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Conduction system disorders Flashcards

1
Q

symptoms of conduction system disorders

A

-Palpitations
-“Extra beat”
-“Fluttering”
-“Heart beating out of chest”
-Shortness of breath
-Chest pain
-Diaphoresis
-Dizziness(room spinning- rule out vertigo)/lightheadedness(sit to stand)
-Syncope
-Cough
-Fatigue
-Weakness

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2
Q

dx of conduction system

A

-12 lead Electrocardiogram (EKG)
-Holter monitor- 24hrs – 30 days
-Implantable Loop Recorder (ILR)- Useful for cryptogenic CVA
-ILR- left of sternum -> records for 3 years

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3
Q

implanted loop recorder

A

-3 year monitor
-Triggered symptom events recorded
-Spontaneous recording of:
-Tachycardia
-Bradycardia
-Pauses
-Irregular rhythms

-Blue tooth home monitor transmissions
-MRI Compatible
-also records when pt hits the activator
-if cryptogenic stroke (recently) pts will get loop recorder to check for afib -> left atrium clot

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4
Q

paroxysmal supraventricular tachycardia

A

-rate 150-250 bpm/min
-MC paroxysmal tachycardia
-Includes:
-Irritate focus above or at the AV junction
-Most commonly AV node re-entry***-P-wave hidden in T-wave
-Narrow QRS complex

-Others:
-Atrial Tachycardia
-Multifocal Atrial Tachycardia
-Junctional Tachycardia- rapid firing from AV

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5
Q

causes of PSVT

A

-Excessive caffeine
-Alcohol consumption
-Ischemic heart disease
-Post myocardial infarction (MI)
-Structural heart disease
-Myocarditis/pericarditis
-Pulmonary embolism- right heart typically affected
-Chronic lung disease
-Medications -Amphetamines
-Idiopathic

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6
Q

SVT tx and prevention

A

-Acute phase
-Hemodynamically unstable vs. stable
-Vagal maneuvers:
-Bearing down, cough, holding breath
-*Carotid massage not recommended
-Narrow complex: Adenosine -6mg IV then 12 mg IV push (makes it go in quicker) -> makes AV node arrest
-if you did adenosine with afib it wouldnt do anything -> not coming from AV node
-Wide complex: Amiodarone (prof doesnt recommend)
-Unstable: synchronized cardioversion- reset heart

-Prevention
-Beta-blockers: atenolol, metoprolol, carvedilol
-Calcium cannel blockers: diltiazem, verapamil

-Definitive treatment: radiofrequency ablation

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7
Q

SVT medications: adenosine

A

-causes vasodilation
-Transient heart block at the AV node
-Half life is less than 10 seconds
-Most common:
-Chest pain
-SOB
-Facial flushing
-Lightheadedness
-Metallic taste*
-“Impending doom”*

-Contraindications:
-Asthma
-Long QT syndrome
-2nd/3rd degree heart blocks

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8
Q

SVT medications: amiodarone- class 3 antiarryhthmic

A

-“<65 yo, ablation not this, this is a very toxic drug”
-Half life is 58 hours
-Common side effects:
-Nausea
-Fatigue
-Tremors

-Adverse effects:
-Hepatotoxicity- every 6 months bw
-Pulmonary fibrosis!!- worst- PFTs 1x year
-Optic neuritis*
-Thyroid dysfunction- MC - every 6 months bw
-Skin Discoloration- blue skin in sun

-Contraindications:
-2nd/3rd degree heart block
-Prolonged QT
-Pregnancy
-Sinus node dysfunction

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9
Q

atrial fibrillation

A

-rate 350 – 450 bpm
-Multiple foci in the atria rapidly firing - Irregularly irregular rhythm
-NO P-wave present
-Irregular QRS intervals
-Length:
-1) Paroxysmal- Less than 7 days
-2) Persistent- Longer than 7 days
-3) Chronic- Arrhythmias presents for at least 1 year without resolution
-Commonly caused by excessive alcohol or withdrawal
-“Holiday heart” syndrome - excessive alcohol or withdrawal

