Tachyarrhythmias

Question 1

Tachyarrythmias etiology:

Answer 1

Genetic 
Structural heart disease 
Metabolic 
Toxic 
Extracardiac

Question 2

Classification of tachyarrythmias :

Answer 2

🔸supraventricular arrhythmias :
1)atrial tachycardia
2)tachyarrythmias involving atrioventricular junction :
a- atrioventricular nodal re-entrant tachycardia (AVNRT)
b-atrioventricular re entrant tachycardia(AVRT )
3)atrial flutter
4)atrial fibrillation
🔸ventricular arrhythmias :
1)premature ventricular complexe
2)ventricular tachycardia

Question 3

Supra-ventricular tachycardia:

Answer 3

• rhythm disorder with rate higher than 100/min
• the site is above His bundle
• it associates a narrow QRS complex <120sec
• may have the expression of a wide QRS

Question 4

Classification of atrial fibrillation:

Answer 4

🔸first diagnosed : not diagnosed before
🔸parixymal: terminates spontaneously or with intervention within 7 days of onset
🔸persistent: continuously sustained beyond 7 days , includes episodes terminated by cardioversion after >7days
🔸long standing persistent: continuous >12 months
🔸permanent: AF that is accepted by the pt and physician , and no futher attempts to restore or maintain sinus rhythm

Question 5

Mechanisms for the different types of atrial fib:

Answer 5

1) paroxysmal: ectopic foci
2) persistent: single circuit re-entry
3) permanent: multiple circuit re entry

Question 6

Clinical presentation of atrial fib:

Answer 6

Sympts: asymptomatic , palpitations , dyspnea, dizziness, angina , syncope
Signs :
Irregular cardiac sounds
Pulse deficit

Question 7

Management of atrial fib:

Answer 7

✅anticouagulant treatment
✅ventricular rate control
✅conversion and maintaining sinus rhythm
***the ABC pathway( a=anticouagulation/avoid stroke , B=better symptom control, c= comorbidities/ CV risk factor )

Question 8

CHADS2-VASc score =

The risk for stroke

Answer 8

C=congestive heart failure 1️⃣
H=hypertension1️⃣
A=age>75 2️⃣
D= DM1️⃣
S2=prior TIA or stroke2️⃣
V=vascular disease 1️⃣
A= age 65-751️⃣
Sc= sex category (female)1️⃣
If>2 males , females >3

Question 9

HAS-BLED Score =

Bleeding risk

Answer 9

Hypertension 1️⃣
Abnormal renal/liver function1️⃣or2️⃣
Stroke 1️⃣
Bleeding tendency1️⃣
Labile INR1️⃣
Age (>65)1️⃣
Drugs or alcohol 1️⃣or2️⃣
Max score 9
>3 high risk of bleeding

Question 10

When cant we adminster DOAC?

Answer 10

Moderate mitral stenosis 

Mechanical valvular prothesis

Question 11

Target of rate control treatment:

Answer 11

HR<80/min at rest

HR<110/min during effort

Question 12

Ventricular rate control drugs :

Answer 12

Beta blockers (bisoprolol, metaprolol) 
Digoxin 
Clacium channel blockers (diltiazem, verapamil)

Question 13

Converstion and maintaining sinus rhythm :

Answer 13

🔸electrical cardio version
🔸drug conversion: 
-Amiodarone 
Ibutilide , dofetilide 
Flecainide, dronedarone , sotalol, 
Propafenone 
🔸radiofrequency transcatheter ablation of AF

Question 14

Atrial Flutter:

Answer 14

-is rarely an arrythmia of a healthy heart , it often complicates structural heart disease
-precipitating factors:
Hypoxemia, hyperthyrodism or alcohol consumption
▪️typical flutter= right atrial macro re entrant circuit with the precipitation of the cavotricuspid isthmus

Question 15

ECG of atrial Flutter:

Answer 15

🔸F waves with rate of 250-350/min

🔸V1 and the inferior leads

Question 16

Atrial flutter mechanism:

