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Semester 1 ( 3rd Year) > Case 7: Palpitations > Flashcards

Case 7: Palpitations Flashcards

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1
Q

what are the inner, middle and outer layers of the heart called

A

inner= endocardium
middle= myocardium
outer= epicardium

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2
Q

function of cardiomyocytes

A

contract in unison to provide and effective pump action to ensure adequate blood perfusion of the organs and tissues

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3
Q

what cells make up the bulk volume of the heart

A

cardiomyocytes

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4
Q

what % of the bodies total cell volume is cardiomyocytes

A

30-40%

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5
Q

which gender have a lower risk of sudden death and AF

A

female

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6
Q

important Qs when taking history for palpitations

A

recent viral illness

history of anxiety

weight loss, diarrhoea (thyroid symptoms)

diet (vegetarian?), heavy menstruation, any other bleeding (possibly anaemia)

high tea/coffee/alcohol intake

family history of sudden death

illicit drug use (amphetamines)

smoker

hypertension

are you pregnant (higher output)

anything else- chest pain, sweating, nausea

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7
Q

what to ask about the palpitations specifically

A

what do you mean by heart beating fast

tap it out

are there beats missing

regular/irregular

is it constant

how long does it last

any precipitating features (on exertion/ at rest)

anything making better/worse

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8
Q

what could be the cause of palpitations

A

normal physiological response- to pain, temperature, hormone response

sinus tachycardia

excess thyroid hormone can cause arrythmias/sinus tachycardia

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9
Q

what is the process of an action potential (ion channels opening and closing)

A

voltage gated Na+ open

Na+ inflow depolarises the membrane and triggers opening of more Na+, creates a positive feedback cycle and rapidly rising membrane voltage

Na+ channels close when cell depolarises and voltage peaks at nearly +30mV

Ca2+ entering slow Ca channels prolongs depolarisation of the membrane (creates plateau)- this falls slightly due to K+ leakage (most K+ stay closed until end of plateau)

Ca2+ close and Ca2+ is transported out of cell, K+ opens and rapid K+ outflow returns membrane to its resting potential

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10
Q

the cardiac conduction cycle

A

the SA node and rest of the conduction system are at rest

SA node initiates AP which sweeps across the atria

after reached AV there is 100 ms delay allowing the atria to complete pumping blood before impulse is transmitted to AV bundle

after delay, impulse travels through AV bundle and bundle branches to purkinje fibres and reaches right papillary muscle via moderator band

impulse spreads to contractile fibres of ventricle

ventricular contraction begins

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11
Q

lead I detects electrical activity from which aspect of the heart

A

left lateral

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12
Q

lead aVR detects electrical activity from which aspect of the heart

A

right atrium

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13
Q

lead V6 detects electrical activity from which aspect of the heart

A

left ventricle

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14
Q

what are the two main classifications of arrhythmias

A

narrow complex and broad complex tachycardias

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15
Q

red flag symptoms with palpitations

A

SOB
chest pain
syncope
heart failure

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16
Q

if patient presents with palpitations what are you looking for

A

HR and rhythm and BP (if signs of haemodynamic instability admit the patient)

check for murmurs suggestive of valvular disease

assess for signs of heart failure (raised JVP, lung crepitations, peripheral oedema)

signs of thyrotoxicosis (as can cause arrhythmia)

anaemia (can result in sinus tachycardia as physiological response to low Hb the heart pumps faster to ensure more O2 reaches organs)

infection and sepsis

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17
Q

signs of thyrotoxicosis

A

goitre
tremor
exophthalmos

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18
Q

signs of anaemia

A

pallor of creases
conjuctivae

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19
Q

signs of infection

A

temperature
flushing

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20
Q

what may be causing a short-lived fast palpitation in someone young

A

sinus tachycardia due to anxiety/stress

intermittent arrythmia such as SVT

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21
Q

cause of flip flopping palpitations

A

extra systoles such as supra ventricular or ventricular premature contractions

there is a pause then forceful contraction and the sensation that the heart has stopped results from the pause

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22
Q

cause of rapid fluttering palpitations

A

sustained supra ventricular arrhythmias

the sudden cessation of this arrhythmia can suggest paroxysmal supra ventricular tachycardia

this is further supported if the patient can stop the palpitations by using Valsalva manoeuvre

