Arrhythmias Flashcards
(93 cards)
1
Q
what is ectopic heartbeat
A
- type of of arrhythmia (irregular heartbeat)
- happens when your heart contracts (beats) too soon
- heart can also skip a beat or feel like it’s racing or fluttering
- usually harmless and doesn’t result from an underlying heart problem or health condition
2
Q
treatment ectopic heartbeat
A
- rarely needed if ectopic beats are spontaneous and pt has normal HR
- otherwise, BB are sometimes effective and may be safer than others
3
Q
2 classifications of arrhythmias
A
- supra ventricular - occur above ventricles, in atria
- ventricular
4
Q
Name the supra ventricular arrhythmias
A
- AF
- atrial flutter
- paroxysmal SV tachycardia
5
Q
name the ventricular arrhythmias
A
- ventricular tachycardia
- ventricular fibrillation
- torsade de pointes
6
Q
is an ECG needed to manage arrhythmias
A
Always , helps diagnosis
7
Q
what is the most common type of arrhythmia
A
AF
8
Q
how does AF occur
A
- fast and irregular heart rhythm originates in atria, overriding the SAN which is the hearts natural pacemaker
- leads to irregular ventricular rhythm
9
Q
ventricular rate of untreated AF
A
160-180bpm, typically slower in elderly
10
Q
Pt with AF presents acutely, with suspected concomitant decompensated HF - considerations about drug treatment (2)
A
AVOID CCBS!
Seek specialist advice on use of BB
11
Q
what is rate control
A
- preferred 1st line for AF (with some exceptions)
- reduces the ventricular rate (aka HR)
12
Q
what is rhythm control
A
attempts to restore normal sinus rhythm of heart
13
Q
Rate control is first line in AF, except in patients…
A
- new onset AF
- atrial flutter suitable for ablation strategy
- AF with reversible cause (eg chest infection)
- HF primarily caused by AF
- rhythm control suitable based on clinical judgement
14
Q
What does rate control consist of
A
Step 1: mono therapy with any of the following
Step 2: combination therapy with two of the following
Step 3: rhythm control
15
Q
When would you consider rate control treatment of AF with digoxin
A
- non-paroxysmal AF who are predominantly sedentary
- other rate control unsuitable
- AF accompanied with congestive HF
16
Q
What is the rate control treatment of AF in pt who have diminished ventricular function (LVEF<40%)
A
- BB licensed in HF (bisop, carvedilol, nebivolol) + digoxin
- AVOID CCBS - worsen HF!!
17
Q
A patient has new onset AF and has had symptoms for <48h, and doesn’t have life threatening haemodynamic instability. What treatment do you offer.
A
rate or rhythm control
18
Q
All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo
A
emergency electrical cardioversion, without delaying to achieve anticoagulation.
19
Q
If urgent rate control is required, what can you give (2 options)
A
IV BB
or RLCCB e.g. verapamil if LVEF is ≥40%
20
Q
If AF has been present for more than 48 hours, electrical cardioversion is preferred to pharmacological cardioversion, but when should you give it?
A
it should be delayed until the patient has been fully anticoagulated for at least 3 weeks.
During the period prior to cardioversion, offer rate control as appropriate
21
Q
What does rhythm control treatment consist of?
A
Sinus rhythm can be restored by electrical cardioversion or by pharmacological cardioversion with an anti-arrhythmic drug such as flecainide acetate or amiodarone hydrochloride.
If atrial fibrillation has been present for more than 48 hours, electrical cardioversion is preferred to pharmacological cardioversion, but should be delayed until the patient has been fully anticoagulated for at least 3 weeks.
22
Q
What would you give if drug treatment is required to maintain sinus rhythm (rhythm control) post cardioversion
A
1st line: standard BB, NOT SOTALOL
- if inappropriate of ineffective, give an anti-arrhythmic e.g. sotalol, amiodarone, flecainide, propafenone (SPAF)
23
Q
You are giving rhythm control to a pt with LV impairment & AF - which drug is preferred?
