Atrial Arrhythmias

Question 1

What is a supraventricular arrhythmia?

Answer 1

An arrhythmia that occurs above the bundle of his

Question 2

What types of arrhythmias require drug treatment?

Answer 2

1. PSVT
2. automatic atrial tachycardias
3. afib/aflutter

Question 3

What is a PSVT?

Answer 3

AV nodal reentry arrhythmia

Question 4

What are the symptoms of PSVT?

Answer 4

1. episodes of rapid HR
2. abruptly start and stop
3. syncope, chest or neck pressure

Question 5

What is the severe symptom of PSVT?

Answer 5

HR > 200 bpm

Question 6

What do you do to correct severe PSVT?

Answer 6

synchronized DCC

Question 7

What do you try first to treat mild-moderate PSVT?

Answer 7

non-pharm treatments

1. unilateral carotid massage
2. valsalva maneuvers
3. induced retching
4. ice water facial immersion

Question 8

What happens if the non-pharm treatments of mild-moderate PSVT fail?

Answer 8

Use drug treatment

Question 9

What are the drug treatments for mild-moderate PSVT?

Answer 9

1. adenosine IV push
2. verapmil slow IV push
3. diltiazem slow IV push

Question 10

What is the MOA for adenosine, verapamil, and diltiazem?

Answer 10

Prolongs conduction time in slow anterograde pathway of the reentrant loop to terminate PSVT

Question 11

What are the interactions with diltiazem and verapamil?

Answer 11

3A4 inhibitors - be careful with statins, HIV meds, and benzos

Question 12

What is another way to treat PSVT other than long-term chronic drug therapy?

Answer 12

transcutaneous catheter ablation using radiofrequency currents

Question 13

What is an automatic atrial tachycardia?

Answer 13

a supraventricular foci with enhanced automatic properties

Question 14

What is often the underlying cause of automatic atrial tachycardias?

Answer 14

Severe pulmonary disease

Question 15

What also causes automatic atrial tachycardias?

Answer 15

1. acute infection
2. sepsis
3. dilated congestive cardiomyopathy

Question 16

How do you treat automatic atrial tachycardias?

Answer 16

Correct the underlying factors (proper oxygenation and correct acid/base/electrolyte disorders)

Question 17

How can you treat a symptomatic patient with automatic atrial tachycardias?

Answer 17

1st line: verapamil, diltiazem

2nd line: IV magnesium (high doses)

Question 18

What is the most common arrhythmia seen in practice?

Answer 18

Atrial fibrillation

Question 19

What leads to higher rates of afib?

Answer 19

1. Worsening HF symptoms
2. Male
3. Caucasians

Question 20

What is a common outcome of afib?

Answer 20

Not mortality –> Stroke!

Question 21

What cardiovascular conditions is afib usually associated with?

Answer 21

1. HF
2. mitral valve disease
3. CAD
4. HTN
5. Diabetes

Question 22

What are the common acute causes of afib?

Answer 22

1. MI or cardiac surgery
2. Hyperthyroidism
3. PE
4. Pericarditis
5. Alcohol intake

Question 23

What is paroxysmal afib?

Answer 23

AF that terminates within 7 days of onset

Question 24

What is persistent afib?

Answer 24

Continuous afib that is sustained for more than 7 days and does not terminate on its own

Question 25

What is permanent afib?

Answer 25

Does not terminate with cardioversion or when the patient and doctor agree to stop trying to restore SR

Question 26

What is acute afib?

Answer 26

onset within last 48 hours

Question 27

What is recurrent afib?

Answer 27

2 or more episodes (either paroxysmal or persistent afib)

Question 28

What is lone afib?

Answer 28

<60 years of age, without evidence of cardiopulmonary disease

Question 29

What is aflutter?

Answer 29

single dominant reentrant substrate

Question 30

What does AF do to CO?

Answer 30

It decreases CO and leads to an irregularly irregular rhythm

Question 31

What are the common symptoms of afib patients (if they are even symptomatic)?

Answer 31

1. palpitations 2. rapid HR 3. worsening HF 4. fatigue 5. chest pain 6. syncope

Question 32

What is a transthoracic ECHO used for?

Answer 32

To assess valve function, chamber size, and hypertrophy

Question 33

What is a transesophageal ECHO used for?

Answer 33

to screen for left atrial thrombus

Question 34

What test should you order for AF?

Answer 34

1. EKG 2. ECHO (TTE and TEE) 3. Thyroid tests 4. Electrophysiological study

Question 35

What are the goals of management of AF?

Answer 35

1. evaluate need for acute treatment 2. achieve ventricular rate control 3. need for SR restoration and maintenance 4. prevent long-term complications (thromboembolism) 5. prevent recurrence

Question 36

How do you determine if patient is hemodynamically unstable?

Answer 36

1. VR > 110 2. Severe hypotension, pulmonary edema, or acute MI

Question 37

What do you do with a hemodynamically unstable patient?

Answer 37

DCC (shock)

Question 38

What energy level is used for shock of atrial flutter?

Answer 38

50 joules

Question 39

What energy level is used for shock of afib?

Answer 39

>200 joules

Question 40

How do you select a drug to control ventricular rate?

Answer 40

Left ventricular function

Question 41

What do you use when LVEF > 40%?

Answer 41

1. IV beta-blockers (metoprolol, propranolol, esmolol) | 2. IV diltiazem, IV verapamil

Question 42

What do you use when LVEF < 40%?

Answer 42

1. IV digoxin | 2. IV amiodarone

Question 43

When do you use rate control?

Answer 43

In patients who are not symptomatic

Question 44

What is the maintenance rate control goal?

Answer 44

HR < 110 bpm according to RACE II trial