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(PA School) Cardiology > AF/ conduction disorders > Flashcards

AF/ conduction disorders Flashcards

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1
Q

Describe normal sinus rhythm/ normal EKGs

A

Rate 60-100 bpm
Regular rhythm
P for every QRS
PR interval 0.12 – 0.2 sec (3-5 small boxes)
Sinus P waves are upright in lead 11 and biphasic in V1

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2
Q

1) The most common sustained supraventricular arrhythmia in primary care setting is what?
2) When does its prevalence increase?

A

1) Atrial fibrillation (AF)
2) With age

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3
Q

AF increases risk of _________ and all cause mortality

A

stroke

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4
Q

True or false: Many patients with atrial fibrillation are asymptomatic

A

True

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5
Q

Besides being asymptomatic, what are some Sx of AF?

A

Palpitations, dyspnea/DOE, fatigue, angina, dizziness, syncope

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6
Q

AF diagnosis is based on ________, should be confirmed with _______________.

A

H&P; 12 lead EKG

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7
Q

Presentation, evaluation, morbidity/mortality and management of what condition is similar to that of atrial fibrillation?

A

Atrial flutter

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8
Q

Differentiate between atrial flutter and AFIB/ AF

A

1) Atrial fibrillation: atrial rate is > 400 bpm, ventricular rate depends on AV node ~ 75-175 bpm
-Irregular irregular rhythm (R-R duration)
2) Atrial flutter: atrial rate is ~ 250-350 bpm, ventricular rate classically 150 bpm or 2:1 conduction
-Rhythm more regular, “atrial flutter waves”

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9
Q

List the non-modifiable risk factors for AFIB

A

Advancing age, male sex, White race, genetics (variations in K, Na, and non-ion channel genes

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10
Q

What is the prevalence of AFIB by age?

A

< 1% in patients under age 50, 4% by age 65, & 12% in those 80 +

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11
Q

What are some chronic illness conditions that put you at risk for AFIB?

A

1) HTN, CAD
2) Valvular heart disease, HF, LAE, hypertrophic cardiomyopathy, congenital heart disease, venous thromboembolic disease, OSA, obesity, COPD, DM, CKD, & smoking

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12
Q

Generally, what decreases risk of AFIB?

A

Regular physical activity

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13
Q

Ultramarathoners, X-country skiers, long distance cyclists have 2-5x increased risk for AF related to what?

A

Structural myocardial changes, greater oxidative stress, & heightened inflammatory response predisposing patients to AF

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14
Q

Who is at risk of secondary AF?

A

Patients with identifiable precipitants of AF

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15
Q

List some patients with identifiable precipitants of AF (secondary AF)

A

1) Sepsis
2) Alcohol intoxication
3) Use of stimulant – Rx or recreational
4) Pulmonary Emboli
5) Thyrotoxicosis (hyperthyroidism)
6) Inflammatory heart conditions
7) Acute myocardial infarction, cardiac and non-cardiac surgery
8) Rx: bisphosphonates, bronchodilators, antipsychotics, amiodarone, adenosine, ivabradine (Corlanor)

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16
Q

Describe screening for AFIB

A

1) USPSTF: I rating in adults 50+
2) Others: screen in context of an established clinical encounter

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17
Q

How does the general population typically screen themselves for AFIB? Does it work?

A

1) Single lead EKG smartphone app
2) 92-99% sensitive, 76-100% specific; should be confirmed with a 12 lead EKG

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18
Q

What is the OLDCARTS for AFIB?

A

CC: new onset palpitations, dyspnea, chest pain
Onset, duration, timing: acute, persistent or paroxysmal, may last for minutes, hours, days, or permanent
Location: symptoms centered around CV system, CNS with stroke
Character: stable vs. unstable hemodynamically
Aggravating: none or exertion, anxiety, stimulants
Alleviating: none or rest
Associated symptoms/ROS: none to myocardial infarction, heart failure, stroke

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19
Q

What will you see on a focused exam if a pt has stable AFIB or atrial flutter?

A

1) Atrial fibrillation: irregular irregular pulse, variable BP
2) Atrial flutter: tachycardia, BP often elevated

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20
Q

What are the Sx of unstable AFIB or atrial flutter?

A

diaphoresis, hypotension, altered mental status

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21
Q

A. fib associated with _________ has higher stroke risk

A

VHD

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22
Q

Why is looking for Murmurs AS and MS important with AFIB?

A

A. fib associated with VHD has higher stroke risk

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23
Q

What may peripheral pulses on an AFIB focused exam show?

A

erratic – pulse ox pulse reading erratic

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24
Q

What are some things that can be evidence of HF with AFIB?