A
amiodarone
24
Q
In which patients should you not give flecainide & propafenone
A
avoid in known ischaemic (e.g. PAD, angina, atherosclerosis, CAD) or structural heart disease
25
Verapamil and BB
- Significant drug interaction
- Caution/AVOID
- Increases the risk of cardiovascular adverse effects when given with BB
26
What is cardioversion
Uses either electrical current or a drug to put heart back into rhythm
27
Which drugs would you use for cardioversion
Anti-arrhythmic: flecainide, amiodarone
28
When is electrical cardioversion preferred to pharmacological cardioversion for AF?
AF >48h
29
What to do if you have to give emergency cardioversion, and the patient has not been anti coagulated for at least 3 weeks?
- rule out left atrial thrombus
- give parenteral AC (heparin) immediately before cardioversion
- oral AC to be given after cardioversion and continued for at least 4 weeks
30
Which class of anti arrhythmic drugs should not be given to pt with ischaemic or structural heart disease
class 1c: e.g. flecainide, propafenone
31
If drug treatment for long term rhythm control is needed, consider...
standard BB (not sotalol) as 1st line
32
what is paroxysmal SV tachycardia
- causes heart to suddenly beat faster than normal for a short while
- occurs in atria
33
treatment of paroxysmal SV tachycardia
- often stops spontaneously
- or use reflex vagal simulation e.g. VALSALVA manoeuvre, immerse face in ice cold water, carotid sinus massage
- these manoeuvres should be perfumed with ECG monitoring
- if these are ineffective, give IV adenosine
- if ineffective, IV verapamil (avoid in pt recently treated with BB)
34
how to manage paroxysmal SV tachycardia if pt is haemodynamically unstable, of if vagal nerve stimulation/IV adenosine/IV verapamil has failed, and alternative diagnosis has not been found
direct current cardioversion
35
how to treat and prevent recurrent episodes of paroxysmal SV tachycardia
- treat: catheter ablation
- prevent: dilt, verap, BB including sotalol, flecainide, propafenone
36
failure to terminate paroxysmal SV tachycardia with reflex vagal stimulation of drug treatment may suggest...
... may suggest arrhythmia of atrial origin e.g. focal atrial tachycardia or atrial flutter
37
paroxysmal tachycardia or rapid irregularity after MI - when to treat
do not administer an anti-arrhthmyic until an ECG has been obtained
38
treating bradycardia, particularly if complicated by hypotension, after MI should be treated with ....
- IV dose of atropine, repeat if necessary
- if risk of systole, or if pt unstable and has failed to respond to atropine, give IV adrenaline and adjust dose according to response
39
pulseless ventricular tachycardia or ventricular fibrillation requires
- resuscitation
- IV injection of amiodarone is given in cardiopulmonary resuscitation for VF or pulseless VT refractory to defibrillation
40
Patients with unstable sustained ventricular tachycardia who continue to deteriorate with signs of hypotension or reduced CO should receive
- direct current cardioversion to restore sinus rhythm
- if this fails, IV amiodarone and repeat direct current cardioversion
41
treatment of pt with sustained ventricular tachycardia who are haemodynamically stable
- IV antiarrhythmics
- amiodarone preferred
others include flecainide, propafenone, lidocaine (less effective)
- if sinus rhythm not restored, direct current cardioversion or pacing should be considered
- catheter ablation is alternative if cessation of arrhythmia is not urgent
42
treatment of non sustained ventricular tachycardia
BB
43
all pt presenting with ventricular tachycardia
refer to specialist
44
long term treatment of ventricular tachycardia following restoration of sinus rhythm
- pt who remain at high risk of cardiac arrest will need maintenance therapy
- most pt treated with implantable cardioverter defibrillator
- BB or sotalol or amiodarone (in combo with standard BB) can be used in addition to the device in some pt; or be used alone with implantable defibrillator not appropriate
45
what is torsade de pointes
ventricular tachycardia associated with long QT interval - usually drug induced, but other factors are implicated e.g. hypokalaemia, severe bradycardia, genetic predisposition
46
episodes of TDP are usually...
