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Cardiology 3
*Cardio III Arrhythmias
82
Medical
Professional
07/19/2005

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Term
In a patient with h/o syncope what tests can be ordered?
Definition
CT...ECG...exercise stress test (to check for V-tach brought on by exercise...treat with Beta-Blockers)
Term
When autonomic dysfunction is suspected as a mechanism for orthostatic hypotension (no increase in heart rate with standing or per tilt-table testing) and is not responsive to non-pharmacologic means (support hose, increased salt) what medication might be prescribed
Definition
Midodrine (ProAmatine) which is a prodrug for desglymidodrine, and alpha agonist that stimulates the alpha-adrenergic receptors of the ARTERIOLAR and VENOUS vessels.
Term
List the 2 usual mechanisms of abnormal rhythms?
Definition
Re-entry and Automaticity
Term
What is the usual mechanisms for most abnormal rhythms...premature complexes, SVT, Atrial flutter, atrial fib, and V-tach. (2/3 of PAT's) PAT's = PSVT's now called reentrant tachycardia
Definition
Re-entry
Term
Automatic rhythms are what type of ectopic rhythms?
Definition
Accelerated Ectopic Rhythms
Term
What do you call an automatic depolarization of an ectopic focus at a slow rate?
Definition
Parasystole...this is a 3rd mechanism (after re-entrant and automatic rhythms) and results in a variable coupling interval, fusion beats, and a regular interval between the PVCs.
Term
How do you treat Parasystole?
Definition
You Don't!...Do NOT treat parasystole.
Term
Describe Sick Sinus Syndrome...
Definition
Any sinoatrial node problem...sinus bradycardia, sinus pauses / blocks / sinus arrest, and tach-brady syndrome. These patients usually do not need eletrophysiologic testing.
Term
When do you need a pacemaker with SSS?
Definition
Symptomatic patients or patients with tachyarrhythmias requiring therapy, which might precipitate significant bradycardia.
Term
What is the usual rate for Atrial Flutter?
Definition
230 - 320
Term
What is the usual block ratio for Atrial Flutter
Definition
2 : 1
Term
What mechanism is usually responsible for Atrial flutter...and where is this located?
Definition
Atria Flutter is usually due to reentry around the tricuspid valve.
Term
Atrial flutter is usually suspect of what type of disease?
Definition
Heart disease or Pulmonary disease.
Term
Is Atrial Flutter stable or unstable?
Definition
Unstable
Term
Mechanism of Sinus Tachycardia?
Definition
Automatic (normal)
Term
Mechanism, Origin and Rate of Sinus Node Reentry?
Definition
Reentry, Sinus node and right atrium,.... Rate = 110 - 180.
Term
Mechanism, Origin and Rate of Atrial Fibrillation?
Definition
Reentry,...Atria...(there is another mechanism thats called Fibrillatory conduction...which originates from the Pulmonary veins, SVC...see table 27-1 Hurst) The rate for the reentry a-fib is 260-450 for the other is ? (again this is from Hurst table 27-1)
Term
Mechanism, Origin and Rate of Atrial tachycardia?
Definition
Reentry, Atria, 150-240
Term
Mechanism, Origin and Rate of WPW or Concealed accessory AV connection?
Definition
Reentry, Circuit includes accessory AV connection, atria, AV node, His-Purkinje system, ventricle;...Rate = 150-220 usually (+/- 30)
Term
Mechanism, Origin and Rate of Accelerated AV junctional tachycardia?
Definition
Autoatic or triggered from digitalis toxicity. Rate 61 - 200
Term
Mechanism, Origin and Rate of Accelerated idioventricular rhythm?
Definition
automaticity...Origin in purkinje fibers ...Rate = > 60
Term
Mechanism, Origin and Rate of Ventricular tachycardia?
Definition
Reentry,...Origin = Ventricle... Rate_120-300
Term
Mechanism, Origin and Rate of Torsades de pointes tachycardia?
