6-7. Arrythmias 8. Heart Failure + Pulmonary Edema

Question 1

Atrial fibrillation cause

Answer 1

Irregularly-irregular rhythm

Question 2

Atrial fibrillation risk factor

Answer 2

Increases with age

Question 3

Atrial fibrillation diagnosis

Answer 3

EKG = No p-waves, irregularly irregular

ALL new A fib dx get ECHOCARDIOGRAM to check for clots

Question 4

Atrial fibrillation treatment of arrythmia/rate

Answer 4

Treat arrythmia:
1. AMIODARONE - best to start in hospital
2. Cardioversion - requires anticoagulants for three weeks and TEE
3. Catheter ablation - better than drugs but increased risk of stroke
4. AV Junction ablation - destroys LA-LV link, requires pacemaker

Treat rate:
Beta-blockers and non-dihydropyridines are first line
Less aggressive rate control preferred (<110bpm better than <80bpm)

Question 5

Atrial fibrillation treatment of stroke risk

Answer 5

CHADS-VASc determines stroke risk

Congestive heart failure
Hypertension
Age
Diabetes
Stroke history
Vascular disease
Age
Sex category

NOACs (-bans and -trans) better than Warfarin

Question 6

Which is the most common super ventricular tachycardia?

Answer 6

AVNRT

Question 7

AVNRT pathophysiology

Answer 7

AV sends impulse back up to atria

AV node stimulates atria and ventricles, can beat together causing cannon waves

Question 8

AVNRT diagnostics

Answer 8

EKG = retrograde P-waves within or after QRS, pseudo R-waves

Question 9

AVNRT treatment

Answer 9

Hemodynamically stable = VALSALVA

Mostly benign, can live with it

If not, Adenosine -> Verapamil -> Ablation if desperate

Question 10

AVRT pathophysiology

Answer 10

Impulse re-entry via accessory pathway

Wolf-Parkinson White

Question 11

AVRT diagnosis

Answer 11

EKG = shortened PR interval, delta waves, Wolf-Parkinson White

Question 12

Young person with syncope, think this arrythmia …

Answer 12

AVRT/Wolf-Parkinson White

Question 13

AVRT treatment

Answer 13

Hemodynamically unstable = urgent cardioversion

Stable = vagal maneuvers -> adenosine -> verapamil -> ablation

Question 14

Compare and contrast focal atrial tachycardia and multifocal atrial tachycardia

Answer 14

FOCAL: Substance caused (meds, caffeine, alcohol)
Incidental, not that important
One atria overrides SA node
Tx = BB or CCB

MULTIFOCAL: Disease caused (respiratory, CHF)
Three of more morphologically distinct p-waves
Treat underlying cause
Otherwise BB or CCB

Question 15

Atrial flutter is uncommon in patients …

Answer 15

Without cardiac or pulmonary disease

Question 16

Atrial flutter diagnosis

Answer 16

EKG: Sawtooth pattern

Echo always done

Question 17

Atrial flutter treatment

Answer 17

Rate control and anticoagulation

Same as A fib (Amiodarone, cardioversion, ablation, beta-blockers, non-dhp CCBs, NOAC)

But ablation works better for this!

Question 18

Ventricular tachyarrhythmias often occur in patients with …

Answer 18

Structural heart disease
Post-MI
CHF

Question 19

Ventricular tachycardia can often degenerate into …

Answer 19

V fib

Question 20

Ventricular tachycardia diagnosis

Answer 20

Any wide QRS complex tachycardia is assumed to be v. tach until proven otherwise

Question 21

Ventricular tachycardia types

Answer 21

Monomorphic: single foci, QRS identical
Polymorphic: several foci, QRS complexes vary

Non-sustained: <30s
Sustained: >30s

Question 22

Ventricular tachycardia treatment

Answer 22

Non-sustained, no symptoms = no treatment

Stable sustained = cardioversion or anti-arrhythmics (amiodarone/lidocaine/procainamide)

