Palpitations

Question 1

Perhaps the commonest arrhythmia causing a

patient to visit the family doctor is the _____

Answer 1

symptomatic
premature ventricular beat/complex (ventricular
ectopic).

Question 2

The commonest cause of an apparent pause on the

ECG is a_______`

Answer 2

blocked premature atrial beat/complex

(atrial ectopic

Question 3

Consider drugs as a cause, including prescribed

drugs and non-prescribed drugs such as ____, _____ and ______`

Answer 3

alcohol,

caffeine and cigarettes

Question 4

Common triggers of paroxysmal supraventricular

tachycardia (PSVT) include _____ and _____

Answer 4

anxiety and cigarette

smoking

Question 5

The commonest mechanism of any arrhythmia is

_____

Answer 5

re-entry

Question 6

If the palpitations are not caused by anxiety or

fever, the common causes are____ and _____

Answer 6

sinus tachycardia and premature complexes/ectopics (atrial or ventricula

Question 7

If the palpitations are not caused by anxiety or

fever, the common causes are _____ and _____

Answer 7

sinus tachycardia and

premature complexes/ectopics (atrial or ventricular

Question 8

Sinus tachycardia can be differentiated clinically
from PSVT in that it starts and stops more gradually
than PSVT (abrupt) and has a ________

Answer 8

lower rate of 100–150

compared with 160–220

Question 9

Sinister life-threatening arrhythmias are

Answer 9

• ventricular tachycardia
• atypical ventricular tachycardia (torsade de pointes)
• sick sinus syndrome (SSS)
• complete heart block

Question 10

The rare tumour,________ presents with
palpitations and the interesting characteristic of
postural tachycardia (a change of more than 20 beats/
min).

Answer 10

phaeochromocytoma,

Question 11

As a working guide, a rate estimated to be about
________ suggests PSVT, atrial flutter/
fibrillation or ventricular tachycardia

Answer 11

150 beats/minute

Question 12

MC cause of palpitations in children

Answer 12

exercise, fever or anxiety

Question 13

Palpitations needing special attention in children

Answer 13

PSVT, heart block and ventricular arrhythmias

Question 14

________ is characterised by beats at 200–300 per

minute, the fastest rates occurring in infants

Answer 14

PSVT

Question 15

The recommended firstline
treatment of PSVT is________ via the
application of ice packs to the upper face (forehead,
eyes and nose) of the affected infant

Answer 15

vagal stimulation

Question 16

Medical Tx of PSVT

Answer 16

Intravenous

adenosine will usually terminate the episode.

Question 17

They are prone to develop
ventricular tachyarrhythmias, which may lead to
sudden death. Consider it in children developing
syncope on exertion.

Answer 17

familial long QT syndrome

Question 18

Occasional atrial

and ventricular arrhythmias, especially___________, occur in 40% of old people

Answer 18

premature

complexes (ectopics)

Question 19

A ____________ is the
only indication for digoxin in the elderly but beware
of _______, especially if dizziness or syncope accompanies
the fibrillation.

Answer 19

rapid ventricular rate with symptoms

SSS

Question 20

In the elderly, thyrotoxicosis may present as sinus
tachycardia or atrial fibrillation with only minimal
signs—the so-called________—so it is
easy to overlook it

Answer 20

‘masked thyrotoxicosis’

Question 21

Avoid digoxin in cases with an _______

Answer 21

accessory pathway

Question 22

The two main indications for permanent

pacemaking are_____ and ______

Answer 22

SSS (only if symptomatic) and

complete heart block

Question 23

When to Tx sinus bradycardia

Answer 23

Treatment is required only if symptomatic, which is uncommon at rates >40–45 beats/min.

Question 24

• Sudden onset without warning
• Patient falls to ground
• Collapse with loss of consciousness
• Pallor and still as if dead with slow or absent
pulse

Answer 24

Stokes–Adams attack

Question 25

• These are usually asymptomatic. • Management is based on reassurance. • Check lifestyle factors such as excess alcohol, caffeine, stress and smoking; avoid precipitating factors

Answer 25

Premature (ectopic) atrial | complexes

Question 26

Medical Mx of PACs

Answer 26

atenolol or metoprolol 25–100 mg (o) daily or verapamil SR 160–480 mg (o) daily

Question 27

• These are also usually asymptomatic (90%). • They occur in 20% of people with ‘normal’ hearts. • Symptoms are usually noticed at rest in bed at night

Answer 27

Premature (ectopic) ventricular | complexes

Question 28

Approximately 60% of SVT are due to____ and _______

Answer 28

atrioventricular (AV) node re-entry and 35% due to accessory pathway tachycardia (e.g. WPW).

Question 29

The structural basis for the arrhythmia of SVT | in WPW syndrome is an ______

Answer 29

accessory pathway that bypasses the AV node.

