Podcast
Questions and Answers
What is the initial treatment for a hemodynamically unstable patient with Wolff-Parkinson-White (WPW)?
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.
In the case of atrial fibrillation, rate control is always prioritized over rhythm control for hemodynamically unstable patients.
False (B)
What is the most common mechanism of tachycardia in Atrial Tachycardia?
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.
Unifocal Atrial Tachycardia shows a narrow QRS complex.
What is the formula to calculate heart rate using the 6 second marker rule?
What is the formula to calculate heart rate using the 6 second marker rule?
Name one medication used to manage Atrial Tachycardia.
Name one medication used to manage Atrial Tachycardia.
If no clots are present, a patient with atrial fibrillation should receive ________ weeks of anticoagulants followed by pharmacological rhythm control.
If no clots are present, a patient with atrial fibrillation should receive ________ weeks of anticoagulants followed by pharmacological rhythm control.
Match the following terms with their definitions:
Match the following terms with their definitions:
The main treatment for multifocal Atrial Tachycardia caused by theophylline is to stop the ____.
The main treatment for multifocal Atrial Tachycardia caused by theophylline is to stop the ____.
Match the types of Atrial Tachycardia to their characteristics:
Match the types of Atrial Tachycardia to their characteristics:
Which of the following drugs is NOT used for rhythm control?
Which of the following drugs is NOT used for rhythm control?
Dabigatran is the drug of choice for valvular atrial fibrillation.
Dabigatran is the drug of choice for valvular atrial fibrillation.
What is the primary action of the CHAâ‚‚DSâ‚‚-VASc score?
What is the primary action of the CHAâ‚‚DSâ‚‚-VASc score?
Patients with paroxysmal A.fib can use the 'Pills in the Pocket' technique involving oral flecainide and ______.
Patients with paroxysmal A.fib can use the 'Pills in the Pocket' technique involving oral flecainide and ______.
Match the drug with its corresponding usage:
Match the drug with its corresponding usage:
Which of the following is a common complication of atrial fibrillation?
Which of the following is a common complication of atrial fibrillation?
Atrial fibrillation is the most common sustained cardiac arrhythmia.
Atrial fibrillation is the most common sustained cardiac arrhythmia.
What is the normal range for atrial rate in atrial fibrillation?
What is the normal range for atrial rate in atrial fibrillation?
One of the risk factors for atrial fibrillation is _______ abnormalities, specifically __________ and __________.
One of the risk factors for atrial fibrillation is _______ abnormalities, specifically __________ and __________.
Match the following classifications of atrial fibrillation with their characteristics:
Match the following classifications of atrial fibrillation with their characteristics:
What shows the flutter waves inverted in lead II?
What shows the flutter waves inverted in lead II?
Typical atrial flutter has a sawtooth appearance on an ECG.
Typical atrial flutter has a sawtooth appearance on an ECG.
What is the typical site for atrial flutter in the heart?
What is the typical site for atrial flutter in the heart?
The management for atrial flutter includes _____ cardioversion as the treatment of choice.
The management for atrial flutter includes _____ cardioversion as the treatment of choice.
Match the following management options with their descriptions:
Match the following management options with their descriptions:
What is the first-line medication administered for AVNRT and AVRT?
What is the first-line medication administered for AVNRT and AVRT?
Adenosine has a half-life of 15 seconds.
Adenosine has a half-life of 15 seconds.
What position should a patient be placed in before administering adenosine?
What position should a patient be placed in before administering adenosine?
The maximum dose of adenosine that can be administered is ______ mg.
The maximum dose of adenosine that can be administered is ______ mg.
Match the medication with its corresponding dose and indication:
Match the medication with its corresponding dose and indication:
What is a significant finding in the ECG of a patient with junctional tachycardia?
What is a significant finding in the ECG of a patient with junctional tachycardia?
Atrial fibrillation can be a possible underlying cause of junctional tachycardia.
Atrial fibrillation can be a possible underlying cause of junctional tachycardia.
What heart rate range is typically observed in junctional tachycardia?
What heart rate range is typically observed in junctional tachycardia?
What characteristic distinguishes AVRT from AVNRT?
What characteristic distinguishes AVRT from AVNRT?
In junctional tachycardia, the P wave is often __________ or buried in the QRS complex.
In junctional tachycardia, the P wave is often __________ or buried in the QRS complex.
In both AVRT and AVNRT, the hemodynamic status is always unstable.
In both AVRT and AVNRT, the hemodynamic status is always unstable.
Match the following conditions with their ECG characteristics:
Match the following conditions with their ECG characteristics:
What is the typical RP interval range for AVRT?
What is the typical RP interval range for AVRT?
The impulse from a premature atrial complex (PAC) enters the AV node but not the _______ tract.
The impulse from a premature atrial complex (PAC) enters the AV node but not the _______ tract.
Match the following features with either AVRT or AVNRT:
Match the following features with either AVRT or AVNRT:
Which characteristic is associated with 2/3rd degree AVNRT?
Which characteristic is associated with 2/3rd degree AVNRT?
AVNRT can be converted to normal sinus rhythm using adenosine.
AVNRT can be converted to normal sinus rhythm using adenosine.
What type of QRS complex is typically seen in Orthodromic AVRT?
What type of QRS complex is typically seen in Orthodromic AVRT?
In Antidromic AVRT, the impulse entry is through the ______.
In Antidromic AVRT, the impulse entry is through the ______.
Match the AVRT type with its characteristics:
Match the AVRT type with its characteristics:
What is the typical heart rate observed in the described ECG analysis?
What is the typical heart rate observed in the described ECG analysis?
The P wave is typically absent in Atrioventricular nodal reentrant tachycardia (AVNRT).
The P wave is typically absent in Atrioventricular nodal reentrant tachycardia (AVNRT).
What does AVNRT stand for?
What does AVNRT stand for?
In a typical AVNRT, the trigger is a __________.
In a typical AVNRT, the trigger is a __________.
Match the types of AVNRT with their characteristics:
Match the types of AVNRT with their characteristics:
Which of the following characteristics indicates that the rhythm originates outside the sinus node?
Which of the following characteristics indicates that the rhythm originates outside the sinus node?
The sinus node can maintain a heart rate above 250 bpm.
The sinus node can maintain a heart rate above 250 bpm.
What does a narrow QRS complex suggest in an ECG analysis?
What does a narrow QRS complex suggest in an ECG analysis?
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 CHAâ‚‚DSâ‚‚-VASc score to determine long-term anticoagulant requirement
CHAâ‚‚DSâ‚‚-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
- Decrease rate:
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
- MOA:
-
Hemodynamically unstable:*
-
Procedure: Synchronized DC cardioversion
-
Procedure steps:
- Put patient in 45° supine position
- Administer Adenosine.
- 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:
- Verapamil: 2.5-5 mg IV; max 15 mg
- Metoprolol: 5 mg IV; max 15 mg
- 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.
