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CVS > Arrhythmia - Narrow Complex / Cardiac Arrest / Pacemaker > Flashcards

Arrhythmia - Narrow Complex / Cardiac Arrest / Pacemaker Flashcards

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1
Q

What should all elderly / people with syncope / stroke get

Other investigations for arrhythmia

A

ECG
Can do continuous if think paroxysmal
FBC, U+E, LFT, glucose, Ca, TSH, Mg
Drug review

Other 
ECHO 
Exercise ECG
Angiogam
Drug review
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2
Q

What type of arrhythmia’s can you get

A

Sinus
Tachy
Brady

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3
Q

What cardiac causes arrhythmia

A 
IHD
Structural changes - dilatation due to MR
Cardiomyopathy
Pericarditis
Myocarditis
Conduction issues
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4
Q

What are non-cardiac causes

A 
Electrolyte imbalane
Metabolic - hypoxia / acidosis / thyroid
Caffiene
Smoking
Alcohol
Phaeochromocytoma
Pneumonia 
Drugs - digoxin / TCA / B2 agonist
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5
Q

How does an arrhythmia present

A 
Asymptomatic
Palpitations
Chest pain
Syncope
Hypotension
Pulmonary oedema
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6
Q

What should you ask in the history of someone with palpitations

A 
SOCRATES
Other cardiac Sx 
Review drugs
PMH
FH sudden cardiac death
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7
Q

What is concerning with syncope

A

Syncope when exercise

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8
Q

What is a sinus arrhythmia

A

Normal conduction at faster frequency
HR increases inspiration
Decreases expiration

Infection / dehydration / pain / exercise / drugs / adrenaline / salbutamol / PE / hypothyroid / hypovolaemia/ MI / fever

No Rx needed

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9
Q

What are indications for temporary pacing

A

Symptomatic bradycardia - particularly if syncope

Prophylactic 2nd or 3rd degree block

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10
Q

What are indications for permanent pacing

A 
2 or 3rd degree block symptomatic
RBBB / LBBB
Sinus node disease
Carotid sinus hypersensitivity
Severe HF 
Malignant vasovagal syncope
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11
Q

When is a ICD indicated

A

Cardiac arrest due to VT or VF not caused by a reversible cause
Often get in HCM
Sustained VT causing syncope
Sustained VT with poor LV function

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12
Q

What type of tachycardia’s is there

A

Supraventricular - narrow complex
Ventricular - broad complex
Sinus

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13
Q

What is sinus arrest

A

SA node fails to generate an impulse

No pulse

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14
Q

How do you Rx sinus arrest

A

CPR pathway

Adrenaline ASAP

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15
Q

Where do narrow complex arise

A

Atria (supraventricular)

Due to extra pathway or extra electrical loop through AV node and back into atria

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16
Q

What is a narrow complex tachycardia

A

> 100BPM
QRS <120
Short P wave
Ventricles depolarised via normal pathway so QRS normal

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17
Q

What causes a regular narrow complex tachycardia

A

Sinus tachycardia
Atrial tachycardia - due to abnormal signal in atria other than SA node
Atrial flutter
AV re-entry tachycardia - WPW
AV nodal re-entrant tachycardia = most common cause of paroxysmal (re-entrant point through AV node)

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18
Q

What is WPW

A

AV re-entrant tachycardia - another pathway through atrial and ventricle not AV ode

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19
Q

What causes irregular narrow complex

A

Atrial fibrillation
Ectopic
Atrial flutter with variable block

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20
Q

What are the symptoms

A 
Asymptomatic
Fast HR 
Palpitations
SOB
Dizzy
Chest pain
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21
Q

What terminates supra ventricular tachycardia

A

Valsalva

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22
Q

What do you suspect if a patient with no history presents with supraventricular tachy / AF / palpitations

