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Medical Series: Essential Arrythmias Part 2: Being irregular or going slow DClinical Fellow in medicineSocial Medias Aims & objectives • Clearly understand the principles of AF management with regard to; Rate control, Rhythm control, and anticoagulation • Create a framework and for bradycardias identification and management AIM: Feel confident in answering finals style questions related to the aboveClinical context Large numbers Impacts lives Many drug treatments Often tested in finals! Case 1 A 68 year old man presents to you 2 days after elective cardioversion for atrial fibrillation. Unfortunately, his symptoms of palpitations have recurred. The patient is particularly upset because he expected to be ‘Cured’. Examination and an ECG demonstrates atrial fibrillation. Despite best further rhythm control management the patient remains in atrial fibrillation and a rate control strategy is commenced. How would you describe this patients arrythmia? A. Paroxysmal Atrial Fibrillation B. Persistent Atrial Fibrillation C. Permanent Atrial Fibrillation D. Atrial Flutter E. Don’t know Case 1 A 68 year old man presents to you 2 days after elective cardioversion for atrial fibrillation. Unfortunately, his symptoms of palpitations have recurred. The patient is particularly upset because he expected to be ‘Cured’. Examination and an ECG demonstrates atrial fibrillation. Despite best further rhythm control management the patient remains in atrial fibrillation and a rate control strategy is commenced. How would you describe this patients arrythmia? A. Paroxysmal Atrial Fibrillation B. Persistent Atrial Fibrillation C. Permanent Atrial Fibrillation D. Atrial Flutter E. Don’t knowClassification of AF Paroxysmal Persistent Permanent AF AF AF 2episodes 2 or more Continuous episodes at>1 yearbrillation spontaneously Not self Resistant to terminating cardioversion Typically last <7 Typically last >7 Astrategy isol days days adopted Case 2 A 58 year old retired Lorry driver presents to you after experiencing intermittent episodes of palpitations lasting up to 30 minutes at a time, occurring most days and described as his heart ‘racing’. He is never dizzy, lightheaded, nor has he lost consciousness or collapsed. He has a background of T2DM, HTN and gout. On examination he has a BMI of 39. Palpation of his radial pulse shows sinus rhythm at 80 bpm, and all observations are within normal limits. A 12 lead ECG performed prior the appointment shows normal sinus rhythm What is the next most appropriate step? A. Order Echocardiogram B. Order outpatient 24 hour tape C. Arrange for 2 week cardiac monitoring D. Refer to cardiology E. Don’t know Case 2 A 58 year old retired Lorry driver presents to you after experiencing intermittent episodes of palpitations lasting up to 30 minutes at a time, occurring most days and described as his heart ‘racing’. He is never dizzy, lightheaded, nor has he lost consciousness or collapsed. He has a background of T2DM, HTN and gout. On examination he has a BMI of 39. Palpation of his radial pulse shows sinus rhythm at 80 bpm, and all observations are within normal limits. A 12 lead ECG performed prior the appointment shows normal sinus rhythm What is the next most appropriate step? A. Order Echocardiogram – Next Slide B. Order outpatient 24 hour tape C. Arrange for 2 week cardiac monitoring - Second Line D. Refer to cardiology – Simple AF is managed is primary care E. Don’t know Case 2 Investigating AF Most patients get a ‘non urgent’ Echocardiogram But this is not part of initial diagnosisRhythm control Essentially two types: • Pharmacological -> Using drugs • Electrical -> includes shocks + ablative therapy And two situations: • New AF • Paroxysmal AF in which rhythm control is