Arrhythmia and AF

Question 1

When is external cardiac pacing used in patients with symptomatic Bradycardia?

Answer 1

When Atropine fails to increase the patient’s heart rate

Question 2

What are some adverse signs associated with symptomatic Bradycardia?

Answer 2

Shock, syncope, myocardial ischaemia, heart failure

Question 3

What is Bradycardia defined as?

Answer 3

< 60 bpm

Question 4

What do the QRS complexes appear like in VT and SVT?

Answer 4

VT = Broad complexes
SVT = Narrow complexes

Question 5

What is Tachycardia defined as?

Answer 5

> 100 bpm

Question 6

A patient with broad complex tachycardia is unstable, what is the first line treatment option?

Answer 6

Cardioversion

Question 7

A patient with broad complex tachycardia is stable, what is the first line treatment option?

Answer 7

Amiodarone, then Lidocaine, then Procaindamide

Question 8

A patient with narrow complex tachycardia is unstable, what is the first line treatment option?

Answer 8

Cardioversion

Question 9

A patient with narrow complex tachycardia is stable, what is the first line treatment option?

Answer 9

Valsalva manoeuvre, if this fails, then Adenosine 6mg, if this fails then Adenosine 12 mg

Question 10

What are the three ECG changes associated with Atrial Fibrillation?

Answer 10

• Absent p waves
• Presence of fibrillatory waves
• Irregularly irregular QRS complexes

Question 11

What is the best way to diagnose Paroxysmal AF?

Answer 11

Holter monitoring

Question 12

Strokes from AF commonly form where?

Answer 12

In left atria appendage

Question 13

Patients with AF have a _ fold increased risk of stroke

Answer 13

Five-fold risk

Question 14

What is the HASBLED tool used for?

Answer 14

To assess the 1-year risk of major bleeding in AF patients taking anticoagulants

Question 15

Discuss the points of HASBLED screening tool? How many points is for each component?

Answer 15

H - Hypertension (1)
A - Abnormal renal / liver function (1/2)
S - Stroke (1)
B - Bleeding (1)
L - Labile INR (1)
E - Elderly >65 (1)
D - Alcohol / drugs (1/2)

Maximum score is 9. >3 is a high risk of bleeding

Question 16

What is the CHADSVASc tool used for?

Answer 16

Used to assess risk of stroke in AF patients

Question 17

Discuss the points of CHADSVSc screening tool. How many is for each component?

Answer 17

C - Congestive Heart Failure (1)
H - Hypertension (1)
A - Age 65-74, >75 (1/2)
D - Diabetes (1)
S - Stroke / TIA (2)
V - Vascular Disease i.e. MI (1)
S - Sex i.e. Female (1)

If >2, Offer coagulation

Question 18

What is Paroxysmal, Persistent and Permanent AF?

Answer 18

Paroxysmal = < 7 days long
Persistent = > 7 days, not self-terminating
Permanent = > 7 days, resistant to therapy

Question 19

If a male patient and a female patient had a CHADSVASc score of 1, how does this guide treatment options?

Answer 19

Males - Consider anticoagulation

Females - Do not consider until score is 2

Question 20

Why are patients cardioverted if symptoms are less than 48 hours, and if longer, why must they be anticoagulated?

Answer 20

When switching from AF to sinus rhythm, this is the most likely point at which a thrombus can cause a stroke. Symptoms must therefore be present <48 hours or patients must be anti-coagulated for a long period of time

Question 21

What is the first-line treatment for symptomatic Bradycardia with adverse signs?

Answer 21

Atropine 500 mcg IV, up to 6 administrations every 3-5mins to a maximum of 3mg

Question 22

What is the definition of 1st degree heart block?

Answer 22

Fixed PR internal >0.2s

Question 23

What is the definition of 2nd degree, Mobitz Type 1 (Wenklebach) heart block?

Answer 23

Progressively prolonged PR interval, with a dropped QRS complex

Question 24

What is the definition of 2nd degree, Mobitz Type 2 heart block?

Answer 24

Fixed PR internal, with a dropped QRS complex

Question 25

What is the definition of 3rd degree heart block?

Answer 25

When p waves and QRS complex are unrelated

Question 26

Where is the conduction pathology in patients with Type 1 heart block?

Answer 26

Between the SAN and AVN (in the atria)

Question 27

Where is the conduction pathology in patients with Type 2 Mobitz Type 1 heart block?

Answer 27

Occurs in the AVN

Question 28

Where is the conduction pathology in patients with Type 2 Mobitz Type 2 heart block?