self limiting but are frequently recurrent and can cause impairment or loss of consciousness
47
what can happen if TDP is not controlled
arrhythmia can progress to ventricular fibrillation and sometimes death
48
treatment TDP
- IV magnesium sulphate is usually effective
- can consider a BB (not totally) and atrial (or ventricular) pacing
49
are anti-arrhythmic drugs used for TDP and why
non because they can further prolong QT interval, thus worsening condition
50
clinical classification of anti-arrhythmic drugs according to where they act - provide examples of each
- act on SV arrhythmias e.g. verapamil
- act on both SV and V arrhythmias e.g. amiodarone
- act on V arrhythmias e.g. lidocaine
51
vaughan williams classification of anti-arrhythmic drugs is based on
the effects of the drugs on the electrical behaviour of myocardial cells during activity
52
what are the 4 classes of the Vaughan Williams classification
1. membrane stabilising drugs e.g. lidocaine, flecainide
2: BB
3. amiodarone, sotalol (also class 2)
4. CCBs (incl verapamil but not dihydropyridines)
53
what to do if 2 or more anti-arrhythmic drugs are prescribed
- negative inotropic effects are usually additive - aka weakens contractions and slows HR
- therefore special care is required, esp if impaired myocardial function
54
SV arrhythmias - treatment to terminate paroxysmal SV tachycardia
- adenosine
- short duration of action (half life ~8-10seconds, but prolonged if taking dipyrimadole) so most SE short lived
- can be used after a BB (unlike verapamil)
- verapamil may be preferable to adenosine in asthma
55
in which arrhythmias are cardiac glycosides contraindicated
SV arrhythmias associated with accessory conducting pathways (e.g. Wolff Parkinson White syndrome)
56
oral administration of a cardiac glycoside e.g. digoxin slows the .... rate in cases of AF and atrial flutter
ventricular
57
IV infusion digoxin is .... ....... for rapid control of ventricular rate
rarely effective
58
which CCB is usually effective for SV tachycardias
- verapamil
- initial IV dose may be followed by oral treatment
- hypotension can occur with large doses
59
verapamil and BB interaction
verapamil contraindicated if BB - risk of reduced CO and HF!!
60
when should verapamil not be used (3)
- do not use for tachyarrhythmias where QRS complex is wide (broad complex) unless SV origin has been established
- contraindicated in AF or atrial flutter associated with accessory conducting pathways (e.g. Wolff Parkinson White syndrome)
- do not use in children with arrhythmias w/o specialist advice as some SV arrhythmias in children can be accelerated by verapamil with dangerous consequences
61
IV administration of ... can be used to achieved rapid control of ventricular rate
BB e.g. esmolol or propranolol
62
drugs for both SV and V arrhythmias
- amiodarone
- BBs
- diopyramide
- flecainide
- procainamide (special)
- propafenone
63
for which arrhythmias can amiodarone be used for
- PSV
- nodal and ventricular tachycardia
- AF and flutter
- ventricular fibrillation
- tachyarrhythmias associated with Wolff Parkinson White syndrome
64
who can initiate amiodarone
only under hospital or specialist supervision
65
advantage of amiodarone
causes little or no myocardial depression
66
oral vs IV amiodarone
unlike oral, IV acts relatively rapidly
67
half life and dosing of amiodarone
- very long half life (several weeks) and only needs to be given OD
- high doses can cause nausea unless divided
- many weeks or months may be needed to achieve steady-state plasma-amiodarone conc
- this is particularly important when drug interactions are likely
68
explain how BBs act as anti-arrhythmic drugs
- attenuate effects of sympathetic system on automaticity and conductivity within the heart
69
sotalol can be used for...