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10
Q

3 questions when looking at afib

A

-hows the rate
-hows the rhythm
-protect from stroke

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11
Q

rate of afib

A

-Rate:
-Based on ventricular rate
-Rate ≥ 100 - Rapid ventricular response
-Rate 60-100- Moderate -> ventricular response
-Rate < 60- Slow ventricular response

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12
Q

causes of atrial fibrillation

A

-Ischemic heart disease
-Structural heart disease -Most commonly mitral stenosis
-Cardiomyopathy- Dilated and hypertrophic
-Pulmonary embolism
-Hyperthyroidism
-Sepsis
-Anemia
-Pheochromocytoma
-Post-operative stress
-Alcohol consumption
-Electrolyte disturbance

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13
Q

afib treatment

A

-Acute phase- Less than 48 hours from onset -> Synchronized cardioversion

-Greater than 48 hours:
-Anticoagulation + rate control 3 weeks then cardioversion -> Increased risk of thromboembolic events*
-clot breaks down in 3 weeks

-Rate control:
-Beta-blockers
-Calcium channel blockers
-Digoxin

-Rhythm control- Antiarrhythmic medications

-TEE – visualize left atrial appendage*- look for clots
-this is for pts you have high concern of clots or if you dont want to wait 3 weeks
-Anticoagulation and rate/rhythm control
-Who do we anticoagulant? -> CHADS2 score vs. CHADSVASC score
-Ablation therapy

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14
Q

CHA2DS2VASc score

A

-CHF - 1 point
-hypertension- 1 point
-age- 65-74 - 1 point, >75 2 points
-diabetes- 1 point
-CVA or TIA- 2 points
-vascular disease (h/o MI, PAD, or aortic atherosclerosis- 1 point
-sex- female- 1 point (only if they have a diff point elsewhere)

-0 points- none or ASA
-1 point- ASA or full anticoagulation
-2 or greater- full anticoagulation

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15
Q

atrial fibrillation: anticoagulation- warfarin

A

-Warfarin- (Coumadin)
-Blocks vitamin K production in the liver-> Factors II, VII, IX, and X, Protein C and Protein S
-Metabolized by Cytochrome P450
-Monitor INR- Standard goal 2-3 and Mechanical valves 2.5 – 3.5 -> if even goes .1 under -> start over therapy
-Can be reversed with Vitamin K or fresh frozen plasma**
-Affecting factors

-Decreasing INR:
-Leafy green vegetables: spinach, broccoli, brussels sprouts
-Phenytoin, phenobarbitol
-St. Jonhs wart- OTC

-Increasing INR:
-Alcohol
-Antibiotics: quinolones, amoxicillin, metronidazole
-Steroids
-Amiodarone
-if INR Is too high -> risk bleeding event

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16
Q

antiarrhythmics- class 1

A

-sodium channel blockers
-depolarization

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17
Q

antiarrhythmics- class 2

A

beta blockers

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18
Q

antiarrhythmics- class 3

A

-K channel blockers
-amiodarone
-sotalol
-repolarization
-messes with QT interval
-high risk

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19
Q

antiarrhythmics- class 4

A

-Ca channel blocker
-plateu phase

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20
Q

afib- anticoagulation- direct oral anticoagulants (DOAC)

A

-for pts with non-valvular afib -> what is valvular afib -> mitral stenosis and mechanical heart valves
-types:
-Dabigatran (Pradaxa)- Direct thrombin inhibitor
-Rivaroxaban (Xarelto)- Factor Xa inhibitor
-Apixaban (Eliquis)- Factor Xa inhibitor

-No monitoring of INR

-Reversal agents (dont need to know):
-Pradaxa = idarucizumab (Praxbind)
-Xarelto/Eliquis = andexanet alpha (Andexxa)