preferred -> ’pill in pocket’ vs maintenance of sinus rhythm Reversable cause Rate or Rhythm? Rate control first line unless Heart failure caused by AF New onset Rhythm cosuitablere based on 'clinical judgement' Case 3 A 48 year old fireman presents to you in the emergency department with palpitations which started suddenly at 1800 yesterday after a hot curry, he describes a racing irregular heartbeat with no chest pain. He is usually otherwise fit and well. A work medical found no abnormality on echo 4 months ago. On examination the patient looks well and has a BMI of 33. Obs: Hr 138 bp 128/68 rr 18, sats 99%, 36.8 deg. An ECG demonstrates atrial fibrillation. A trial of vagal manouvers is commenced to no effect. What is the next most appropriate first line management? A. Digoxin loading dose B. Bisoprolol 5mg po STAT C. Amiodarone 5mg/kg IV infusion over 20 to 120 minutes D. Flecainide 200 to 300mg po STAT E. Adenosine 6mg IV rapid bolus Case 3 A 48 year old fireman presents to you in the emergency department with palpitations which started suddenly at 1800 yesterday after a hot curry, he describes a racing irregular heartbeat with no chest pain. He is usually otherwise fit and well. A work medical found no abnormality on echo 4 months ago. On examination the patient looks well and has a BMI of 33. Obs: Hr 138 bp 128/68 rr 18, sats 99%, 36.8 deg. An ECG demonstrates atrial fibrillation. A trial of vagal manouvers is commenced to no effect. What is the next most appropriate first line management? A. Digoxin loading dose B. Bisoprolol 5mg po STAT C. Amiodarone 5mg/kg IV infusion over 20 to 120 minutes D. Flecainide 200 to 300mg po STAT E. Adenosine 6mg IV rapid bolus Case 3 What is the next most appropriate first line management? A. Digoxin loading dose – Not first line, is used in Heart failure B. Bisoprolol 5mg po STAT – Correct C. Amiodarone 5mg/kg IV infusion over 20 to 120 minutes – Third line, many potential side effects D. Flecainide 200 to 300mg po STAT – Second line if structurally normal heart E. Adenosine 6mg IV rapid bolus – Will not usually terminate AF NEW ATRIAL FIBRILLATION ASSESSMENT AND DIAGNOSIS REVERSABLE CAUSE? HEART FAILURE? NEW ONSET? RHYTHM RATE CHADSVASC/HASBLED CONTROLL MORE SUITABLE ON NO CONTROL ANTICOAGULATION ADVERSE CLINICAL JUDGEMENT? FEATURES? FIRST LINE YES YES No RHYTHM BETA SECOND LINE ADD DIGOXIN OR CONTROL BLOCKER ? DILTIAZEM ALS GUIDELINES <48HRS >48HRS HEPARINISE PATIENT RISK OF CLOT + CVE CONSIDER RATE CONSIDER B CAUTION IN Yes LIMITING CALCIUM BLOCKER ASTHMATICS CHANNEL BLOCKER FAIL 3 WEEKS ONLY IF CONSIDER STRUCTURALLY ANTICOAG FLECAINIDE NORMAL HEART FAIL SECONDARY CARE CONSIDER ONLY AMIODARONE DC CARDIOVERSION SENIOR TO CONSIDER Case 4 A 78 YO retired vet presents to you in general practice to discuss symptoms of his known persistent AF. Routine echocardiogram demonstrates an enlarged left atrium with preserved ejection fraction. He is anticoagulated on warfarin and currently takes 10mg oral bisoprolol once per day. Previous treatment included, DC cardioversion which had been successful for 2 weeks before reverting to AF. In periods of sinus rhythm he feels ‘like a new man’. A trial of digoxin was unsuccessful. OE there is no evidence of heart failure. His HR is 78 and irregular. The patient asks you what else can be done? A. Add in verapamil B. Offer pill in pocket flecainide C. Add in diltiazem D. Start amiodarone today E. Refer to cardiology Case 4 A 78 YO retired vet presents to you in general practice to discuss symptoms of his known persistent AF. Routine echocardiogram demonstrates an enlarged left atrium with preserved ejection fraction. He is anticoagulated on warfarin and currently takes 10mg oral bisoprolol once per day. Previous treatment included, DC cardioversion which had been