Term
|
Definition
sensation of an abnormally perceived heartbeat.
it can be rapid, irregular or forceful but it is perceived as unusual to the pts normal heart beat. |
|
|
Term
| broadly define causes of palpitations |
|
Definition
cardiac arrhythmias
structural heart disease
psychosomatic
systemic causes
medications |
|
|
Term
| which cardiac arrhythmias can cause palpitations? |
|
Definition
extrasystoles (ventricular or supraventricular)
tachycardias including SVT, AF and atrial flutter
Bradycardias: less commonly perceived as palpitations |
|
|
Term
| name some structural heart disease that can cause palpitations |
|
Definition
valvular heart disease; prolapse, regurge, mechanical valves
congenital heart disease
heart failure
cardiomegaly or hypertrophic cardiomyopathy |
|
|
Term
| psychosomatic causes of palpitations include? |
|
Definition
anxiety
panic
depression
somatisation disorder |
|
|
Term
| systemic causes of palpitations? |
|
Definition
hyperthyroid
fever
anemia
pregnancy
pheochromocytoma
menopause
hypoglycemia
postural orthostatic hypotension syndrome |
|
|
Term
| drugs that can cause palpitations? |
|
Definition
alcohol
nicotine
caffeine
recreational drugs e.g. amphetamines, cocaine
withdrawal of beta blockers
beta 2 agonists, vasodilators |
|
|
Term
| which arrhythmia is found to be more common in competitive athletes? |
|
Definition
|
|
Term
| questions to ask when taking a palpation history |
|
Definition
SOCRATES
tap out beat
any present palpitations?
FHx
medications
caffeine
drugs, alcohol, smoking, illicit drugs
general health well being
relationship to exercise e.g. does it come on with exercise. |
|
|
Term
| what would you look for in a person who has palpitations when you are examining them? |
|
Definition
general state
weight change
temperature
anemia
tremor
bulging eyes
nicotine smell/stain
swollen ankles |
|
|
Term
|
Definition
ECG 12 lead
bloods: FBC, UE, LFTs, TFTs
ambulatory ECG if ECG doesn't give diagnosis
echo
exercise testing |
|
|
Term
| with regard to palpitations what is the criteria for referal? |
|
Definition
refer those with current palpitations and:-
VT
SVT that doesnt respond to valsalva or carotid massage
hemodynamic compromise (low BP and tachycardia)
significant SOB
chest pain
syncope or near syncope
FHx of sudden cardiac death <40 years
onset precipitated by exercise
when there is a serve systemic cause for palpitations such as severe thyrotoxicosis, anemia or sepsis |
|
|
Term
| mx of palpitations in primary care |
|
Definition
education: stop smoking, less cocaine, diet, exercise
refer to cardiology if there are changes in resting ECG including atrial flutter, SVT, WPW, LBBB. |
|
|
Term
|
Definition
loss of association between cardiac apex beat and loss of radial pulsation
causes: CHD, valvular heart disease, HTN, hyperthyroid, alcohol, DM
ECG: no p waves and R-R interval variability
ix: ECG, FBC, TFT, LFT, UE, Echo
Mx: rate/rhythm control with thromboprophylaxis to prevent strokes.
medical management: rate or rhythm control (cardioversion or drugs)
surgical option: AV node ablation. |
|
|
Term
Atrial flutter
there are 2 types what are they?
commoner in which sex?
ECG trace?
gold standard for diagnosis?
mx
anticoagulation? |
|
Definition
type1 <350 bpm type 2 >350 bpm
> common in men and common during 1st week after open heart surgery
ECG trace: saw tooth pattern of type 1. 12 lead ECG gold standard for diagnosis
mx: rate control with cardioversion or medications
for recurrent disease: radio frequency or cryotherapy catheter ablation.
pt with flutter are anti coagulated in the same way as those with AF |
|
|
Term
| Rate or rhythm control on AF? |
|
Definition
rate control 1st line in AF except:
when there is a reversible cause to AF
when they have HF due to AF
new onset AF
mx: beta blocker (not sotaloll) or calcium channel blocker
consider digoxin only if the pt is very sedentary
if one is not working consider combo of the following:-
beta blocker, calcium channel blocker or digoxin |
|
|
Term
| when can you consider digoxin as mono therapy? |
|
Definition
| for people with non-paroxysmal AF only if they are sedentary (do no or very little physical exercise). |
|
|
Term
| what do you do in rhythm control for AF? |
|
Definition
offer electrical rather than pharmacological cardioversion if AF has been longer than 48 h
consider amiodarone 4 weeks before and up to 12 months after cardioversion to maintain sinus rhythm |
|
|
Term
| if someone has heart structural defects which anti arrhythmic should they not have? |
|
Definition
| flecanide or any other 1c anti arrythmitic |
|
|
Term
| what method could be employed for those with paroxysmal AF? |
|
Definition
Pill in pocket.
