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Cardiac EP IV

Cardiac Electrophysiology IV--evaluation and tx

QuestionAnswer
What is the first tool used in the evaluation of a patient with palpitations? The 12 lead ECG
What are the pros + limitations of using an ECG? painless, widely available, inexpensive; single 10 sec recording of the heart rhythm
If the heart beat doesn't occur within the 10 sec of an ECG, what can be used to monitor for up to 24 hours (noninvasive)? Holter or Ambulatory monitoring; can provide beat by beat analysis of the rhythm; most helpful if symptoms occur at least once every 24 hours
When should loop recorders be used? What are the limitations of using a loop recorder? Useful if symptoms less frequent (once ever 2-6 weeks); patient wears recorder and activates it (must be conscious) when they get symptoms; information transmitted via telephone to central station
What's an alternative to a loop recorder if the patient is frail or if the symptom includes frank syncope? Implantable loop recorder automatically activate when it senses pauses, slow, or fast heart rates; DOES REQUIRE SUBCUTANEOUS IMPLANTATION
When is signal averaged ecg useful? What types of ECG abnormalities affect the reliability of the measurement? Assessment of risk for significant ventricular arrhythmias and predicting mortality after an MI. Specificity is decreased with baseline conduction abnormalities.
What is heart rate variability (HRV) technique useful for? examines cyclic changes in HR; time between consecutive beats analyzed in either time or frequency domain; decreased HRV may predict arrhythmic events
What is decreased parasympathetic activity to the heart associated with? increased mortality; inspect using Heart rate variability (HRV)
What is the T-wave alternas method? What is it useful for? Looks at microvolt changes in T-wave amplitude; studies suggest that negative predictive power of test could be used to identify low risk population
What is the gold standard for the evaluation of cardiac arrhythmias? The electrophysiology study (EP); invasive
What information does the EP study provide? Assessment of 1) SA and AV node function, 2) intracardic conduction times and localization of heart block 3) reproducing reentrant arrhythmias 4) mapping of circuits reponsible for abnormal rhythm, 5) 3D mapping of heart circuits
Vaughn-Williams Class I drugs Essentially Na+ Channel blockers: Procainamide, Quinadine, Disopyramide
Vaughn-Williams Class II drugs Beta adrenergic blockers
Vaughn-Williams Class III K+ channel blockers
Vaughn-Williams Class IV Ca++ channel blockers
What 2 notable antiarrhythmics do not fit in the Vaughn-Williams classification? Adenosine and digoxin
Vaughn-Williams Class IA drug actions increase AP duration and ERP, increased QRS and QT duration, decreased slope phase 0
Vaughn-Williams Class IB drug actions decreased AP and QT duration; no change in ERP; decreased slope phase 0
Vaughn-Williams Class IC drug actions no change in ERP and A duration; decreased slope phase 0 & 4
Vaughn-Williams Class II drug actions Decreased AV conduction, increased AV nodal refractoriness, decreased chronotropy
Vaughn-Williams Class III drug actions Increase AP duration and ERP; increased PR interval; increased QRS duration; increased QT duration
Vaughn-Williams Class IV drug actions Increased ERP of AV node, blocks slow Ca++ channel current
Vaughn-Williams Class I side effects GI distress, CNS symptoms, allergic reactions, lupus, thrombocytopenia, pro-arrhythmias, syncope
Vaughn-Williams Class II side effects Hypotension, Bradycardia, worsening CHF, worsening asthma or COPD
Vaughn-Williams Class III side effects Amidarone: pulmonary toxicity, bradycardia, GI symptoms, thyroid and liver abnormalities. Sotalol: All class II side effects + proarrhythmia. Dofetilidie: torsade de Pointes
Vaughn-Williams Class IV side effects Hypotension, bradycardia, worsening AV lock, Liver function abnormalities
In general, what Tx are available for patients with supraventicular arrhythmias? What if AV node is involved? VW Class Ia, Ic, and III drugs; II and IV if AV ivolved; Ib do not appear useful
How do you treat atrial fibrillation? Prevent embolic complications and treat abnormal rhythm
With afib, what risk factors are associated with high risk for stroke? Moderate? Low? RHEUMATIC VALVULAR DISEASE. CHF within last 3 months, history of hypertension or arterial thromboemboli, global LV dysfunction, LA size > 4.7 cm, left sided valvular abnormalities. No risk factors and < 60 yoa
What two drugs have been shown to been effective in reducing the risk of stroke in patients with afib? Warfarin (coumadin) and aspirin; warfarin shown to lower risk the most.
CHADS2 risk factors Prior stroke or TIA (high); Age>75 yoa, hypertension, diabetes mellitus, heart failure
How should you treat a patient with afib that is symptomatic and unstable? Minimally or asymptomatic? Symptomatic + unstable: restore sinus rhythm; Minimally/asymptomatic: rate control or rhythm control
Anticoagulation and rate control are needed for: recurrent paroxysmal atrial fibrillation and recurrent persistent atrial fibrillation
Antiarrhythmic drug therapy is needed for A.fib. patients if: disabling symptoms are present
What are the only recommendations for patients with permanent atrial fibrillation? Anticoagulation and rate control
What are some of the advantages + disadvantages of using digoxin for rate control during a.fib.? Advantages: inexpensive, widely available. Disadvantages: poorly controls rate during activity, digitalis toxicity serious problem
What are some of the advantages + disadvantages of using beta and calcium channel blockers for rate control during a.fib.? Advantages: controls rate well during activity, relatively inexpensive, widely available. Disadvantages: effective rate controlling doses can have intolerable side effects
What are some of the advantages + disadvantages of using amiodarone for rate control during a.fib.? Advantages: may help restore sinus rhythm, widely available. Disadvantages: pulmonary and thyroid side effects, interactions with other drugs (e.g. warfarin), can lead to bradycardia, long half-life
What are some of the advantages + disadvantages of using AV node ablation for rate control during a.fib.? Advantages: complete control of ventricular rate. Disadvantages: requires life long permanent pacemaker
How do you treat atrial fibrillation in a patient with Wolff-Parkinson-White Syndrome? AVOID DIGOXIN, as blocking AV node allows atrial activity to escape through accessory pathway; treat with procainamide to slow both AV node and accessory pathway
How do you treat VT in patients with CAD? ICD shown to be more effective than drug therapy (amiodarone not as effective as ICD in both ischemic and non-ischemic pop)
How do you treat patients with AV node reentrant tachycardia and SVT associated with WPW? Ablation therapy: radiofrequency energy applied to critical portion of the tachycardia circuit; very low morbidity and almost no mortality
Ablation therapy can be used to treat... Supraventricular tachycardias and ventricular tachycardias
Brady Theray-pacemaker therapy Class I indications: symptomatic bradycardia; asystole > 3.0 seconds; symptomatic complete or high grade AV block; asymptomatic complete heart block with an escape rate <40 bpms
Tachy therapy--defibrillator (ICD) therapy Class I Indications: sudden cardiac death not due to transient or reversible cause; sustained, spontaenous VT; severe LV dysfunction that persists despite appropriate therapy
How would you treat a patient with BBB and 1) Class III or IV CHF despite optimal medical therapy, 2) Ejection fraction less than 36%, and 3) QRS that is at least 120 ms in duration Bi-ventricular pacing; up to 75% show improvement with reduction in LV size and increases in LV ejection fraction
Created by: karkis77