-All metabolized through the kidneys- Warning in renal impairment patients

21
Q

HASBLED score- bleed risk

A

-Hypertension (uncontrolled)- 1 point
-Abnormal liver or renal function (Cr > 2.26) (bili x2 or AST/ALT/AkP x3)- 1 or 2 points
-Stroke- 1 point
-Bleeding (major bleeding event)(labile INR)- 1 point
-Elderly (>65)- 1 point
-Drugs or alcohol (drugs causing bleeding) (>8 drinks a wk)- 1 or 2 points

22
Q

atrial flutter

A

-rate 250 – 350 bpm (rate of atrium not HR)
-Rapid firing of atrial focus
-Reentry circuit in the atrium
-*Produces a “saw-tooth” pattern
-Classified as atrial to ventricular conduction ratio
-can be lifetime -> recircuit
-around the valves

-Causes:
-COPD*
-Cardiomyopathy
-Structural heart disease -Atrial septal defect
-Myocarditis
-Hyperthyroidism
-Idiopathic
-these things just exacerbate the deformity thats already there

-Treatment:
-Anticoagulation
-Treatment for atrial fibrillation
-More successful with ablation therapy
-ablation is tx for life

23
Q

ventricular tachycardia

A

-Rapid ventricular focus
-3 of more premature ventricular contractions in a row
-Unifocal (monomorphic)
-Multifocal (polymorphic)

-Nonsustained vs. sustained
-NSVT: < 30 seconds
-Sustained VT: > 30 seconds -> Even if spontaneous resolution
-sustained- deliberator

24
Q

ventricular tachycardia causes

A

-Coronary artery disease- MC in patient after MI
-Cardiomyopathy
-Congenital defects
-Prolonged QT syndrome- can be candidate for defibrillator- sudden death
-Illicit drug use
-Medications

