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ARRHYTHMIAS Flashcards

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1
Q

Normal QRS

A

Rate = 60-100
Regularity = R-R interval is same

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2
Q

Wide QRS

A

Ventricular Tachycardia

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3
Q

Normal sinus Rhythm

A

Normal P wave before every QRS
Upright P wave in Lead II
Biphasic P wave in V1

Every P wave followed by QRS

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4
Q

Normal Intervals

A

PR interval = 0.12-0.21 s
QT interval = <0.4 s

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5
Q

Sinus Tachycardia (5)

A

> 100 bpm
Normal p wave followed by QRS
Regular R-R interval
Narrow QRS
Camel hump (P merge with T)

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6
Q

Sinus Tachycardia- Pathophysiology

A

Sympathetic activation or vagal withdrawl on SA node

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7
Q

Sinus Tachycardia- Causes (3)

A

1- Increased sympathetic tone e.g. exercise, anxiety, pain, pregnancy
2- Alcohol, caffeine, drugs e.g. B-adrenergic agonists, anticholinergic drugs
3- Systemic etiology: fever, hypotension, hypovolemia, anemia, thyrotoxicosis, CHF, MI, shock, pulmonary embolism

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8
Q

Sinus Tachycardia- Treatment

A

Treat underlying cause
Consider beta blockers if symptomatic (if beta blocker is contraindicated use CCB)

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9
Q

Respiratory Sinus Arrhythmia

A

Change in sinus rhythm during respiration
Inspiration —> Faster
Expiration —> Slower

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10
Q

Supraventricular Tachycardias (2)

A

Arising above the level of the Bundle of His

Narrow QRS

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11
Q

Paroxysmal Supraventricular Tachycardia- Overview (2)

A

1- In young patients with no structural heart disease, abrupt onset and offset
2- Seen with re-entry tachycardia

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12
Q

Paroxysmal Supraventricular Tachycardia- Types (2)

A

1- AVRT (Atrioventricular)
- Anatomical reentry; accessory pathway (extra piece of conducting tissue between atria and ventricles)
- e.g. Wolf-Parkinson-White (WPW) syndrome: short PR interval, delta wave

2- AVNRT (AV node) (more common)
- Functional reentry within AV node (fast and slow pathways in AV node)

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13
Q

Paroxysmal Supraventricular Tachycardia- ECG (4)

A

1- Regular, 250bpm (fast)
2- Narrow QRS
3- P-wave sometimes hidden in QRS (bc it’s very fast)
4- ST depression

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14
Q

Paroxysmal Supraventricular Tachycardia- Treatment (3)

A

1- Termination by acutely blocking AV nodal conduction
- 1st line —> vagal manuevers, carotid massage. If not terminated —> IV Adenosine
- 2nd line —> IV BB, Diltiazem (CCB), Verapamil (CCB)
2- Preferred to cure: ablation of accessory pathway
3- Unstable patient: emergency cardioversion

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15
Q

Atrial Fibrillation- Overview (3)

A

1- Irregularly irregular, no p-waves (only fine oscillations), narrow QRS
2- Can be fast or slow depending on AV conduction
3- Tachycardia with an irregularly irregular pulse

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16
Q

Atrial Fibrillation- Most feared complications (3)

A

V. Fib, Embolism, Stroke

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17
Q

Atrial Fibrillation- Symptoms (5)

A

Palpitations, Fatigue, Dyspnea, Syncope, may precipitate or worsen heart failure

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18
Q

Atrial Fibrillation- Causes (7)

A

Cardiac (most common):
- MI
- Mitral stenosis
- HTN

Non-cardiac:
- Thyrotoxicosis
- Pulmonary embolism
- Alcohol
- Hypokalemia

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19
Q

Atrial Fibrillation- Diagnostic Approach (4)

A

1- Suspected A.Fib —> obtain an ECG
2- Confirmed A.Fib (new diagnosis) —> echo to assess cardiac function and rule out underlying structural cardiac disease (MS)
3- If A.Fib is not confirmed on ECG but strong clinical suspicion —> Holter monitor
4- Investigate for underlying cause

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20
Q

Atrial Fibrillation- Treatment (5)

