Cardio E2: Arrhythmias

What procedure can be used to destroy a critical region of impulse generation/propagation in the heart that is causing arrhythmias?

Ablation

What device is a small battery-powered electrical impulse generator that can be implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation?

Automated Implantable Cardioverter-Defibrillator (AICD)

How is severe, symptomatic sinus bradycardia treated?

Atropine, then pacemaker (if atropine is not effective)

What is another term for Sick sinus syndrome?

Sinus Node Dysfunction (SND)

How is sick sinus syndrome treated if the ejection fraction is normal?

Pacemaker

How is sick sinus syndrome treated if the ejection fraction is <35%?

AICD

What are the 3 classic ECG findings associated with WPW?

• Short PR interval (<120ms)

• Wide QRS w/ slurred delta wave

• Secondary ST-T wave changes

What should unstable WPW patients be treated with?

Synchronized cardioversion

Patients with A fib + WPW + rapid ventricular response should be treated with what medications?

Amiodarone or Procainamide (to stabilize HR)

What is the long term treatment of symptomatic WPW?

Radiofrequency ablation

You should NOT use what type of agents alone for treatment of WPW?

- this will accentuate the accessory pathway and worsen the arrhythmia

AV nodal blocking agents (BBs, CCBs, adenosine, digoxin)

Which medications should NOT be used alone for treatment of WPW?

BBs, CCBs, Adenosine, Digoxin

Acute A fib:

New-onset A fib lasting <48 hours

Paroxysmal A fib:

Recurrent A fib that typically lasts <48 hours and converts spontaneously to normal sinus rhythm

Permanent A fib:

A fib with duration >7 days, unable to maintain sinus rhythym

Rapid ventricular response in atrial fibrillation is when the ventricular rate is greater than ____ BPM

100

TTE or TEE:
Evaluation of left atrial thrombus

TEE

TTE or TEE:
To guide cardioversion

TEE

TTE or TEE:
To evaluate pericardial disease

TTE

TTE or TEE:
To evaluate atrial and ventricular chamber/wall dimensions

TTE

TTE or TEE:
To evaluate for valvular heart disease

TTE

TTE or TEE:
To estimate ventricular function

TTE

TTE or TEE:
To estimate pulmonary systolic pressure (pulm HTN)

TTE

TTE or TEE:
Better for looking at the left side of the heart + more resolution

TEE

TTE or TEE:
2D doppler that can be done at bedside

TTE

What is the drug of choice for treatment of acute A fib for rate control?

IV Cardizem (Diltiazem)

We should be cautious with giving what drug in acute treatment of A fib, because it can cardiovert to NSR?

Amiodarone

How should a patient with acute stable A fib be treated?

HR control (Diltiazem)

How should a patient with acute unstable A fib be treated?

Cardioversion

What is the last option to treat A fib, and only used if the patient is also in heart failure?

Digoxin

If the patient has been in A fib for _____ hours, you can assume no clot is in the atrium.

<48

If the patient has been in A fib for >48 hours, what do we have to assume?

There is a clot

What must be done for treatment if the patient has been in A fib for >48 hours?

Get a TEE to prove there is no clot before cardioversion, OR min 3 months of anticoagulation

What must be done for treatment if the patient has been in A fib for <48 hours, but cannot be converted to NSR?

Anticoagulation

What is the CHA2DS2-VASc score used for?

To estimate risk of stroke in patients w/ A fib

What drug do you give for any valvular heart disease + A fib?

Warfarin

What is the recommended treatment for a CHA2DS2-VASc score of 0?

Low risk- no therapy is reasonable

What is the recommended treatment for a CHA2DS2-VASc score of 1?

Patient/provider decision- may do nothing, OR oral anticoagulation, OR ASA

What is the recommended treatment for a CHA2DS2-VASc score of >2?

High risk- DOAC or Warfarin recommended
(DOAC = direct oral anticoagulants)

How many CHA2DS2-VASc points:
CHF history

1

How many CHA2DS2-VASc points:
HTN (BP > 140/90)

1

How many CHA2DS2-VASc points:

Age >75 years

2

How many CHA2DS2-VASc points:
DM

1

How many CHA2DS2-VASc points:
Prior stroke/TIA/Thromboembolsim

2

How many CHA2DS2-VASc points:
Vascular disease

1

How many CHA2DS2-VASc points:
Age 65-74

1

How many CHA2DS2-VASc points:
Sex category (female)

1

What are the Direct Oral Anticoagulants (DOACs)?

