Arrhythmias

Question 1

what are ectopic beats

Answer 1

electrical hearts beats are spontaneous heart beats that come out outside the normal electrical nodes. This causes an extra heart beat

note patients can still have a normal heart beat and have these occur

Question 2

what are arrhythmias

Answer 2

irregular heart beat

Question 3

what should you do if a patient has an ectopic beat but still has a normal heart beat

Answer 3

• no treatment needed. just reassure patient

Question 4

what should you do if a patient has an ectopic beat but the symptoms are troublesome

Answer 4

can give the patient a beta blockers

e.g bisoprolol, atenolol, propranolol

Question 5

what are the 2 aims of treatment for atrial fibrillation (AF)

Answer 5

• reduce symptoms

- prevent complications (most common complication= stroke)

Question 6

what do you need to assess in all patients with atrial fibrillation (AF)

Answer 6

Assess:
- risk of stroke and thromboembolism (balanced with risk of bleeding)

note: when you have AF, the irregular heart beat can leave residual blood in the heart which can form a blood clot, if blood clot moves away into brain (through pumping of blood) this causes a stroke

Question 7

what are the 2 types of drug treatment to manage atrial fibrillation (AF)

Answer 7

• control ventricular rate (rate control)
• restore and maintain sinus rhythm (rhythm control) through meds + cardioversion
• e.g through cardioversion (using electrical pads, to send synchronized electricity to get the heart beat back to normal)*

Question 8

what is sinus rhythm

Answer 8

the normal rhythm of the heart

(normal heart rhythm made up of: a normal heart rate between 60-100 BPM, electrical signal starts from the SAN node, electrical impulse follows normal path of the heart + electrical impulse moves at normal speed)

Question 9

which drugs are used in RATE control treatment for atrial fibrillation

Answer 9

• beta blockers (not sotalol) most commonly used

- rate-limiting CCB: verapamil (common) + diltiazem (unlicensed)

Question 10

which beta blocker is NOT used for rate control treatment in atrial fibrillation

Answer 10

sotalol

Question 11

which drugs are used in RHYTHM control after cardioversion in atrial fibrillation

Answer 11

• first line = beta blockers (can use sotalol)

if beta blockers fail, then can use:

• flecainide
• amiodarone

Question 12

which type of atrial fibrillation treatment can we use sotalol

Answer 12

sotalol can be used in rhythm control

‘(but NOT IN RATE CONTROL)

Question 13

how do you assess a patient’s risk of stroke and risk of bleeding

Answer 13

• risk of stroke: use CHAD2DS2-VASC tool (looks at patients risk of cardiovascular disease)
• risk of bleeding: use HAS-BLED tool

Question 14

what should you do if a patient has a low risk of stroke after using the CHA2DS2-VASC tool

give the figures which mean low risk

Answer 14

low risk CHADS score is: men = 0 and women = 1

if they have this low risk score, the patient doesn’t need any treatment to prevent stroke (no thromboprophylaxis)

Question 15

which drug is class 2 and class 3 on the vaughan williams classification

Answer 15

sotalol

Question 16

describe the classes for anti-arrhythmic drugs based on the vaughan williams classification

Answer 16

Class I: membrane stabilising drugs (e.g. lidocaine, flecainide)

Class II: beta-blockers

Class III: amiodarone; sotalol (also Class II)

Class IV: rate-limiting calcium-channel blockers (includes verapamil but not dihydropyridines)

Question 17

which drugs are used to treat supraventricular arrhythmias

Answer 17

• adenosine (first line choice because it has a short half life of 8-10 secs. so has short-lived side effects + can be used in combination with beta blockers)
• verapamil
• cardiac glycosides (e.g digoxin)

Question 18

which drugs are used to treat ventricular arrhythmias

Answer 18

• lidocaine

- sotalol

Question 19

which drugs can be used to treat both supraventricular + ventricular arrhythmias

Answer 19

• amiodarone (first line choice. can be I.V or oral but should be started in hospital/ under specialist supervision)
• beta blockers

Question 20

which drug class must NOT be combined with verapamil

Answer 20

beta blockers
(because they interact and cause side effects)

Question 21

what is an advantage of using amiodarone to treat supraventricular + ventricular arrhythmias

Answer 21

it causes little/ no myocardial depression

Question 22

why might amiodarone still cause interactions with other drugs even if a patient has stopped taking it

Answer 22

because amiodarone has a very long half life (weeks/months) so amiodarone can still be present in the body weeks/months after the patient has stopped taking it

Question 23

which cardiac glycoside can be used in a patient who has both atrial fibrillation (AF) and chronic heart failure (CHF)

Answer 23

digoxin

Question 24

what is atrial fibrillation

Answer 24

a rapid and irregular heart beat

Question 25

which drugs are used for EMERGENCY RATE control in patient with acute presentations of atrial fibrillation

Answer 25

use I.V verapamil or I.V beta blocker

Question 26

which drugs are used for EMERGENCY RHYTHM control in patients with acute presentations of atrial fibrillation

Answer 26

use I.V amiodarone or I.V flecainide

Question 27

what are the 2 types of cardioversion

Answer 27

- electrical | - pharmacological (with amiodarone or flecainide which can be given I.V or oral)

Question 28

what is cardioversion

Answer 28

when an abnormally fast heart rate or cardiac arrhythmia is converted back to sinus rhythm (normal heart rhythm)

Question 29

what should you do for 3 weeks before attempting electrical cardioversion

Answer 29

make sure the patient is fully anticoagulated | procedure carries an increased risk of thromboembolism

Question 30

what is paroxysmal atrial fibrillation what is the treatment

Answer 30

atrial fibrillation (rapid + irregular heartbeat) that comes and goes (paroxysmal). - it usually stops on its own within 48 hours - can use a standard beta blocker to treat symptoms. (if beta-blocker not tolerated, use other anti-arrhythmias e.g amiodarone/flecainide/ sotalol)

Question 31

what is the "pill-in-pocket" approach and when is it used

Answer 31

when patients with infrequent (random) episodes of paroxysmal atrial fibrillation are given a supply of oral flecainide or propafenone which they can use to self-treat whenever they get the random episode of atrial fibrillation

Question 32

what is paroxysmal supraventricular tachycardia and what is the treatment for this

Answer 32

paroxysmal supraventricular tachycardia = random/ intermittent rapid heart rate that occurs in the atria. treatment: - often stops spontaneously - can treat with reflex vagal stimulation such as a Valsalva manoeuvre, immersing the face in ice-cold water, or carotid sinus massage - if previous treatments not effective, can give i.v adenosine or i.v verapamil (if adenosine intolerated)

Question 33

what is Torsade de pointes what is the treatment

Answer 33

a type of ventricular tachycardia that has a a prolonged QT interval. it is usually self-limiting but recurrent. if it's not controlled it can progress to ventricular fibrillation and lead to death treatment: - I.V magnesium sulfate - beta blocker (not sotalol)