management of ventricular arrhythmias
70
use of disopyramide
- can be given via IV injection to control arrhythmias after MI, including those not responding to lidocaine
- but it impaired cardiac contractility
- oral administration is useful but has antimuscarinic effect which limits its use in pt susceptible to CAG or with prostatic hyperplasia
71
dose for flecainide when concurrent use of amiodarone
reduce dose by half with concurrent use of amiodarone
72
use of propafenone
used for prophylaxis and treatment of ventricular arrhythmias and also for some SV arrhythmias
73
use of propafenone in obstructive airways disease and why
has weak beta-blocking activity to caution in obstructive airways disease, contraindicated if severe
74
name 3 drugs for SV arrhythmias
adenosine, cardiac glycosides, veramapil
75
name a drug used for ventricular arrhythmias
lidocaine
76
pt presenting with acutely w/o haemodynamic instability with new onset AF
- Offer rate or rhythm control if onset <48 hours
- Rate control preferred if onset >48h/uncertain
77
pt acutely presents with life-threatening haemodynamic instability caused by new onset AF
pt to undergo emergency cardioversion without delaying to achieve anticoagulation
78
what are some symptoms of haemodynamic instability
- rapid pulse (>150bpm)
- low BP (systolic <90)
- unconscious
- severe dizziness/syncope
- ongoing chest pain
- increasing breathlessness
79
4 most common causes of AF
- ischaemic heart disease
- valvular heart disease
- hypertension
- hyperthyroidism
80
complications of AF
- stroke: atria do not have enough time to fully contract and empty blood, leading to blood pools, clot formation, and embolus
- TIA
- heart failure: heart cannot pump blood efficiently around body
81
symptoms of AF
- palpitations
- floppy fish in chest (pounding or fluttering)
- dyspnoea
- dizzy, syncope
- tired
- polyuria
- reduced exercise tolerance
- irregular pulse!
82
describe an ECG of a pt with AF
No p waves, chaotic baseline, irregular ventricular rate
83
when to suspect AF - pulse
irregular pulse
absence of irregular pulse = unlikely!
84
treatment options atrial flutter
like AF: the ventricular rate control (rate control) or attempting to restore and maintain sinus rhythm (rhtyhm control)
However, atrial flutter generally responds less well to drug treatment than AF
85
is rate control long term treatment for atrial flutter? and which drugs for rate control?
Ventricular rate control is usually an interim measure pending restoration of sinus rhythm (i.e. temporary until rhythm is restored)
Rate control drugs: BB, RLCCB
Rapid rate control: IV BB or verapamil
Digoxin can be added if rate control remains inadequate, and may be particularly useful in those with HF
86
when can you use digoxin in atrial fibrillation rate control
Digoxin can be added if rate control remains inadequate (with BB/ RLCCB), and may be particularly useful in those with HF
87
atrial flutter how to achieve sinus rhythm control (3)
electrical cardioversion (by cardiac pacing or direct current)
pharmacological cardioversion
catheter ablation
88
rhythm control if duration of atrial flutter is unknown, or it has lasted >48 hours,
cardioversion should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.
89
..... is usually the treatment of choice when rapid conversion to sinus rhythm is necessary (e.g. when atrial flutter is associated with haemodynamic compromise)
Direct current cardioversion
90
Patient presents with atrial flutter and haemodynamic instability. what should you offer
Direct current cardioversion usually treatment of choice when rapid conversion to sinus rhythm necessary e.g. when atrial flutter associated with haemodynamic compromise
91
.... is preferred for the treatment of recurrent atrial flutter.
catheter ablation
92
discuss use of anti arrhtyhmic drugs in atrial flutter
There is a limited role for anti-arrhythmic drugs as their use is not always successful. Flecainide or propafenone can slow atrial flutter, resulting in 1:1 conduction to the ventricles, and should therefore be prescribed in conjunction with a ventricular rate controlling drug such as a BB or RLCCB
Amiodarone hydrochloride can be used when other drug treatments are contra-indicated or ineffective.
93
assess stroke risk for people with...
af and atrial flutter
