Medicine Marrow Pg No 397-406 (ECG)
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Questions and Answers

What is the initial treatment for a hemodynamically unstable patient with Wolff-Parkinson-White (WPW)?

  • Synchronized DC cardioversion (correct)
  • Anticoagulants for 4 weeks
  • Observation and monitoring
  • Pharmacological rhythm control

    • In the case of atrial fibrillation, rate control is always prioritized over rhythm control for hemodynamically unstable patients.

    False

    What is the most common mechanism of tachycardia in Atrial Tachycardia?

  • Triggered activity
  • Reentry
  • Atrioventricular nodal reentry
  • Enhanced automaticity (correct)

    • Unifocal Atrial Tachycardia shows a narrow QRS complex.

    <p>True</p> Signup and view all the answers

    What is the formula to calculate heart rate using the 6 second marker rule?

    <p>HR = number of QRS complexes in 30 large boxes x 10</p> Signup and view all the answers

    Name one medication used to manage Atrial Tachycardia.

    <p>metoprolol</p> Signup and view all the answers

    If no clots are present, a patient with atrial fibrillation should receive ________ weeks of anticoagulants followed by pharmacological rhythm control.

    <p>3</p> Signup and view all the answers

    Match the following terms with their definitions:

    <p>Multifocal atrial tachycardia (MAT) = Characterized by 23 morphologically different P waves Trans Esophageal Echo (TEE) = Used to assess for clots CHA₂DS₂-VASc score = Determines need for long-term anticoagulants Synchronized DC cardioversion = Immediate treatment for unstable patients with WPW</p> Signup and view all the answers

    The main treatment for multifocal Atrial Tachycardia caused by theophylline is to stop the ____.

    <p>theophylline</p> Signup and view all the answers

    Match the types of Atrial Tachycardia to their characteristics:

    <p>Unifocal AT = Narrow QRS, Regular rhythm, Uniform P waves Multifocal AT = Irregular RR intervals, ≥ 3 P wave morphologies AT with AV block = Associated with digoxin Chronic Tachyarrhythmia related cardiomyopathy = Structural heart abnormalities</p> Signup and view all the answers

    Which of the following drugs is NOT used for rhythm control?

    <p>Esmolol</p> Signup and view all the answers

    Dabigatran is the drug of choice for valvular atrial fibrillation.

    <p>False</p> Signup and view all the answers

    What is the primary action of the CHA₂DS₂-VASc score?

    <p>To assess the need for anticoagulants in patients with atrial fibrillation.</p> Signup and view all the answers

    Patients with paroxysmal A.fib can use the 'Pills in the Pocket' technique involving oral flecainide and ______.

    <p>β-blockers</p> Signup and view all the answers

    Match the drug with its corresponding usage:

    <p>Flecainide = Rhythm control Esmolol = Rate control Dabigatran = Anticoagulant Ibutilide = IV Rhythm control</p> Signup and view all the answers

    Which of the following is a common complication of atrial fibrillation?

    <p>Stroke</p> Signup and view all the answers

    Atrial fibrillation is the most common sustained cardiac arrhythmia.

    <p>True</p> Signup and view all the answers

    What is the normal range for atrial rate in atrial fibrillation?

    <p>300-600 bpm</p> Signup and view all the answers

    One of the risk factors for atrial fibrillation is _______ abnormalities, specifically __________ and __________.

    <p>electrolyte, hypokalemia, hypomagnesemia</p> Signup and view all the answers

    Match the following classifications of atrial fibrillation with their characteristics:

    <p>Paroxysmal = Self-terminating episodes Valvular = Associated with mitral stenosis or prosthetic valves Non-valvular = Not associated with heart valve issues</p> Signup and view all the answers

    What shows the flutter waves inverted in lead II?

    <p>Typical atrial flutter</p> Signup and view all the answers

    Typical atrial flutter has a sawtooth appearance on an ECG.

    <p>True</p> Signup and view all the answers

    What is the typical site for atrial flutter in the heart?

    <p>Lateral wall of the right atrium</p> Signup and view all the answers

    The management for atrial flutter includes _____ cardioversion as the treatment of choice.

    <p>DC</p> Signup and view all the answers

    Match the following management options with their descriptions:

    <p>DC Cardioversion = Initial treatment method that uses electrical shock Ibutilide = Medication used for rhythm control Catheter ablation = Invasive procedure targeting specific heart areas Cavotricuspid isthmus = Anatomical site commonly treated in catheter ablation</p> Signup and view all the answers

    What is the first-line medication administered for AVNRT and AVRT?

    <p>Adenosine</p> Signup and view all the answers

    Adenosine has a half-life of 15 seconds.