Apixaban (Eliquis)
Dabigatran (Pradaxa)
Edoxaban (Savaysa)
Ribaroxaban (Xarelto)

DOACs are first line therapy for what condition?

A fib

Which drug has strongest evidence for chronic A fib with prosthetic mechanical heart valves?

Warfarin

What is the association between alcohol use and rhythm disturbances, particularly supraventricular arrhythmias in apparently healthy people?

Holiday heart syndrome

What is the most common rhythm disorder seen in Holiday Heart Syndrome?

A fib

What is the most common symptom of atrial flutter?

Palpitations

What does Atrial flutter show on an EKG?

Sawtooth pattern

Refractory cases of atrial flutter should undergo what procedure?

Ablation

What is a common arrhythmia that can be caused by alcohol, coffee, stimulants, and excitement?

SVT/PSVT

What is the rate for SVT/PSVT?

150-250 BPM

What is first line therapy for SVT/PSVT? Why?

Vagal maneuvers- kicks in the parasympathetic system to slow the rhythm

Which vagal maneuver is dangerous in older people?

Carotid massage

What is a vagal maneuver that should NOT be done if a bruit is heard or if the person is older?

Carotid massage

What is the pharmacologic agent that is 2nd line treatment for SVT/PSVT?

Adenosine (avoid in WPW/COPD/asthma)

What causes the R on T phenomenon?

When PVC occurs so early that it falls during the repolarization, which can result in V fib

What is the treatment for PVCs?

Empiric BBs

Torsades de pointes is associated with what on an EKG?

Prolonged QT interval (may be congenital or acquired)

In a young patient with Torsades, what should be considered?

Congenital long QT syndrome

What is the drug of choice for treatment of Torsades?

IV Mag sulfate

What is the most commonly identified arrhythmia in cardiac arrest patients?

Ventricular fibrillation

What is the treatment for ventricular fibrillation?

Immediate defibrillation

What kind of pulse will a patient in V fib have?

Pulseless

What arrhythmia is the cause of most sudden cardiac deaths?

VT or VF

What has a very fast ventricular rate that is usually dissociated from an underlying atrial rate?

V tach

How should a stable patient in V tach with a pulse be treated?

Amiodarone or Procainamide

How should an unstable patient in V tach with a pulse be treated?

Synchronized cardioversion

What is the treatment for a patient who is pulseless in V tach?

Defibrillation, CPR, Amiodarone, Epi

Ashman's phenomenon:

Aberrant ventricular conduction, usually of RBBB morphology, which follows a short R-R interval and preceding relatively prolonged R-R interval

What is often seen in A fib, but is clinically asymptomatic on its own?

Ashman's phenomenon

How should 2nd degree AV block Mobitz I be treated if the patient is symptomatic?

Atropine, Transcuatenous pacing

3rd degree AV blocks should be treated with what device?

Dual-chamber permanent pacemaker

Which class of antiarrhythmics:
Quinidine

1A

Which class of antiarrhythmics:
Procainamide

1A

Which class of antiarrhythmics:
Disopyramide

1A

Which class of antiarrhythmics:
Lidocaine

1B

Which class of antiarrhythmics:
Diphenylhydantoin (Phenytoin)

1B

Which class of antiarrhythmics:
Flecainide

1C

Which class of antiarrhythmics:
Propafenone

1C

Which class of antiarrhythmics:
Beta blockers

2

Which class of antiarrhythmics:
Amiodarone

3

Which class of antiarrhythmics:
Sotalol

3

Which class of antiarrhythmics:
Verapamil

4

Which class of antiarrhythmics:
Diltiazem

4

Which class of antiarrhythmics:
Adenosine

5

Which class of antiarrhythmics:
Digoxin

5

Which class of antiarrhythmics:
Block sodium channels

1A, 1B, 1C

Which class of antiarrhythmics:
Block potassium channels

3

What are some adverse effects of Quinidine?

Prolonged QT interval, Torsades

Which antiarrhythmic can cause Lupus like syndrome?

Procainamide

What is the primary use of Lidocaine as an antiarrhythmic?

Prevention of recurrent ventricular tachyarrhythmias

What is a common side effect of Tocainide?

Toxic CNS effects

Which class of antiarrhythmics:
Tocainide

1B

Which class of antiarrhythmics:
Mexilitine

1B