Arrhthymias

Question 1

What are ectopic beats?

Answer 1

Beats or rhythms that originate in places other than the SA node

Question 2

Are ectopic beats always dangerous?

Answer 2

No, depends on how they affect cardiac output

Question 3

Can myocarditis cause an arrhythmia?

Answer 3

Yes

Question 4

What is the congenital long QT syndrome a mutation of?

Answer 4

mutation of cardiac ion channels (can cause arrhythmias)

Question 5

What causes WFW syndrome?

Answer 5

presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles

Question 6

What do local areas of ischemia or necrosis do to automaticity of neighboring cells?

Answer 6

increase

Question 7

What is triggered activity thought to be the underlying mechanism for?

Answer 7

digoxin toxicity, Torsades de Pointes in the long QT syndrome and hypokalaemia

Question 8

What does a stress ECG look for?

Answer 8

Looks for myocardial ischaemia, exercise related arrhythmias

Question 9

What are q waves a sign of?

Answer 9

previous MI

Question 10

What is pre-excitation a sign of?

Answer 10

WPW syndrome

Question 11

What does an echo help find?

Answer 11

structural heart disease (e.g enlarged atria in AF, LV dilatation, previous MI scar, aneurysm)

Question 12

There is generally no treatment for Atrial Ectopic Beats, but what may help?

Answer 12

avoiding stimulants, B-blockers

Question 13

What type of MI is ischaemia commoner in?

Answer 13

STEMI

Question 14

What is the treatment for sinus bradycardia?

Answer 14

Atropine (acute cases)

Pacing if haemodynamic compromise: hypotension, CHF, angina, collapse

Question 15

What is the treatment for sinus tachycardia?

Answer 15

Treat underlying cause

B-blockers

Question 16

What may SVTs be due to?

Answer 16

AV nodal re-entrant tachycardia
Accessory pathway tachycardia i.e., Wolff Parkinson White syndrome
Ectopic atrial tachycardia

Question 17

What is the acute management for an SVT?

Answer 17

Vagal manoeuvres, carotid massage
IV Adenosine
IV Verapamil

Question 18

What is the chronic management for an SVT?

Answer 18

Avoid stimulants
Radiofrequency ablation 
Antiarrhythmic  drugs (Class II or IV)

Question 19

What does this describe: Selective cautery of cardiac tissue to prevent tachycardia, targeting either an automatic focus or part of a re-entry circuit?

Answer 19

Ablation

Question 20

In ablation, catheters are placed in the heart via what vein?

Answer 20

femoral

Question 21

What does ablation involve?

Answer 21

Intracardiac ECG recorded during sinus rhythm, tachycardia and during pacing manoeuvres
Catheter placed over focus / pathway and tip heated to 55-65C

Question 22

What does an intracardiac ECG show?

Answer 22

shows the activation sequence of the heart

Question 23

Which is more detailed, an intracardiac ECG or an ECG?

Answer 23

intracardiac ECG

Question 24

What drugs can cause AVN conduction disease?

Answer 24

B-blockers

Calcium channel blockers

Question 25

What disease may these genetic conditions cause: Lenegre’s disease, myotonic dystrophy?

Answer 25

AVN conduction disease

Question 26

What happens to the PR interval in first degree heart block?

Answer 26

P-R interval longer than normal (> 0.2 sec)

Question 27

What is the treatment for 1st degree heart block?

Answer 27

None (but follow up recommended)

Question 28

What is 2nd degree heart block?

Answer 28

Intermittent block at the AVN (dropped beats)

Question 29

What happens in Mobitz 1?

Answer 29

progressive lengthening of the PR interval, eventually resulting in a dropped beat

Question 30

What happens in Mobitz 2?

Answer 30

Intermittent non-conducted P waves without progressive prolongation of the PR interval

Question 31

Where is Mobitz type 2 almost always located?

Answer 31

bundle branches

Question 32

Why would a transcutaneous pacer be used?

Answer 32

emergency temporary use till venous access achieved

Question 33

Is transcutaneous pacing painful?

Answer 33

Yes

Question 34

What vein should be used if patient had received streptokinase and is at risk of major bleed if the artery is punctured accidentally?

Answer 34

femoral

Question 35

What does a single chamber pacemaker pace?

Answer 35

the right atria or right ventricle only

Question 36

What does a dual chamber pacemaker pace?

Answer 36

the RA and RV

Question 37

What is a dual chamber pacemaker used for?

Answer 37

AVN disease

Question 38

What are atrial pacemakers used in?

Answer 38

isolated Sino-atral node disease but normal AV node

Question 39

What type of pacemaker would be used in AF with a slow ventricular rate?

Answer 39

ventricular single pacemaker

Question 40

Are Premature Ventricular Ectopics common?

Answer 40

yes

Question 41

What may premature ventricular ectopics be a marker for?

Answer 41

inherited arrhythmia syndromes e.g. cardiomyopathy

Question 42

When would you need to investigate a Premature Ventricular Ectopic beat further?

Answer 42

if it worsens on exercise

Question 43

What is used to treat Premature Ventricular Ectopics?

Answer 43

beta blockers

Question 44

Who are VTs common in?

Answer 44

patients with significant heart disease e.g. Coronary artery disease A previous myocardial infarction

Question 45

What is a familial arrhythmial syndrom which can cause VT?