Definition
? Triggered (EADs) with reentry... Origin in the Ventricles...Rate > 200
Term
If Procainamide is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose?
Definition
20 - 30 mg/min loading infusion, up to 12 to 17 mgkg. This may be followed by an infusion of 1 - 4 mg/min iv.
Term
If Amiodarone is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose?
Definition
150 mg infused over 10 minutes, followed by a constant infusion of 1.0 mg/min for 6 hours, then a maintenance infusion of 0.5mg/min.
Term
If Lidocaine is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose?
Definition
1.0 - 1.5 mg/kg. Supplemental boluses of 0.5 - 0.75 mg/kg every 5 - 10 minutes to a maximum of 3 mg/kg total loading dose may be given as needed. Follow loading with infusion of 2 -4 mg/min (30 - 50 micro-gm/kg/min)
Term
Rupture of a papillary muscle...with which type of MI most frequently and when?
Definition
Inferior MI usually 3 -7 days after the Inferior MI the patient rapidly develops shock! Listen for a NEW SHORT, EARLY SYSTOLIC MURMUR. Do emergency echo to diagnose ...URGENT CARDIOTHORACIC SURGERY is needed.
Term
Acute Ventricular septal defect associated with what type of MI and when?
Definition
Anteroseptal MI... usually 3 - 7 days after the anteroseptal MI. Patient rapidly develops shock. LOUD, HOLOSYSTOLIC MURMUR is heard widely over the precordium. O2 "step-up" from the right atrium to the pulmonary artery of at least 10%. Do emergency echo to diagnose. URGENT CARDIOTHORACIC SURGERY is needed. Mortality rate is very high.
Term
Indications for temporary pacing at the time of an MI:
Definition
Asystole...symptomatic bradycardia... Bilateral BBB...New or ? age bifascicular block... Mobitz type I
Term
What do you do with a patient having an MI that developes hypotension and Type II second degree AV block and is not responsive to atropine?
Definition
Temporary Pacing!
Term
What do you do with a patient having an MI that developes RBBB alternating with LAFB/LPFB of any age?
Definition
Temporary Pacing
Term
What do you do with a patient having an MI that deveopes Mobitz type II second degree AV block?
Definition
Temporary Pacing
Term
Free-wall rupture: With what type of MI and when does this usually occur?
Definition
Large Anterior MI usually 3-7 days after a Large Anterior MI in an elderly hypertensive female.. The sudden go syncopal. The NECK VEINS are GROSSLY ENGORGED from TAMPONADE. ...Emergency Surgery.
Term
When is Permanent Pacing Indicated?
Definition
Mobits II or complete heart block..especially if symptomatic.
Term
What is the most effective treatment for Atrial Flutter?
Definition
Eletrical Cardioversion
Term
At what energy do you cardiovert A-flutter?
Definition
100 - 200 joules is used any less will more likely and probably convert the patient to atrial fibillation.
Term
Describe how you might cardiovert Atrial Flutter medically?
Definition
IV diltiazem or beta-blocade to control the rate. Then attempt conversion with FLECAINIDE, IBUTILIDE, SOTALOL, or AMIODARONE...depending on the clinical situation.
Term
Which medication are used to prevent recurrence of Atrial Flutter after it is converted?
Definition
Flecainide, Quinidine, Sotalol, Amiodarone, or Dofetilide...(FQ-SAD)
Term
What drugs are to be avoided in patients with atrial flutter and pre-excitation syndrome (eg. WPW)?
Definition
Digoxin, Calcium channel-blockers, and beta-blockers are to be avoided in WPW and patients with atrial flutter and pre-excitation syndrome
Term
What procedure is used for recurrent Atrial Flutter?
Definition
Radioablation
Term
When a patient has refractory A-Fib and annot tolerate meds what is the treatment?
Definition
AV node ablation with Permanent pacing.
Term
What does Atrial Flutter usually convert to?
Definition
A-Fib or Sinus
Term
What can you do to slow the rate and get a better evaluation of Atrial Flutter?
