Arrythmias

Question 1

Ectopic beats - Treatment

Answer 1

If non troublesome treatment may not be required, however Beta-blockers are first line if troublesome

Question 2

Atrial Fibrillation - Aims of Treatment and how this is achieved?

Answer 2

Reduce symptoms and prevent complications such as stroke. This is done by either rate or rhythm control

Question 3

AF with life threatening haemodynamic instability - Acute presentation treatment

Answer 3

Emergency electrical cardioversion

Question 4

AF presenting acutely without life threatening haemodynamic instability treatment
A) onset of arrhythmia < 48 hours
B) onset of arrhythmia > 48 hours

Answer 4

A) rate or rhythm control
B) rate control is preferred

Question 5

If urgent rate control is required what are the two options?

Answer 5

IV Beta blocker or rate limiting calcium channel blocker such as Verampamil*
*if Left ventricular ejection fraction is >40%

Question 6

Which drugs can be used for a pharmacological cardioversion?

Answer 6

Flecanide acetate or Amiodarone

Question 7

When is an electric cardioversion preferred?

Answer 7

If AF has been present for longer than 48 hours.
But this should be delayed until patient has been fully anti-coagulated for at least 3 weeks before and 4 weeks after the electric cardioversion.

Question 8

What treatment is first line strategy for AF?

Answer 8

Rate control (except in new-onset, with atrial flutter suitable for ablation, with a reversible cause or with heart failure with AF as the cause).

Question 9

Rate control drugs include:

Answer 9

-Beta-blocker (not sotalol!)
-Rate limiting calcium channel blocker such as diltiazem
-Verapamil

Question 10

How should rate control drug be decided?

Answer 10

A mixture of individual symptoms, heart rate, co-morbities, patient preference.

Question 11

When should digoxin be considered as monotherapy in atrial fibrillation?

Answer 11

Digoxin monotherapy should only be considered for initial rate control in patients with non-paroxysmal atrial fibrillation who are predominantly sedentary, or in those where other rate-limiting drugs are unsuitable.

Question 12

How do you measure A) stroke risk and B) bleeding risk in patients with AF

Answer 12

A) CHA2DS2-VASc
B) ORBIT

Question 13

Atrial Flutter treatment

Answer 13

Rate control- interim measure whilst awaiting restoration of sinus rhythm (usually with beta-blocker, verapamil or diltiazem)
Rhythm control- digoxin

Question 14

What is paroxysmal supraventricular tachycardia

Answer 14

A sudden rapid increase in heart rate

Question 15

How to treat paroxysmal supraventricular tachycardia

Answer 15

Often responds well to reflex vagal stimulation such as immersing the face in ice cold water.

Question 16

What is torsades de pointes?

Answer 16

A form of ventricular tachycardia associated with long QT interval.

Question 17

Which factors contribute to torsades de pointes?

Answer 17

Most often drug induced however other factors such as hypokalaemia, severe bradycardia and a genetic predisposition.

Question 18

How are anti-arrhythmic drugs classified?

Answer 18

Those that act on;
Supraventricular tachycardias- Verampanil
Both Supraventricular and ventricular arrhythmias- Amioderone
Ventricular arrhythmias- Lidocaine

Question 19

Vaughan Williams classification based on effects on electrical behaviours of myocardial cells?

Answer 19

Class I- membrane stabilising drugs (fleccanide)
Class II - beta-blockers
Class III - Amioderone, sotalol
Class IV- Calcium channel blockers (verampanil not dihydropyridines)

Question 20

Supraventricular arrhythmia treatment-

Answer 20

Adenosine is first line in paroxysmal supraventricular tachycardia as as half life is only around 8-10 seconds.