25
watchman procedure
(nonvalvular) NVAF with atrial fibrillation -reduce stroke risk that originate in LAA -seals the pocket in the LA -high CHAD and bleeding risk -> consider this
26
ventricular tachycardia tx
-pulseless tx- ACLS -stable sustained- synchronized cardioversion + antiarrhythmic -unstable sustained- synchronized cardioversion -nonsustained-beta blocker therapy -treating underlying cause: -myocardial ischemia- catheter -cardiomyopathy- echo -electrolytes -medication
27
ventricular tachycardia treating the underlying cause
-Myocardial ischemia- Cardiac catheterization -Cardiomyopathy: -Echocardiogram to assess ejection fraction and walls -Medical management of cardiomyopathy -Electrolyte abnormalities (find the cause: diuretics, dialysis): Potassium Magnesium Calcium -Medications: Sotalol, Amiodarone, Mexiletine
28
torsades de pointes
-form of polymorphic ventricular tachycardia -“Twisting of the points” -QRS complex twists around axis -Warning sign of ventricular fibrillation - prolonged QT -Treatment: -First line: magnesium 1g IV push* -Defibrillation -can sometimes pop out on its own but not typical and you should be ready
29
ventricular fibrillation
-ventricular rate of 300 - 400bpm -Rapid firing of multiple foci leading to no uniform ventricular contraction -No cardiac output -No blood pressure -Irregular and shapeless QRS pattern on EKG -Most commonly caused by ischemic heart disease*
30
ventricular fibrillation causes
-Ischemic heart disease* -Antiarrhythmics-Prolongation of the QT interval -Atrial fibrillation with rapid ventricular response -Drug toxicity -Sepsis -Hemorrhagic shock -Electrolyte abnormalities
31
ventricular fibrillation treatment
-Definitive treatment: defibrillation -CPR -Follow ACLS protocol- Defibrillation -> Epinephrine -> Defibrillation -> Epinephrine* -Amiodarone IV - 24 to 48 hours following conversion -Treat the underlying cause- Requires an ischemic evaluation -Prevention- AICD placement
32
cardiac arrest
-sudden cessation of blood flow due to failure of the heart -Inability of contractility -Death within minutes -MC cause is coronary artery disease -MC rhythm is ventricular fibrillation
33
causes of cardiac arrest
-Coronary artery disease**- ischemic -Heart failure -Genetics: pro-longed QT syndrome, -Brugada syndrome, Hypertrophic cardiomyopathy (thick septum obstructs- congenital) -Low magnesium, potassium -Anemia, hemorrhage -Trauma
34
brugada syndrome
-Genetic inheritance- Autosomal dominant disorder -Mutation of the sodium ion channels in the cardiac muscle- >60 mutations -Characterized by ST elevations with negative T wave in precordial leads V1-V3 appearance without structural cardiac abnormalities -Increased risk for sudden death for ventricular fibrillation -Onset occurs during adulthood -Definitive treatment: ICD placement
35
defibrillator
-leads go into the subclavian vein -snake into right ventricle -dual chamber- RA lead -if they have left? bundle branch block they can snake it through coronary sinus (biventricular device)
36
sick sinus syndrome
-chronic dysfunction of the sinoatrial (SA) node -Encompasses alternating dysrhythmias including: -Sinus bradycardia -Sinus tachycardia -Sinus pauses -Sinus arrest -MC in the elderly* -MC asymptomatic*
37
causes of sick sinus syndrome
-Myocardial scarring -Medications: -Beta-blockers, CCB -Antiarrhythmics -Digitalis -Lithium -Methyldopa -Genetic: Familial sick sinus syndrome -Sarcoidosis, amloydosis -lyme disease
38
sick sinus syndrome treatment
-Discontinuation of medication -Definitive treatment: permanent pacemaker placement*
39
bundle branch blocks
-Blocked conduction of the right or left bundle branch leading to delay in activation of correlating ventricle -Ventricular conduction is not in sync -1) Right bundle branch block - Left conduction -> right conduction -2) Left bundle branch block- Right conduction -> left conduction -right-left contraction -if pt also has left ventricle HF the left is weak and has to contract against the already contracted right ventricle -Measured by QRS complex: -> 0.12 seconds -> >3 small boxes -“Rabbit ears”- Overlapping of QRS complex
40
right bundle branch block (RBBB)
-leads V1 and V2 -RsR complex -T-wave inversions -Causes: -Idiopathic -Increased right ventricular pressures: -Cor pulmonale -PE -Myocardial ischemia -Treatment- Rule out underlying cause
41
left bundle branch block (LBBB)
-Leads V5 and V6 -Broadened R wave -T-wave inversions -Widened QRS in V1 and V2 -Causes: -Myocardial fibrosing: -HTN -Myocardial ischemia- LAD -Cardiomyopathies -Treatment- Rule out underlying disease
42
atrioventricular (AV) block
-Intermittent or complete failure of the conduction system between the atria and ventricles -3 classifications of heart block -First degree AV block -Second degree AV block: -1) Mobitz I (Wenckebach) -2) Mobitz II -Third degree AV block aka complete heart block
43
AV block causes
-Aging -Coronary artery disease- MI -Rheumatic heart disease -Lyme disease -Sarcoidosis -Hematomachrosis -Hyperthyroidism -Congenital -Hyperkalemia
44
AV block treatment
-First degree: no treatment required -Second degree: -Type I: No treatment required unless symptomatic -Type II: more likely to progress to third degree -> Requires permanent pacemaker -Third degree: Requires permanent pacemaker (PPM)
45
first degree heart block
-not a true block -> conduction delay -delay in the AV node -fix prolonged PR interval > .2 s and > 5 small boxes
46
second degree type 1
-Intermittent block within the AV node -Progressive lengthening of PR interval with eventual non-conducting P wave* -Caused by conduction arriving at time when AV node is absolutely refectory
47
second degree type 2
-Intermittent block within the His-Purkinje system -Fixed PR interval with eventual non-conducting P-wave* -Wide QRS complex -Can progress to complete heart block
48
third degree heart block
-complete -dissociation of electrical activity between the atria and ventricles

Cardiology (11 decks)

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