Definition
Vagal Maneuver.
Term
A patient presents with new onset Atrial Flutter and no prior hx of Lung or Heart disease...what do you want to rule out?
Definition
Pulmonary Emboli (Multiple!) and Thyroid Disease.
Term
What is the normal block for Atrial Flutter?
Definition
2:1 if it is 3:1 the cause is either AV node disease or drugs.
Term
Which has the most frequent systemic embolization...Atrial Flutter or FIB?
Definition
A-Fib has the most frequent systemic embolization.
Term
List some structural causes of Atrial Fibrillation...
Definition
MVP... Large Left Atrium...Cardiomyopathy... HOCM... CAD... COPD
Term
If A-Fib is not responsive to the usual treatment what do you want to consider as a cause?
Definition
HYPERTHYROIDISM, HYPOmagnesemia, alcoholism, cocaine abuse... excessive caffeine and nicotine.
Term
Describe a Fast, Cost effective, way to evaluate atrial fibrillation when the time of onset is unclear...
Definition
TEE-guided cardioversion
Term
Where is the thrombus usually found in patients with atrial fibrillation?
Definition
Left Atrium or Left-Atrial appendage.
Term
If considering cardioversion for atrial fibrillation and a left atrium or atrial appendage thrombus is found how do you treat?
Definition
Give patient anticoagulation and the recheck for thrombus in 3-4 weeks. You will have to continue the anticoagulation for another 4 weeks AFTER successful cardioversion, too.
Term
What is the arterial emboli rate for patients with chronic atrial fib.?
Definition
5% per year.
Term
Pts with Chronic Atrial Fib should all take ASA...who should be started on warfarin with an INR of 2.0-30?
Definition
prior CVA / TIA...HTN...DM...HF... Left-atrial enlargement... valvular heart disease...age > 75 yo
Term
Which medication has the best exercise tolerance for chronic atrial fibrillation?
Definition
Verapamil...if the pt is relatively healthy otherwise. Verapamil will not convert the rhythm however.
Term
Why do a temporary pacemaker BEFORE electrical cardioversion?
Definition
To prevent the patient from developing asystle after cardioversion... these patients have nodal disease and may develope asystole after cardioversion. No more a-fib...No more pulse either...so consider a pacemaker prior to electrical cardioversion!
Term
What arrhythmia is associated with COPD and also can be a result of theophylline toxicity?
Definition
Multifocal atrial tachycardia (MAT).
Term
List some causes of MAT...
Definition
COPD...theophylline...very low K and Mg.
Term
How do you treat Multifocal atrial tachycardia (MAT)?
Definition
diltiazem and verapamil are effective... AV Node ablation with permanent pacing for refractory cases.
Term
MAT is what type of arrhythmia?
Definition
Nonreentrant Atrial Tachycardia
Term
Describe the ECG in MAT...
Definition
MAT requires three or more consecutive P waves of different morphologies at rates greater than 100 beats/min. MAT usually has an irregular ventricular rate because of varying AV conduction. There is a high incidence of AF (50 to 70%) in patients with MAT.
Term
Paroxysmal Supraventricular Tachycardia: The presence of an AV bypass tract provide the substrate for the vast majority of cases of PSVT... What type of PSVT do you have with Antegrade vs Retrograde conduction?
Definition
A bypass tract may conduct antegradely, in which case the Wolff-Parkinson-White (WPW) syndrome is said to be present. When the bypass tract manifests only retrograde conduction, it is termed a concealed bypass tract
Term
What is the usual rate for PSVT?
Definition
150 - 230
Term
How do the P waves appear in PSVT?
Definition
They are burried in the QRS...can NOT see them.
Term
Where do most of the PSVTs originate?
Definition
AV node.
Term
What can CURE PSVT?
Definition
Radioablation can cure PSVT
Term
List the differential diagnoses of WIDE-COMPLEX TACHYCARDIA...
Definition
PSVT with aberrant conduction...WPW...SVT with LBBB... and last but not least: V-TACH.