they need to have no structural heart defects
SBP >100mmHg
know how to take the drug
HR > 70bpm |
|
|
Term
how would you assess stroke risk in someone with AF?
how do you asses bleeding risk in someone with AF? |
|
Definition
stroke risk: CHA2DS2VASc
bleeding risk: HASBLED |
|
|
Term
what does CHA2DS2VASc stand for?
what scores are significant? |
|
Definition
Congestive heart failure
HTN
Age 65-74, age >75
Diabetes
Stroke/TIA/thromboembolism
VAscular disease
Sex category: female
scores
0= low risk
1= and male. consider anticoagulant. female score 1 for being female
2 or > = high risk, anticoagulant recommended |
|
|
Term
what does HASBLED stand for?
what is it used for? |
|
Definition
HTN uncontrolled > 160mmHg
Abnormal renal liver fx : on dialysis or LFT 3x normal
Stroke:
Bleeding: prior bleeding or predisposition to bleeding
Labile INRS:
Elderly: >65 years
Drugs or alcohol: > 8 drinks a week
used to determine 1 year risk of major bleed in someone with AF.
score is out of 9 based on 8 parameters. kidney and liver dysfunction =2. |
|
|
Term
who should you offer anticoagulation to?
what different forms are there? name them |
|
Definition
those with cha2ds2vasc score of 2 or more
those available are:-
warfarin
apixiban
rivaroxaban
dabigatran
etexilate
edoxaban |
|
|
Term
| if a person had non valvular AF and other risk factors for stroke which NOAC would be suitable for them? |
|
Definition
Apixaban.
suitable if they have non valvular AF and other risk factors suchs as age 75 years or older, hypertension, diabetes mellitus, and symptomatic heart failure. |
|
|
Term
| what would you use to reverse the effects of Dabigatran? |
|
Definition
|
|
Term
| which two rhythms associated with cardiac arrest are shockable? |
|
Definition
|
|
Term
| which rhythms associated with cardiac arrest are not shockable? |
|
Definition
|
|
Term
| what is the prognosis for those who survive VF? |
|
Definition
if within 48h of MI there is no bearing of prognosis but if it occurs > 48h post MI, associated with poor prognosis
they should get a ICD
those who get CABG needs a normal ejection fraction or they won't benefit |
|
|
Term
|
Definition
more common in men
can be due to congenital accessory pathway
it is a form of SVT
there are 2 types. Type A and Type B
complications: can turn into VF and result in sudden death
ECG: delta waves, broad QRS and short PR interval
mx: asymptomatic pts may need periodic review.
radiotherapy ablation 1st line for symptomatic
drug therapy if they refuse radio ablation: amiodarone or sotalolol (but not if they have structural heart defects)
surgical ablation if they are getting open heart surgery at the same time. |
|
|
Term
|
Definition
digoxin
may accelerate conduction through the bypass tract, causing potentially lethal ventricular arrhythmias or haemodynamic instability during atrial fibrillation. |
|
|
Term
| wpws is an example of what type of tachycardia? |
|
Definition
| atrioventricular re-entrant tachycardia |
|
|
Term
| how would you reduce someones HR if they were in Aflutter or SVT? |
|
Definition
vagal manouevres
adenosine or verapamil
if they fail or are CI then DC cardioversion |
|
|
Term
| management of accessory pathways |
|
Definition
ablation of the accessory pathways.
if there are 2 pathways the we can ablate the slower pathway. |
|
|
Term
| contra indications to catheter radio ablation |
|
Definition
in presence of known atrial thrombus
mechanical prosthetic heart valves
women should not be explodes to fluoroscopy if there is a chance that they are pregnant. |
|
|
Term
| indications for catheter ablation |
|
Definition
symptomatic SVT
WPWS and atrial flutter
AF with life impairing symptoms
symptomatic idiopathic VT |
|
|
Term
what do pacemakers do?
what do they consist of
what is the life span of the battery? |
|
Definition
provide electrical stimuli to cause cardiac contraction when intrinsic stimuli is absent or slow.