A
  • If patient is hemodynamically unstable —> DC cardioversion
  • If patient is stable:
    1- Rate control (to decrease heart rate):
    - BB, CCB
    - Digoxin
    2- Rhythm control:
    - Electrical —> DC cardioversion
    - Pharmacological:
    - If structural heart disease —> amiodarone
    - If no heart disease —> flecianide, or propafenone
    3- Anticoagulation
    - Valvular A.Fib (prosthetic or moderate-severe MS) —> anticoagulate all with warfarin or NOACs
    - Non-valvular A.Fib —> decide on anticoagulation using the CHA2DS2VASc score
    4- Treatment of underlying cause
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21
Q

CHA2DS2VASc score (8)

A
  • CHF or LVEF <= 40% (1) score of 0 —> no prophylaxis
  • Hypertension (1) score of 1 —> aspirin
  • Age > 75 (2) score of 2 or more —> warfarin or NOAC
  • Diabeties (1)
  • Stroke/TIA/Thromboembolism (2)
  • Vascular disease (1)
  • Age 65-74 (1)
  • Female (1)
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22
Q

Atrial Flutter - Overview (3)

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A
  • No p-waves; saw-toothed flutter waves
  • Always some degree of AV block (2:1, 3:1, 4:1)
    • 150bpm, 2:1. After vagal maneuver goes to exactly 75 bpm (characteristic)
  • Often occurs with A.Fib
23
Q

Atrial Flutter - Associated with (5)

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A
  • Underlying heart disease, cardiomyopathy, COPD, hyperthyroidism, hypertension
24
Q

Atrial Flutter - ECG

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A

Sawtoothed waves better seen in inferior leads (II, III, aVF)