Answer 45

Long QT, Brugada syndrome

Question 46

Can cardiomyopathy cause VT?

Answer 46

yes (a rare cause)

Question 47

What does this describe: Chaotic ventricular electrical activity which causes the heart to lose the ability to function as a pump?

Answer 47

ventricular fibrillation

Question 48

What is the treatment for VF?

Answer 48

Defibrillation, Cardiopulmonary resuscitation

Question 49

What is the acute treatment for VT?

Answer 49

DC cardioversion if unstable If stable: consider pharmacologic cardioversion with AAD If unsure if VT or something else - adenosine

Question 50

What changes in electrolyte balance could cause VT?

Answer 50

Hypokalaemia, hypomagnesaemia

Question 51

What medications could cause VT?

Answer 51

that prolong the QT interval i.e. sotalol, quinidine, terfenadine, erythromycin

Question 52

How could you correct ischaemia in VT?

Answer 52

revascularisation

Question 53

Should anti-arrhythmic drugs be used for long term VT?

Answer 53

No

Question 54

What should be used for life threatening long term VT?

Answer 54

Implantable cardiovertor defbrillators (ICD)

Question 55

What types of AF are there?

Answer 55

paroxysmal, persistent or permanent

Question 56

What is the common sustained arrhythmia?

Answer 56

AF

Question 57

How long does paroxysymal AF last?

Answer 57

less than 48 hours

Question 58

What is permanent AF?

Answer 58

cannot restore NSR by any method

Question 59

Can persistent AF be carioverted to NSR?

Answer 59

Yes

Question 60

Is Sick sinus syndrome ‘tachy brady syndrome’ related to AF?

Answer 60

Yes

Question 61

Can idiopathic AF be genetic?

Answer 61

Yes

Question 62

What are the symptoms of AF?

Answer 62

``` Chest pain Dyspnea Sweatiness Fatigue Palpitations Pre-syncope (dizziness) Syncope ```

Question 63

In AF what is there an ectopic focus around?

Answer 63

pulmonary veins

Question 64

What is the atrial rate in AF?

Answer 64

>300bpm

Question 65

What can be seen on an ECG in AF?

Answer 65

Irregularly irregular pulse Absence of P waves Presence of ‘f’ waves

Question 66

Can AF exist with a slow ventricular rate?

Answer 66

Yes

Question 67

What happens to cardiac output in AF?

Answer 67

decreased

Question 68

Which rate control drugs should be used in AF?

Answer 68

Betablockers Verapamil, diltiazem Digoxin (not first line)

Question 69

How can rhythm be controlled in AF (to restore NSR)?

Answer 69

- Pharmacologic cardioversion (anti-arrhythmic drugs e.g. amiodarone) - Direct Current Cardioversion (DCCV)

Question 70

How can NSR be maintained in AF?

Answer 70

Anti-arrhythmic drugs Catheter ablation of atrial focus/ pulmonary veins Surgery (Maze procedure)

Question 71

What class of anti-arrhythmic drugs are sodium channel blockers?

Answer 71

1

Question 72

What class of anti-arrhythmic drugs are beta-blockers?

Answer 72

2

Question 73

What class of anti-arrhythmic drugs are potassium channel blockers?

Answer 73

3

Question 74

What class of anti-arrhythmic drugs are calcium channel blockers?

Answer 74

4

Question 75

What action potential phase is blocked in each of the anti-arrhythmic drug classes?

Answer 75

Class 1 - 0 Class 2 - 4 Class 3- 3 Class 4 - 2

Question 76

Which anti-arrhythmic drug classes are rate control and which are rhythm control?

Answer 76

Rate - 2,4 | Rhythm - 1,3

Question 77

Which anti-arrhythmic drug class prolongs action potentials?

Answer 77

3

Question 78

What are examples of class 3 anti-arrhythmic drugs?

Answer 78

Amiodarone, sotalol, dronedarone

Question 79

What do Torsades de Pointes have a rate of?

Answer 79

200 - 250 bpm

Question 80

How do Torsades de Pointes appear on an ECG?

Answer 80

Long QT interval Wide QRS Continuously changing QRS morphology Irregular rhythm

Question 81

What events can cause TdP?

Answer 81

``` Hypokalemia Prolongation of the action potential duration (drug induced) Renal impairment (increased drug levels) ```

Question 82

Does Thyrotoxicosis put you at risk of thromboembolism?

Answer 82

Yes

Question 83

Which valve diseases are an indication for thromboembolism?

Answer 83

MS and MR

Question 84

Why would radiofrequency ablation be used in AF?

Answer 84

To maintain SR by ablating AF focus (usually in the pulmonary veins) For rate control Ablation of the AVN to stop fast conduction to the ventricles

Question 85

Is atrial flutter usually paroxysmal?

Answer 85

Yes

Question 86

What circuit is Atrial Flutter sustained by?

Answer 86

macro-reentrant

Question 87

In atrial flutter, where is the circuit confined to?

Answer 87

Circuit is confined to the right atrium

Question 88

What does atrial flutter usually progress to?

Answer 88

AF

Question 89

Is radiofrequency ablation successful in Atrial flutter?

Answer 89

Yes

Question 90

What should drug treatment for Atrial flutter aim to do?

Answer 90

Slow the ventricular rate Restore sinus rhythm Maintain sinus rhythm once converted