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23
Q

what may irregularly irregular palpitations indicate

A

AF

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24
Q

what may an irregular pounding sensation in the neck suggest

A

atrioventricular dissociation (atria are contracting against closed tricuspid and mitral valves, therefore producing cannon A waves)

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25
what may palpitations induced by exercise represent
cardiomyopathy ischemia channelopathies
26
excess of what during stress and exercise may cause palpitations
catecholamines
27
secondary advice to reduce palpitations
smoking cessation weight reduction reduced caffeine anxiety management
28
what tests would you do on a young patient presenting with short lived intermittent palpitations
FBC- to rule out anaemia TFTs- even if no symptoms as thyroid disease can present with intermittent palpitations only
29
pathophysiology of bradycardias
depolarisation fails to initiate or conduct properly in SA node disease or heart block (AV node, His-bundle)
30
pathophysiology of tachycardias
abnormal depolarisation occurring in the heart in enhanced automaticity or reentry
31
what is seen on ECG with sinus bradycardia
normal upright P wave preceding every QRS with a ventricular rate of less than 60BMP
32
normal causes of sinus bradycardia
seen in athletes or when asleep
33
when would you need to consider treatment for sinus bradycardia
if symptomatic- SOB, syncope, fatigue, haemodynamical instability
34
what may be needed for sinus bradycardia
pacemaker
35
what is sinus pause
is a bradycardia SA node fails to generate electrical impulse for what is generally a brief period of time
36
symptoms of sinus pause
missed/skipped beats flutters palpitations hard beats presyncope dizzy/lightheaded syncope
37
pathophysiology of sinus pause
if the heart misses a beat blood does not flow during that time period resulting in a lack of O2 perfusion throughout body
38
treatment for sinus pause
may involve medication possible temporary/permanent pacemaker
39
what us sinoatrial exit block (heart block)
the depolarisations that occur in the sinus node cannot leave the node towards the atria- they are blocked
40
what is seen on ECG with sinoatrial exit block (heart block)
seen as a pause SA exit block can be distinguished from sinus arrest because the pause in SA exit block is a multiple of the P-P interval that preceded the pause
41
types of heart block
1st degree 2nd degree (wenckeback or mobitz type I) 2nd degree (mobitz type II) 3rd degree
42
what is automaticity in terms of tachycardias
an area of myocardial cells depolarise faster than the SA node may be atrial or ventricular tissue most occur at a single focal site
43
what is reentry in terms of tachycardias
an electrical pathway which is not supposed to be there connecting two areas which should not be connected these connections can be congenital or because of heart disease if this connection exists it can form an electrical circuit
44
what is a supraventicular tachycardia (SVT)
heart condition where the heart suddenly beats much faster than normal this originates from faulty electrical impulses in upper part of the heart (atria/nodes) rather than from the ventricles
45
what is a venticular tachycardia (VT)
sequence of 3 or more ventricular beats frequency must be higher than 100BMP (mostly 110-250BMP)
46
types of SVT
AF atrial flutter AVNRT AVRT atrial tachycardia
47
types of VT
ventricular tachycardia ventricular fibrillation
48
wolff Parkinson white syndrome is a form of which SVT
AVNRT
49
pathophysiology of Wolff Parkinson white
SVT which uses an AV accessory tract this accessory pathway may also allow conduction during other supra ventricular arrhythmias such as AF or flutter
50
how are the types of Wolff Parkinson white classified
based off ecg findings
51
what is type A Wolff Parkinson white
delta wave and QRS predominantly upright in precordial leads dominant R wave in lead V1 may be misinterpreted as right bundle branch block
52
what is type B Wolff Parkinson white
delta wave and QRS complex predominantly negative in leads V1 and V2 and positive in other precordial leads, resembling left bundle branch block
53
how common is Wolff Parkinson white
found in 1-3 people per 1000 found in all ages but most common in young previously healthy people
54
what complication has Wolff Parkinson white been linked to
sudden cardiac death in children and young adults
55
how can vagal manoeuvres help with tachycardias
