Term
| In a patient with h/o syncope what tests can be ordered? |
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Definition
| CT...ECG...exercise stress test (to check for V-tach brought on by exercise...treat with Beta-Blockers) |
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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 |
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Definition
| Midodrine (ProAmatine) which is a prodrug for desglymidodrine, and alpha agonist that stimulates the alpha-adrenergic receptors of the ARTERIOLAR and VENOUS vessels. |
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Term
| List the 2 usual mechanisms of abnormal rhythms? |
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Definition
| Re-entry and Automaticity |
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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 |
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Definition
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Term
| Automatic rhythms are what type of ectopic rhythms? |
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Definition
| Accelerated Ectopic Rhythms |
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Term
| What do you call an automatic depolarization of an ectopic focus at a slow rate? |
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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. |
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Term
| How do you treat Parasystole? |
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Definition
| You Don't!...Do NOT treat parasystole. |
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Term
| Describe Sick Sinus Syndrome... |
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Definition
| Any sinoatrial node problem...sinus bradycardia, sinus pauses / blocks / sinus arrest, and tach-brady syndrome. These patients usually do not need eletrophysiologic testing. |
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Term
| When do you need a pacemaker with SSS? |
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Definition
| Symptomatic patients or patients with tachyarrhythmias requiring therapy, which might precipitate significant bradycardia. |
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Term
| What is the usual rate for Atrial Flutter? |
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Definition
|
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Term
| What is the usual block ratio for Atrial Flutter |
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Definition
|
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Term
| What mechanism is usually responsible for Atrial flutter...and where is this located? |
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Definition
| Atria Flutter is usually due to reentry around the tricuspid valve. |
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Term
| Atrial flutter is usually suspect of what type of disease? |
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Definition
| Heart disease or Pulmonary disease. |
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Term
| Is Atrial Flutter stable or unstable? |
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Definition
|
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Term
| Mechanism of Sinus Tachycardia? |
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Definition
|
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Term
| Mechanism, Origin and Rate of Sinus Node Reentry? |
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Definition
| Reentry, Sinus node and right atrium,.... Rate = 110 - 180. |
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Term
| Mechanism, Origin and Rate of Atrial Fibrillation? |
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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) |
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Term
| Mechanism, Origin and Rate of Atrial tachycardia? |
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Definition
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Term
| Mechanism, Origin and Rate of WPW or Concealed accessory AV connection? |
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Definition
| Reentry, Circuit includes accessory AV connection, atria, AV node, His-Purkinje system, ventricle;...Rate = 150-220 usually (+/- 30) |
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Term
| Mechanism, Origin and Rate of Accelerated AV junctional tachycardia? |
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Definition
| Autoatic or triggered from digitalis toxicity. Rate 61 - 200 |
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Term
| Mechanism, Origin and Rate of Accelerated idioventricular rhythm? |
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Definition
| automaticity...Origin in purkinje fibers ...Rate = > 60 |
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Term
| Mechanism, Origin and Rate of Ventricular tachycardia? |
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Definition
| Reentry,...Origin = Ventricle... Rate_120-300 |
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Term
| Mechanism, Origin and Rate of Torsades de pointes tachycardia? |
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Definition
| ? Triggered (EADs) with reentry... Origin in the Ventricles...Rate > 200 |
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Term
| If Procainamide is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose? |
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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. |
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Term
| If Amiodarone is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose? |
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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. |
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Term
| If Lidocaine is used to treat sustained VT NOT associated with hemodymanmic instability what is the dose? |
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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) |
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Term
| Rupture of a papillary muscle...with which type of MI most frequently and when? |
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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. |
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Term
| Acute Ventricular septal defect associated with what type of MI and when? |
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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. |
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Term
| Indications for temporary pacing at the time of an MI: |
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Definition
| Asystole...symptomatic bradycardia... Bilateral BBB...New or ? age bifascicular block... Mobitz type I |
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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? |
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Definition
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Term
| What do you do with a patient having an MI that developes RBBB alternating with LAFB/LPFB of any age? |
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Definition
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Term
| What do you do with a patient having an MI that deveopes Mobitz type II second degree AV block? |
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Definition
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Term
| Free-wall rupture: With what type of MI and when does this usually occur? |