25
Atrial Flutter - Treatment (4)
- If unstable (e.g. hypotension, CHF, angina) —> electrical cardioversion - If stable: - Rate control: BB, Dilitiazem, Verapamil, or Digoxin - Chemical cardioversion: Sotalol, Amiodarone, Type I antiarrhythmatics, or electrical cardioversion - Anticoagulation (guidlines same as patients with A.Fib) - Treatment of long-term atrial flutter includes anti-arrhythmics (Amiodarone, Flecianide, Propafenone) and radiofrequency or catheter ablation
26
Multifocal Atrial Tachycardia- Overview (6)
- A rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria - Most commonly seen in patients with severe COPD or congestive heart failure - Characteristically commonly seen in COPD. Other hints to COPD: right axis deviation, tall R wave in V1 and deep S wave in V6 (due to right ventricular hypertrophy - cor pulmonale) - Usually a transitional rhythm between frequent premature atrial complexes (PACs) and atrial fibrillation (differentiate from A.Fib as both have irregular narrow complex tachycardia) - Heart rate >100bpm (usually 100-150bpm; may be as high as 250bpm) - Irregulary irregular rhythm with varying PP, PR, and RR intervals. No flutter waves - At least *3 distinct p-wave morphologies* in the same lead
27
Multifocal Atrial Tachycardia- Treatment
Resolves following treatment of the underlying disorder
28
Multifocal Atrial Tachycardia- Progonisis
Considered by a poor prognostic sign when developing during an acute illness (—> increased mortality due to the underlying illness)
29
Ventricular Tachycardia - Definition (2)
- Arising below the level of the Bundle of His. - Wide QRS
30
Ventricular Tachycardia - Overview (5)
- 3 or more consecutive premature ventricular beats - Regular, Rate > 100 (usually 140-200) - Sustained if > 30 secs; non-sustained < 30 secs - Wide aberrant bizzare-shaped QRS - Capture beats and fusion beats
31
Ventricular Tachycardia - Symptoms (6)
- Dizziness, syncope, SOB, chest pain, palpitations, sudden death
32
Ventricular Tachycardia - Causes (2)
- IHD - Cardiomyopathy (hypertrophic/dilated)
33
Ventricular Tachycardia - Types (2)
- Monomorphic (more common) - Polymorphic (torsade’s)
34
Ventricular Tachycardia - Treatment (3)
- Hemodynamically unstable: electrical cardioversion (100J) - If hemodynamically stable: electrical cardioversion, amiodarone, Type I agents (procainamide, quinidine) - Correction of reversible causes (hypokalemia, ischemia, HF, hypotension)
35
Torsade’s de points - Definition (4)
Polymorphic ventricular tachycardia (twisting of the axis: beat to beat variation in QRS shape), usually occurs in patients with a baseline of QT prolongation due to: - Congenital Long QT syndrome - Drugs: class IA (quinidine), class III (sotalol), phenothiazines (TCAs), erythromycin, quinolones, antihistamines - Electrolyte disturbances: Hypokalemia, hypomagnesemia
36
Torsade’s de points - Treatment
IV Magnesium sulfate. Correct the underlying cause of prolonged QT
37
Ventricular Fibrillation - Definition
A very rapid and irregular ventricular activation with no mechanical effect and therefore no cardiac output
38
Ventricular Fibrillation - Presentation
Patient pulseless and becomes rapidly unconscious, and respiration ceases (cardiac arrest)
39
Ventricular Fibrillation - Treatment
Immediate defibrillation Survivors at high risk of sudden death and treatment is with an ICD
40
Cardioversion Vs Defibrillation (5)
Cardioversion: - Shock in synchrony with QRS complex - Has a pulse but hemodynamically unstable - A.Fib, atrial flutter, SVT, VT with a pulse - 50-200 Joules - Elective, patient awake and frequently sedated Defibrillation: - Shock NOT in synchrony with QRS complex - Patient is pulseless - V.Fib, VT without pulse - 200-360 Joules - Emergency, patient is unconscious
41
Sinus Bradycardia - Definition
< 60 bpm. Normal p-wave followed by QRS. Regular (regular R-R interval)
42
Sinus Bradycardia - Causes (3)
- Normal —> during sleep, athletes - Extrinsic to heart: BB intake, hypothyroidism, hypothermia - Intrinsic to heart: - Acute ischemia and infarction of the node (complication of MI) - Degenerative changes: fibrosis of atrium and node “sick sinus syndrome”
43
Sinus Bradycardia - Treatment (2)
- Could be normal/stop offending agent (BB, CCB)/Atropine - Patients with persistent symptomatic bradycardia treated with a permanent cardiac pacemaker
44
Sick Sinus Syndrome- Definition
Failure of sinus node to depolarize (sinus arrest) or failure of the sinus impulse to propagate to the atria (sinoatrial block) —> BRADYCARDIA —> this will cause ectopic pacemaker activity and tachyarrhythmias (tachy-brady syndrome)
45
Sick Sinus Syndrome- ECG
Severe sinus bradycardia or intermittent long pauses between consecutive P waves
46
Sick Sinus Syndrome- Treatment (2)
Permanent pacemaker insertion and anti-coagulation
47
AV Blocks - 1st Degree (2)
- AV conduction excessively slowed (but all conducted) - Constant PR
48
AV Blocks - 2nd Degree
AV conduction occasionally blocked - Mobitz I: PR increases progressively until beat dropped - Mobitz II: PR is constant then beat is dropped
49
AV Blocks - 3rd Degree (complete heart block)
AV conduction is completely blocked - P waves marching through - QRSs without correlating P waves
50
AV Blocks - Treatment (2)
- Unstable: Atropine then percutaneous pacing - Mobitz II and 3rd degree: Pacemaker
51
Bundle Branch Blocks - Left bundle branch block (4)
- Wide QRS - Broad R with prolonged upstroke in the lateral leads (I, aVL, V5, V6) - ST depression and T wave inversion - Reciprocal changes in V1 and V2
52
Bundle Branch Blocks - Right Bundle Branch Block (4)
- Wide QRS - RSR’ in V1 and V2 (rabbit ears) - ST depression and T wave inversion - Reciprocal changes in the lateral leads (I, aVL, V5, V6)
53
Anti-arrhythmics (4)
NO BODY KNOWS CARDIOLOGY 1- No —> Na channel blockers - Increased AP —> quinidine procainamide - Decreased AP —> lidocaine - Same AP —> Flecianide 2- Body —> Beta blockers - MOA: decreased HR, decreased force of contraction, decreased BP - e.g. Propanolol, atenolol, bisoprolol - side effects: bradycardia, increased intermittent claudication, decreased glucose tolerance 3- Knows —> K channel blockers - e.g. Amiodarone, sotalol - side effects: hypo/hyperthyroidism, skin, liver toxicity, corneal micro-deposits 4- Cardiology —> Ca channel blockers - Non dihydro: verapamil, dilitazem
54
Anti-arrhythmics - General rules
If hemodynamically stable: - Bradycardia: Atropine - Supraventricular tachycardia: ABCD (adenosine, BB, CCB, digoxin) - Ventricular tachycardia: LAPS (Lidocaine, Amiodarone, Procainamide, Sotalol) If hemodynamically unstable: - Bradycardia: Pacemaker - Tachycardia: DC shock

CARDIOLOGY (22 decks)

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