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Rhythm abnormalities Flashcards

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1
Q

What are the four classifications (sites affected) of a bradycardia?

A
  1. Sinus node dysfunction
  2. AV conduction disturbance
  3. Escape Rhythms
  4. AV dissociation
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2
Q

Bradycardia: Give examples of sinus node dysfunction?

A

Sinus bradycardia
Sinus pause / arrest - any termination > 3s
Sinus tachy/Brady syndrome - usually episodes of tachycardia, followed by pause, followed by episodes of bradycardia

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3
Q

Bradycardia: Give examples of AV conduction disturbances?

A

1st degree HB - PR > 200ms (5 small squares)
2:1 (progressive lengthening then drop a QRS)
2:2 (Ratio)
Complete HB

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4
Q

Bradycardia: Give examples of escape rhythms, and ECG findings?

A

When your sinus rate slows other structures can activate:

Atrial - Normal QRS, abnormal p waves, short PR. 60-80BPM

Junctional (above BoH) - Narrow QRS, no p waves. 40-60 BPM

Ventricular (Below BoH) - Broad QRS. 20-40 BPM

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5
Q

What are the causes of bradycardia?

A

DIVISION:

Drugs: ABCD = Anti-Arrhythmias e.g. amiodarone, BB, CCB, digoxin
Ischaemia / infarction
Vagal
Infection - Rheumatic fever or endocarditis
Sick sinus syndrome
Infiltration e.g. cardiomyopathy
O’s = Hypothyroid, hypokalaemia, hypothermia
Neurological - Raised ICP

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6
Q

Clinical features of a bradycardia?

A

SOB
Syncope / dizziness and light headedness
Fatigue and exercise intolerance

Canon a waves in JVP - Atria often contract against closed tricuspid valve

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7
Q

Investigations once a bradycardia has been identified?

A

Bloods: Cardiac markers, TFT’s, FBC, U+E’s, Calcium, serum drug levels e.g. digoxin
Holter tape
Echo - can dictate whether you need just a PPM or ICD as well (ICD too if LVEF <30%)

Can consider implantable loop recorder if intermittent symptoms and not picked up on ECG or Holter.

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8
Q

Management of haemodynamically unstable bradycardia?

A

1 - atropine 0.5mg IV bolus, repeat, max 3mg.

2 - Epinephrine IV

3 - Temporary jtransvenous Pacing > If unresponsive to medical therapy or one of the below:

  • Complete heart block with broad QRS
  • Recent asystole
  • Mobitz type 2
  • Ventricular pause > 3 seconds
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9
Q

Management of Bradycardia in haemodynamically stable patients?

A
  1. Treat underlying cause - most common reversible are drugs and electrolyte imbalance
  2. If non-reversible or symptomatic may consider pacing
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10
Q

Risks of transvenous pacing and the one contraindication?

A

Contraindication = mechanical tricuspid

Risks = happen in about 20%:

  • Venous access problems
  • Infection
  • thrombo-emboli
  • Heart perforation
  • Lead dislodgement
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11
Q

What are the two types of tachycardia?

A

Narrow complex and broad complex

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12
Q

What are the two classes of narrow complex tachycardia, and examples of each?

A

AV node independent :

  • Sinus tachy = from the SA node
  • Atrial tachycardia = abnormal p waves
  • Atrial flutter = At about 150bpm
  • AF = no p waves

AV node dependant:

  • AVNRT - two pathways within AV node
  • AVRT - accessory pathway
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13
Q

Management of narrow complex tachycardia - haemodynamically unstable?

A

DC cardiovert x3
Amiodarone 300mg IV over 10 minutes
Repeat shock
Amiodarone 900mg over 24 hours

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14
Q

Management of narrow complex tachycardia - stable?

A
  1. Adenosine 6mg IV bolus, followed by 12mg and 12mg (Verapamil in asthmatics)
    - This acts on AV node so should slow the rate to allow you to see underlying cause or if does not slow you know it is AV independent e.g. AF, flutter, A tachy.

Atrial tachy = 1. Diltiazem (or verapamil in asthmatics)
2. Amiodarone

Atrial Flutter = BB then amiodarone if refractory

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15
Q

Types of broad complex tachycardia and examples?