successful for 2 weeks before reverting to AF. In periods of sinus rhythm he feels ‘like a new man’. A trial of digoxin was unsuccessful. OE there is no evidence of heart failure. His HR is 78 and irregular. The patient asks you what else can be done? A. Add in verapamil – Risk of complete heart block B. Offer pill in pocket flecainide – Structurally abnormal heart C. Add in diltiazem – rate is already well controlled D. Start amiodarone today – Not started in primary care E. Refer to cardiology – Needs consideration of AF ablation etcSPECIALIST MANAGEMENT Case 5 You are a final year medical student on cardiology rotation. A patient on your ward was admitted with difficult to control atrial fibrillation and the cardiologists have elected to start Amiodarone. A particularly mean and keen cardiologist asks by what basic mechanism does this drug works? A. Beta blockade B. Calcium channels C. Sodium channels D. Potassium channels E. Transient blockade at the AV node Case 5 You are a final year medical student on cardiology rotation. A patient on your ward was admitted with difficult to control atrial fibrillation and the cardiologists have elected to start Amiodarone. A particularly mean and keen cardiologist asks by what basic mechanism does this drug works? A. Beta blockade B. Calcium channels C. Sodium channels D. Potassium channels E. Transient blockade at the AV node ABSOLUTE BASICS – CARDIAC DRUGS VAUGHAN WILLIAMS BASIC DRUG MECHANISM KEY DRUG EXAMPLES 1 Na Channel effects FLECAINIDE, LIDOCAINE, PHENYTOIN 2 Beta Blockers BISOPROLOL, ATENOLOL 3 K Channel blockers AMIODARONE, SOTALOL 4 Calcium channel blockers DILTIAZEM, VERAPAMIL NOTABLE OTHERS DRUG BASIC MECHANISM ADENOSINE Transient blockage of conduction at AV node DIGOXIN Na/K atp-ase pump DON’T DWELL BUT WORTH KNOWING! KCL out Ca in K out Na in K/Na equilibrated K/Na equilibratedRate control • Key to AF management • Refers to the ventricular rate • Untreated the average rate in AF is 160! • Rate is a trade off with pressure Case 6 An 84 year-old man who lives in supported living is recently diagnosed with atrial fibrillation following an ischaemic stroke. An anticoagulation plan is in place. The stroke team have asked for your review of his rate control now he has been discharged back to community care. He has a background of Gout, hypertension, severe asthma and early onset dementia. The district nurses have recorded his rate at 90 to 130 over the week Current medications include: Clopidogrel 75mg po od, Simvastatin 80mg po od, Salbumatol 100 inh PRN, Clenil modulate 100 micrograms inh BD, allopurinol 100mg po od, Ramipril 5mg po od. What is the most appropriate drug to manage his rate? A. Bisoprolol B. Sotolol C. Verapamil D. Diltiazem E. Amiodarone Case 6 An 84 year-old man who lives in supported living is recently diagnosed with atrial fibrillation following an ischaemic stroke. An anticoagulation plan is in place. The stroke team have asked for your review of his rate control now he has been discharged back to community care. He has a background of Gout, hypertension, severe asthma and early onset dementia. The district nurses have recorded his rate at 90 to 130 over the week Current medications include: Clopidogrel 75mg po od, Simvastatin 80mg po od, Salbumatol 100 inh PRN, Clenil modulate 100 micrograms inh BD, allopurinol 100mg po od, Ramipril 5mg po od. What is the most appropriate drug to manage his rate? A. Bisoprolol – First line but pt is asthmatic! B. Sotolol – Not a classic Bblocker, not used as primary rate control C. Nifedipine – Less rate limiting than diltiazem D. Diltiazem – correct E. Amiodarone – Not for use in rate control - NICE NEW ATRIAL FIBRILLATION ASSESSMENT AND DIAGNOSIS REVERSABLE CAUSE? HEART FAILURE? NEW ONSET? RHYTHM RATE NO CHADSVASC/HASBLED