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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. |
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Term
| When is Permanent Pacing Indicated? |
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Definition
| Mobits II or complete heart block..especially if symptomatic. |
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Term
| What is the most effective treatment for Atrial Flutter? |
|
Definition
|
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Term
| At what energy do you cardiovert A-flutter? |
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Definition
| 100 - 200 joules is used any less will more likely and probably convert the patient to atrial fibillation. |
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Term
| Describe how you might cardiovert Atrial Flutter medically? |
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Definition
| IV diltiazem or beta-blocade to control the rate. Then attempt conversion with FLECAINIDE, IBUTILIDE, SOTALOL, or AMIODARONE...depending on the clinical situation. |
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Term
| Which medication are used to prevent recurrence of Atrial Flutter after it is converted? |
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Definition
| Flecainide, Quinidine, Sotalol, Amiodarone, or Dofetilide...(FQ-SAD) |
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Term
| What drugs are to be avoided in patients with atrial flutter and pre-excitation syndrome (eg. WPW)? |
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Definition
| Digoxin, Calcium channel-blockers, and beta-blockers are to be avoided in WPW and patients with atrial flutter and pre-excitation syndrome |
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Term
| What procedure is used for recurrent Atrial Flutter? |
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Definition
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|
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
|
|
Term
| What can you do to slow the rate and get a better evaluation of Atrial Flutter? |
|
Definition
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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. |
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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. |
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|
Term
| Which has the most frequent systemic embolization...Atrial Flutter or FIB? |
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Definition
| A-Fib has the most frequent systemic embolization. |
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Term
| List some structural causes of Atrial Fibrillation... |
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Definition
| MVP... Large Left Atrium...Cardiomyopathy... HOCM... CAD... COPD |
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Term
| If A-Fib is not responsive to the usual treatment what do you want to consider as a cause? |
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Definition
| HYPERTHYROIDISM, HYPOmagnesemia, alcoholism, cocaine abuse... excessive caffeine and nicotine. |
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Term
| Describe a Fast, Cost effective, way to evaluate atrial fibrillation when the time of onset is unclear... |
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Definition
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|
Term
| Where is the thrombus usually found in patients with atrial fibrillation? |
|
Definition
| Left Atrium or Left-Atrial appendage. |
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Term
| If considering cardioversion for atrial fibrillation and a left atrium or atrial appendage thrombus is found how do you treat? |
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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. |
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|
Term
| What is the arterial emboli rate for patients with chronic atrial fib.? |
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Definition
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|
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 |
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Term
| Which medication has the best exercise tolerance for chronic atrial fibrillation? |
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Definition
| Verapamil...if the pt is relatively healthy otherwise. Verapamil will not convert the rhythm however. |
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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! |
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|
Term
| What arrhythmia is associated with COPD and also can be a result of theophylline toxicity? |
|
Definition
| Multifocal atrial tachycardia (MAT). |
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Term
| List some causes of MAT... |
|
Definition
| COPD...theophylline...very low K and Mg. |
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|
Term
| How do you treat Multifocal atrial tachycardia (MAT)? |
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Definition
| diltiazem and verapamil are effective... AV Node ablation with permanent pacing for refractory cases. |
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Term
| MAT is what type of arrhythmia? |
|
Definition
| Nonreentrant Atrial Tachycardia |
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|
Term
| Describe the ECG in MAT... |
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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. |
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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? |
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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 |
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Term
| What is the usual rate for PSVT? |
|
Definition
|
|
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
|
|
Term
|
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. |
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Term
| Where does Adenosine work? |
|
Definition
| It works on the AV node. The T1/2 is only 10 seconds...DOC for PSVT |
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|
Term
| When you hear the term KENT bundle what do you think of? |
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Definition
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|
Term
| Another name for "pre-excitation syndrome" is what? |
|
Definition
|
|
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. |
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Term
| How do you treat a pt with WPW and narrow complex tachycardia? |
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Definition
| The rate is usually a little less than 200 ...TREAT THE SAME AS ANY SVT... Vagal Maneuvers, Cardioversion, Procainamide, Verapamil, or adenosine. |
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|
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
|
|
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. |
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|
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) |
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|
Term
| HURST on PVCs with NO STRUCTURAL heart disease... |
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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. |
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Term
| HURST on PVCs associated WITH STRUCTURAL HEART DISEASE... |
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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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