Tachycardia

Question 1

people that present with tachycardia and heart palpitations should get what test

Answer 1

12 lead EKG

Question 2

what is narrow complex tachycardia

Answer 2

1. sinus tachycardia
2. AV nodal re-entrant tachycardia
3. AV reciprocating tachyc ardia orthodromic
4. multifocal atrial tachy
5. atrial fibrillation
6. atrial flutter

Question 3

what is wide complex tachycardia

Answer 3

1. AVRT - antidromic - WPW
2. ventricular tachycardia
3. ventricular fibrillation

Question 4

etiologies of sinus tachy

Answer 4

• exercise
• ansxiety
• pain
• exposure to stimulants (caffeine)
• volume depletion (dehydration/sepsis)
• anemia
• hypoxia
• hyperthyroidism
• pulm embolism
• pericarditis

Question 5

symptoms of sinus tachy

Answer 5

asymptomatic
heart palpitations
SOB (esp with exertion)

Question 6

symptoms of sinus tachy in pts with heart dz

Answer 6

heart palpitations 
SOB
chest discomfort
lightheadedness
fatigue

Question 7

treatment of sinus tachycardia

Answer 7

treat underlying cause:

1. dehydration - IV fluid
2. pain - pain meds
3. pulm embolism - anticoagulants
4. sepsis - treat source
5. anxiety - consider anxiolytics

**No specific treatment for the tachycardia itself

Question 8

what is supraventricular tachycardia

Answer 8

• regular, rapid rhythm
• narrow complex (originates above ventricles)
• no discernible p waves

Question 9

examples of supraventricular tachycardia

Answer 9

atrioventricular nodal reentry tachycardia
orthodromic AV reciprocating tachycardia
junctional tachycardia

Question 10

symptoms of SVT

Answer 10

• sudden onset racing heart palpitations
• lightheadedness, pre syncope, syncope
• SOB
• anxiety
• if underlying heart dz: chest pain
• often self limiting, ends abruptly as well

begins suddenly and ends suddenly

Question 11

management of persistent SVT stable pts:

Answer 11

• vagal maneuvers
• carotid massage (listen for bruit, risk of stroke esp >50yo)
• adenosine (initial dose 6mg IVP, then 12mg IVP, then 12mg IVP)
• CCB or BB

Question 12

tx for pts with frequent attacks of SVT

Answer 12

consult EP –> confirm aberrant pathway –> radiofrequency catheter ablation

Question 13

management of persistent SVT unstable pts:

Answer 13

vagal maneuvers then if unsuccessful immediate DC cardioconversion

Question 14

what is DC & how does it work

Answer 14

direct cardioconversion

• medical procedure which converts cardiac arrhythmias to normal sinus rhythm using electricity
• two electrode pads are placed on the pt (chest and back)
• electrode pads are connected to a machine via cables
• the cardioverter delivers a shock which causes momentary depolarization of most cardiac cells allowing the sinus node to resume normal pacemaker activity

Question 15

what is (AVNRT)

• which gender more predominant
• triggered by?
• HR

Answer 15

atrioventricular nodal reentrant tachycardia

• most common cause of SVT
• 75% female
• reentrant circuit around the AV node
• healthy hearts and sick hearts
• triggered by exertion, caffeine, alcohol
• HR 140-280 regular

Question 16

what is AVRT

Answer 16

atriventricular reciprocating tacycardia

• accessory pathway
• healthy and sick hearts
• wide or narrow QRS complexes
• seen in WPW

Question 17

tx of stable pts with narrow complex (orthodromic) AVRT

Answer 17

• vagal maneuvers
• adenosine
• CCB or BB

Question 18

if orthodromic AVRT is associated with afib/flutter how would you treat?

Answer 18

avoid nodal blocking meds, use class Ia, Ic II antiarrhythmics - procainamide

Question 19

how would you treat orthodromic AVRT in unstable pts

Answer 19

immediate cardioversion

Question 20

orthodromic AVRT

antidromic AVRT

Answer 20

• orthodromic = narrow complex

- antidromic = wide complex

Question 21

antidromic AVRT is difficult to distinguish from what?