A

Alcohol binge

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23
Q

What is atrial tachycardia

A

Group of atrial cells act as pacemaker

P wave different (more pointy) but everything else same

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24
Q

What can cause an atrial tachycardia

A

Digoxin toxicity

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25
What is AVRT
Accessory pathway e.g. WPW allows electrical activity from atrial to ventricles New circuit created
26
What is AVNRT
Circuits form in AVN | Very common
27
What are adverse signs of supra ventricular tachy which you should assess for
``` Chest pain / MI Syncope Shock - Hypo / pallor / sweating / confusion / impaired consicous Heart failure - Pulmonary oedema or raised JVP ``` Can be peri-arrest and go into VF or asystole = emergency
28
If rate is irregular what is the most likely Dx
AF
29
What do you do if rate is regular
Continuous ECG Valsalva manœuvre Carotid sinus massage
30
What do you do when someone presents in SVT
``` ABCDE O2 if low sats IV access Bloods Monitor ECG and BP 12 lead ECG to see if narrow or broad Identify and treat reversible cause e.g. electrolyte ```
31
What should you do if someone has adverse signs
``` Treat as VT rater than SVT Put out crash call DC shock up to 3 times under sedation SEEK EXPERT HELP Correct electrolyte IV Amiadarone after shock 300mg over 10-20 mins Repeat shock IV amiadarone infusion over 24 hours ```
32
What do you do for sinus tachy
Not an arrhythmia so no cardio version Rx = treat cause If no cause can be found = BB
33
What do you do if suspect AVRT / AVNRT
Block AV node by performing Valsalva or carotid sinus massage (will stop tachy)
34
What do you do if Valsalva / carotid sinus massage fails What is needed When is it CI and what do you give instead What do you warn patient about
IV adenosine - resets back to sinus rhythm 6mg then 12mg then 12mg if no response Need continuous ECG Given as rapid bolus into large proximal vein Can cause Brady which is scary but transient - warn patient as half life 10s Do ECG during infusion CI in asthma / COPD / HF / heart block / severe hypo so give verapamil May need to cardiovert if doesn't work
35
If sinus rhythm is restored what does this suggest
AVRT | Consider anti-arrhythmia prophylaxis if recurs
36
What do you suspect if sinus rhythm not achieved with adenosine and what is required
Atrial flutter AF if irregular SEEK expert help and rate control with BB
37
How do you prevent supra ventricular tachy
BB / CCB / amiadarone - block AV node | Ablation to take out accessory pathway
38
What is the Valsalva manoeuvre
``` Forced expiration against closed glottis Increases intrathoracic pressure Reduced venous return due to increased atrial pressure Reduced preload Reduced CO ```
39
What is WPW
Congenital accessory conduction pathway Leads to AVRT Early excitation of ventricles by bypassing AV node
40
What is risk of WPW
Degneration to VF as does not slow conduction as AV node is bypassed
41
How does WPW present
``` SVT - associated AF / flutter or tachy Palpitations SOB Dizzy Chest pain Sweating Anxious Syncope ```
42
What is associated with WPW
HOCM Mitral valve prolapse Ebstein Thyrotoxicosis
43
What does ECG show
Short PR <0.12 Wide QRS with slurred upstroke and delta wave which is the accessory pathway ST changes
44
What is type A
L pathway so RAD | Dominant R in V1
45
What is type B
R pathway so LAD | No dominant R wave
46
How do you treat WPW
Radiofrequency Ablation = definite | Amiadarone / fliecanide if AF (rhythm control)
47
What should you avoid
Verapamil as blocks AV node | Possibly digoxin
48
What causes atrial fibrillation
SA node isn't firing properly = disorganised signal Other sites as well as SA node initiate conduction CO drops as ventricles not primed reliably leading to cariogenic shock / HF / increased risk of stroke
49
What are the types of AF
``` First episode Paraoxysmal - <7 days and self terminate (most in <48 hours) Will often become persistent Persistent - >7 days Permanent - resistant to Rx ```
50
What are cardiac causes of AF
Valvular vs non valvular Valvular = MS / prosthetic heart valve issue ``` Non-valvular Ischaemia = most common UK Rheumatic = common world wide HF Hypertension IHD Cardiomyopathy Myocarditis Endocarditis Surgery ```
51
What ar non-cardiac causes
``` Sepsis PE Bleed Pneumonia Hyperthyroid Alcohol Caffiene Drugs Post op Decreased K / Mg / Ca Acidosis ```
52
Mneumonic for causes