they consist of a pulse generator and pacing wires
battery in permanent pacemakers has a life span of 5-9 years |
|
|
Term
| explain unipolar pacemakers |
|
Definition
a single contact is made with the heart usually in ventricle
used where AV conduction is likely to return
if the AV function is normal but the issue is in the SA node then the pacing wire is place in RA. |
|
|
Term
| explain dual chamber pacemakers |
|
Definition
there are pacing electrodes in both RA and RV
Allow maintenance of the physiological relationship between atria and ventricles and allow increase in sinus rare during exercise. |
|
|
Term
| explain dual site atrial pacing |
|
Definition
there are 2 atrial leads, one in right atrial appendage and the other in the coronary sinus or its os.
ventricular lead placed in apex of outflow tract of RV
promising rx option for paroxysmal AF |
|
|
Term
| explain biventricular pacemakers |
|
Definition
Leads in RA, RV and LV
useful in those with HF who also have abnormal intraventricular conduction eg. LBBB |
|
|
Term
|
Definition
rx cardiac tachyarrthmia directly
if the device senses a ventricular rate that exceeds the cut off rate then it perform cardioversion/defib |
|
|
Term
| indications for permanent pacing |
|
Definition
mobitz type II
persistant symptomatic bradycardia
complete AV block
prevention of AF |
|
|
Term
|
Definition
LVEF <35% and VT
LVEF <30% and broad QRS
long QT
after surviving VT or VF induced cardiac arrest |
|
|
Term
| where is the lead for and ICD? |
|
Definition
|
|
Term
| explain the pacemaker code |
|
Definition
the first letter is the chamber being paced.
the second letters the chamber being sensed
the 3rd letter is the mode of sensing
1st A-atrium V-ventricle D- dual, both
2nd A-atrium V-ventricle D- dual, both
3rd I - inhibited T- triggered D- inhibited and triggered |
|
|
Term
| patient advice for those with ICD |
|
Definition
Keep your ICD card with you at all times (make, model and settings of the device).
Sexual activity - the device will not cause any harm, even if a shock is delivered to you during intercourse.
Electrical equipment (such as drills) can be safely used. Electromagnetic interference (radios, fridges, cookers, computers and microwaves) will not affect your ICD.
Travel: the ICD may set off the airport security alarm. Your ICD will be unharmed provided you walk briskly through the arch. Many ICD clinics carry a list of ICD-friendly insurance companies.
Arc welding - should be avoided.
Mobile phones - keep handsets six inches away from the ICD (hold the phone over the ear on the opposite side to the device). |
|
|
Term
|
Definition
It is safe to have a bath or shower after 3-4 days.
Keep the arm on the same side as the defibrillator below shoulder level until after the first ICD check-up (there is a small chance the leads can move).
Do gentle arm and shoulder exercises to keep the arm mobile.
Following recovery (4-6 weeks) increase your level of activity if possible.
A programmer is used to check device settings (takes about 15 minutes).
CXR is used to check lead positions.
Battery lifespan is 6-7 years. |
|
|
Term
| define 1st degree heart block |
|
Definition
| PR interval > 0.2 seconds |
|
|
Term
| what ECG pattern would you see on second degree heart block Mobitz type I aka Wenckebache |
|
Definition
prolongation of PR interval then a dropped QRS as the impulse fails to conduct to the ventricles. following this the baseline is recovered and the cycle repeats itself.
this is due to impaired AV nodal conduction. |
|
|
Term
| what ECG pattern would you see on second degree heart block Mobitz type II |
|
Definition
PR interval is constant but there are intermittent dropped QRS complexes. There may be a regular block e.g 2:1 or a 3:1 block. means for ever 2 or 3 p waves a QRS is dropped.
QRS complexes are wider in type II than type I as the defect is due to impaired conduction in the bundle of His or bundle branches |
|
|
Term
| prognosis of second degree type I and II heart blocks |
|
Definition
Type I usually due to AV nodal disease, non progressive, usually benign and good long term prognosis
Type II block due to His purkinje fibre abnormalities. It can progress to complete heart block and needs a pacemaker. |
|
|
Term
| explain 3rd degree complete heart block CHB |
|
Definition
there is no communication between atria and ventricles.
the P waves usually at 75 bpm.
the block can be at the AV node or infra nodally.
If at the AV node then escape rhythm arises from above of from the bundle of His. the QRS will be narrow and the beat is relatively rapid. pts with this are less symptomatic
If the block occurs at or below bundle of His then the escape rhythm is generated by the right or left bundles and this is slow, resulting in symptoms and wide QRS. |
|
|
Term
| how would you acutely rx complete heart block? |
|
Definition
| atropine and temporary pacing |
|
|
Term
| what is the QRS in complete BBB? |
|
Definition
| > 0.12 seconds > 3 small squares |
|
|
Term
Class Ia anti arrhythmic drugs
which 3 are in them
MOA
SE |
|
Definition
Quinidine
Procainamide
Disopyramide
Block Na channels and increase AP (action potential) duration.
