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Block 1 Year 3 > Week 7 - Palpitations > Flashcards

Week 7 - Palpitations Flashcards

1
Q

With regards to the layers of the heart, is the myocardium the
A) inner layer ?
B) middle layer ?
C) outer layer ?

A

Myocardium = Middle layer

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2
Q

With regards to the layers of the heart, is the endocardium the
A) inner layer ?
B) middle layer ?
C) outer layer ?

A

Endocardium = inner layer

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3
Q

With regards to the layers of the heart, is the epicardium the
A) inner layer ?
B) middle layer ?
C) outer layer ?

A

Epicardium = outer layer

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4
Q

Which of the 3 layers of the heart is the thickest layer ?

A

Myocardium (middle layer)

this is the muscular part of the heart wall

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5
Q

Describe the contraction of heart muscle, in terms of ionic flow.

A
  1. Voltage gated Na+ channels open
  2. Na+ floods in, depolarising the membrane, opening more Na+ channels
  3. Cell depolarises at 30mV, Na+ channels close
  4. Ca2+ channels open slowly, causing a plateau in depolarisation. K+ channels stay closed
  5. Ca2+ channels close. K+ channels open so K+ leaves rapidly, depolarising membrane
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6
Q

Which aspect/area of the heart does Lead I and II detect electrical activity from?

A

Left lateral

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7
Q

Which aspect/area of the heart does Lead aVR detect electrical activity from?

A

Right atrium

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8
Q

Which aspect/area of the heart does Lead V6 detect electrical activity from?

A

Left ventricle

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9
Q

Which ECG leads detect electrical activity from the left lateral aspect of the heart ?

A
  • Lead I
  • Lead II
  • Lead aVL
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10
Q

Which ECG leads detect electrical activity from the left ventricle of the heart ?

A
  • Lead V5
  • Lead V6
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11
Q

Which ECG leads detect electrical activity from the inferior aspect of the heart ?

A
  • Lead III
  • Lead aVF
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12
Q

Which ECG leads detect electrical activity from the right atrium of the heart ?

A

aVR

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13
Q

Which ECG leads detect electrical activity from the right ventricle of the heart ?

A
  • Lead V1
  • Lead V2
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14
Q

Which ECG leads detect electrical activity from the ventricular septum of the heart ?

A
  • Lead V3
  • Lead V4
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15
Q

What type of arrhythmia can be seen in some anaemia patients and why ?

A

sinus tachycardia

Hb is low so heart pumps faster to ensure oxygen reaches all organs

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16
Q

What are the clinical signs of heart failure ?

A
  • raised JVP
  • basal crepitations
  • peripheral oedema
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17
Q

What examination findings are indicative of thyrotoicosis ?

A
  • goitre
  • tremor
  • exophthalmos
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18
Q

What are the 3 most common descriptions of cardiac-related palpitations ?

A
  • flip flopping in the chest
  • rapid fluttering in the chest
  • pounding in the neck
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19
Q

What is thought to be the cause of “flip flopping” palpitations ?

A

Extra systoles, such as premature supraventricular or ventricular contractions

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20
Q

What is thought to be the cause of “rapid fluttering” palpitations ?

A

Result from a sustained ventricular or supraventricular arrhythmia

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21
Q

What type of pulse rhythm suggests AF as the cause of palpitations?

A

Irregularly irregular rhythm

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22
Q

What is thought to be the cause of “pounding in the neck” palpitations ?

A

Atrioventricular dissociation

atria are contracting against closed AV valves

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23
Q

What is thought to be the cause of palpitations induced by exercise ?

A
  • cardiomyopathy
  • ischaemia
  • channelopathies
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24
Q

What do the rhythm abbreviations SVT and VT mean when talking about palpitations ?

A

SVT = supraventricular tachycardia
- heart suddenly beats much than normal
- originates from faulty electrical impulses in upper areas of heart (atria or SA/AV nodes)

VT = ventricular tachycardia
- sequence of 3 or more ventricular beats
- frequency higher than 100bpm

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25
Q

What endogenous chemicals/hormones cause palpitations associated with exercise and stress ?

A

Catecholamine excess

catecholamines = dopamine, noradrenaline, adrenaline

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26
Q

What advice do you give someone who doesn’t wish to stop smoking?

A
  • think about stopping
  • let them know they can come back for help if they decide to in the future
  • record their smoking status and ask again in future
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27
Q

What advice do you give someone who wants to stop smoking ?