THE ATRIAL FIBS Thyroid Hypothermia Embolism ``` Alcohol Trauma Recent surgery Ischaemia Atrial enlargmenet Lone ``` Fever / anaemia / high output Infarct Bad valves -MS Stimulants - cocaine / caffeine OR PIRATES P - pulmonary - COPD / PE or phaeochromocytoma I - ischaemia R - rheumatic heart disease A - anaemia / acid base T - thyrotoxicosis / tachy E - ethanol / endocarditis / elevated BP S - sepsis ``` Most common causes = SMITH Sepsis Mitral valve - S or R IHD Thyrotoxicosis Hypertension ```
53
How does AF present
``` Asymptomatic May feel irregular irregular pulse Tachycardia Palpitations SOB Chest pain Fatigue Syncope Collapse Heart failure ```
54
What are signs of unstable patients (most present stable)
``` Hypotension Syncope HF Chest pain / signs of ischaemia WPW Known severe valve disease HR >150 HCM ```
55
What is DDX of irregularly irregular heart beat
Ventricular ectopic | Flutter with block
56
What will ECG show
Narrow complex QRS Irregular Tachycardia No clear P wave (wobbly baseline) suggest AF Irregular QRS - Tachy can make it look regular so really have to look Flutter waves often accompany AF
57
What do you do if present in ED if stable or alongside DC cardioversion
``` Immediate IV access 12 lead ECG Full bloods VBG for K Look and correct underlying cause - e.g. sepsis / bleed / MI Control rate and rhythm Anti-coagulant - LMWH Stop anti-platelet ``` After Calculate CHADVAS Decide long term Rx / OAC
58
What do you do if unstable
``` ABCDE Crash call DC cardioversion Immediate life support ATLS tachy ```
59
How do you investigate AF
``` ECG on everyone with irregular pulse 24 ECG if symptomatic = useful Bloods CXR - Look for pulmonary oedema / cardiomegaly May get fast abdominal USS in A+E to rule out bleed HASBLED / CHAD score ECHO within 6 months Angio to check carotid ```
60
What bloods
``` Look for cause FBC U+E LFT TFT CRP Bone profile + Mg Cardiac enzymes + troponin for MI ```
61
What may ECHO show
LA enlargement Mitral valve Poor LV function
62
What are the risks of AF / tachycardia
Risk of stroke = 6x greater Reduced CO as heart can't fill Can get cardiogenic shock if acute presentation Heart failure
63
What score is used to determine appropriate long-term coagulation in patient with AF and what does it look at
``` CHA2-DS2-VAS CCF HTN Age = >75 (2) >65 (1) DM Stroke or TIA previous = 2 Vascular disease Sex - F ```
64
What score indicated need for coagulation and what do you give
0= no Rx 1 = Rx if M 2 = Definite Rx Warfarin vs DOAC
65
What score is used to weight up risk of bleeding on anti-coagulation
``` HASBLED Hypertension Abnormal renal or liver Stroke Hx Bleeding tendency Labile INR Elderly Drugs that predispose - NSAID / anti-platelet / alcohol ```
66
What suggests high risk of bleeding
Score >3
67
What do you do if develop AF post stroke
Aspirin for 2 weeks Anti-Coagulation after life long Warfarin or DOAC Give LMWH to bridge gap until stable INR if using warfarin Only give anti-platelet if needed for co-morbid as higher risk of haemorrhoid stroke
68
What is summary of AF Rx
``` All patients anti-coagulation for 4 weeks Life-long anti- coagulation if CHADVAS Control ventricular rate Control rhythm If unstable = immediate cardio version ```
69
What always requires anti-coagulation and what do you give When would you delay cardioversion
ACUTE PRESENTATION If <48 hours LMWH until DC cardio version as quick acting Must do TOE to rule out if LAA thrombosis if not on anti-coagulation Delay for 3 weeks and do rhythm if - No anti-coagulation and >48 hours - TOE unavailable - TOE shows LAA thrombus - Suspicion of self-termination - Reversible cause e.g thyroid
70
Wha do you do if >48 hours since symptoms
Anti-coagulate with warfarin / DOAC for 3 weeks before elective DC Cardioversion or pharmacological cardioversion Warfarin always if valvular heart disease
71
Who gets life-long anticoagulation
Do CHAD-VAS
72
Who may not get anticoagulation
If sinus rhythm No RF No risk of recurrence
73
What is target INR on anti-coagulation
2.5-3.5
74
What are your options if <48 hours since symptoms
``` Unstable = cardiovert Rate or rhythm control If choosing rhythm must decide whether early or delayed cardioversion Most get delayed Anti-coagulate with LMWH ``` Delay for 3 weeks and do rhythm if - No anti-coagulation and >48 hours - TOE unavailable - TOE shows LAA thrombus - Suspicion of self-termination - Reversible cause e.g thyroid
75
What ar your options if >48 hours from symptom onset
Rate control Need 3 weeks anti-coagulation as risk clot has developed in heart if going to do rhythm control LMWH to bridge gap if using warfarin
76
How do you control rate