Term
Where does Adenosine work?
Definition
It works on the AV node. The T1/2 is only 10 seconds...DOC for PSVT
Term
When you hear the term KENT bundle what do you think of?
Definition
WPW
Term
Another name for "pre-excitation syndrome" is what?
Definition
WPW
Term
How do you treat Atrial Fib/Flutter in a WPW patient?
Definition
IV procainamide...NEVER digoxin, verapamil, beta-blocker.
Term
How do you treat the majority of patients with WPW?
Definition
You don't!...Most patients are totally asymptomatic and have no dysrhythmia.
Term
What is the PR interval in a pt with WPW?
Definition
< 0.12 seconds. The PR interval is < 0.12 seconds due to a DELTA wave.
Term
What is the QRS in a pt with WPW?
Definition
> 0.12 seconds. There is a fusion of the QRS current and the current which bypasses the AV node.
Term
How do you treat a pt with WPW and narrow complex tachycardia?
Definition
The rate is usually a little less than 200 ...TREAT THE SAME AS ANY SVT... Vagal Maneuvers, Cardioversion, Procainamide, Verapamil, or adenosine.
Term
How do you treat a pt with WPW and WIDE complex tachycardia?
Definition
IV procainamide... the DOC for wide complex tachycardia in WPW...wide complex tachycardia with WPW is frequently acute AF or A-flutter. NEVER use digoxin, verapamil, or beta-blockers for this.
Term
List the major Supraventricular Tachycardias...
Definition
Atrial Flutter and Fibrillation...MAT...PSVT...WPW
Term
List some Major Ventricular Arrhythmias...
Definition
PVCs, V-Tach,
Term
What is a compensatory pause?
Definition
The time between the sinus beats that are on either side of the PVC = 2 basic RR intervals.
Term
How do you know when and how to treat PVCs?
Definition
The treament is based on ELECTROPHYSIOLOGIC TESTING...DON'T treat simple PVCs... and for the treatment to be considered successful the number of PVCs Must Decrease by 80% or more!!! or STOP TREATMENT.
Term
What is the difference between the Simple and Complex PVC?
Definition
Simple PVCs occur BEYOND the T-wave, are uniform, and have constant coupling (re-entrant)
Term
HURST on PVCs with NO STRUCTURAL heart disease...
Definition
Patients with structurally normal hearts and frequent PVCs have no increased risk of sudden death; therefore no specific therapy is indicated. In patients with significantly symptomatic PVCs, therapy aimed at alleviating symptoms may be necessary. Initial treatment should include reassurance and the avoidance of exogenous stimulants (caffeinated beverages and other stimulants, environmental stress). If these measures fail, trial of a low-dose beta blocker may be sufficient to alleviate symptoms. Although the response to beta-adrenergic blockers is likely a pharmacologic class effect, acebutolol is approved by the U.S. Food and Drug Administration (FDA) for treatment of PVCs and may be better tolerated due to its intrinsic sympathomimetic properties.
Term
HURST on PVCs associated WITH STRUCTURAL HEART DISEASE...
Definition
Patients with PVCs associated with structural heart disease should be evaluated carefully, as they may be at increased risk of sudden death. Patients with ischemic cardiomyopathy and frequent PVCs are a high-risk subgroup. These patients should be approached with a heightened vigilance to further risk stratification for sudden death. Patients with an LV ejection fraction < 40 percent should receive an ambulatory electrocardiographic (ECG) (Holter) monitor. If nonsustained VT (three or more successive ventricular beats) is detected, the patient should undergo invasive electrophysiology study and, if the study is positive, should be offered an implantable cardioverter/defibrillator (ICD). Independent of the presence of PVCs or NSVT, patients with chronic ischemic cardiomyopathy and severely depressed ejection fraction (EF < 30 percent) should be considered for an ICD.22 Patients with PVCs associated with nonischemic cardiomyopathy require no specific treatment other than aggressive heart failure management.
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