrhythmia that we were not able to find any reversible cause
implantable cardioverter defibrillator ICD
in pts that havent experienced any ventricular arrhythmias but they are at high risk
- low ejection fraction
- Dilated cardiomyopathy with HF at least class II and severe left ventricular dysfunction
- some of the pts they have hypertrophic cardiomyopathy or arrhythmogenic cardiomyopathy : LQT , Brugada,SQT