Need to know LVEF as CCB can only be given if normal as -ve inotropic so perform ECHO ``` LVEF >40% BB = 1st line - Can't be given if acute HF Rate limiting CCB - diltiazem / verapamil Add digoxin if not controlled ``` LVEF <40% - Use smallest dose of BB to get rate control but avoid if acutely decompensated - Digoxin - 1st choice if HF / acutely decompensated / severely reduced - Can add amiadarone Want to titrate to <110
77
What do you add if not controlled
Digoxin (1st choice if HF) | Amiodarone
78
What do you never combine
BB and rate limiting CCB as -ve inotrope
79
How does rate control work and when is it 1st line to do and w
``` Slows rate to avoid -ve cardiac function Aim <110 BPM but avoid brady Usually 1st line especially if - IHD - >65 - Asymptomatic - Persistent >1 year - LA diameter >5cm ```
80
What must you do prior to rhythm control and when is it preferred
ECHO to look for clot and to look for structural abnormality esp if doing <48 hours Rhythm if <65 or >65 but failed rate control
81
What are options for rhythm control
Elective DC Cardioversion | Chemical cardioversion
82
What is 1st line if harm-dynamically unstable
DC cardio version Do on R wave to prevent VF Put out crash call and start tachy arrhythmia ATLS guidelines
83
What must you do after DC Cardioversion
Anti-coagulate for at least 4 weeks
84
What are options for rhythm control with chemical cardioversion
Fleicanide = 1st line as fast onset - Can do IV or pill in pocket if paroxysmal - Unsuitable if LV dysfunction / CAD / structural heart) Amiadarone if structural heart disease - Central venous career due to thrombophlebitis risk - Longer onset of action so delayed conversion to sinus
85
When are you more likely to do rhythm over rate which is usually 1st line
``` New onset - 48 hours <65 Symptomatic despite rate control - feel themselves go into AF First presentation Reversible causes e.g. infection Congestive HF ``` As AF worsens more go onto rate
86
What do you do if refractory to Rx
AVN ablation Pulmonary vein isolation Done if refractory to drugs or younger patients paroxysmal
87
What drug is good in HF and what drug is bad
Digoxin good as small inotrope affect | Verapamil bad as depresses cardiac function
88
What is atrial flutter
Form of SVT Rapid atrial depolarisation faster and more often than ventricles May have 4 atrial to one ventricular contraction - 4P to 1 QRS Re-entrant due to extra irregular pathway through AV node which goes round and round Heart beat is regular but faster and more often than ventricle
89
What is associated with flutter
Hypertension IHD Cardiomyopathy Thyrotoxicosis
90
What does ECG show
Clear P wave QRS removed - not always Can have 4 P to 1 QRS Saw tooth appearance
91
How do you Rx
Similar to fibrillation Control rate or rhythm Anti-coagulate
92
What can be curative in atrial flutter
Radiofrequency ablation of extra pathway
93
What does ventricular / HR depend on
Degree of AV block
94
What are pacemakers
Deliver controlled electrical impulses to improve heart function
95
How are they implanted
Under skin - L side usually Wire fed into relevant chamber of the heart Battery lasts 5 years
96
What are indications
``` Symptomatic brady MObitz type II or c3rd degree HCM Severe HF Carotid hypersensitivity Malignant vasovagal BBB ```
97
What do you have in HCM
Implantable defibrillators which detects rhythm and shocks if VT detected
98
What is shown on ECG and how do you know what type of pacemaker
``` Straight sharp vertical line If before P wave = in atria If before QRS = in ventricle If before both = dual chamber If just one = single chamber ```
99
What are CI when have a pacemaker
MRI - newer ones are compatible TENS Diathermy
100
When is Fleicanide CI in chemical cardioversion and amiadarone used
``` LV dysfunction Post MI AV block Structural - HF Flutter ```
101
If shocked what is it important not to give
BB as would slow down heart | Digoxin - would slow down CO
102
If someone presents with tachycardia what do you need
ECG to decide management
103
What can AF be
Paroxysmal due to infection so may hold of putting on anti-coag Can rate-control in interim with BB
104
DOAC
Different DOAC have different timings
105
What does cardioversion required
Sedation If low BP may be difficult as sedation will worsen May burn
106
How can patient in AF present
Cardiogenic shock
107
Who gets warfarin
Mechanical heart valve | Moderate or severe mitral stenosis
108
What is issue with DOAC
CI severe CKD Increased risk GI bleed compared to warfarin Most go on
109
What does amiadarone and flueicanide both require
ECG monitoring due to risk of QT prolongation
110
DDX of SOB and chest pain (come and go)
``` AF SVT Sinus tachy ACS PE Pneumothorax ```
111
How would you investigate
ABCDE 12 lead ECG CXR Bloods inc cardiac

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