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58 Cards in this Set

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Non cardiac predisposing factors for Arrhythmias
Electrolyte imbalance (K+, Mg++, Ca++)
Drugs (caffeine, alcohol, cocaine, adrenergic, inotropic agents)
Digitalis (almost any arrhythmia or heart block)
Thyrotoxicosis
Intra cardiac catheters (bangs against heart wall causing PVC) and tumors
Diagnostic tools of the trade
for arrhythmias
12 lead ECG
Holter monitor
Event monitor (push button when event happens)
Home telemetry
Reveal device (stays in pt 4ever)
Permanent pacers and defibrillators
Sinus tachy is appropriate with what conditions?
Pain
Fever
Anxiety
Hypovolemia
Anemia
Thyrotoxicosis
Reduced stroke volume (eg, CMO)
If BPM is over 150, you should think what condition?
atrial flutter
Coming off of Beta blockers, what heart condition can you expect?
sinus tachycardia
What meds can cause sinus tachy?
adrenergics
DHP calcium blockers
hydralazine
Is there anything bad going to come from sinus tachy?
Usually none, unless underlying heart disease (CMO, CAD)
Treatment of sinus tachy
Treat underlying problem
Beta blockers but not until underlying problem elicited
Clinical consequences of sinus brady?
Hypotension
CHF if underlying CMO
Weakness, syncope, dyspnea
Treatment of sinus brady?
Correct underlying problem if any (med withdrawal, thyroid replacement
Pacemaker therapy in selected cases
causes of sinus brady
Vagal overtone (during sleep)
Drugs
Hypothyroidism
CNS disease/trauma (CVA, meningitis)
Sinus node dysfunction
What condition?
Irregular R-R intervals, other criteria for sinus rhythm
Cycle length variation of 120 ms or greater
Normal in young patients
Usually no treatment needed
Sinus arrythmia
What condition?

Not sinus
Abnormal P axis (inverted P waves in I, II, AvF, precordial leads
Usually no clinical consequence
Consider decreasing or discontinuing negative chronotropic agents
Ectopic atrial rhythm
What condition?

