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Arrythmias Flashcards

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1
Q

What are the 5 main clinical causes of arrythmias?

A

I DAMAG(E)

  • Inflammation (viral myocarditis
  • Drugs (direct or indirect)
  • Abnormal anatomy (LVH, acc. pathways)
  • Metabolic (hypoxia, ischaemia, electrolyte)
  • Autonomic nervous system
  • Genetic (ion channel genes)
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2
Q

What are ectopic beats?

A

Beats or rhythms that originate in places outwith the SA node

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3
Q

What is Wolf Parkinson White syndrome?

A
  • Accessory pathway tachycardia
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4
Q

What is triggered activity?

A
  • In the terminal phase of the AP (phase 3) a small depolarisation may occur and if of sufficient magnitude can lead to a sustained train of depolarisations (TA)
  • This mechanism underlies digoxin toxicity, TdP in the long QT syndrome and hypokalaemia
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5
Q

What what two factors can cause rentry?

A
  • —Structural abnormalities: accessory pathways, scar from myocardial infarction, congenital heart disease
  • —Functional: Conditions that depress conduction velocity or shorten refractory period promote functional block, e.g. ischaemia, drugs
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6
Q

What are the main symptoms of an arrhythmia?

A
  • Palpitations
  • Dyspnoea
  • Dizziness
  • Presyncope/Syncope
  • Sudden cardaic death
  • Angina
  • Heart failure
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7
Q
A
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8
Q

Why would you use a 12 lead ECG when dealing with arrythmias?

A
  • To assess rhythm
  • Signs of previous MIs (Q waves) or pre-excitation (Wolf Parkinson White syndrome)
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9
Q

What does pre excitation look like on an ECG?

A
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10
Q

Why would you do an exercise ECG for a suspected arrhythmia?

A
  • To assess for ischaemia
  • Test for exercise induced arrhythmia
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11
Q

When would you use a 24hr Holter ECG when testing for arrhythmia?

A
  • To assess for paroxysmal arrhythmia
  • To like symptoms to underlying heart rhythm
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12
Q

Why would you use an echo with suspected arrhythmia?

A

To assess for structural diseases e.g.

  • enlarged atria in AF
  • LV dilatation
  • previous MI scar, aneurysm
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13
Q

What is an electrophysiological study?

A
  • Trigger the clinical arrhythmia and study its mechanism/pathway
  • Opportunity to treat arrhythmia by delivering radiofrequency ablation to extra pathway
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14
Q

What is Normal Sinus Arrhythmia?

A
  • Variation in heart rate, due to reflex changes in vagal tone during the respiratory cycle
  • Inspiration reduces vagal tone and increases HR
  • Physiological (normally seen in young, healthy people)
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15
Q

What is sinus bradycardia and what can cause it?

A
  • <60 bpm
  • physiological (i.e. athlete)
  • drugs (ß blocker)
  • ischaemia: common in inferior STEMIs
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16
Q

What is the treatment of sinus bradycardia?

A
  • atropine (if acute, e.g. acute MI)
  • pacing if haemodynamic compromise
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17
Q

What is and what causes sinus tachycardia?

A
  • >100 bpm
  • physiological (anxiety, fever, hypotension, anaemia)
  • inappropriate (drugs etc.)
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18
Q

How do you treat sinus tachycardia?

A
  • Treat underlying cause
  • ß blockers
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19
Q

What are the symptoms and treatment of atrial ectopic beats?

A
  • Asymptomatic
  • Palpitations
  • Generally no treatment
  • ß blockers may help
  • Avoid stimulants e.g. coffee/cigarettes
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20
Q

What are AVNRT, AVRT and EAT

A
  • AVNRT = AV nodal reentrant tachycardia
  • AVRT = AV reentrant tachcardia (via an accessory pathway)
  • EAT = ectopic atrial tachycardia
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21
Q
A
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22
Q

What is orthodomic AVRT? What does it look like on a 12 lead ECG?

A

Antegrade (moving forward) conduction through AV node due to accessory pathway

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23
Q

What is antidromic AVRT? What does it look like on a 12 lead ECG?

A

Retrograde (moving backwards) conduction through AV node

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24
Q

What is the management of acute supraventricular tachycardia?

