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Cardiac Arrhythmias - Coggle Diagram

- - - - HR <60 bpm
    - - HR >100 bpm
- - - - PR interval >0.22
    - - No association between atrial and ventricular depolarisation
      - Causes
        
        Toxic conc. of drugs (digoxin, verapamil or β blockers)
      - Pathophysiology
        
        Complete heart block
        
        No P waves conducted to ventricles
        
        Resultant spontaneous escape rhythms with either broad (>0.1 s) or narrow ( <0.1 s) QRS complexes
      - Treatment
        
        Discontinuation of drug
        
        Occasionally temporary pacemaker
- - - - HR
        
        Atrial: 280- 350 bpm
        
        Ventricular: 150 bmp
        Every second atrial flutter conducts to ventricles
      - Treatment
        
        Acute paroxysym: Electrical cardioversion
        
        Amiodarone (Class III)
        Maintanence
        
        Sotalol
        Maintanence
        
        β blockers
        Long standing atrial flutter
        
        Calcium channel blockers
        Long standing atrial flutter
        
        Digoxin
        Reduce ventricular rate
    - - Continuous rapid activation of the atria with V rate between 120 - 180 bpm)
      - Aetiology / Causes
        
        Ischaemic heart disease
        
        Valvular heart disease
        
        Hypertension
        
        Thyrotoxicosis
      - Irregularly irregular R - R intervals
        Abscence of distinct repeating P waves
      - Types
        
        Paroxysmal AF
        
        Terminates spontaneously or with intervention within 7 days of onset
        
        Persistent AF
        
        Sustained beyond 7 days
        
        Long standing AF
        
        Greater than 12 month duration
      - Management
        
        A Anticoagulation / Avoid stoke
        
        Stroke risk assesment
        
        Risk factors for bleeding with oral anticoagulants
        
        B Better symptom management / Rate control
        
        Anti-arrhythmic Medication
        
        Calcium channel blockers
        Verapamil
        
        Digoxin
        Controlling rate at rest
        Care to avoid bradycardia
        
        β Blockers
        Metoprolol
        Bisoprolol
        Carvedilol
        
        Long term
        
        Amiodarone (Class III)
        
        Flecanide (Class Ic)
        
        Propafenone (Class Ic)
        
        Dronedarone (Class III)
        
        Target rate of <110 bpm
        
        Cardioversion
        
        Catheter ablation
        
        C Cardiovascular and Comorbidity optimization
        
        Targeted therapy of underlying conditions
        
        ACE inhibitors
        
        ARBs
        
        CA2+ channel blockers
        
        β blockers
        
        Metformin
        
        SGLT2 inhibitors
        
        GLP1-RA
        
        Statins
    - - Reflex vagal stimulation
        
        Carotid sinus massage
        
        Valsalva manoeuvre
      - Often remits spontaneously
      - Adenosine
        
        IV 3mg
        
        6mg after 1 -2 min
        
        12mg after 1 - 2 min
      - Electrical cardioversion
  - - - Presentation
        
        Pt describes "Missing beats" or "Heavy beats"
        
        Irregular pulse
      - Treatment
        
        Class 1,2,3 anti-arrhythmics
        
        No treatment in abscence of heart disease
    - - Three or more ventricular beats occuring at a rate of 120 bpm
      - Rapid V rhythm
        Broad abnormal QRS complexes
      - Presentation
        
        Hypotensive
        
        Ill (MI)
        
        Some are well tolerated
      - Treatment
        
        Urgent depending on haemodynamic status
        
        Electrical cardioversion
        
        IV Class I (Lignocaine)
        
        Amiodarone IV
        
        Prophylaxis
        
        β blocker if exercise induces the arrhythmia
        
        Class 1 (Disopyramide)
        
        Class 3 amiodarone
        
        Long term high risk pt
        ICD - Implantable cardioverter defibrillator
    - - Rapid irregular V activation with no mechanical effect
      - Presentation
        
        Pulseless
        
        Becomes unconcious
        
        Respiration ceases
      - Causes
        
        Ventricular ectopic (post MI)
        
        VT
        
        Torsades de pointes
      - Treatment
        
        Electrical Defibrillation
        
        Prophylaxis
        
        Amiodarone
        
        β blockers
        
        Implantable defibrillator
    - - It is a polymorphic ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram
      - Twisting of the points - refers to the beat to beat changes in the QRS axis
      - Can be fatal
        
        Associated with prolongation of QT interval (AT >500msec)
        
        Prolongation of QT interval associated with TdP is most common cuase of withdrawal / restriction of marketed drugs
      - Causes
        
        Drug Therapy
        
        Quinidine, procainamide, disopyramide, sotalol
        
        Amiodarone
        
        Clarithromycin, erythromycin, pentamidine
        
        Chlorpromazine, haloperidol, thioridazine
        
        Methadone
        
        Congenital long QT syndromes
        
        Risk factors
        
        Female
        
        Hypokalaemia
        
        CCF
        
        Long QT syndrome
        
        High drug conc.
        
        Rapid rate of IV infusion witha QT prolonging drug
    - - Coronary artery disease
      - Hypertenion
      - Cardiomyopathy
- - - - SVT
      - AFib
      - A Flutter
      - VT
      - VFib
    - - Structural analogue of thyroid hormone
    - - Prolongs PR, QRS and QT intervals
      - Prolongs action potential
    - - IV or PO
      - Loading dose 200mg 3x daily for 1 week
        200mg twice daily for 2nd week
        Maintenance 200 mg/day
    - - Bioavailability 30%
      - Metabolised by hepatic cytochrome P450 3A4
      - Half life 28-45days
      - Interactions by inhibiting hepatic metabolism eg Wafarin (CYP 2C9)
        Inhibiting P-glucoprotein eg Digoxin
    - - Cardiac
        
        Bradycardia
        
        Hypotension
        
        QT prolongation
        
        Arrhythmia
      - Resp
        
        Pulmonary fibrosis :butterfly:
      - Occular
        
        Corneal microdeposits
      - Hepatic
        
        Abnormal LFT
        
        Inhibiton of CYP450
      - Neuromuscular
        
        Peripheral neuropathy
        
        Muscle weakness
      - Dermatological
        
        Photosensitivity
      - Endocrine
        
        Hypothydroidim
        
        Thyrotoxicosis
  - - - Ventricular Arrhythmias post MI
    - - Na+ channel blocker
      - Local anaesthetic
    - - Little effect of PR and QRS
      - Shortens AP
    - - Extensive first pass metabolism
      - Metabolised by P450 3A4
      - Half life: 1.5 - 2 hours
      - Active metabolites :
        
        Glycine xylidide
        
        Monoethyl GX
    - - IV
      - 100mg bolus
        Infusion of 4 mg / min x 30min
        1mg / min
    - - CNS
        
        Dizziness
        
        Paraesthesia
        
        Tremor
        
        Dysarthria
        Confusion
        
        Resp depression
        
        Convulsion
      - Cardiac
        
        Bradycardia
        
        Hypotension
        
        Negative inotropic effect