Tachy and bradyarrhythmias Flashcards by katie louise

What would be an appropriate first line treatment for atrial fibrillation in a sedentary 78 year old lady with a new diagnosis of atrial fibrillation who has no other health problems and no allergies? She is normotensive and has no evidence of heart failure.

beta blocker-atenolol

NICE guidelines suggest all patients with AF should have rate control as first line unless:
There is reversible cause for their AF
Their AF is of new onset
Their AF is causing their heart failure

Principles of treating AF

Rate or rhythm control
Anticoagulation

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Which tests must you perform prior to starting amiodarone treatment?

TFTs (thyroid dysfunction)
LFTs (liver fibrosis and hepatitis)
U+Es (hypokalaemia risk)
CXR (pulmonary fibrosis)

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Patient’s ECG demonstrates complete heart block. What intervention should be done?

transvenous pacing

(catheter ablation for AF and WPW)
(synchronised electrical cardioversion is for AF or tachyarrhythmia with adverse signs of shock)

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What is the indication for unsynchronised DC cardioversion?

life-threatening tachyarrhythmias= defibrillation

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Define tachyarrhythmia

> 100 HR

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Where does sinus tachy originate from?

SA node

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Name two triggers for tachy arrhythmia

macrolides
haloperidol
tricyclic antidepressants
ondansetron
electrolyte imbalance

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Three causes of AF?

heart disease- structural
Infection
Dehydration

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Name two rate control drugs for AF

bisoprolol
digoxin
CCB

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When is digoxin used in AF?

heart failure + AF

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What are the principles for AF treatment?

rate/rhythm control (rate preferred)

anticoag

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When is flecainide used?

NOT used for structural heart disease, therefore most typically used in young patients=pill in pocket

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What CHADVASC score implies the need to anticoagulate

> 1 in men

>2 in women

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Which score must CHADVASC be compared to?

HAS-BLED

risk of bleeding versus cerebrovascular event

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What are the indications for warfarin?

prosthetic valves
antiphospholipid syndrome
high risk of GI bleeding
(?obesity, ?renal hepatic impairment)

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Where does atrial flutter originate?

tricuspid annulus

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Two risk factors for AVNRT?

young female
caffeine
drugs

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Which is the most common AVRT?

wolf parkinson white

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Name one ECG feature of WPW

delta wave

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What is the aberrant pathway in WPW?

bundle of kent

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How is VT described?

monomorphic

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How is torsades de pointes described?

polymoprhic

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What is the general management of tachyarrhtyhmias?

Is this sinus?
Are they unstable? If yes then synchronised DC cardioversion
If no signs of haemodynamic instability then try: vagal manoeuvres followed by adenosine

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What are the signs of an unstable patient with tachyarrythmia?

Shock, MI, HF, syncope (poor blood to organs, heart, congestion, and brain)

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When would you do cardioversion in AF patient?

if proven acute episode (ECG and <48hr)

In which tachyarrhtymias would ablation be appropriate?

AF | AVRT/AVNRT

Name two methods to carry out vasalva manouvre

blow into syringe | carotid massage

How to do synchronised DC shock on monitor?

point arrow to QRS and sync (not T wave!)

Can you do synchronised DC in conscious patient?

need to sedate beforehand

What is the management of torsades de pointes?

Place pads on patient before turning to magnesium. Phone cardio reg

Patient with D&V, what electrolyte abnormality will be present?

hypokalaemia

Causes of prolonged QT?

``` low calcium, potassium, magnesium congenital clarithromycin/erythromycin (macrolides) Haloperidol SSRIs Amiodarone ```

Two differentials for irregularly irregular pulse?

AF AF with variable block atrial multifocal tachy

You see a new LBBB on ECG. What do you do?

Concern for STEMI, escalate. Don't assume NSTEMI

Signs of right heart strain on ECG?

RBBB | T wave inversion in anterior leads

Triggers for AF?

sepsis, thyrotoxicosis, HF, MI (NOT hyperkalaemia...)

Signs of hyperkalaemia on ECG?

think of dance... tall T waves Widened QRS short p waves

What is Brugada syndrome?

Na+ channelopathy cause of sudden cardiac death genetic association

What is HOCM?

muscle hypertrophy | thickening of myocardium, septal and ventricular

Which ECG change would indicate aortic root abscess following infective endocarditis?

1st degree AV block (aortic root=close proximity to AV node)

Define bradyarrhythmia

<60 HR (<50 is when you would worry)

How do you determine if bradyarrhythmia is nodal or subnodal?

nodal would give rate 40-55 whilst subnodal would give 25-40 | Wherein the rate reduces the further down the electrical pathway you go i.e. to the Purkinje fibres

What is the pathway of electrical activity in the heart

SA node - AV node - Bundle of His (atrioventricular) - Left and right bundle branches - purkinje fibres

MI affecting which coronary arteries can result in heart block?

RCA + proximal LAD

Three differentials for bradyarrhythmia?

neuro, cariac, infections, infiltrative, metabolic

Examples of cardiac causes of brady?

ischaemia conduction cardiomyopathy

Name two infective causes of bradyarrhtyhmias?

IE | Lyme's disease

Name one infiltrative cause of brady arrhythmia?

sarcoidosis

Management of acute bradyarrhtymia?

``` ECG atropine (affects SA and AV nodes but not subnodal therefore if problem originates elswhere then atropine won't be effective) Isoprenaline Pacing leads Call cardio reg if atropine doesn't work ```

Should you treat sinus brady or tachy?

NO. Treat underlying problem, withhold drugs but don't administer anything

Why is a QRS dropped few cycles in Mobitz type 1?

affects AV node, cells fatigue and don't pass on conduction. Patient is usually stable and no intervention unless haemodynamically unstable

What is a normal PR interval?

120-200ms

How to tell whether CXR shows pulmonary oedema or pleural effusion?

pulmonary oedema- patchy consolidation (alveolar oedema) while pleural effusion: complete hazy white out Apical sparing in pulmonary oedema due to gravity

Why does ventricular depolorisation occur sporadically in mobitz type 2?

some fibrosis exists within fibres but some healthy fibres. therefore conduction sometimes arises. = all or nothing phenomenon

Three differentials for bradyarrhtyhmia?

``` hypothermia hyperkalaemia MI cardiomyopathy hypothyoridism ```

Which additional blood tests should you always add on in brady and tachy arrhtyhmias?

``` bone profile (calcium, vit D, PTH) Magnesium ```

Normal QT interval?

9-11 small squares | 360-440ms

Signs on ECG of digoxin overdose?

Flattened, inverted, or biphasic T waves Shortened QT Mustache ST depression!

Pulse is described as weak and late. Which valvular abnormality?

aortic stenosis= pulsus parvus et tardus | only aortic valves give abnormal pulse, the other is collapsing for AR

How to accentuate murmur of HOCM?

valsalva manoeuvre | HOCM is subvalvular lesion, septum, dynamic obstruction