Answer 28

After the AVN, at the level of the bundle of His

Question 29

Where is the conduction pathology in patients with Type 3 heart block?

Answer 29

Anywhere after the AVN

Question 30

Long QT syndrome is believed to be caused by dysfunction of which channels?

Answer 30

L-type Calcium channels

Question 31

What are the two treatments for Long QT syndrome?

Answer 31

Beta blockers | Implantable cardioverter defibrillators

Question 32

What medications can cause Long QT syndrome?

Answer 32

Class Ia anti-arrhythmics Class III anti-arrhythmics: Sotalol, Amiodarone TCAs, SSRIs (Citalopram) Methadone, Chloroquine, Erythromycin, Haloperidol, Ondansetron

Question 33

What are five causes of Atrial Fibrillation?

Answer 33

``` SMITH mnemonic S - Sepsis M - Mitral valve pathology (stenosis, regurgitation) I - Ischaemic Heart Disease T - Thyrotoxicosis H - Hypertension ```

Question 34

In patients with Atrial Fibrillation, how do you decide between rate and rhythm control?

Answer 34

# Choose rate control UNLESS: - Patient has first event of AF - There is a clear reversible cause - They have HF caused by AF - They are symptomatic Chose rate control especially: - When they are above 65 years old - Have Ischaemic Heart Disease

Question 35

What are the medication options of rate control when managing patients with Atrial Fibrillation?

Answer 35

1. Beta blockers (Contraindicated with asthmatics) 2. CCBs i.e. Diltiazem or Verapamil 3. Digoxin - only those with heart failure

Question 36

Outline the two ways patients can be treated by rhythm control if they have Atrial Fibrillation?

Answer 36

1. Pharmacological cardioversion 2. Electrical cardioversion Can be immediate, or delayed

Question 37

1. How do you decide whether to rhythm control someone immediately or delayed? 2. What other treatments must be provided alongside delayed cardioversion? 3. How might you pharmacologically cardiovert a patient with Atrial Fibrillation?

Answer 37

1. - If hemodynamically unstable, then IMMEDIATE CARDIOVERSION - If symptoms less than 48 hours, then iMMEDIATE CARDIOVERSION - If symptoms greater than 48 hours and hemodynamically stable, then DELAYED CARDIOVERSION 2. If having delayed cardioversion, must be anticoagulated for at least 3 weeks prior and 4 weeks after, OR can have a TOE to exclude a L atrial appendage, heparinised and cardioverted immediately 3. Amiodarone if structural heart disease, Flecainide or Amiodarone if no structural heart disease

Question 38

What are the two basic principles of management of a patient with Atrial Fibrillation?

Answer 38

1. Rate vs rhythm control | 2. Anticoagulation

Question 39

1. What tool is used to assess whether an AF patient needs to be anticoagulated? 2. What medications are used for anticoagulation? 3. When do patients with AF + stroke start anticoagulation?

Answer 39

1. CHA2DS2VS 2. Warfarin or DOACs 3. 2 weeks after stroke

Question 40

Amiodarone: 1. What class anti-arrhythmic agent is it? 2. What is the mechanism of action? 3. What is the half life? 4. Why must it be given by a central vein? 5. What syndrome can cause it? 6. Is it a P450 Inhibitor or inducer? 7. What are some adverse effects? 8. What is the initial and later monitoring of Amiodarone?

Answer 40

1. Class III, some Class I action 2. Potassium channel blocker 3. Long half life, 20-100 days 4. Causes thrombophlebitis 5. Long QT syndrome 6. P450 Inhibitor 7. Hypo/hyperthyroidism, grey appearance, corneal deposits, pulmonary fibrosis, liver fibrosis thrombophlebitis, bradycardia, long QT 8. Initially: CXR, U&E, LFTs, TFTs, later TFTs and LFTs every 6 months

Question 41

1. What is Atrial Flutter? 2. What is the main ECG finding? 3. What is the underlying atrial rate? 4. If the ventricular rate in AFlutter is 2:1, what is the rate? 5. What is the management of Atrial Flutter?

Answer 41

1. A type of supraventricular tachycardia, characterised by rapid atrial depolarisation 2. Sawtooth baseline 3. 300 bpm 4. 150 bpm 5. Similar to AFib, however medications are less effective and cardioversion is more effective. Radiofrequency ablation of tricuspid valve isthmus is curative

