Arrhythmias

Question 1

Tachycardia with pulse with adverse features:

• What are the adverse features to look for ?
• Management?

Answer 1

Adverse features:

• Shock
• Syncope
• Heart Failure
• MI

Management = DC shock (3 attempts)

Broad complex or AF = 120-150 joules

Narrow complex or atrial flutter = 70-120 joules

Question 2

Broad complex (>0.12s) tachycardia management? Regular and irregular

Answer 2

Regular: Ventricular Tachycardia = treat with amiodarone 300mg IV over 20-60mins

If known to be SVT with BBB: follow narrow complex guidelines.

Irregular: seek expert help

Question 3

Narrow complex management: regular and irregular

Answer 3

Narrow complex and regular: Vagal manoeuvres then adenosine

Adenosine given in 6mg, 12mg then 12mg

If irregular = probable AF :

• consider rate control with beta blocker or diltiazem
• If in heart failure consider digoxin or amiodarone

Question 4

If there are adverse features/risk of asystole with a bradycardia then what is the management?

Answer 4

Atropine 500micrograms (repeat up to 3mg)
Or
Transcutaneous pacing

Adrenaline 2-10mcg min IV

Question 5

What are the risks of aystole for a bradycardia?

Answer 5

• Recent asystole
• Mobitz II AV block
• Complete heart block with QRS complex.
• Ventricular pause > 3.5s

If there are no adverse features and no risk of asystole then just continue to observe.

Question 6

Management of AF:

Answer 6

Rate control = Bisoprolol or diltiazem
If one drug does not do the trick, then use a combination of:
- Beta blocker, diltiazem, digoxin.

Rhythm control - electrical cardio version if patient is unstable; following this patient should be anticoagulated for 4 weeks.

• Amiodarone if patient has structural heart disease.
• Flecanide without structural heart disease

Patients must have had a short duration of symptoms (<48h) or be anticoagulated for 3 weeks before attempting cardioversion.

Question 7

Management of AF rate if patient in heart failure?

Answer 7

Digoxin.

Question 8

What are the components of the CHA2DS2VS score?

What is it used for?

Answer 8

Congestive heart failure = 1
Hypertension = 1
Age >= = 75 = 2
Age 65-74 = 1
Diabetes mellitus = 1
Stroke/TIA/thromboembolism = 2
Vascular disease = 1
Sex female = 1

Calculates stroke risk for patients with AF and suggests anticoagulation.

Question 9

What do the scores for CHA2DS2VS suggest?

Answer 9

0 = no treatment

1 = males consider anticoagulation, females no treatment.

2= offer anticoagulation

Question 10

What type of drug is diltiazem?

Answer 10

Calcium channel block

Question 11

What type of drug is amiodarone?

Answer 11

Potassium channel antagonist

Question 12

What does the ECG show in wolf Parkinson white syndrome?

Answer 12

• Short PR interval

- Slurred upstroke of R wave = delta wave

Question 13

Management of wolf Parkinson white syndrome?

Answer 13

• Avoid drugs that affect the AV node e.g. verapamil, BB, digoxin.
• Medical = amiodarone
• Surgical = radioablation of the pathway

Question 14

What is the choice of drug for anticoagulating in AF before the CHadvasc score is calculated etc?

Answer 14

Heparin.

Question 15

Management of chronic AF?

Answer 15

• Rate control is usually the treatment of choice:
  1st line = BB or CCB.
  2nd line = + digoxin

Digoxin can be used as mono therapy in sedentary patients.

• Rhythm control is not usually the treatment of choice. If it is considered 1st line is satolol or amiodarone for 4 weeks.

Question 16

What is the management of torsades de pointes

Answer 16

IV magnesium sulphate.