ANTICOAGULATION ADVERSE CONTROLL MORE SUITABLE ON CONTROL FEATURES? CLINICAL JUDGEMENT? FIRST LINE YES YES No RHYTHM BETA DIGOXIN OR CONTROL BLOCKER ? SECOND LINE ADD DILTIAZEM ALS GUIDELINES <48HRS >48HRS HEPARINISE PATIENT RISK OF CLOT + CONSIDER RATE CVE CONSIDER B CAUTION IN LIMITING CALCIUM Yes BLOCKER ASTHMATICS CHANNEL BLOCKER FAIL 3 WEEKS CONSIDER ONLY IF ANTICOAG FLECAINIDE STRUCTURALLY NORMAL HEART FAIL SECONDARY CARE CONSIDER AMIODARONE ONLY DC CARDIOVERSION SENIOR TO CONSIDERAnticoagulation in AF • Must include educated patient decision making -> NICE tools • Calculate risks using CHADSVaSC -> Worth learning for finals 69 yo man HTN = 2.2% risk stroke/yr 75 yo lady diabetes 6.7% risk/yr • Balance against HASBLED/ORBIT • NOACS generally proffered over warfarin, however warfarin has benefits Case 7 An 69 year-old lady has presented to you do discuss anticoagulation after a recent diagnosis of AF following a preoperative anesthetic check for a routine hernia repair. Her past medical history includes; recurrent urinary tract infection, simple hernia and mild osteoarthritis of the knees. She is a retired tennis coach, and continues to exercise regularly. She generally avoids doctors, and lives quite remote from the practice. She does not like taking tablets. Her Chadsvasc score is calculated at 2 and her Hasbled score is 1. What drug option would be most appropriate for her? A. Warfarin B. Apixaban C. Rivaroxaban D. Dabigatran E. Aspirin Case 7 An 69 year-old lady has presented to you do discuss anticoagulation after a recent diagnosis of AF following a preoperative anesthetic check for a routine hernia repair. Her past medical history includes; recurrent urinary tract infection, simple hernia and mild osteoarthritis of the knees. She is a retired tennis coach, and continues to exercise regularly. She generally avoids doctors, and lives quite remote from the practice. She does not like taking tablets. Her Chadsvasc score is calculated at 2 and her Hasbled score is 1. What drug option would be most appropriate for her? A. Warfarin – Requires lots of drug monitoring B. Apixaban – Twice daily drug C. Rivaroxaban - Once daily preparation D. Dabigatran – Strict criteria – generally post stroke (reversable) E. Aspirin – Do not use aspirin as a single agent to prevent CVE with AF ANTICOAGULATION – KEY POINTS DRUG POSITIVES NEGATIVES OTHER KEY WARFARIN REVERSABLE REGULAR LICENSED FOR MONITORING ALMOST ALL SCENARIOS AND AFFECTED BY P450 METALIC VALVES ETC MULTIPLE TABLETS LONG HALF LIFE… RIVAROXABAN ONE PILL A DAY MUST BE TAKEN DOSE NO MONITORING WITH FOOD ADJUSTMENTS FOR NON REVERSABLE RENAL APIXABAN DOESN’T HAVE TO TWO PILLS A DAY DOSE BE TAKEN WITH ADJUSTMENTS FOR FOOD RENAL NO MONITORING DABIGATRAN NOT TAKEN WITH FEW LICENSES DOSE FOOD ADJUSTMENTS FOR NO MONITORING RENAL ONE PILL A DAY ANTIDOTE NEW ATRIAL FIBRILLATION ASSESSMENT AND DIAGNOSIS REVERSABLE CAUSE? HEART FAILURE? NEW ONSET? RHYTHM RATE NO CHADSVASC/HASBLED ANTICOAGULATION CONTROLL MORE SUITABLE ON CONTROL ADVERSE CLINICAL JUDGEMENT? FEATURES? FIRST LINE YES YES No RHYTHM BETA SECOND LINE ADD DIGOXIN OR CONTROL BLOCKER DILTIAZEM ALS GUIDELINES <48HRS >48HRS HEPARINISE PATIENT RISK OF CLOT + CVE CONSIDER RATE CONSIDER B CAUTION IN LIMITING CALCIUM Yes BLOCKER ASTHMATICS CHANNEL BLOCKER FAIL 3 WEEKS ONLY IF ANTICOAG CONSIDER STRUCTURALLY FLECAINIDE NORMAL HEART FAIL SECONDARY CARE CONSIDER ONLY AMIODARONE DC CARDIOVERSION SENIOR TO CONSIDERBradycardia – Key bradyarrhythmias Why does this matter? • Common cause of collapse and non vertiginous dizziness • Can be life threatening • Comes up in exams!Investigating arrythmias INITIALLY LATER • History • Bloods Drugs (iatrogenic? Accidental OD?) Electrolytes (inc Mg, Ca) Prev cardiac history? Eg IHD TSH, drug levels (digoxin?) • Examine (A to E) • Echo Stable or unstable? Structural heart disease? • ECG PR interval and relationship to QRS • Consider Underlying disease, eg Angiography, Signs of ischaemia? inherited cardiac diseases Case 8 An 78 year-old man presents to ED with lightheaded episodes when standing and a general sense of fatigue for approximately 2 weeks. On one occasion he thinks he passed out at the table but cant recall it very well, he denies any head injury. BG – Htn, Nstemi 2002 with 2xDES, Osteoarthritis, T2DM On admission the nurses have performed an ECG which they show to you, What is the most prominent ECG finding? A. Second degree heart block Mobitz type 2 B. Complete (third degree) heart block C. Atrial fibrillation with slow ventricular rate D. Second degree heart block Mobitz type 1 E. Sinus bradycardia Case 8 An 78 year-old man presents to ED with lightheaded episodes when standing and a general sense of fatigue for approximately 2 weeks. On one occasion he thinks he passed out at the table but cant recall it very well, he denies any head injury. BG – Htn, Nstemi 2002 with 2xDES, Osteoarthritis, T2DM On admission the nurses have performed an ECG which they show to you, What is the most prominent ECG finding? A. Second degree heart block Mobitz type 2 B. Complete (third degree) heart block C. Atrial fibrillation with slow ventricular rate D. Second degree heart block Mobitz type 1 E. Sinus bradycardiaComplete heart block (third degree HB) Pathophysiology Fundamentals • Either due to progressive (and complete) AV nodal failure • OR due to complete failure ois rkinjesystem (eg in MI) • Complete absence of • Can be caused byischaemia, Drugs or congenital abnormalities AV conduction • Ventricular rhythm ECG features initiated by ventricular -Regular P waves not related to QRS ‘escape’ base rate -Broad QRS waves at a slow rate • Can result in cardiogenic failure and death Case 9 An 78 year-old man presents to ED with lightheaded episodes when standing and a general sense of fatigue for approximately 2 weeks. On one occasion he thinks he passed out at the table but cant recall it very well, he denies any head injury. BG – Htn, Nstemi 2002 with 2xDES, Osteoarthritis, T2DM On admission the nurses have performed an ECG which they show to you, you confirm complete heart block. The nurses complee observations in resus at which time the patient is syncopal. Hr 30, Bp 86/56 sats 98% air, tempo 37.0. What is the most appropriate first line management? A. DC cardioversion B. IM adrenaline C. Transcutaneous pacing D. Atropine STAT E. Adenosine STAT Case 9 An 78 year-old man presents to ED with lightheaded episodes when standing and a general sense of fatigue for approximately 2 weeks. On one occasion he thinks he passed out at the table but cant recall it very well, he denies any head injury. BG – Htn, Nstemi 2002 with 2xDES, Osteoarthritis, T2DM On admission the nurses have performed an ECG which they show to you, you confirm complete heart block. The nurses complee observations in resus at which time the patient is syncopal. Hr 30, Bp 86/56 sats 98% air, tempo 37.0. What is the most appropriate first line management? A. DC cardioversion B. IM adrenaline C. Transcutaneous pacing D. Atropine STAT E. Adenosine STATAtropine works to bind to and inhibit muscarinic acetylcholine receptor In the heart this inhibits your vagus nerve which usually slows the heart rate down Noradrenaline SAN ACH Comparing heart blocks 1st degree AVB Key features; • Prolonged PR interval (>200) • Delay but consistent Atrioventricular conduction Many causesinc; • Increased vagal tone • Ischemia • Athleticism • Drugs Clinical significance • Isolated finding • Not usually treated alone Comparing heart blocks 2 nddegree AVB Mobitz 1 Key features • Malfunctioning AV nodal cells fatigue