Pulseless = defibrilation

Prevention = ICD

Question 23

Long QT syndrome causes

Answer 23

Congenital or acquired

Sources: Drugs (anti-arrythmics), hypokalemia, hypomagnesemia

Question 24

Long QT syndrome symptoms

Answer 24

Syncope is a big clue, especially in children

Question 25

Long QT syndrome prognosis/risks

Answer 25

Risk of Torsades (PVC falls in QT) Risk of sudden death

Question 26

Long QT syndrome treatment

Answer 26

Beta blockers Sympathectomy

Question 27

Torsades de pointes treatment

Answer 27

Magnesium short term B-blockers (propranolol) long term

Question 28

Ventricular fibrillation treatment

Answer 28

CPR + defibrillation

Question 29

Ventricular tachycardia drugs to avoid

Answer 29

Calcium channel blockers

Question 30

Which premature beat HAS a compensatory pause?

Answer 30

PVC

Question 31

Sinus bradycardia treatment

Answer 31

IV atropine

Question 32

Drugs that can cause sinus bradycardia

Answer 32

Beta-blockers

Question 33

How to treat heart blocks

Answer 33

Mobitz type 2 and 3rd degree blocks treat with pacemaker

Question 34

Heart failure left sided presents as ... whereas right sided presents as ....

Answer 34

Left sided: DYSPNEA Decreased cardiac output Increased pulmonary venous pressure Right sided: PERIPHERAL EDEMA Fluid retention

Question 35

Systolic vs Diastolic heart failure

Answer 35

Systolic: <40% EF, dilated LV Diastolic: >50% EF, impaired filling

Question 36

Heart failure classifications A, B, C, D

Answer 36

A: Increased risk, no abnormality B: Structural abnormality, no symptoms C: Structural abnormality with symptoms D: End-stage, RIP

Question 37

Heart failure etiology

Answer 37

CAD (2/3 cases) HTN DM Infiltrative causes: Amyloidosis Hemochromatosis Sarcoidosis

Question 38

Acute decompensated heart failure cause

Answer 38

Sudden worsening of new or chronic heart failure

Question 39

Consider acute decompensated heart failure in an older patient with ...

Answer 39

Shortness of breath

Question 40

Acute decompensated heart failure signs

Answer 40

Displaced apical impulse (more lateral) Worse prognosis if cold, altered mental status, narrow pulse pressure

Question 41

Acute decompensated heart failure diagnosis

Answer 41

History most important BNP is GOLD STANDARD BIOMARKER EKG = Q-waves, LVH Echo for EF and wall motion (determines systolic from diastolic) Chest x-ray (pulm edema, enlarged heart)

Question 42

Acute decompensated heart failure treatment

Answer 42

ACE/ARNI Beta blockers Spironolactone SGLT2 Loop diuretics if lots of fluid Ionotropes if low perfusion (dobutamine/milirinone)

Question 43

CHF with reduced ejection fraction treatment

Answer 43

Same meds as acute decompensated HF: (ACE/ARNI, BB, Spiro, SGLT2) Can also do: ICD Cardiac resync Heart transplant LV assisted device

Question 44

CHF with preserved ejection fraction treatment

Answer 44

Control risk factors (BP, CAD, DM) Start with SGLT2 if mild volume overload (diuretics if more severe) Spironolactone If stable potassium and creatinine, start ARNI

Question 45

Pulmonary edema causes

Answer 45

Increased capillary pressure from left heart failure

Question 46

Pulmonary edema progression

Answer 46

Interstitial > alveolar

Question 47

Pulmonary edema risk factor

Answer 47

Anything that causes LV to fail

Question 48

Pulmonary edema diagnosis

Answer 48

History always most important CHEST X-RAY BEST INITIAL ASSESSMENT Cephalization/stag sign -> Kerley B lines -> Butterfly/Bat wings Echo BNP