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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; SA impulse is delayed thru AV. PR >.20 (long but consistent). All beats conducted to ventricle.
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 with RVR 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)
CHAD2-VASC = CHF, HTN, Age 65-74, >75), DM, Stroke; vaxcular disease (MI, PVD), female
Class I antiarrhythmic agent MOA Na channel blockade. A: procainamide, quinidine. B: lidocaine. C: flecainide, propafenone.
Class II antiarrhythmic agent MOA beta blockade. Propranolol, sotalol
Class III antiarrhythmic agent MOA Action potential prolongation. Amiodarone, dofetilide (Tikosyn).
Class IV antiarrhythmic agent MOA CCB. Verapamil, adenosine
Order this lab in new-onset A-fib patients TSH
In a patient with Graves disease and irregular HR (160-175), what is tx of choice? Atenolol (beta blocker)
What is most important med to give to a pt with A-fib? Anticoagulant agent (eg, warfarin)
Pt with WPW cannot be given: adenosine or CCBs
Created by: Abarnard
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