over time causing ‘dropped beats’ • AKA Wenckebach • Progressively prolonged PR interval Many causesinc; • Drugs • Vagal tone • Athleticism • Inferior MI • Post cardiac surgery Clinical significance • Usually benign with very low risk of transformation to other arrythmias • Asymptomatic–- no treatment • Symptomatic– AtropineComparing heart blocks 2nd degree HB Mobitz 2 Key features • Failure of hispurkinjesystem • Typically preexisting BBB/fascicular block Many causesinc; • Ischaemia • Fibrosis • Hyperkalaemia • Drugs • Amyloidosis • Cardiac surgery Clinical significance • High risk of transformation to CHB or extreme bradycardia • Sudden cardiac death • 35% risk asystoleyr • Indication for urgent PPM Increasing concern! nd 2 degree AVB Mobitz 1 2nd degree HB Mobitz 2 Key features rd 1st degree AVB • Malfunctioning AV nodal 3 degree (complete) heart block Key features cells fatigue over time • Failure of hispurkinjesystem Key features Key features; causing ‘dropped beats’ • Typically preexisting • Complete absence of AV • Prolonged PR interval (>200) • AKA Wenckebach • Delay but consistent • Progressively prolonged BBB/fascicular block conduction • Ventricular rhythm initiated by Atrioventricular conduction PR interval Many causesinc; ventricular ‘escape’ base rate • Ischaemia Many causesinc; Many causesinc; • Increased vagal tone • Drugs • Fibrosis Pathophysiology • Vagal tone • Hyperkalaemia • Either due to progressive (and • Ischemia • Drugs complete) AV nodal failure • Athleticism • Athleticisim • Amyloidosis • OR due to complete failure of his • Drugs • Inferior MI • Post cardiac surgery • Cardiac surgery purkinjesystem (eg in MI) Clinical significance • Can be caused byischaemia, Clinical significance Drugs or congenital abnormalities • Isolated finding Clinical significance • High risk of transformation to • Not usually treated alone • Usually benign with very low risk of transformation CHB or extreme bradycardia Clinical significance to other arrythmias • Sudden cardiac death • Indication for PPM and or • 35% risk asystoleyr temporary acute care • Asymptomatic–- no • Indication for urgent PPM treatment • Symptomatic– Atropine Case 10 A 73 year old lady with early onset dementia is brought to ED after being found to be fatigued and drowsy by her relatives, nearby medication packets were almost empty despite her daughter collecting the scripts only last week. They are suspicious she has taken an accidental overdose. Reg meds included Bblockers, aspirin, paracetamol, codeine. After initial assessment including paracetamol levels and a dose of naloxone the patient remains drowsy. There are no focal signs of neurology. An ECG is performed. What is the most appropriate first line management? A. DC cardioversion B. IM adrenaline C. Vagal manouvers D. Glucagon STAT E. Atropine STAT Case 10 A 73 year old lady with early onset dementia is brought to ED after being found to be fatigued and drowsy by her relatives, nearby medication packets were almost empty despite her daughter collecting the scripts only last week. They are suspicious she has taken an accidental overdose. Reg meds included Bblockers, aspirin, paracetamol, codeine. After initial assessment including paracetamol levels and a dose of naloxone the patient remains drowsy. There are no focal signs of neurology. An ECG is performed. What is the most appropriate first line management? A. DC cardioversion B. IM adrenaline C. Vagal manouvers D. Glucagon STAT E. Atropine STATIt is thought that glucagon bypasses the B-receptors to increase calcium channel movement causing depolarization despite B blockade O O F Feedback & Instagram + 3C N O Please complete feedback to receive slides and cheat sheet!Follow our In3tagram pa e for MCQs! NH O Cl CH 3 CH3 OH CH 3 CH OH 3 3HC CH3 3HC O