Answer 21

ventricular tachycardia

Question 22

immediate tx of antidromic AVRT: unstable vs stable if you know it’s a preexcitation syndrome

Answer 22

immediate DC in unstable pts

procainamide in stalbe pts

Question 23

subsequent tx of antidromic AVRT

Answer 23

catheter radiofrequncy ablation of accessory pathway

Question 24

what is WPW

Answer 24

-pre-excitation syndrome involving an accessory pathway

Question 25

how many pts are symptomatic in WPW

Answer 25

25-50%

Question 26

range of symptoms in WPW

Answer 26

palpitations to syncope

Question 27

most common cause of WPW on EKG

Answer 27

paroxysmal supraventricular tachycardia which is usually AVRT

Question 28

distribution of people affected by WPW

Answer 28

bi modal - early childhood - early adulthood

Question 29

1/3 of pts with WPW also have

Answer 29

afib - potentially serious arrhythmia in WPW pts - afib may result in rapid ventricular response - subsequent degeneration to ventricular fib = sudden death

Question 30

management of WPW with normal rate and stable

Answer 30

- catheter ablation of accessory pathway (standard of care) | - medical therapy if unable (BB, adenosine, antiarrhythmics - procainamide, amiodarone)

Question 31

management of WPW with fast rate

Answer 31

same as other forms of AVRT - unstable: DC - stable: procainamide - subsequent: catheter radiofrequency ablation

Question 32

what is multifocal atrial tachycardia | -therapy?

Answer 32

``` >=3 p wave morphologies 100-150bpm -therapy involves tx of underlying medical problems (typically pulm dz) -verapamil -flecainide or propafenone ```

Question 33

what is ventricular tachycardia (sustained) - associated with what? - rate? - complication of what conditions?

Answer 33

-fast wide complex rhythm -often associated with structural heart dz -frequently associated with syncope >= consecutive ventricular premature beats -usual rate 160-240bpm -moderately regular -frequent complication of MI and dilated cardiomyopathy

Question 34

symptoms of ventricular tachycardia

Answer 34

- asymptomatic - heart palpitation - lightheadedness - chest pain - SOB - diaphoresis - near syncope - syncope - sustained LOC - pulseless electrical activity (death)

Question 35

tx of acute ventricular tachycardia - pulse present

Answer 35

pulse present: - if vtach causes hypotension, heart failure, myocardial ischemia = DC - if pt is stable = amiodarone 150mg IV bolus followed by continuous infusion - implantable cardioverter-defibrillator

Question 36

tx of acute ventricular tachycardia - pulseless

Answer 36

- CPR - DC - epinephrine

Question 37

what is NSVT

Answer 37

3+ consecutive ventricular beats - a rate of >120 bpm - duration of less than 30s

Question 38

NSVT - symptoms - how is it found? - prognosis in healthy vs structural heart dz - potential marker for what?

Answer 38

- common - asymptomatic - dx on routine EKG or exercise stress test - usually benign - potential marker for development of sustained ventricular arrhythmias and sudden death - in presence of structural heart dz, more serious pronogisis

Question 39

goals of tx for NSVT

Answer 39

- prevent sustained arrhythmia and sudden death | - eliminate symptoms

Question 40

NSVT and associated diseases

Answer 40

- hypertrophic cardiomyopathy - 25% - idiopathic dilated cardiomyopathy - 80% - valvular heart dz - 20% of pts with MVP, MR, AS - chorinc coronary heart dz - left ventricular dysfunction

Question 41

management of NSVT | -frequent vs infrequent

Answer 41

1. if infrequent, no specific intervention except: - optimize electrolytes, BB, manage underlying conditions/risk modification 2. frequent: consider amiodarone

Question 42

what is torsades de pointes

Answer 42

a type of vtach

Question 43

what is torsades de pointes triggered by

Answer 43

hypokalemia, hypomagnesemia, drugs that prolong QTc

Question 44

meds that prolong QTc - antiarrhythmic agents

Answer 44

antiarrhythmic agents: amiodarone flecainide sotalol

Question 45

meds that prolong QTc - antipsychotics

Answer 45

``` chlorpromazine haloperidol olanzapine quetipine risperidone ```

Question 46

meds that prolong QTc - antibiotics

Answer 46

macrolides (azithro) | quinolones (levo/cipro)

Question 47

meds that prolong QTc - antidepressants

Answer 47

citalopram | tricyclic antidepressants

Question 48

tx of torsades de pointe

Answer 48

unstable - prompt defibrillation | stable - IV magnesium (1st line); temp transvenous overdrive pacing if no response to magnesium

Question 49

ventricular fibrillation

Answer 49

often associated with severe CAD and caused by acute MI (ACS) - sudden death may be initial manifestation of coronary dz in 20% of pts - pts are pulseless and unresponsive

Question 50

causes of ventricular fibrillation

Answer 50

- myocardial ischemia and infarction - heart failure - hypoxemia or hypercapnia - hypotension/shock - electrolyte imbalances - stimulants (drugs, caffeine) - preceded by Vtach

Question 51

associated conditions with V fib

Answer 51

- LVH - HOCM (hypertrophic obstructive cadriomyopathy) - CHF - AS - brugada syndrome

Question 52

tx of v fib

Answer 52

- cpr - defibrillation - if pulse regained = coronary arteriogrphy , (cardiac cath) to view and tx AAD - implantalbe cardioverter-defibrillator