    <p>False</p> Signup and view all the answers

    What position should a patient be placed in before administering adenosine?

    <p>45° supine position</p> Signup and view all the answers

    The maximum dose of adenosine that can be administered is ______ mg.

    <p>30</p> Signup and view all the answers

    Match the medication with its corresponding dose and indication:

    <p>Adenosine = 6mg, then 12mg, max 30mg Verapamil = 2.5-5mg IV, max 15mg Metoprolol = 5mg IV, max 15mg Digoxin = Used in heart failure cases with AVNRT</p> Signup and view all the answers

    What is a significant finding in the ECG of a patient with junctional tachycardia?

    <p>Narrow QRS complex</p> Signup and view all the answers

    Atrial fibrillation can be a possible underlying cause of junctional tachycardia.

    <p>True</p> Signup and view all the answers

    What heart rate range is typically observed in junctional tachycardia?

    <p>100-110 bpm</p> Signup and view all the answers

    What characteristic distinguishes AVRT from AVNRT?

    <p>P wave falls outside the QRS</p> Signup and view all the answers

    In junctional tachycardia, the P wave is often __________ or buried in the QRS complex.

    <p>absent</p> Signup and view all the answers

    In both AVRT and AVNRT, the hemodynamic status is always unstable.

    <p>False</p> Signup and view all the answers

    Match the following conditions with their ECG characteristics:

    <p>AV Node Reentry Tachycardia = Regular rhythm with narrow QRS complex Atrial Fibrillation = Irregular rhythm with absent P waves Atrial Flutter with 2:1 AV Block = Regular rhythm with sawtooth P waves Junctional Tachycardia = Absent P wave with irregular RR interval</p> Signup and view all the answers

    What is the typical RP interval range for AVRT?

    <p>80-100 ms</p> Signup and view all the answers

    The impulse from a premature atrial complex (PAC) enters the AV node but not the _______ tract.

    <p>bypass</p> Signup and view all the answers

    Match the following features with either AVRT or AVNRT:

    <p>Synchronous activation = AVNRT P wave falls outside QRS = AVRT Short RP interval = AVNRT Structured heart disease present = AVRT</p> Signup and view all the answers

    Which characteristic is associated with 2/3rd degree AVNRT?

    <p>Absent P waves</p> Signup and view all the answers

    AVNRT can be converted to normal sinus rhythm using adenosine.

    <p>True</p> Signup and view all the answers

    What type of QRS complex is typically seen in Orthodromic AVRT?

    <p>Narrow</p> Signup and view all the answers

    In Antidromic AVRT, the impulse entry is through the ______.

    <p>Bundle of Kent</p> Signup and view all the answers

    Match the AVRT type with its characteristics:

    <p>Orthodromic AVRT = Impulse entry through AV node Antidromic AVRT = Wide QRS complex</p> Signup and view all the answers

    What is the typical heart rate observed in the described ECG analysis?

    <p>200 bpm</p> Signup and view all the answers

    The P wave is typically absent in Atrioventricular nodal reentrant tachycardia (AVNRT).

    <p>True</p> Signup and view all the answers

    What does AVNRT stand for?

    <p>Atrioventricular Nodal Reentrant Tachycardia</p> Signup and view all the answers

    In a typical AVNRT, the trigger is a __________.

    <p>Premature Atrial Complex (PAC)</p> Signup and view all the answers

    Match the types of AVNRT with their characteristics:

    <p>Typical AVNRT = 95% incidence; Trigger: PAC Atypical AVNRT = 5% incidence; Trigger: Premature ventricular complex</p> Signup and view all the answers

    Which of the following characteristics indicates that the rhythm originates outside the sinus node?

    <p>Absence of P waves</p> Signup and view all the answers

    The sinus node can maintain a heart rate above 250 bpm.

    <p>False</p> Signup and view all the answers

    What does a narrow QRS complex suggest in an ECG analysis?

    <p>That the tachycardia is likely associated with atrial activity.</p> Signup and view all the answers

    Study Notes

    ECG Management

    • ECG: Suggests Atrial Fibrillation (A.fib)
    • 6 second marker rule: HR = number of QRS complexes in 30 large boxes x 10.
    • Multifocal atrial tachycardia (MAT): characterized by ≥ 3 morphologically different P waves
    • Atrial tachycardia + AV block: Conducted and missed P waves

    Hemodynamically unstable (Wolff-Parkinson-White (WPW))

    • Synchronized DC cardioversion
    • Rate control is prioritized over rhythm control
    • Initial dose: 100 Joules
    • Maximum dose: 200 Joules