A
  • offer referral to smoking cessation services
  • tell them that services offer interventions like behavioural support, advice about treatments, supply/arrange prescriptions for treatment
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28
Q

What are the 5 steps of giving weight advice ?

A
  1. Assess patients habits, beliefs, aims etc
  2. Lifestyle interventions
  3. Behavioural interventions
  4. Physical activity interventions
  5. Dietary help
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29
Q

What is considered a low-calorie diet ?

A

800-1600 kcal/day

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30
Q

What are some recommended physical activity changes for weight loss ?

A
  • activities that can be incorporated into life e.g brisk walking, cycling, gardening…
  • other activities e.g swimming, stair climbing, monitor steps per day
  • supervised exercise programmes
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31
Q

What are various ways a patient can protect themselves from stress ?

A
  • eat healthy reduces diet-related diseases and affects mood
  • reduce drinking and smoking they often exacerbate problems
  • exercise/fresh air relieves stress and releases endorphins
  • rest and relax otherwise your body will decide for you later
  • be mindful meditation can help the mind in many ways including insomnia
  • good sleep
  • don’t be hard on yourself*maintain perspective *
32
Q

When do you request an ECG in the event of palpitations with an unclear cause ?

A

if symptoms are relatively infrequent (less than once a week) and last for an hour or more then advise the person go to A&E during their next episode and request an immediate ECG

if symptoms are short lived then arrange ambulatory monitoring in primary care if available, or refer to cardiology

33
Q

What 3 categories can palpitations be put into based on their pathogenesis ?

A
  • high cardiac output states (pregnancy, anaemia)
  • structural cardiac issues (valvular heart disease, IHD, hypertension)
  • catecholamine excess (high caffeine, stress, anxiety, illicit drugs)
34
Q

What is considered Bradycardia in an adult ?

A

Resting HR <60 bpm

35
Q

What is considered tachycardia in an adult ?

A

Resting HR >100 bpm

36
Q

What is the pathophysiology of bradycardia ?

A

Occur when depolarisation fails to initiate or conduct properly

e.g
- SA node disease
- Heart block (AVN, bundle branch)

37
Q

What is the pathophysiology of tachycardia ?

A

Occurs when there is abnormal depolarisation occuring in the heart

e.g
- reentry
- enhanced automaticity

38
Q

What is SA node disease ?

A

When the SAN fails to act as pacemaker

39
Q

What are the 3 forms of SA node disease ?

A
  • sinus bradycardia
  • sinus pause
  • heart block (SA exit block)
40
Q

How does sinus bradycardia present on an ECG ?

A

Normal rhythm but at a rate <60 bpm

41
Q

What causes sinus bradycardia ?

A

Most common:
- sleeping
- being an athlete
- old age

If symptomatic:
- sick sinus syndrome
- inflammatory conditions e.g pericarditis
- MI

42
Q

What is the likely treatment for symptomatic sinus bradycardia ?

A

Pace maker

43
Q

What causes sinus pause ?

A

SA node fails to generate an impulse for a brief period of time, causing a pause and lack of perfusion/O2 during that time

44
Q

How does sinus pause feel to the patient ?

A
  • missed/skipped a beat
  • flutters or palpitations
  • hard beats
  • dizzy, faint, lightheaded or syncope
45
Q

What is the treatment for sinus pause ?

A
  • medication, or
  • permanent/temporary pacemaker
46
Q

What is the pathophysiology of SA exit block / heart block ?

A

Impulses from the SA node get stuck there and cannot leave to depolarise the atria

47
Q

How many types of heart block there ?

A

4

48
Q

What are the types of heart block ?

A
  • 1st degree
  • 2nd degree (Mobitz type I)
  • 2nd degree (Mobitz type II)
  • 3rd degree
49
Q

What is 1st degree heart block?

A

Slow conduction through the AV node

50
Q

What is 2nd degree/Mobitz I heart block ?

A

Mobitz I = Progressive prolonging of PR interval (between p and QRS) until a P wave is completed blocked

Beats are skipped in a regular pattern

51
Q

What is 2nd degree/Mobitz II heart block ?

A

Mobitz II = PR intervals are consistent, but some P waves don’t conduct into a QRS

Beats are skipped in an irregular pattern

52
Q

What is 3rd degree heart block ?

