Clinical arrhythmia lecture

Question 1

Some antiarrhythmics (Class 1A, 1C, Class III), erythromycin, antifungals, tricyclic antidepressants

…can cause?

Answer 1

Prolonged QT interval

Question 2

Atrial fibrillation with controlled or slow rate in absence of meds that slow AV conduction.

Answer 2

Sick sinus syndrome variation

Question 3

Brady-Tachy Syndrome- paroxysmal atrial tachyarrhythmias accompanied by sinus node dysfunction and symptomatic bradycardia.

Answer 3

Sick sinus syndrome variation

Question 4

Presence of symptoms clearly related to sinus node dysfunction (pauses) proven by ECG.
40% will have concomitant AV Node dysfunction, heart block.

Answer 4

Sick sinus syndrome

Question 5

Most common cause of sick sinus syndrome?

Answer 5

AGING

Question 6

Sinus node dysfunction
AV node dysfunction

…treatment

Answer 6

permanent pacemaker

Question 7

Sick sinus syndrome tx

Answer 7

step 1…eliminate offending drug (if applicable)

step 2..pacemaker

Question 8

PAC precipitating factors

Answer 8

ETOH
caffeine
adrenergic stimulation

Question 9

*Paroxysmal and persistent forms.**
May be seen in healthy individuals (5%) without HD
*can be precipitated by emotional stress, use of stimulants, following surgery, or with acute ETOH intoxication (“holiday heart”).
*Also occurs in absence of a precipitant

Answer 9

A fib

Question 10

95% of A fib cases seen in the presence of…

Answer 10

underlying cardiac or pulmonary pathology

Question 11

_____ most often seen in valvular, hypertensive and coronary heart disease
*frequently develops in adults with atrial septal defects

Answer 11

A fib

Question 12

Irregularly irregular rhythm
atrial depol 400-600/min

*if new/untreated…ventricular rate tachycardia (often 120-180)

Answer 12

A fib

Question 13

If rate continuously exceeds 200 bp, consider A fib with…

Answer 13

WPW

Question 14

First priority when assessing A fib patient….

Answer 14

ASSESS HEMODYNAMIC STABILITY

most yes. if no…cardioversion

Question 15

Must worry about thromboembolic if in A fib for longer than….

Answer 15

48-72 hours

Question 16

Diagnostic test that all new onset A fib patients must have

Answer 16

Cardiac ultrasound (echo)

Question 17

If hemodynamically stable, initial goal for a fib tx

Answer 17

Rate control

Question 18

IV _____ is best for rapid rate control in ED for A fib

Answer 18

Diltiazem

Question 19

Oral diltiazem, verapamil, or beta blockers

Answer 19

Best for chronic rate control of A fib

Question 20

If A fib present for longer than 72 hours…

Answer 20

MUST FULLY ANTICOAGULANT

no cardioversion until 3 weeks of anti coagulation

Question 21

2 chronic A fib management strategies

Answer 21

1. rhythm control

2. rate control

Question 22

cardioversion to NSR+ drug Rx to maintain sinus rhythm→↑ CO/function, but side effects of meds, recurrences of Afib.

Answer 22

Rhythm control strategy of A fib

Question 23

leave in afib, control ventricular rate + anticoagulate (warfarin* for most patients)

Answer 23

Rate control strategy of A fib

Question 24

CHADS2 or CHADS VAS

Answer 24

used to calculate risk of stroke

Question 25

If a pt with a fib has a CHADS score of 0...

Answer 25

Can leave in a fib, don't need to anticoagulate

Question 26

Definitive treatment for A fib rhythm control...

Answer 26

Ablation with surgery or catheter | 65-90% success

Question 27

This drug class appears to increase risk of developing a fib or a flutter

Answer 27

NSAIDs

Question 28

Underlying heart disease always present. **Paroxysmal and persistent forms. Embolization risk less than Afib but occurs. *Rate usually 240-350; ventricular rate most often 1/2 the flutter rate; less stable hemodynamically; difficult to slow with meds.

Answer 28

A flutter

Question 29

Most effective tx for A flutter

Answer 29

DC cardioversion | often need meds to prevent recurrence

Question 30

If you see a 4:1 atrial flutter..is this person already being treated?

Answer 30

Most likely yes

Question 31

Re-entry is responsible for vast majority of cases Seen in any age group, especially healthy young adults. ***Narrow complex, regular tachycardia, rate usually 150-220. **P waves usually not identifiable; may come after QRS

Answer 31

PSVT

Question 32

2 pathways of AV node

Answer 32

Alpha and beta

Question 33

Requires dual AV nodal (α & ß pathways) that can conduct in either direction. **Initiated by PAC conducted antegrade down one (β) AV pathway; if conduction slow enough to allow previously refractory other (α) pathway time to recover, impulse will be conducted retrograde back through the AVN initiating a re-entry circuit

Answer 33

PSVT

Question 34

DOC for PSVT

Answer 34

Adenosine

Question 35

Interventions that increase vagal tone (e.g. carotid message or valsalva) may abruptly terminate the rhythm.

Answer 35

PSVT

Question 36

Selective ablation of AV node can be tx for

Answer 36

PSVT

Question 37

Accessory A-V bypass tract (Kent Bundle) allows conduction to ventricles as alternative to the AV node. ECG findings: Short PR interval and Delta waves

Answer 37

WPW

Question 38

Can you use Adenosine, ß-Blockers, Diltiazem, Verapamil in a WPW pt with A fib or A flutter?

Answer 38

NO!!!! | can use Procainamide or Amiodarone

Question 39

Lidocaine will slow conduction through...

Answer 39

kent bundle! (in WPW)

Question 40

Radio Frequency Ablation: Catheter ablation of the bypass tract is effective (90%) and curative. Treatment of choice for most ____ patients.

Answer 40

WPW

Question 41

Most patients developing VF within 1st 48 hrs of an acute MI have a _____ prognosis if successfully resuscitated

Answer 41

good long term

Question 42

Resuscitated VF unassociated with acute MI has a very high recurrence rate (> 30% recur within the first year following the initial event), and carries a....

Answer 42

very poor prognosis *tx with ICD

Question 43

most common cause of sudden cardiac death

Answer 43

V fib

Question 44

V fib sometimes occurs following administration of antiarrhythmic drugs - especially in patients with....

Answer 44

prolonged QT interval

Question 45

prominent jugular pulsation and palpable parasternal lift * harsh systolic murmur best heard at second and third left intercostal space * radiates to left shoulder * early systolic sound precedes the murmur during expiration

Answer 45

Pulmonic stenosis