SE: Quinidine toxicity causes cinchonism (headache, tinnitus, thrombocytopaenia)
Procainamide may cause drug-induced lupus |
|
|
Term
Class Ib anti arrhythmic drugs
which 3 are in them
MOA
SE |
|
Definition
Lidocaine
Tocainide
Mexiletine
Block Na channel but decrease duration of AP |
|
|
Term
Class Ic anti arrhythmic drugs
which 3 are in them
MOA
SE |
|
Definition
Flecainide
Encainide
Propafenone |
|
|
Term
| class II anti arrhythmic drugs |
|
Definition
Propranolol
Atenolol
Bisoprolol
Metoprolol |
|
|
Term
|
Definition
Amiodarone
Sotalol
Ibutilide
Bretylium |
|
|
Term
|
Definition
|
|
Term
amiodarone
what class anti aryhtmic drug is it?
half life?
SE: |
|
Definition
class III
MOA: blocks K channels. This inhibits depolarisation and prolongs AP. also block Na channels.
Long t 1/2 life: 20-100 days
prolongs QT, causes thrombophlebitis (give in central vein), decreases metabolism of warfarin |
|
|
Term
| what monitoring do pts on amiodarone need? |
|
Definition
| TFT and LFT every 6 months. |
|
|
Term
|
Definition
thyroid dysfunction
corneal deposits
pulmonary fibrosis/pnemonitis
liver fibrosis/hepatits
peripheral neuropathy/myopathy
photosensitivity
slate grey appearance
thrombophlebitis and injection site reactions
bradycardia |
|
|
Term
VT mx:
what are adverse signs that suggest they need cardioconversion?
what drug therapy can be used?
which drug should NOT be used in VT? |
|
Definition
SBP <90mmHg, chest pain, HF, syncope
in absence of such signs use anti antiarrythmitics. if these fail do cardioversion.
drug therapy
amiodarone: central vein
Lidocaine: caution in severe LV impairment
Procainamide
VERAPIMIL should not be used in VT
if drug therapy fails do electrophysiological studys and consider ICD |
|
|
Term
VT has potential to turn in what?
there are 2 types of VT what are they? |
|
Definition
VF
There are two main types of VT:
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. |
|
|
Term
| congenital causes of prolonged QT interval |
|
Definition
Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
Romano-Ward syndrome (no deafness) |
|
|
Term
| drug related causes of prolonged QT interval |
|
Definition
amiodarone
sotalolol
class Ia anti arrhythmic drugs
TCA
fluoxetine
chloroquine
erythromycin
terfenadine |
|
|
Term
| other causes of prolonged QT |
|
Definition
hypocalcemia
hypokalemia
hypomagnesia
acute MI
myocarditis
hypothermia
subarachnoid haemorrhage |
|
|
Term
| name two important drug interactions that amiodarone has |
|
Definition
decreased metabolism of warfarin so increased INR
increases digoxin levels so toxicity |
|
|
Term
what is digoxin used for in AF?
MOA? |
|
Definition
rate control. it is a cardiac glycoside.
MOA: decreases conduction through AV node so slows ventricle rate in AF and flutter
inhibits Na/K ATPase pump and this increases force of cardiac contraction. Also stimulates vagus nerve. |
|
|
Term
| digoxin toxicity increases when levels are between 1.5 -3mcg/l what are signs of toxicity? |
|
Definition
unwell, lethargy, nausea, vomiting, aorexia
confusion, yellow-green vision
arrhytmias AV block, bradycardia
man boobs |
|
|
Term
| what factors can precipitate digoxin toxicity? |
|
Definition
hypokalemia
increasing age
renal failure
myocardial ischemia
hypomagnesia, hypercalcemia, hypernatremia, acidosis
hypoalbuminemia
hypothermia
hypothyroid
Drugs |
|
|
Term
| which drugs can precipitate digoxin toxicity? |
|
Definition
amiodarone
quinidine
verapamil
diltiazem
spirinolactone
ciclosporin
also drugs that cause hypokalemia e.g. thiazides and loop diuretics. |
|
|
Term
|
Definition
ABC
digibind
Rx arrhythmias
monitor potassium |
|
|
Term
| what associations are found with WPWS? |
|
Definition
HOCM
mitral valve prolapse
Ebsteins anomaly
thyrotoxicosis
secundum ASD |
|
|
Term
|
Definition
amiodarone, flecainide and sotalolol.
avoid sotalolol if there is co existing AF |
|
|
