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PVC: tx beta blocker, amiodarone, possibly ablation
Tachyarrhythmia pathophysiology narrow complex (QRS <.12) or wide (usu VT); either by abnormal impulse formation (enhanced automaticity) or abnormal impulse propagation (reentry)
Most common cause of tachyarrhythmia reentry; >1 pathway
SVT risk factors hyperthyroid, HTN, MV dz; VT: prior MI, ischemia, long QT, antiarrhythmics, low Mg
AVRT/AVNRT tx nodal blockers
AV block Pathophysiology: 1st degree: AV node most common site; AV impulse is delayed; PR >.20
Wenckebach usually due to: normal pt w/heightened vagal tone, or drugs (digitalis, CCB, beta blocker)
2nd degree Mobitz type II is usually due to lesion located: at bundle of His
3rd degree AV block is usually due to lesion located: distal to bundle of His; bilateral BBB
3rd degree AV block: Sx/Sx: wide QRS & V-rate <50; wide pulse pressure, cannon venous neck pulses; syncope
AV block Tx Mobitz II or 3d degree: need ventricular pacing
2nd degree AV block Type I (Wenckebach) is characterized by: progressively lengthening PR interval, until QRS is dropped
2nd degree AV block Type II (Mobitz) is characterized by: intermittent dropped QRS with uniform PR interval; atrial > V-rate; often a 2:1 or 3:1 pattern
3rd degree AV block is characterized by: complete disassociation between atria and ventricles; no atrial impulses reaching ventricles. If ectopic pacemaker is ventricular, QRS is wide
Wolff Parkinson White (WPW) is characterized by: delta wave / slurred upstroke of QRS; wide WRS >0.10; short PR <0.12
Abrupt onset of HR 200-250bpm, from atrial or junctional foci; common presentation of WPW or reentry phenomenon = Paroxysmal SVT
HR in atrial flutter: 250-300 bpm; often with AV block causing 2:1 or 3:1 ratio of atrial to V-rate
Atrial flutter mgmt Rate control (BB/sotalol, CCB, or digoxin); cardioversion (50-100 J) (use with anticoag if >48h). If chronic: amiodarone, ibutilide/dofetilide, or EPS with ablation
A-fib mgmt (if stable): Rate control (firstline: diltiazem, verapamil; secondline: Lopressor/atenolol, digoxin); consider cardioversion with amiodarone
A-fib mgmt (if unstable): Synchronized electrical cardioversion with / without ibutilide. If in AF >48h & stable, do TEE first to look for atrial thrombus
A-fib mgmt: if atrial thrombus is present: anticoagulate x4 weeks prior to cardioversion & 4 weeks after
Rhythm control agents used in A-fib: Firstline: dronedarone (Maltaq); secondline: amiodarone, propafenone, flecainide, dofetilide
V-tach is characterized by: HR 150-250 bpm, originating from ectopic ventricular focus; wide & regular
V-tach mgmt: Firstline: amiodarone (2: procainamide; 3: sotalol). Unstable: defibrillate. Stable: sync cardioversion +/- IV lidocaine
Premature junctional contractions = ectopic premature beats originating from AV node or junction; retrograde P waves (may be inverted or buried in QRS, or appear after narrow QRS)
Drugs that prolong QT interval: TCAs (amitriptyline, desipramine, doxepin, imipramine, nortriptyline); macrolides, FQs, imidazole, antimalarials; Haldol; pentamidine
Risk for thromboembolic event is greatest when A-fib has been present for: >48 hours
In A-fib, anticoagulation (warfarin) reduced stroke risk by: 50-80%
In WPW, what is the drug of choice for converting A-fib? procainamide (2nd: flecainide)
DO NOT use rhythm control agents (for A-fib) along with: dabigatran (Pradaxa)
A-fib: high risk factors = prior CVA, TIA, systemic VTE
A-fib: moderate risk factors = >75 y.o., HTN, HF, LVEF <35%, DM
A-fib: warfarin is superior to: Plavix and aspirin
A-fib: digoxin is indicated in patients with: HF and reduced LV function
Treat pulseless V-tach the same as: V-fib (1st: defib 120-200J; 2nd: epi or vasopressin; 3rd: amiodarone 300mg x1 then maybe 150; 4th: lidocaine)
V-fib mgmt: Tx of choice: defib 120-200J -> CPR 5 cycles (30:2) -> repeat defib, etc.
V-fib medications: 1st: Epi / vasopressin; 2nd: amiodarone 300mg x1 then maybe 150; 3rd: lidocaine (maybe) 1-1.5mg/kg, then 0.5-0.75mg/kg IV
SVT mgmt: 1st: vagal maneuvers, then adenosine (6mg/12mg/12mg = 30mg total); 2nd: diltiazem; 3rd: electrical cardioversion; 4th (outpatient): flecainide
Flecainide mechanism of action regulates flow of Na in heart -> prolongation of cardiac cycle -> slows tachy or arrhythmia
Meds contraindicated in AV block: CCBs (interfere with SA conduction)
Created by: Adam Barnard Adam Barnard