ECG Arrhythmias pt. 1

Question 1

List 3 sinus arrhythmias

Answer 1

1) Sinus arrhythmia
2) Sinus bradycardia
3) Sinus tachycardia

Question 2

List 4 atrial arrhythmias

Answer 2

1) Premature atrial complex (PAC)
2) Atrial flutter
3) Atrial fibrillation
4) Supraventricular tachycardia

Question 3

List 6 ventricular arrhythmias

Answer 3

1) Abnormal ventricular conduction (BBB)
2) Premature ventricular complex (PVC)
3) Ventricular tachycardia
4) Ventricular fibrillation
5) Ventricular asystole
6) Pulseless electrical activity

Question 4

List 1 conduction abnormality

Answer 4

1) First degree atrioventricular block

Question 5

Define ectopy

Answer 5

1) Describes heartbeats that originate from an area other than the heart’s natural pacemaker (SA node)
2) Can be benign or a problem

Question 6

Define foci

Answer 6

Areas within the heart that are not normal pacemaker (SA node) but can initiate electrical impulses & lead to premature beats or arrhythmias

Question 7

List 3 areas foci can be located

Answer 7

1) Atria
2) AV junction
3) Ventricles

Question 8

List two arrhythmias that are considered ectopic beats

Answer 8

1) Premature ventricular complex (PVC)
2) Premature atrial complex (PAC)

Question 9

Explain premature atrial complex Hint: 3

Answer 9

1) Premature activation of the atria
2) Usually no significance
3) Can occur in anyone

Question 10

Explain what is happening on this ECG strip showing PAC

Answer 10

In the middle of the strip we see that the P to P & R to R is equal; then towards the end of the 6 sec strip we see a change in the P wave & the R to R interval happens a lot closer together meaning the SA node was not ready to fire

Question 11

What does it mean if we see a PAC strip?

Answer 11

The beat came from a different foci (atria) from an area other than the SA node (ectopic atrial foci)

Question 12

List 5 causes of PAC

Answer 12

1) Caffeine
2) Smoking
3) Alcohol
4) MI
5) COPD

Question 13

Is a PAC always symptomatic?

Answer 13

NO → can be asymptomatic or feel like a skipped beat

Question 14

Tx options for PAC

Answer 14

1) Usually do not need TX
2) Can get loop monitor placed under the skin

Question 15

Describe the ECG findings on PAC Hint: 3

Answer 15

1) P wave will look different
2) Shortened PR interval
3) R to R will not be equal

Question 16

What is the patho behind A-fib?

Answer 16

Multiple ectopic foci, often originating in the pulmonary veins, override the SA node causing atria to depolarize rapidly & erratically (up to 300-600 bpm) leading to incomplete atrial contraction

Question 17

In A-fib are the atrial beats actual beats?

Answer 17

No → it is just fibrillating

Question 18

Why do we not see a ventricular rate of 300+ bpm when someone is in A-fib?

Answer 18

The AV node filters many of the atrial impulses, so the ventricles beat more slowly, but still irregular (100-175 bpm)

Question 19

What happens to cardiac output in A-fib?

Answer 19

Decreases from losing atrial kick (up to 30%)

Question 20

List 4 ECG findings for A-fib

Answer 20

1) Rhythm is irregularly irregular
2) NO P WAVES
3) Uncontrolled rate → > 100 bpm
4) Controlled rate → < 100 bpm

Question 21

List 5 causes of A-fib

Answer 21

1) HTN
2) Valvular heart disease
3) Heart failure
4) Cardiac surgery
5) Hyperthyroidism

Question 22

What commonly occurs in people with A-fib caused by HTN?

Answer 22

Increase risk of falls if rate goes too high

Question 23

What should we suspect is the cause of A-fib if a patient comes in with no noticeable risk factors?

Answer 23

Precursor to diagnosing hyperthyroidism

Question 24

How does hyperthyroidism cause A-fib?

Answer 24

It increases sympathetic activity

Question 25

How do HTN & valvular heart disease cause A-fib?

Answer 25

Increases atrial pressure

Question 26

What is the significance of the left atrial appendage in A-fib?

Answer 26

Blood goes and sits here (like a pond for the atria); it becomes stagnant & can form clots that can rupture & travel (embolus)

Question 27

Where do the clots that form in the left atrial appendage normally travel to?