A

Most will be ventricular e.g. VT, VF, torsades des pointes

Or they will be an SVT with aberrant conduction :

  • AVNRT with LBBB
  • Atrial tachy with pre-excitation = WPW
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16
Q

Broad complex tachycardia: Causes of a VT?

A

MILDE:

Myocarditis
Infarction
Long QT syndrome
Dilated cardiomypoathy
Electrolytes - Hypomagnesaemia, hypokalaemia, hypocalcaemia
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17
Q

Broad complex tachycardia - investigations?

A

ECG:
- Need to distinguish between VT and aberrant SVT as medication for SVT can be adverse / fatal for VT patient.

Bloods - Troponin, U+E’s, TFT’s

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18
Q

Management of broad complex tachycardias - unstable?

A

VF - Pulseless, cardiovert

Unstable VT = DC cardiovert x 3, amiodarone 300 over 10 minutes, repeat shock and amiodarone 900 over 24 hours.

TdP = as above but aggressively replenish magnesium and potassium.

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19
Q

Management of broad complex tachycardia - stable?

A
  1. Correct any reversible causes e.g. electrolytes
  2. Amiodarone
  3. If poor response consider cardioversion
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20
Q

What are the causes of atrial fibrillation?

A

Cardiac = HTN, LV failure, IHD, valvular disease

Non-cardiac = Thyrotoxicosis, pulmonary e.g. PE, drugs + alcohol, electrolyte imbalance

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21
Q

Investigations in atrial fibrillation?

A

ECG
Bloods - FBC, U+E’s, TFT’s, troponin
CXR may show signs of heart failure
Echo - for signs of heart failure, structural abnormality, valvular disease

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22
Q

Management of unstable AF?

Study These Flashcards
A

DC cardioversion

If unknown onset / > 48 hours need TOE to exclude atria thrombus

23
Q

Management of acute AF?

Study These Flashcards
A

> 65 or Hx of IHD = RATE CONTROL:

  • Metoprolol or diltiazem
  • If asthmatic start with CCB
  • If heart failure use digoxin

<65, symptomatic, first presentation, reversible cause = RHYTHM CONTROL:

  • < 48 hours = immediate cardioversion
  • DC with amiodarone 12 months after
  • Flecainide single dose or Amiodarone if evidence of structural heart disease

Anticoagulate if CHADS score >2

  • Apixiban if non-valvular
  • Warfarin if valvular or severe kidney disease
24
Q

Management of high INR on warfarin: 5-8 with no bleeding?