Rate 150 to 250 bpm
Reentrant tachycardia
Slower rates more likely to be asymptomatic or without hemodynamic compromise
Supraventricular Tachycardia SVT
Causes of SVT
Medication related
Bypass tract (WPW) or abnormal circuit related to scar, myopathy
Clinical manifestations of SVT
Palpitations
Chest pain
Dyspnea
Pre syncope/syncope
Treatment of SVT
Valsalva, carotid massage, other vagal maneuvers (cold water to face)
Adenosine
B blockers, NDP CCB, digitalis, anti arrhythmics
Catheter radiofrequency ablation
Surgical
Rates of A fib and A flutter
A flutter 250-350
A fib > 350
Causes of A fib and flutter
Indeterminate
Aged heart
Hyperthyroidism
Drugs
Sick sinus syndrome
Hypertensive heart disease
CMO
Valvular heart disease
Ischemia
Intra cardiac tumor, eg, myxoma
Clinical manifestations of A fib and flutter
Asymptomatic
Palpitations
Chest pain, dyspnea, fatigue
Pre-syncope/syncope
Embolic episodes
Treatment of A fib and flutter
Rate control BB, NDP CCB, digoxin)
Anticoagulation
Pharmacologic conversion
DC cardioversion
Anti-arrhythmic agents
Ablation (younger pts, short duration, no structural heart disease
a drug for conversion of A fib or flutter
amiodarone
When you might decide not to anticoagulate before cardio-version
Echo (trans-esophageal) show no left atrium thrombus
Warfarin for anticoag A fib pt
Warfarin treatment, INR 2.0 to 3.0
Can convert A fib pt immediately if duration of AF or Afl is less than ____ hours
48
Cardioversion does not correct underlying cause or change the threshold for re-occurrence. Must be backed up with _____
drugs
Emboli particularly common in presence of ______
mitral stenosis
Risk factors for emboli in A fib:
age, hypertension, diabetes, ischemic or valvular heart disease, CMO
If A fib patient spontaneously converts, can use ______
antiarrhythmic agent
Full anticoagulation for ___ weeks prior to conversion of A fib pt
4
Tachy-brady syndrome, AV conduction disease
Patients may have af, aflutter, brady, degrees of heart block
Implies diseased and malfunctioning sinus node, but concomitant AV nodal disease and other conduction disease common
Dilemma is treating tachy with negative inotropes and dealing with heart block and significant brady.
Sick Sinus Syndrome
differentiating criteria of Wandering Atrial Pacemaker and Multifocal Tachycardia
rate
Wandering Atrial Pacemaker and Multifocal Tachycardia Almost always associated with what disease
advanced chronic or severe acute exacerbation of lung
Wandering Atrial Pacemaker and Multifocal Tachycardia Requires 3 different _________, thus multiple atrial origins for rhythm
P wave morphologies
Wandering Atrial Pacemaker and Multifocal Tachycardia :
Rate difficult to control
Negative chronotropes
Treat ________
lung disease
PR interval > .20
AV node level or higher
Usually no clinical significance
Can be in presence of negative chronotropic agent
For severely prolonged PR intervals (> .30 or .35) negative chronotrope withdrawal may be more urgent
First Degree AV block
Progressively longer PR interval till non conducted P, then reset to shorter PR interval again
May be present in normal heart
Normally occurs in vagal overdrive, eg, during sleep
Block at AV node or higher
Usually benign
Medication related (negative inotrope, particularly prominent with digitalis
Rarely would a pacemaker be required
Second degree type I AV block (Wenckebach)
More ominous, clinically important
Non conducted P waves more consistent (2:1, 3:1, etc)
Block usually at level below AV node
Mandates negative chronotrope withdrawal
Often will need pacemaker
Second Degree, type II AV block
Complete heart block (CHB) and AV dissociation
AV dissociation present with narrow QRS complex, more benign, may reverse
Complete heart block present with wide QRS, indicating block is below bundle of His
CHB usually requires pacemaker
Third Degree AV block
Bifasicular block
May represent underlying pathology such as acute or old MI, CMO, diseased conduction system
Of itself no treatment usually needed
If present with a significant first degree block may need to consider pacemaker (trifasicular block)
Left bundle branch block (LBBB)
Unifasicular block
Often no clinical significance
May represent underlying pathology, less often than LBBB
Often associated with anterior (LAH) or posterior (LPH), making it now a bifasicular block. Still, usually no clinical significance)
If RBBB with either LAH or LPH, and long 1st degree, might need pacemaker (trifasicular block)
Right bundle branch block (RBBB)
Beware of _________bundle branch blocks
alternating left and right
Narrow complex, no P wave, or short PR interval, or inverted P wave after the QRS
Normal junctional rate is 35 to 60 bpm
If faster, called accelerated junctional or junctional tachycardia
Many times no clinical significance when rate is not excessive
Consider digitalis toxicity
Negative inotropes may be useful, or withdrawal of negative inotropes if rate relatively slow (eg, 60-100 bpm)
Junctional Rhythm
Usually benign extrasystoles, even when frequently occurring
May be sign of underlying heart disease
Drugs, stimulants, irritants (caffeine, alcohol)
Symptoms usually limited to palpitations
Beware of digitalis toxicity
Beta blockers symptomatic treatment of choice
PAC’s, PVC’s and PJC’s
Potentially malignant arrhythmia
Non sustained (< 30 seconds duration) may be totally benign but not until proven otherwise
Ventricular Tachycardia
Normal ventricular rate is
<45 bpm
Ischemic VT more likely to be polymorphic; monomorphic more likely to be a sign of _______
underlying scar or CMO
Considerations: with VT
electrolyte imbalance, hypoxia, acute ischemia, digitalis toxicity, pro arrhythmia secondary to anti-arrhythmic agents
polymorphic VT in setting of prolonged QT interval. Evaluate for magnesium deficiency, pro arrhythmia, congenital long QT interval
Etiology of “quinidine syncope”
Torsades De Pointes:
indications for pacemaker
symptomatic brady, heart block, sick sinus syndrome
Therapy for bradyarrhythmias
Pacemaker
Pacemaker
Nomenclature: 5 lettered entries
1. chamber paced, 2. chamber sensed, 3. inhibited action or triggered, 4. rate responsitivity, 5. cardioversion potential
D=dual, A= atrial, V= ventricle, I=inhibited, T=triggered, O=neither, R=rate responsive
DDDR pacemaker mode then means WHAT?
dual paced, dual sensed, both triggered and inhibited, rate responsive
VVI means what?
v paced, v sensed, inhibited action of sensing
VOO means what?
v paced, no sensing, neither triggered or inhibited since no sensing
Implanted cardiac defibrillators (ICD) now indicated for patients with _______-
known malignant VT, history of sudden cardiac death VT mediated, and certain clinical situations in which patients are at risk of sustained VT/sudden death
Bi-ventricular pacing to make electrical pacing more physiologic
Exclusive RV pacing (unipolar transvenous pacing) is physiologically equivalent to LBBB, which results in non physiologic ventricular depolarization, effectively reducing cardiac performance
Indicated in patients with wide QRS complexes, particularly LBBB
Includes defibrillator capability
Newer versions contain ability to detect early CHF by measuring body tissue impedence
Resynchronized Cardiac Therapy (RCT)
Monitor heart, and basedd on parameter settings, will administer therapy in the form of overdrive pacing or cardioversion, defibrillation
Implanted cardiac defibrillators (ICD)