Question 42

ADAM-STOKES ATTACK 1. What is it?

Answer 42

1. Periodic fainting spell, with intermittent complete heart block. Causes loss of spontaneous circulation and poor flow to brain

Question 43

BRUGADA SYNDROME 1. What is it? 2. What is the inheritance pattern? 3. What ethnicity is it more common in? 4. What are the ECG findings? 5. What is the investigation? 6. What is the management?

Answer 43

1. An inherited cardiovascular disease of sudden cardiac death 2. Autosomal dominant 3. More common in Asians 4. Partial RBBB, ST elevation and negative T wave in V1-3 5. Ajmaline or Flecainide - ECG changes become more apparent 6. Implantable cardioverter defibrillator

Question 44

LONG QT SYNDROME 1. What drugs cause Long QT Syndrome? 2. What are other causes of Long QT Syndrome? 3. What is a complication of Long QT Syndrome? 4. How do you manage Long QT Syndrome?

Answer 44

1. Amiodarone, Sotalol, TCAs i.e. Citalopram, Escitalopram, Methadone, Chloroquine, Erythromycin, Haloperidol, Ondansteron 2. Hypocalcaemia, hypomagnesemia, hypokalaemia, hypothermia, acute MI, SAH 3. Torsades de Pointes 4. Avoid offending drug, beta-blockers and in severe cases an implantable cardioverter

Question 45

TORSADES DE POINTES 1. What is the management of Torsades de Pointes?

Answer 45

1. Magnesium Sulphate

Question 46

WOLFF-PARKINSON WHITE 1. What is it? 2. What are the ECG features? 3. What is the definitive management? 4. What are other forms of management?

Answer 46

1. A congenital accessory conduction pathway between the atria and the ventricle 2. Widened QRS complexes with a slurred upstroke "delta wave", short PR interval. Can also get LAD and RAD 3. Radiofrequency ablation of pathway 4. Sotalol

Question 47

HOCM 1. What is HOCM? 2. What is the inheritance pattern? 3. What type of heart failure does it cause? 4. What murmur is associated with HOCM? 5. What makes the HOCM murmur quieter? 6. What makes the HOCM murmur louder? 7. What are findings on the Echo? MR SAM ASH 8. What are findings on ECG? 9. What is the management of HOCM?

Answer 47

1. The most common cause of sudden cardiac death 2. Autosomal dominant 3. Diastolic dysfunction 4. Ejection systolic, crescendo-decrescendo murmur 5. Squatting, handgrip manoeuver 6. Standing up, valsalva 7. Mitral regurgitation, Systolic anterior motion (of mitral valve) and asymmetric hypertrophy 8. LVH 9. ABCDE (Amiodarone, Beta blockers, cardioverter defibrillator, dual chamber pacemaker and endocarditis prophylaxis

Question 48

SUPRAVENTRICULAR TACHYCARDIA 1. What is SVT also known as? 2. How is it defined on an ECG? 3. If a patient has SVT and adverse signs, how do you treat? 4. If a patient has SVT and no adverse signs, how do you treat? 5. What is the half-life of adenosine? 6. What are SEs to warn patients of for adenosine? 7. Adenosine is contraindicated in which patients? What is an alternative? 8. How should Adenosine be given?

Answer 48

1. Narrow Complex Tachycardia 2. ECG rate >100 bpm, with a QRS <0.12s (3 small squares) 3. DC Cardioversion 4. Vagal manoeuvres, followed by Adenosine 6mg, Adenosine 12mg, Adenosine 12mg 5. 10 seconds 6. Flushing 7. Asthmatics, give Verapamil instead 8. Via a wide-bore cannula due to short half-life

Question 49

BROAD COMPLEX TACHYCARDIA 1. How is BCT defined on an ECG? 2. If a patient has BCT and adverse signs, how do you treat? 3. What electrolyte abnormalities can cause Broad Complex Tachycardia? 4. If a patient has BCT and no adverse signs, how do you treat? 5. How is this medication administered? 6. What are other options? 7. What medication is absolutely contraindicated in Broad Complex Tachycadia? 8. If a patient has Pulseless VT or VF, how do you initially manage them?

Answer 49

1. ECG rate >100 bpm, with a QRS >0.12s (3 small squares) 2. DC Cardioversion 3. Hypokalaemia, hypocalcaemia, hypomagnesemia 4. 300mg Amiodarone IV 5. Via a central line 6. Procainamide, Lignocaine 7. Verapamil 8. 1 shock + 2mins of CPR, or if witnessed and monitored already, then 3 shocks. Only after 3 shocks can you give 1mg adrenaline and 300mg Amiodarone