vagal manœuvres make your vagus nerve act on the hearts natural pacemaker slowing down its electrical impulses the vagus nerve (goes from brainstem to abdomen) plays major role in parasympathetic nervous system which controls a number of things including HR
56
diagnostic uses of vagal manoeuvres
valsalva can be used to distinguish between ventricular tachycardia and suparventricular tachycardias by slowing the rate of conduction at SA or AV nodes carotid sinus massage are used to diagnose carotid sinus hypersensitivity
57
therapeutic uses of vagal manoeuvres
they are first line treatment of haemodynamically stable supraventricular tachycardia (slows down arrhythmia) they have reported a success rate of conversion to sinus rhythm for SVT around 20-40% possibly higher for AVNRT (an SVT associated with a bypass tract)
58
examples of vagal manoeuvres
valsalva- lying on back take deep breath and act like you're exhaling but with nose and mouth closed for 10-30 seconds- should feel like you're trying to breath out air into a blocked straw diving reflex- while sitting take several deep breaths, hold breath then quickly but whole face into a container of ice water, keep face submerged as long as you can carotid sinus massage- lie on back with head turned to one side, doctor will use fingers to push down on your carotid sinus for 5-10secs gag reflex cough handstand for 30 seconds applied abdominal pressure- lie on back and fold lower body toward face until feet are past head, take breath and strain for 20-30 secs
59
what would mean patient is unstable and not suitable for vagal manoeuvres
low BP chest pain SOB hypoxia poor perfusion to organs
60
what are the DVLA rules regarding arrhythmias
group 1- must stop driving if arrhythmia has caused or is likely to cause incapacity, driving may be permitted if underlying cause has been identified and has been controlled for at least 4 weeks group 2- disqualifies from driving if arrhythmia has caused or is likely to cause incapacity, DVLA must be informed
61
are atrial ectopic beats worrying
no they are normal findings and do not require treatment
62
what are one of the most common causes of palpitations
atrial (supraventricular) or ventricular ectopics
63
what are atrial (supraventricular) or ventricular ectopics usually described as
skipped/missed beats the often occur in clusters (hour of frequent ectopics occurring once a month)
64
what may women describe a link with their atrial (supraventricular) or ventricular ectopics with
their menstrual cycle
65
are ventricular ectopics worrying
no can be a normal finding usually associated with good long-term prognosis in patients with structurally normal hearts in those with structural heart disease they should be evaluated more carefully (can give rise to LV dysfunction- tachycardiomyopathy/ tachycardia induced cardiomyopathy)
66
what can be used to treat sinus tachycardia induced by stress/anxiety
propanolol
67
what is seen on ECG with AF
absent/ abnormal P waves irregularly irregular QRS complexes (R interval) ventricular rate is usually fast
68
how to calculate ventricular rate on an ECG with AF
count number of QRS complexes on the rhythm strip and multiply by 6
69
what is heart rate like in AF with rapid ventricular response
over 180 BMP
70
what do you need to assess for before administering IV fluids
signs of heart failure
71
why might you do a FBC
look for raised WCC (infection)
72
why might you do Us and Es
check for dehydration
73
why might you do LFTs
baseline is required before administering medication
74
why might you do troponin
due to ischaemic changes on ECG to exclude cardiac event however, troponin is often raised with AF and rapid ventricular response
75
why might you do CRP
marker of inflammation and infection if raised
76
why might you do MSU (mid stream urine)
look for infection
77
why might you do chest X-Ray
to exclude pneumonia
78
why might you do blood culture
if patient has temperature (infection)
79
why might you do and ABG
if patient is hypoxia/hypercapnic can get lactate as well to assess for sepsis
80
if palpitations last seconds what may it be
ectopy
81
if palpitations last minutes-hours what may it be
SVT AF atrial flutter VT
82
if palpitations come on suddenly what may it be
SVT paroxysmal AF
83
if palpitations come on gradually what may it be
sinus tachycardia atrial tachycardia
84
what can palpitations result in
cardiac arrest increased risk of sudden death heart failure haemodynamic instability resulting in dizziness/syncope hospitalisation
85
how many patients have been diagnosed with AF in the UK
1.5 million
86
what is the most common sustained arrhythmia
AF
87
AF is most common at what age