Answer 27

The brain → can cause strokes

Question 28

List the 3 major concepts A-fib Tx is based on

Answer 28

1) Stroke prevention 2) Heart rate control 3) Return to sinus rhythm

Question 29

What % of strokes are caused by A-fib?

Answer 29

15%

Question 30

What is the Tx option to prevent strokes in A fib?

Answer 30

Anticoagulation therapy essential for sustained (over 7 days) & paroxysmal (under 7 days) A fib

Question 31

Anticoagulants: List 4 things to remember regarding Warfarin (Coumadin)

Answer 31

1) PT/INR (2-3) needs to be checked every month 2) Antidote → Vit. K (vit. K antagonist) 3) Avoid leafy green vegetables & alcohol 4) Bridge therapy → start on hep until warfarin kicks in after 5 days

Question 32

Anticoagulants: List 4 DOAC Factor Xa meds

Answer 32

1) Dabigatran (Pradaxa) 2) Apixaban (Eliquis) 3) Rivaroxaban (Xarelto) 4) edoxaban (Savaysa)

Question 33

Anticoagulants: List 3 pros and a con of the DOAC factor Xa anticoags

Answer 33

Pros: 1) Short half life 2) No drug monitoring needed 3) Risk for bleeding is less than Warfarin Cons: 1) Very expensive

Question 34

Anticoagulants: Which DOAC factor Xa med must be kept in it's original pill bottle?

Answer 34

Dabigatran (Pradaxa)

Question 35

Anticoagulants: List 3 important things to list about IV heparin

Answer 35

1) Antidote → Protamine Sulfate 2) Labs to monitor → aPTT 3) Can cause diff types of thrombocytopenia

Question 36

Anticoagulants: List 4 things to remember about Enoxaparin (Levonox)

Answer 36

1) LMWH 2) Given SubQ 3) Does not affect plts as much 4) No drug monitoring needed

Question 37

List the 3 medications used for rate control in A-fib

Answer 37

1) Beta blockers (metoprolol) 2) CCBs (Diltiazem) 3) Digoxin (not 1st line)

Question 38

What type of CCBs should be used for rate control & why in patients with A fib?

Answer 38

Non-dihydropyridines → b/c they affect HR unlike the dihydropyridines (suffix "pine")

Question 39

What is the Tx used for A-fib to achieve sinus rhythm?

Answer 39

Cardioversion

Question 40

What must be completed prior to cardioversion & why?

Answer 40

TEE → probe down esophagus into left atrial appendage to determine if there is a clot

Question 41

What is the plan of care if a clot is found on TEE?

Answer 41

Anticoagulant therapy for 3 weeks prior to cardioversion to dissolve the clot

Question 42

What is cardioversion used for? **Hint: 4**

Answer 42

**Organized but abnormal rhythms** 1) A fib 2) A flutter 3) SVT 4) VTAC → with a pulse

Question 43

Explain timing of the shock produced by cardioversion

Answer 43

Synchronized shock occurring with the R wave

Question 44

What should patient status be to determine use of cardioversion over defibrillation

Answer 44

Patient is often conscious → will require sedation (usually propofol: sedates in 40 sec & lasts 6 min)

Question 45

What is the goal of cardioversion?

Answer 45

restore patient's normal sinus rhythm

Question 46

What is defibrillation used for? **Hint: 2**

Answer 46

**Deadly, disorganized rhythms** 1) V-fib 2) Pulseless VTAC

Question 47

Explain timing produced from defibrillation

Answer 47

Shock is delivered immediately, without synchronization

Question 48

What should patient status be to determine defibrillation over cardioversion

Answer 48

Unresponsive, pulseless, usually NOT breathing

Question 49

What is the goal of defibrillation?

Answer 49

Stops chaotic activity so the heart's natural pacemaker (SA node) can restart

Question 50

List 2 Tx used to maintain sinus rhythm for A-fib

Answer 50

1) Cardiac radiofrequency ablation 2) Antiarrhythmic meds

Question 51

What does a cardiac radiofrequency ablation do?

Answer 51

Eliminates foci that are causing the arrhythmia (hopefully tries to put the pt back into sinus rhythm forever)

Question 52

List an example of an antiarrhythmic used for A-fib & how it works

Answer 52

Amiodarone → hopefully keeps the pt in sinus rhythm; usually only seen in very symptomatic pts when benefits outweigh risks

Question 53

What is the purpose of a watchman & when is it used?

Answer 53

Used for non-valvular A-fib → designed to permanently close the LAA to prevent clots from forming; endothelialized device & we confirm seal with TEE