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Block 1 Year 3 > Week 7 - Palpitations > Flashcards

Week 7 - Palpitations Flashcards

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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
What endogenous chemicals/hormones cause palpitations associated with exercise and stress ?
Catecholamine excess *catecholamines = dopamine, noradrenaline, adrenaline*
26
What advice do you give someone who doesn’t wish to stop smoking?
- 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
27
What advice do you give someone who wants to stop smoking ?
- offer referral to smoking cessation services - tell them that services offer interventions like behavioural support, advice about treatments, supply/arrange prescriptions for treatment
28
What are the 5 steps of giving weight advice ?
1. Assess patients habits, beliefs, aims etc 2. Lifestyle interventions 3. Behavioural interventions 4. Physical activity interventions 5. Dietary help
29
What is considered a low-calorie diet ?
800-1600 kcal/day
30
What are some recommended physical activity changes for weight loss ?
- 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
31
What are various ways a patient can protect themselves from stress ?
- **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
When do you request an ECG in the event of palpitations with an unclear cause ?
**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
What 3 categories can palpitations be put into based on their pathogenesis ?
- high cardiac output states *(pregnancy, anaemia)* - structural cardiac issues *(valvular heart disease, IHD, hypertension)* - catecholamine excess *(high caffeine, stress, anxiety, illicit drugs)*
34
What is considered Bradycardia in an adult ?
Resting HR <60 bpm
35
What is considered tachycardia in an adult ?
Resting HR >100 bpm
36
What is the pathophysiology of bradycardia ?
Occur when depolarisation **fails to initiate or conduct properly** *e.g - SA node disease - Heart block (AVN, bundle branch)*
37
What is the pathophysiology of tachycardia ?
Occurs when there is **abnormal depolarisation** occuring in the heart *e.g - reentry - enhanced automaticity*
38
What is SA node disease ?
When the SAN fails to act as pacemaker
39
What are the 3 forms of SA node disease ?
- sinus bradycardia - sinus pause - heart block *(SA exit block)*
40
How does sinus bradycardia present on an ECG ?
Normal rhythm but at a rate **<60 bpm**
41
What causes sinus bradycardia ?
Most common: - sleeping - being an athlete - old age If symptomatic: - sick sinus syndrome - inflammatory conditions e.g pericarditis - MI
42
What is the likely treatment for symptomatic sinus bradycardia ?
Pace maker
43
What causes sinus pause ?
**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
How does sinus pause feel to the patient ?
- missed/skipped a beat - flutters or palpitations - hard beats - dizzy, faint, lightheaded or syncope
45
What is the treatment for sinus pause ?
- medication, or - permanent/temporary pacemaker
46
What is the pathophysiology of SA exit block / heart block ?
Impulses from the SA node get stuck there and cannot leave to depolarise the atria
47
How many types of heart block there ?
4
48
What are the types of heart block ?
- 1st degree - 2nd degree (Mobitz type I) - 2nd degree (Mobitz type II) - 3rd degree
49
What is 1st degree heart block?
Slow conduction through the AV node
50
What is 2nd degree/Mobitz I heart block ?
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
What is 2nd degree/Mobitz II heart block ?
Mobitz II = PR intervals are consistent, but some P waves don’t conduct into a QRS *Beats are skipped in an irregular pattern*
52
What is 3rd degree heart block ?
Complete heart block - no conduction to the ventricles
53
What is automaticity in terms of tachycardias ?
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
What is reentry in terms of tachycardias ?
Reentry = electrical pathway connecting 2 areas that shouldn’t be connected, forming a circuit *can be congenital or form due to heart disease*
55
What are 5 types of SVT ?
- AF - atrial flutter - atrial tachycardia - AVNRT *(AV nodal reentrant tachycardia)* - AVRT *(AV reentry tachycardia)*
56
Different between AVNRT and AVRT…
AVNRT = reentry circuit within AV node AVRT = reentry circuit through accessory bundle
57
What do the p waves look like on ECG for each of the SVT types?
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
What are the 2 types of VT tachycardias ?
- ventricular tachycardia - ventricular fibrillation
59
What type of supraventricular tachycardia (SVT) is Wolff-Parkinson-white (WPW) syndrome ?
Wolff-Parkinson-white syndrome = an AVRT *AVRT = reentry circuit via accessory bundle*
60
What are the diagnostic elements for Wolff-Parkinson-White syndrome ?
- pre-excitation on a 12 lead ECG (short PR interval) - symptoms - an SVT
61
How do they 2 types of Wolff-Parkinson-White syndrome differ on an ECG ?
**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
How common/rare is Wolff-Parkinson-white syndrome ?
1 in 3 people Found in all age groups
63
Which demographic is seen most commonly in Wolff-Parkinson-white syndrome ?
Young, previously healthy people
64
What vagal manoeuvre can differentiate between a VT and an SVT ?
The valsalva manoeuvre *slows conduction at the SA or AV nodes so can distinguish between the two easier*
65
Which vagal manoeuvre is used to diagnose carotid sinus hypersensitivity ?
Carotid sinus massage
66
What type of arrhythmias are vagal manoeuvres the first-line treatment for ?
* haemodynamically stable* **SVTs**, specifically AVNRTs
67
List some examples of vagal manoeuvres …
- valsalva manoeuvre - carotid sinus massage - gag reflex - coughing - diving reflex - handstand for 30 seconds - applied abdominal pressure
68
How do you perform the valsalva manoeuvre?
- 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
How do you perform the carotid sinus massage?
- 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
How do you perform the diving reflex ?
- 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
How do you perform the ‘applied abdominal pressure’ manoeuvre?
- lie on back - fold lower body towards face until feet are past head - take a breath and strain for 20-30 secs
72
When are vagal manoeuvres unsafe to do ?
If patient is unstable: - low BP - chest pain - SOB - hypoxia - inability to perfuse organs
73
What is a good way to assess for suspected arrhythmias ?
24-48 hr ECG
74
What does the DVLA say regarding arrhythmias and driving a car or motorbike ?
- stop driving if it’s caused/will likely cause incapacity - driving permitted when underlying cause is identified and controlled for >4weeks
75
What is an ectopic heart beat ?
“Missed beats” A common cause of palpitations and are usually benign and normal

Block 1 Year 3 (7 decks)

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