1 in 3 have it over 65
88
what is the atrial beat like in AF
over 300 BMP
89
pathophysiology of AF
here is disorganised electrical activity within the atria gives rise to abnormal/absent P waves (sometimes called fibrillation waves) AV node is usually unable to conduct as such rapid rates so there is consequently a degree of AV block ventricular conduction is random and hence gives rise to irregularity of ventricular beats (causes irregular RR interval)
90
what is a major trigger for AF
pulmonary vein ectopy (enters the left atrium and triggers AF)
91
is AF or ventricular tachycardia more likely to result in cardiac arrest
ventricular tachycardia
92
there is an increased risk of death by what in AF
stroke (five fold increase and usually more severe and disabling) heart failure (reduced LV systolic function)
93
what two conditions can cause each other
AF can cause heart failure heart failure can cause AF
94
what tool should be used for stroke prevention with AF
CHA2DS2VASc score
95
how is the CHA2DS2VASc score used to treat patients with AF
if high stroke risk offered anticoagulation (DOACs 1st line) need to assess bleeding risk
96
what tool is used to assess bleeding risk
HASBLED score (3 or more is high risk and requires close monitoring)
97
which DOAC is licensed for patients with chronic kidney disease
apixaban
98
what therapies may be used for symptom control in AF
for rate control beta blockers to maintain sinus rhythm amiodarone/flecainide catheter ablation to maintain sinus rhythm (pulmonary vein isolation ablation) permeant pacemaker to allow use of medications +/- an AV node ablation (pace and ablate)
99
what risk factors/co morbidities may increase AF risk
overweight alcohol excess hypertension diabetets sleep apnoea heart failure
100
what timeframe is non sustained AF
< 30 seconds
101
what timeframe is long standing persistent AF
> 1 year
102
what timeframe is paroxysmal AF
between 30 seconds - 1 week
103
common causes for sustained palpitations
AF sinus tachycardia SVT
104
less common causes for sustained palpitations
ventricular tachycardia
105
common causes for non-sustained palpitations
atrial ectopic
106
less common causes for non-sustained palpitations
ventricular ectopic
107
what may be the underlying cause to sinus tachycardia
pain exercise anaemia anaemia thyrotoxicosis pheochromocytoma anxiety
108
what is torsades de pointes
ventricular tachycardia characterised by sinusoidal waveforms on ECG can progress to ventricular fibrillation rare but potentially life threatening
109
what beta blocker is used fo AF commonly
bisoprosol 2.5mg OD
110
what are some reversible causes of AF
lower respiratory tract infection hyperthyroidism excess alcohol heart failure/cardiomyopathy ischaemic heart disease PE hypokalaemia
111
what other test can help assess bleeding risk in patients with AF
ORBIT score
112
what findings fit with a diagnosis of pneumonia
raised urea raised WCC raised CRP raised lactate consolidation on X-Ray
113
warfarin mechanism and dose
vitamin K antagonist variable INR (target 2.5, range 2-3)
114
apixaban mechanism and dose
factor Xa inhibitor 5mg twice daily (reduced to 2.5mg twice daily)
115
dabigatran mechanism and dose
direct thrombin inhibitor 150mg twice daily (reduced to 110mg twice daily)
116
edoxaban mechanism and dose
factor Xa inhibitor 60mg once daily (reduced to 30mg once daily)
117
rivaroxaban mechanism and dose
factor Xa inhibitor 20mg once daily (reduced to 15mg once daily)
118
who would be offered warfarin instead of DOACs
patients with mechanical heart valves or moderate-severe rheumatic mitral stenosis
119
what is the significance of a dilated left atrium
it is common in patients with hypertension indicates left atrial stretch due to high intra cardiac pressures may predispose to AF and other atrial arrhythmias
120
what is first line for rate control in AF
beta blockers (bisoprolol) use with caution in patients with acute heart failure or elderly due to risk of hypotension
121
what is second line for rate control in AF
calcium channel blockers (diltiazem/verapamil) avoid in patients with left ventricular systolic dysfunction as has negative inotropic effect
122
why do you avoid using bisoprolol and rate limiting calcium channel blockers together
high risk of AV block
123
what is the most common drug used for rhythm control in AF
flecainide avoid in patients with coronary artery disease and structural heart disease beta blocker or calcium channel blocker should be taken at the time to reduce risk of atrial flutter

Semester 1 ( 3rd Year) (12 decks)

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