A

Rales, S3 gallop, JVD

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25
What are the labs for atrial flutter + AFIB? (same for both)
BMP, CBC, coagulation panel, cardiac biomarkers, BNP, lipids, A1C, TSH Other studies as indicated – drug and tox studies, inflammatory markers
26
AFIB and atrial flutter imaging: When should you use a CXR?
If pulmonary edema suspected, cardiomegaly
27
AFIB and atrial flutter imaging: What does an ECHO do?
Assess atrial size & thrombus, LV systolic function, & valvular anatomy and function
28
What should you often do to screen for ASCVD with AFIB or atrial flutter?
Often perform system screening for ASCVD - carotids
29
Describe imaging for AFIB or atrial flutter
1) CXR – if pulmonary edema suspected, cardiomegaly 2) ECHO – assess atrial size & thrombus, LV systolic function, & valvular anatomy and function 3) Often perform system screening for ASCVD - carotids
30
Give some DDxs for atrial flutter and AFIB
1) Premature atrial contraction 2) Multifocal atrial contraction 3) Wolf-Parkinson-white syndrome 4) Premature ventricular contraction
31
Describe the 3 key EKG findings with AFIB
1) Absence of P waves 2) Irregular irregular ventricular rate (R-R) -Often RVR but variable 3) Narrow QRS (supraventricular) unless other conduction abnl present
32
How is AFIB classified?
By duration of episodes
33
What are the 4 classifications of AFIB? Describe
1) Paroxysmal AF terminates spontaneously or with treatment within 7 days 2) Persistent AF is continuously sustained for > 7 days 3) Long standing persistent AF sustained for > 12 months 4) Permanent AF refers to shared decision to no longer pursue rhythm control
34
_____________ or________________ AF refers to asymptomatic AF episodes detected on cardiac monitoring in patients without previously known AF
Subclinical; device detected
35
True or false: We no longer use the terms lone AF, valvular AF, & chronic AF
True
36
AFIB management options are based on what?
Patient stability, rate, and/or rhythm control
37
How should you manage most hemodynamically stable pts with AFIB?
Determine stroke risk, bleeding risk & mitigation Rate control Rhythm control based on some risk factors and shared decision
38
Describe how to manage hemodynamically unstable pts with AFIB
Rhythm control Electrical cardioversion may be appropriate as 1st line rhythm control
39
___________________ is becoming more common as definitive Tx for AFIB
Catheter ablation
40
Management of stable AF: 1) Define stable AFIB 2) Can it be treated outpatient? 3) What risk should you manage?
1) Stable hemodynamically even in presence of RVR 2) Treated as outpatient is more common now 3) Stroke risk and mitigation
41
Management of stable AF: What is a key management decision? Describe
Rate control vs. rhythm control is key management decision Rate control uses drugs – CCB or BB Rhythm control includes drugs, electrical cardioversion, & ablation
42
For stable AFIB, older studies reported no significant differences between ____________ or ____________ control for QOL, mortality, stoke, or bleeding risk
rate or rhythm
43
Immediate synchronized DC cardioversion for patients with AF and hemodynamic instability; give examples of Sx of this. What should you not wait for to cardiovert?
Ischemic chest pain, hypotension, syncope, HF, CNS Do not wait for anticoagulation
44
Management of unstable AFIB: Describe when cardioversion is less urgent but indicated
Rapid control of HR with IV diltiazem (verapamil and BB are options but not as efficacious) Avoid CCB in HFrEF Amiodarone or digoxin preferred in HFrEF
45
A. Fib/flutter & anticoagulation for stroke prevention: 1) Benefit? 2) Risk? 3) Explain what these are like for most pts
Benefit - Reduce risk of embolic stroke from heart Risk - Increases risk of bleeding Most patients: Benefit > Risk, especially with newer direct oral AC [Treatment recommendations are for A. Fib & A. Flutter.]
46
Aflutter and AFIB: 1) How do you calculate stroke risk? 2) What abt bleeding risk?
1) CHA2DS2-VASc 2) HAS-BLED (others)
47
CHA2ds2-VASc identifies patients with __________ risk of stroke very well
low
48
Risk of stroke with AFIB or a flutter increases with what?
Age
49
AFIB + aflutter stroke risk: _________ sex category is a risk modifier, especially in older folks
Female
50
Give examples of major bleeding
Intracranial bleeding Bleeding requiring hospitalization Hemoglobin decrease of > 2 g/dL Need for transfusion secondary to bleeding
51
Rx for rate control is an option for __________ patients with AFIB
stable
52
What drugs should you use for rate control for stable pts with AFIB?
1) B-blockers or non-dihydropyridine calcium channel blockers (verapamil or diltiazem) = preferred drugs for rate control in AF without significant left HFrEF 2) HFrEF – b-blockers are preferred drug 3) Other drugs – amiodarone and digoxin
53
When should beta blockers, non-dihydro CCBs, and other drugs be avoided for AFIB rate control? Why?
In WPW – preexcitation with accessory pathway bypassing AV node - may stimulate ventricular fibrillation
54
EKG findings in WPW include what? How do you Tx the rate?
short PR interval, delta wave (slurred upstroke in the QRS complex) Ibutilide or procainamide are options in stable AF
55
What HR should you aim for when treating AFIB rate?