Answer 16

▪️CC:
-Anticlockwise reentry circuit forms in the R. Atrium
-Left atrial activation occurs via Bachman’s bundle and the coronary sinus os (first occur via os )
-the majority of left atrial conduction and activation occur in a retrograde manner , forming negative flutter waves in inferior leads (
▪️C:
-clockwise reentry circuit forms in the right atrium
-left atrial activation fist occur via BB
-majority of left atrial activation occurs in an anterograde manner , forming positive flutter waves in inferior leads

Question 17

Atrial flutter management:

Answer 17

Acute treatment:
✅hemodynamic degradation-> electrical cardioversion50-150J
✅hemodynamically stable patient : Amiodarone , ibutilide , dofetilide
Long term treatment:
-thrombolytic risk -> anticoagulant
-HR control: bb, ccb
-rhythm control: radio-frequency ablation of ICT
-elective electrical cardioversion

Question 18

PSVT: ( paroxymal supraventricular taxhycardia)

Arryhthmia involving atrioventricular junction

Answer 18

Frequent arrhythmia

• clinically: episodes of palpitation with fast rhythm , regular , with sudden onset and end
• outside the crisis , the person has characterstics of healthy person

Question 19

Types of PSVT:

Answer 19

1) atrioventricular nodal re entrant tachycardia

2) atrioventricular reentrant tachycardia

Question 20

AVNRT=

Answer 20

-appears frequently in normal women
-clinically: palpitations felt in the neck “cannon waves”
-ECG:
Narrow complex tachycardia (150-200/min)
PR short
Without visible p waves / retrograde p waves

Question 21

Treatment of AVRT :

Answer 21

Vagal maneuvers :
✅ forced exhalation with closed glove ✅blown into an empty syringe
✅immersion of the face in a cold watter or application of ice to the chest
✅pressing the eyeballs
✅squatting position
Carotid massage
Adenosine
——-
-Giving up consumption of coffee , cola , energy drinks
-Intense symptoms, cardiopathology, risky professions :
Bb, ccb, propafenone , flecainide
- ablation of the slow intranodal pathway and accessory pathways

Question 22

Premature ventricular complexes :

Ventric. tachyarrhythm

Answer 22

🔸PVC is a large QRS complex that occurs early with origin in the ventricular myocardium
🔸sympts: palpitations , dyspnea, thoracic discomfort
🔸ECG: a large QRS with a morphology of a bundle branch block
****
PVCs originating in the left ventr. Have a RBBB morphology while pVCs originating in the right ventr. Have a LBBB morph.

Question 23

Treatment of PVCs:

Answer 23

✅pts with no symptoms: no need for treatment
✅ pts with symptoms need treatment:
- first bb treatment + electrolyte supplementation ( k, mg)
- class IC or IIIantiarrhythmic
-radiofrequency ablation-> monomorphic ESV
-AMIODARON- > structural heart disease

Question 24

Vtach:

Answer 24

Defined as 3 or more consecutive PVCs at a rate grater than 100/min

Question 25

Vtach classifications:

Answer 25

🔸according to duration:
Non sustained: less than 30 sec
Sustained : longer than 30 sec or hemodynamic instability

Question 26

Vtach symptoms:

Answer 26

Palpitations 
Chest pain
Dyspnea 
Syncope 
Sudden cardiac death

Question 27

Important questions :

Answer 27

1. QRS regular ? 
Yes => Vtach/ SVT
No =>atrial  fibrillation
——
2.QRS large ? 
Yes=> Vtach
No=> SVT
——
3.historic ? Responses to vagal maneuvers? 
-Age , preexisting pathology

Question 28

Vtach , unstable hemodynamically;

Answer 28

Electric shock

Question 29

Treatment of different types of Vtach:

Answer 29

Vtach originated from ischemia : amiodarone +BB
✅Bidirectional Vtach: treatment of digitalis intoxication
✅brugada synd: quinidine
✅torsades de point: magnesium sulfate
✅fascicular tachycardia: verapamil
✅catecholaminergic polymorphic tachycardia: nadolol, propanolol

Question 30

Implantable cardiac defibrillator (ICD)=

Answer 30

-sustained VT, structural heart disease
-documented myocardial scar and sustained Vt
-

Question 31

Radiofrequency ablation:

Answer 31

-no structural heart disease -> improvement of sympt.
- structural heart disease :
- when anti arrhythmic medications are not tolerated or recurrent under treatment
-the causes are not reversible
-