    Hemodynamically stable

    • Onset < 48 hours or unknown: Risk of embolism
      • Rate control, prioritize over rhythm control
    • Onset > 48 hours:
      • Trans Esophageal Echo (TEE)/Cardiac CT to assess for clots
      • If clots present: Pharmacological rhythm control
      • If no clots present: 3 weeks of anticoagulants followed by pharmacological rhythm control
    • 4 weeks of anticoagulants: Assess CHA₂DS₂-VASc score to determine long-term anticoagulant requirement

    CHA₂DS₂-VASc Score

    • Score ≥ 2: Requires anticoagulants
    • Score = 1: ± Anticoagulants

    Atrial Tachycardia

    • Structurally abnormal heart
    • Chronic Tachyarrhythmia related cardiomyopathy
    • Follows all 3 mechanisms of tachycardia (most common: Enhanced automaticity)
    • Management:
      • Decrease rate:
        • Sinus rhythm
        • β-blockers: metoprolol
        • CCB: verapamil (rare failure)
      • Antiarrhythmics

    Types

    • Unifocal AT
    • Multifocal AT
    • AT with AV block: associated with digoxin

    ECG Interpretation

    • Unifocal AT:
      • Narrow QRS
      • Rate: ~150 bpm
      • Rhythm: Regular
      • P wave: Uniform, abnormal morphology
      • PR interval: Long, PR interval: Short
    • Multifocal AT:
      • Irregular RR interval + ≥ 3 different P wave morphologies
      • Most common cause: COPD/theophylline
      • Management: Stop theophylline. β-blocker/CCB: Decrease HR

    Drugs Used for Rhythm Control

    • Flecainide
    • Propafenone
    • Vernakalant: DOC (Not available in India)
    • Ibutilide: Second DOC (Most common use) - IV over 10 minutes
    • Amiodarone: DOC for structurally abnormal heart
      • 150mg IV bolus OR 5mg/kg over 1 hour

    Drugs for Rate Control

    • Verapamil: 5-10 mg over 2 minutes (max: 20mg)
    • Esmolol: 500 mcg/kg over 1 minute
    • Propranolol: 1 mg IV over 2 minutes (max: 5mg)
    • Digoxin: Failed left ventricle

    Anticoagulants

    • DOC: Dabigatran
    • Exceptions:
      • Valvular A.fib
      • A.fib + ESRD: DOC: Warfarin

    Pills in the Pocket Technique

    • Oral flecainide + β blockers
    • For patients with paroxysmal A.fib
    • Advised to consume at symptom onset

    Atrial Fibrillation

    Features

    • Most common sustained cardiac arrhythmia (after sinus tachycardia)
    • Chaotic, disorganized, ineffective contractions
    • Risk factors:
      • Age
      • Most common site: Appendages
      • Complication: Stasis of blood → Embolism → Stroke
      • Hypertension

    ECG

    • Narrow QRS tachycardia
    • Rate: Variable (Atrial rate: 300-600 bpm)
    • R-R interval: Irregular
    • Fibrillatory waves

    Classification
    Paroxysmal Self-terminating (usually < 7 days), often triggered by caffeine, alcohol, stress.
    Persistent Lasts > 7 days
    Permanent Responds poorly to antiarrhythmics

    Etiology

    • OSAS (Obstructive sleep apnea syndrome)
    • CKD
    • Psoriasis
    • Thyroid disease
    • Alcohol
    • Any cardiac/lung disease
    • Electrolyte abnormalities → Hypokalemia → Hypomagnesemia

    C/F

    • Angina: Increased demand
    • Syncope: Decreased circulation
    • Dyspnoea: Decreased cardiac output
    • Palpitation: Increased HR

    Atrial Flutter

    Types & Mechanism

    • Typical atrial flutter: Flutter waves are inverted in lead II
    • Reverse typical atrial flutter: Flutter waves are upright in lead II

    Features

    • Site: Lateral wall of the right atrium (90%)
    • Onset: Less than 1 week after open-heart surgery
    • ECG: Sawtooth appearance

    Management

    • DC Cardioversion (TOC): 25-50 J
    • Ibutilide
    • Catheter ablation: Site → Cavotricuspid isthmus

    AVNRT, AVRT and Supraventricular Tachycardia Management

    • Goal:*

    • AVNRT

    • AVRT

    • Atrial tachycardia

    • Hemodynamically stable:*

    • Procedure: Operate through AV Node → AV nodal block

    • Medication: Adenosine

      • MOA:
        • AVNRT/AVRT: Blocks PAC
        • Atrial tachycardia: Decrease HR
      • Pharmacokinetics:
        • T1/2: 6 seconds
        • Arm-to-arm circulation time: 15 seconds
        • Arm-to-heart circulation time: 7.5 seconds
      • Administration: 6mg through brachial vein (can repeat with 12mg + 12mg max dose of 30mg)
      • Follow-up: Saline flush/push/chase