Optimal HR unclear Strict control < 80 – persistent symptoms or tachycardia induced cardiomyopathy Lenient control < 110 for others is reasonable
56
Atrial fibrillation/flutter rhythm control: Prior to cardioversion attempt (Rx or synchronized) obtain __________________ to clear the left atrium of clot
transesophageal echo
57
Atrial fibrillation/flutter rhythm control: slide 31
AF > 48 hours or unknown duration – AC for 3 weeks prior and 4 weeks after cardioconversion (Rx or synchronized)
58
What are 3 cardioversion options?
Electrical cardioversion Rx Catheter ablation
59
Electrical cardioversion for rhythm control [AFIB]: How effective is it?
Restores sinus rhythm in 75-87% of patients – recurrence rate is ~ 60% within 4 months
60
Electrical cardioversion for rhythm control [AFIB]: What should you pretreat with? For how long and why?
Pretreatment with **amiodarone** for 4-6 weeks improves immediate rhythm conversion and maintenance of sinus rhythm with minimal side effects from amiodarone
61
Electrical cardioversion for rhythm control [AFIB]: What is long term AC based on? Describe
CHA2DS2-VASc score: CHA2DS2-VASc score 2 or more in most patients = High risk = Long term AC
62
What are some drugs used in drug cardioversion for rhythm control of AFIB? What else should be used?
1) Dofetilide, dronedarone, flecainide, ibutilide, propafenone, sotalol and more recently ranolazine 2) Same anticoagulation recommendations as electrical conversion
63
Describe the Pill in the pocket (PITP) option for paroxysmal AF
1) Flecainide or propafenone widely used, ranolazine used off label 2) Take BB or CCB 30 minutes prior to flecainide to prevent atrial flutter with RVR -Side effects: hypotension, atrial flutter, bradycardia) -? Whether PITP patients should start AC
64
Catheter ablation for rhythm control: What are the indications for this?
1) Paroxysmal, persistent, or long-standing AF 2) Symptomatic 3) Unable to tolerate at least 1 antiarrhythmic drug
65
What is increasingly used as 1st line treatment rather than rate or rhythm control with drugs for AFIB?
Catheter ablation for rhythm control
66
How effective is catheter ablation?
@ 2 years after ablation, 53% of patients still in normal sinus rhythm (NSR)
67
slide 34
Particularly beneficial in HFrEF and AF mediated, tachycardia induced cardiomyopathy AC fully prior and for up to 2 months post ablation - recent studies support discontinuation of AC after 2 months CHA2DS2-VASc – 2 or more……. High risk, ongoing studies in long term AC
68
What is the 2nd most common sustained supraventricular arrhythmia (SVA)?
Atrial flutter (AFL)
69
What characterizes AFL (a flutter)? Who is it uncommon in?
Characterized by rapid regular atrial beats ~ 300/min with variable regular ventricular beats (2:1, 3:1 or 4:1 ventricular response) Uncommon in structurally normal hearts
70
Describe predisposing conditions of AFL (atrial flutter)
Similar to AF AFL can occur after ablation or initiation of antiarrhythmic drugs
71
Treatment principles for AFL are similar to those for AFIB; describe
1) Initial rate control – nondihydropyridine CCB or BB, more difficult to achieve than in AF 2) Restoration of NSR 3) Anticoagulation – stroke risk are comparable to AF and treatment is similar
72
Describe restoration of NSR for atrial flutter
1) Synchronized DC cardioversion preferred over drug cardioversion 2) Recurrence is high 3) Ablation is preferred treatment
73
Sinus node dysfunction (aka sick sinus syndrome): 1) What is it? What is it typically assoc. with? 2) What is it characterized by?
1) Sinus node dysfunction; senescence of SA node and surrounding atrial myocardium 2) Chronic SA node dysfunction, chronotropic incompetence (inappropriate heart rate response to physiologic demands)
74
Sinus node dysfunction: What is the presentation a combination of?
EKG + signs and symptoms
75
Describe the EKG signs of sinus node dysfunction
1) Sinus brady (< 60/min) 2) Pauses (< 3 second pause) 3) Arrest (> 3 second pause) 4) Sinus exit block (SA node fires but can not conduct out of nodal area) 5) Alternating tachycardia-bradycardia syndrome
76
Describe the Sx of sinus node dysfunction and their frequency
1) May be intermittent with gradual progression in frequency and severity 2) Fatigue, palpitations, DOE, angina 3) Light headedness, pre-syncope, syncope
77
How do you diagnose sinus node dysfunction?
1) No standard criteria 2) Key: establish a link between symptoms and EKG 3) Ambulatory monitoring: Event monitor 2-4 weeks
78
Sinus node dysfunction: What does initial management depend on?
Symptoms related to ventricular rate
79
What should you do for unstable pts with sinus node dysfunction? (typically not hemodynamically unstable for prolonged time)
ACLS for symptomatic bradycardia Atropine, dopamine, epinephrine Temporary pacer – transcutaneous or transvenous
80
What should you do for stable pts with sinus node dysfunction?
Continuously monitor with pacer pads in place, review medications for drug related to bradycardia
81
Describe long term management of sinus node dysfunction
1) Asymptomatic when bradycardic: follow over time 2) Symptomatic with bradycardic: Implanted cardiac device (ICD) pacer

(PA School) Cardiology (42 decks)

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