Question 30

_____ is the first treatment of choice for PSVT

Answer 30

Carotid sinus massage

Question 31

Other methods of vagal stimulation

Answer 31

* Valsalva manoeuvre (easiest for patient) * self-induced vomiting * ocular pressure (avoid) * cold (ice) water to face or swallowing ice * immersion of the face in water

Question 32

How to give Adenosine if vagal stim does not work

Answer 32

give adenosine IV (try 6 mg first over 5–10 seconds, then 12 mg in 2 minutes if unsuccessful, then 18 mg in 2 minutes if necessary and well tolerated

Question 33

2nd line of Tx if vagal stim does not work

Answer 33

Second-line treatment is verapamil IV 1 mg/min up to 10–15 mg (provided patient is not taking a beta blocker).

Question 34

Adenosine causes less hypotension than verapamil but may cause ______ in asthmatics

Answer 34

bronchospasm

Question 35

When to avoid Verapamil

Answer 35

AVOID verapamil if taking β -blockers and persistent tachycardia with QRS complexes >0.14 s (suggests ventricular tachycardia

Question 36

In the rare event of failure of medical treatment in SVT, | consider ____ and ____

Answer 36

DC cardioversion or overdrive pacing.

Question 37

Meds to prevent recurrences of SVT

Answer 37

To prevent recurrences (frequent episodes) use atenolol or metoprolol, flecainide (only if no structural heart damage) or sotalol

Question 38

In SVT, _______, which is usually curative, is indicated for frequent attacks not responding to medical therapy

Answer 38

Radiofrequency catheter | ablation

Question 39

_________ causes vagal stimulation and | its effect on SVT is all or nothing

Answer 39

Carotid sinus massage

Question 40

T or F, Carotid sinus massage has no effect on ventricular tachycardia

Answer 40

T

Question 41

How does carotid massage work?

Answer 41

It slows the sinus rate and | breaks the SVT by blocking AV nodal conduction.

Question 42

In general, right carotid pressure tends to________and left carotid pressure tends to ____

Answer 42

slow the sinus rate impair AV nodal conduction

Question 43

Wc pts to avoid carotid massage?

Answer 43

Avoid in the elderly (risk of embolism or bradycardia

Question 44

No cause is found in ________—isolated atrial | fibrillation

Answer 44

12%

Question 45

With sustained atrial fibrillation there is a______ chance per annum of embolic episodes. There is a fivefold risk of CVA overall

Answer 45

5%

Question 46

in Af, _______ controls the ventricular rate but does not | terminate or prevent attacks

Answer 46

Digoxin

Question 47

______, ________, _______are used for conversion of atrial fibrillation and maintenance of sinus rhythm

Answer 47

Sotalol, flecainide and amiodarone

Question 48

in AF,________ should never be prescribed in patients with reduced LV function

Answer 48

Flecainide

Question 49

Beta blockers and calciumchannel antagonists benefited rate control but ________ was much less effective than amiodarone at restoring cardiac rhythm

Answer 49

verapamil

Question 50

The ECG of _________has a regular saw-tooth baseline ventricular rate of 150 with narrow QRS complexes. This is a 2:1 AV block

Answer 50

atrial flutter

Question 51

The _______study confirmed that there was no statistically significant difference between the rate and rhythm of control groups. However, patients fare marginally better (in terms of mortality) with just rate control rather than trying to get them back into sinus rhythm if they are asymptomatic in atrial fibrillation.

Answer 51

AFFIRM

Question 52

Mx of Rapid, urgent control of ventricular rate:

Answer 52

verapamil 1 mg/min IV up to maximum 15 mg then orally or metoprolol 5 mg (1 mg/min) IV to max 20 mg (provided no evidence of heart failure and wellmonitored BP)

Question 53

Routine control and maintenance of AF

Answer 53

``` verapamil SR 160–480 mg (o) daily or diltiazem CR 180–360 mg (o) daily or atenolol or metoprolol 25–100 mg (o) bd ```

Question 54

In AF Tx, when do we consider rhythm control?

Answer 54

This should be considered if the patient is symptomatic and the arrhythmia is of recent onset— less than 6 months

Question 55

If the rate cannot be well controlled despite | maximal medical therapy, consider _____ and ______

Answer 55

AV node ablation | and a permanent pacemaker

Question 56

What surgical procedure? Specific abnormal foci in the conducting pathways can be ablated using direct current electrical surgery or radiofrequency ‘burns’ via a catheter electrode

Answer 56

Catheter electrode ablation

Question 57

_________which will probably supplant surgery as a form of treatment, is indicated for recurrent episodes of supraventricular tachycardia

Answer 57

Radiofrequency ablation,

Question 58

This expensive implant is the most effective therapy yet devised for the prevention of sudden cardiac death in patients with documented sustained ventricular tachycardia or fibrillation

Answer 58

Automatic implantable cardiac | defibrillator (AICD)

Question 59

IACD Operative mortality should be less than ______, after which survival at 1 year is over _____

Answer 59

10% 90%.

Question 60

T or F A normal ECG in sinus rhythm does not exclude an accessory pathway

Answer 60

t

Question 61

Consider conduction disorders such as the WPW syndrome in PSVT. Avoid ______ in WPW syndrome.

Answer 61

digoxin