    • Hemodynamically unstable:*

    • Procedure: Synchronized DC cardioversion

    • Procedure steps:

      1. Put patient in 45° supine position
      2. Administer Adenosine.
      3. Shift patient to prone position and raise arms overhead

    • Safety protocols:

      • Have defibrillator ready
      • If AVRT → AF → VT → VF → Death

    • Note: COPD/BA: Adenosine C/I (Can cause bronchospasm)

    • Alternatives:

      1. Verapamil: 2.5-5 mg IV; max 15 mg
      2. Metoprolol: 5 mg IV; max 15 mg
      3. Esmolol

    • Additional considerations:

      • Heart failure with AVNRT: Digoxin

    Orthodromic AVRT

    • Well timed PAC
    • P falls just outside QRS

    ECG

    • Narrow QRS tachycardia
    • RP interval: 2 boxes ~ 80 ms

    AVRT > AVNRT

    Atria

    • PAC enters AV Node, not bypass tract
    • Impulse is conducted slowly through the AV Node

    Ventricles

    Feature AVNRT AVRT
    Synchronous activation + -
    P wave Absent in 2/3rd patients Falls outside QRS
    RP interval < 80 ms 80-100 ms
    Hemodynamic status Stable Stable/unstable
    Structural heart disease - WPW syndrome
    Circuit Intervals micro re-entry macro re-entry
    Additional information Short RP; long PR -

    ECG Analysis

    • P wave buried in QRS complex: In about 2/3rd of patients
    • Sinus Rhythm
    • Premature Atrial Complex(PAC)
    • ECG Characteristics:
      • HR: Approximately 200 bpm
      • Rhythm: Regular
      • Narrow QRS Tachycardia
      • Absent P waves
      • Sinus Tachycardia Incapability: Sinus node unable to maintain a rate above 180 bpm
      • AVNRT > AVRT: AVNRT is more likely than AVRT
    • ECG Leads: I, II, III, aVR, aVL, aVF, V1-V6

    Types of AVNRT

    Feature Typical AVNRT Atypical AVNRT
    Incidence 95% 5%
    Trigger PAC Premature ventricular complex
    Pathway Enter: Slow; Exit: Fast Enter: Fast; Exit: Slow

    Conclusion

    • ECG and text suggest a tachyarrhythmia, potentially AVNRT, requiring further investigation and possible treatment

    ECG Interpretation

    • Patient ID: 402
    • Diagnosis: Junctional Tachycardia
    • ECG Findings:
      • Rhythm: Irregular RR interval
      • P wave: Absent or buried in QRS complex, suggesting possible AV block
      • PR interval: Not always consistent
      • QRS Complex: Narrow, supraventricular origin
      • Heart rate: 100-110 bpm
      • AV block: 2:1 AV block evident
      • Other findings: Multiple leads showing characteristic features of junctional tachycardia
    • Summary: Evidence of junctional tachycardia
    • Possible Causes: AVNRT, AVRT, other supraventricular mechanisms
    • Further Investigation: Detailed history, clinical evaluation, additional diagnostic tests

    AVNRT (Atrial Ventricular Nodal Reentrant Tachycardia)

    • Typical AVNRT Characteristics:
      • 2/3rd degree: Synchronous A-V activation, absent P waves
      • 1/3rd degree: P waves outside the QRS complex
      • Pseudo S wave: P wave just outside the QRS complex
      • Pseudo R' wave: P wave occurring on the R wave
      • Pseudo Q wave: P wave occurring just before the Q wave
    • Features:
      • Can be converted to normal sinus rhythm using adenosine
      • Rare compared to AVRT
      • Can be associated with WPW syndrome
    • Types:
      Feature Orthodromic AVRT Antidromic AVRT
      Impulse entry AV node Bundle of Kent (Bypass tract)
      Exit Bundle of Kent AV node
      QRS complex Narrow Wide

    ECG

    • Shows characteristic patterns of depolarization and repolarization of the heart, which are crucial in the diagnosis
    • Different leads (V1, V2, V3, V6, AVL, AVF) are shown, allowing various heart electrical activity signals to be seen.

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    Description

    This quiz covers key concepts in ECG management, specifically focusing on atrial fibrillation and related conditions. It encompasses approaches for both hemodynamically unstable and stable patients, emphasizing the importance of rate and rhythm control. Test your knowledge on the guidelines and pharmacological considerations involved in treatment.

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