A
  • Increase vagal tone (valsalva, carotid massage)
  • Slow AVN conduction - IV adenosine or verapamil
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25
What is the management of chronic supraventricular tachycardia?
* —Avoid stimulants * Electrophysiologic study and Radiofrequency ablation (first line in young, symptomatic patients * Beta blockers * Antiarrhythmic drugs
26
What is RFCA?
* Radiofrequency catheter ablation * Selective cautery of cardiac tissue to prevent tachycardia, targeting either an automatic focus or part of a re-entry circuit
27
What does the Electrophysiologic Study and RFCA procedure involve?
* ECG catheters to heart via femoral veins * Intracardiac ECG recorded during sinus rhythm, tachycardia and during pacing manouvres to locate tachycardia mechanism * catheter placed over focus/pathway and tip heated to 55-65oC
28
What is heart block?
AVN conduction disease
29
What are some causes of heart block?
* Ageing * Acute MI * Myocarditis * Infiltrative disease (amyloid) * Drugs (ß blockers, CCBs) * Calcific aortic valce disease * Post-aortic valve surgery * Genetic: Lenegre's disease, myotonic dystrophy
30
What defines 1st degree heart block, what is the treatment and what is the follow up?
* PR interval longer than normal (\>0.2s) * Treatment: none * Long term follow up reccomended as advanced block may develop over time
31
What is Mobitz 1 second degree heart block? What does it look like on an ECG?
Mobitz I * progressive lengthening of the PR interval, eventually resulting in a dropped beat * usually vagal in origin
32
What is 3rd degree heart block? What is the treatment of it and what does it look like on a 12 lead ECG?
* Where no APs from the SA node/atria get through the AV node * Ventricular pacing = treatment
33
What is Mobitz 2 second degree heart block? What is its treatment and what does it look like on an ECG?
* —Pathological, may progress to complete heart block (3rd degree HB) * Usually 2:1, or 3:1, but may be variable * Permanent pacemaker indicated
34
What are the types of pacemakers?
* Single chamber (paces the RA or RV only) * Dual chamber (paces both RA and RV) - maintains AV syncrony (preseves atrial kick), used for AVN disease
35
What are some causes of ventricular ectopics?
* Structural causes: LVH, heart failure, myocarditis * Metabolic: Ischaemic heart disease, electrolytes * May be a marker for inherited cardaic conditions
36
When do you need to further investigate ventricular ectopics and what can be done to treat it?
* Further investigation if worse on exercise * ß blockers * Ablation of focus
37
What is the danger of ventricular tachycardia and what are the causes
* Can cause sudden death * Most patients have CAD/a precious MI * More rare: cardiomyopathy or inherited syndromes such as Long QT or Brugada
38
What are the defining ECG characteristics of VT?
* Rapid, wide, distorted QRS * Large, inverted T waves * Usually no P waves
39
What is ventricular fibrilation overall?
* Chaotic ventricular electrical activity which causes the heart to lose the ability to function as a pump
40
What is the long term treatment
* Correct ischaemia e.g. revascularisation * Optimise congestive heart failure therapies * ICD * VT catheter ablation
41
What should you treat a wide QRS tachycardia with a history of CAD/HF as?
VT until proven otherwise
42
What use are AADs in VTs
Reduce symptoms - ineffective on survival
43
What is Atrial Fibrilation?
* —Chaotic and disorganized atrial activity * Causes a irregular heartbeat * Most common sustained arrythmia * Incidence increases with age
44
What are the three types of atrial fibrilation?
* Paroxysmal - lasting \<48 hrs, often recurrent * Persistent - Episode \>48 hrs that can be cardioverted to NSR, unlikely to spontaneously revert to NSR * Permanent - no way to restore NSR
45
What are the methods of termination of atrial fibrilation?
* Pharmacologic cardioversion with AADs (30% effective) * Electrical cardioversion (90% effective) * Spontaneous reversion to sinus rhythm
46
What is lone A Fib?
* —A Fib with absence of any heart disease and no evidence of ventricular dysfunction * Could be gnetic * Significant stroke rate if \>75 yo
47
What are the symptoms of A Fib?
* ——Palpitations * Pre-syncope (dizziness), Syncope * Chest pain * Dyspnoea * Sweatiness * Fatigue
48
What is the atrial rate, rhythm, ventricular rate and signs of A Fib on an ECG?
* Atrial: \>300bpm * Rhythm: Irregularly irregular * Ventricular rate: variable * Signs: no P waves, presence of F
49
What complication can be caused by A Fib?
* Reduced diastole, reduced CO * Can lead to congestive heart failure, especially if diastolic dysfunction
50
What is a dangerous ventricular rate in A Fib?
* \<60 bpm points to AV conduction disease * Caution w AADs * May require permanent pacing
51
What are the main aims of atrial fibrilation management?
* Rhythm control - attempt to maintain SR OR * Rate control - accept AF but control V rate * Anticoagulation for both if approaches high risk for thromboembolism
52
What four drugs can be used to slow down AVN conduction and treat rate control of A Fib?
* —Digoxin * Betablockers * Verapamil, diltiazem * Alone or in combination
53
What can be dine to restore and maintain NSR in A Fib?
Restore * Pharmacological (AAM e.g. amiodarone) Maintain * AAMs * Catheter ablation of atrial focus / pulmonary veins * Surgery (Maze procedure)
54
What is TdP?
Torsades de Pointes * —Heart rate: 200 - 250 bpm * Rhythm: Irregular * Recognition: * Long QT interval * Wide QRS * Continuously changing QRS morphology
55
What score can be used to identify likelhood of a stroke?
CHA2DS2-VASC
56
If you have A Fib and mitral valve disease what should be done?
Anticoagulation
57
What is A Flutter, where does it originate and what can it lead to?
* Rapid and regular form of A tachycardia * Usually paroxysmal * Sustained by macro-reentrant circuit in RA * Can lead to A Fib or result in thrombo embolism
58
What is the defining characteristic of a A Flutter ECG?
Sawtooth baseline
59
What are the A Flutter treatment options?
* RF ablation (80-90% long term success * AAM - slow ventricular rate, restore and maintain NSR * Cardioversion * Warfarin to prevent thromboembolism
60
What are shockable and unshockable rhythms?
* Shockable * VF * Pulseless VT * Non-shockable * PEA * Asystole

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