A

Complete heart block - no conduction to the ventricles

53
Q

What is automaticity in terms of tachycardias ?

A

Automaticity = an area of myocardial cells depolarise faster than the SA node

can be either atrial or ventricular tissue, most occur at a focal site

54
Q

What is reentry in terms of tachycardias ?

A

Reentry = electrical pathway connecting 2 areas that shouldn’t be connected, forming a circuit

can be congenital or form due to heart disease

55
Q

What are 5 types of SVT ?

A
  • AF
  • atrial flutter
  • atrial tachycardia
  • AVNRT (AV nodal reentrant tachycardia)
  • AVRT (AV reentry tachycardia)
56
Q

Different between AVNRT and AVRT…

A

AVNRT = reentry circuit within AV node

AVRT = reentry circuit through accessory bundle

57
Q

What do the p waves look like on ECG for each of the SVT types?

A

AF = absent p waves
Atrial flutter = negative sawtooth in lead II
Atrial tachycardia = differs from sinus p waves
AVNRT = in QRS complex
AVNT = RP < PR

58
Q

What are the 2 types of VT tachycardias ?

A
  • ventricular tachycardia
  • ventricular fibrillation
59
Q

What type of supraventricular tachycardia (SVT) is Wolff-Parkinson-white (WPW) syndrome ?

A

Wolff-Parkinson-white syndrome = an AVRT

AVRT = reentry circuit via accessory bundle

60
Q

What are the diagnostic elements for Wolff-Parkinson-White syndrome ?

A
  • pre-excitation on a 12 lead ECG (short PR interval)
  • symptoms
  • an SVT
61
Q

How do they 2 types of Wolff-Parkinson-White syndrome differ on an ECG ?

A

Type 1 = delta wave and QRS complex are upright in all leads V1-6. A dominant R wave in V1 may be misinterpreted as right BBB

Type 2 = delta wave and QRS complex are negative in V1 and V2, positive in the other V leads. Resembles left BBB

62
Q

How common/rare is Wolff-Parkinson-white syndrome ?

A

1 in 3 people
Found in all age groups

63
Q

Which demographic is seen most commonly in Wolff-Parkinson-white syndrome ?

A

Young, previously healthy people

64
Q

What vagal manoeuvre can differentiate between a VT and an SVT ?

A

The valsalva manoeuvre

slows conduction at the SA or AV nodes so can distinguish between the two easier

65
Q

Which vagal manoeuvre is used to diagnose carotid sinus hypersensitivity ?

A

Carotid sinus massage

66
Q

What type of arrhythmias are vagal manoeuvres the first-line treatment for ?

A
  • haemodynamically stable* SVTs, specifically AVNRTs
67
Q

List some examples of vagal manoeuvres …

A
  • valsalva manoeuvre
  • carotid sinus massage
  • gag reflex
  • coughing
  • diving reflex
  • handstand for 30 seconds
  • applied abdominal pressure
68
Q

How do you perform the valsalva manoeuvre?

A
  • lie on back
  • take deep breath
  • try to exhale without letting air out of your mouth or nose for 10-30 secs

should feel like trying to breath through a blocked straw

69
Q

How do you perform the carotid sinus massage?

A
  • lie on back
  • turn head to one side
  • doctor will push on your carotid sinus for 5-10 secs

try again in a minute or on other side of neck if it doesn’t work

70
Q

How do you perform the diving reflex ?

A
  • sit up
  • take several deep breaths
  • quickly put whole face into a container of ice water
  • stay submerged as long as you can

alternatively use a bag of ice cold water or an ice-cold wet towel

71
Q

How do you perform the ‘applied abdominal pressure’ manoeuvre?

A
  • lie on back
  • fold lower body towards face until feet are past head
  • take a breath and strain for 20-30 secs
72
Q

When are vagal manoeuvres unsafe to do ?

A

If patient is unstable:
- low BP
- chest pain
- SOB
- hypoxia
- inability to perfuse organs

73
Q

What is a good way to assess for suspected arrhythmias ?

A

24-48 hr ECG

74
Q

What does the DVLA say regarding arrhythmias and driving a car or motorbike ?

A
  • stop driving if it’s caused/will likely cause incapacity
  • driving permitted when underlying cause is identified and controlled for >4weeks
75
Q

What is an ectopic heart beat ?

A

“Missed beats”

A common cause of palpitations and are usually benign and normal

Block 1 Year 3 (7 decks)

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