Study These Flashcards
A

Hold 1/2 doses and reduce subsequent dosing

25
Management of high INR on warfarin: >5 with minor bleeding?
Stop warfarin IV vitamin K Repeat if INR high after 24 hours Restart warfarin when INR <5
26
Management of high INR on warfarin: >8 no bleeding?
Stop warfarin, oral vitamin K Repeat if INR still high after 24 hours Restart warfarin when INR <5
27
Management of high INR on warfarin: Major bleeding?
Stop warfarin IV vitamin K Prothrombin complex
28
Unstable angina vs NSTEMI
Unstable angina is ischaemia but not sufficient ischaemia to cause elevated cardiac biomarkers NSTEMI is an infraction sufficient to cause elevated cardiac biomarkers
29
Clinical features of NSTEMI / UA?
Rest angina that is new onset Crescendo pattern in occurence Radiation to the jaw / arm / neck NSTEMI - also sweaty / clammy / anxious / nausea. Could be silent in diabetics
30
Investigations in NSTEMI / UA?
ECG = ST-depression and t wave inversion Bloods - troponin. FBC and clotting, lipid profile CXR Angio is gold standard
31
Management of NSTEMI / UA?
ACUTE: Grace score - low risk (<3%) = conservative - >3% = angio within 96 hours. If significant findings PCI. If high risk add in tirofiban.
32
Cardiac rehab and medical prophylaxis in any ACS?
Control any risk factors Exercise and diet MI - No driving/sex for 1 month, work in 2 months Aspirin for life, clop for 1 year statin, BB and ACE I
33
ECG STEMI leads to area?
Inferior = 2,3, aVF = RCA Lateral = 1, V5, V6 = LCx ``` Anterior = V2-V4 = LAD Septal = V1-V2 = LAD ``` Posterior = V1-V3 depression = RCA and LCx
34
Initial management of any ACS?
INITIAL: IV access Morphine (+metoclopramide) , oxygen, nitrates and anti-platelets = Clopidogrel and aspirin 300mg each, fondaparinux 2.5mg s/c
35
Management of STEMI?
If access within 120 minutes and PC < 12 hours = PCI - consider if presenting > 12 hours If access > 120 minutes = THROMBOLYSIS
36
Indications for a CABG? (4)
1. Severe angina refractory to treatment 2. Left main stem stenosis 3. Triple vessel disease 4. Unsuccessful PCI
37
Short term side effect following MI? (5)
Ventricular fibrillation = most common cause of death post-MI Sinus Brady / 1st HB / 2:1 HB = RCA occlusion, due to AV node infarction Complete heart block in anterior infarcts due to LAD occlusion = supplies septum and LV Papillary muscle rupture = mitral regurgitation Dresslers syndrome = 2-10 weeks post MI, low grade fever chest pain and pericardial rub.
38
Long term side effects of an MI?
Recurrent MI Heart failure Ventricular arrhythmias
39
What is the new you heart association classification of heart failure?
``` 1 = no limitation 2 = Slight limitation of physical activity 3 = Marked limitation, although comfortable at rest 4 = Inability to carry out any physical activity without discomfort ```
40
Causes of left sided heart failure?
Systolic dysfunction: 1. Any myocardial damage e.g. Infarction, toxins, immune mediated like SLE 2. Dilated cardiomyopathy 3. Long standing HTN Diastolic dysfunction: 1. Longstanding HTN - causes concentric hypertrophy which reduces ventricle space 2. Aortic stenosis - concentric hypertrophy 3. Restrictive cardiomyopathy - ventricle less compliant
41
Causes of right sided heart failure?
Left sided heart failure ASD/VSD Cor pulmonale - chronic lung disease causes pulmonary HTN = hypertrophy and failure Pulmonary and tricuspid valve disease
42
Symptoms of left sided heart failure?
Exertional dyspnoea Orthopnoea Fatigue Symptoms secondary to pulmonary oedema e.g. pink sputum, wheeze
43
Signs of left sided heart failure?
Cold peripheries and cyanosed Tachycardia and Gallop rhythm (S3 straight after S2) Cardiomegaly and displaced apex Basal crackles
44
What causes gallup rhythm?
Mitral valve opening then ventricles rapidly filling and reaching their limit = S3.
45
Symptoms of right sided heart failure?
Fatigue Abdominal discomfort Nausea and wasting
46
Signs of right sided heart failure?
``` Raised JVP Pleural effusions Pitting oedema Ascites Hepato-splenomegaly ```
47
Investigations in heart failure?
If previous MI - echo within two weeks No previous MI - Measure BNP, of > 400 echo within 6 weeks. If 100-400 echo within 6 weeks. Bloods - FBC, U+E's, TFT's. BNP <100 rules out heart failure ECG - Arrhythmias, LVH, infarction ``` CXR: A - Alveolar oedema B - KB lines, upper lobe vascular redistribution C - Cardiomegaly D - Dilated upper lobe vessels E - Effusion (if RVF) ```
48
Management of reduced EF heart failure?
1. Treat any underlying cause 2. Conservative = stop smoking, optimise weight, annual influenza and one off pneumococcal . 3. A-SBA = Aspirin, stati , BB, ACEI for all! - second line spironolactone or ARB - Use furosemide if congested only.
49
Investigations for HTN?
2 separate measurements, and offer ambulatory blood pressure monitoring to confirm diagnosis Look for signs of organ damage: - Urinalysis, - ECG for LVH, - metabolic panel - renal problems - Fundoscopy for retinopathy
50
Who do we start medical management of HTN on?
Initiate if stage 1 (140/90) in end organ damage / CVS or renal disease / diabetes Initiate in all stage 2 = 160/ 100
51
Medical management of HTN?
1. <55 = ACEI/ARB. > 55 or black = CCB 2. Combine the above two 3. add in thiazide 4. further diuretic e.g. Spiro, specialist help.
52
What is malignant HTN?
HTN >180/110, with signs of end organ damage
53
Clinical features of malignant HTN?
Visual disturbances Headache SOB Hypertensive encephalopathy
54
Management of malignant HTN?
Admit to hospital, and controlled reduction in BP over several days to avoid stroke. 1st line is labetalol IV

Cardiology (6 decks)

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