Cardiology 7 — Arrhythmias

Lecture Outline

I. Antiarrhythmic Drugs
A. Class I (Na+ channel-blockers)
B. Class II (β-blockers)
C. Class III (K+ channel-blockers)
D. Class IV (Ca2+ channel-blockers)
II. Bradycardia
A. Sinus bradycardia/Sick Sinus Syndrome
B. AV nodal block
1. 1st degree AV block
2. 2nd degree AV block
3. 3rd degree AV block
III. Supraventricular arrhythmias
A. Atrial fibrillation
B. Atrial flutter
C. Paroxysmal supraventricular tachycardia
IV. Ventricular arrhythmias
A. Premature ventricular contractions (PVCs)
B. Ventricular tachycardia (VTach)
C. Torsades de Pointes

Antiarrhythmic Drugs

1. What are the 4 basic classes of antiarrhythmic drugs?

• Class I
• Class II
• Class III
• Class IV

2. List examples of each class of antiarrhythmic drugs.

Class IA

Class IB

Class IC

Class II
Class III
Class IV

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Bradycardia

3. What medications can cause bradycardia?

4. What are the EKG characteristics of each type of AV block?

1st degree AV block

2nd degree AV block

Mobitz 1

Mobitz 2
3rd degree AV block

5. Which types of AV block require a pacemaker?

Atrial Fibrillation/Flutter

6. What are the EKG characteristics of atrial fibrillation?

7. What tests should always be performed when looking for underlying causes of new-onset atrial fib?

8. What classes of drugs are typically used for rate control in atrial fibrillation?

9. What are the two main concerns in the chronic treatment of atrial fibrillation?

10. What is the risk of stroke associated with atrial fibrillation?

11. What drug is used to reduce the risk of stroke in patients with atrial fibrillation?

12. What are the EKG characteristics of atrial flutter?

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Quick Review

13. Classify the following antiarrhythmic drugs (Class IA, IB, IC, II, III, or IV).

Amiodarone

Quinidine

Diltiazem

Flecainide
Procainamide

Metoprolol

Sotalol
Lidocaine
Verapamil

Digoxin

14. What drugs are most commonly used to control the heart rate in acute atrial fibrillation with rapid ventricular
response?

15. A 66-year-old man with a history of hypertension and diabetes presents to your office with a complaint of
palpitations for 1 week. EKG reveals atrial fibrillation with a resting HR of 72. After discussing treatment
options, he decides that he would prefer a trial of electrical cardioversion in order to avoid lifelong
anticoagulation. What preliminary steps would need to be undertaken before cardioversion?

16. Amiodarone is sometimes used to help maintain sinus rhythm in patients with atrial fibrillation. What studies
are commonly followed in patients taking amiodarone, to monitor for toxicity?

Paroxysmal Supraventricular Tachycardia

17. What are the two most common causes of paroxysmal supraventricular tachycardia (pSVT)?

18. What vagal maneuvers can be used to slow or break pSVT?

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19. What drug can be used to break or slow pSVT?

Ventricular Arrhythmias

20. What does a premature ventricular contraction (PVC) look like?

21. What do we call >3 PVCs in a row?

22. What are the EKG characteristics of ventricular tachycardia (VTach)?

23. If untreated, into what rhythm will VTach often degenerate?

24. How is VTach managed? Complete the chart below.

Is the VTach sustained?

NO YES
O
Non-sustained VTach Sustained VTach: Is the patient
hemodynamically stable?

NO YES
O

Unstable VTach: Does the Stable VTach

patient have a pulse?

NO YES
O

Pulseless VTach Unstable VTach with Pulse

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End of Session Quiz

1. Wolff-Parkinson-White (WPW) syndrome is caused by an abnormal connection between atria and ventricles
through an accessory bypass tract. What is the most common accessory bypass tract causing WPW
syndrome?

2. What rhythm is classically described as being “irregularly irregular”?

3. What rhythm is classically described as having a “saw tooth” pattern on the baseline?

4. A 68-year-old man with a history of coronary artery disease (CAD) presents to the ER with a complaint of
chest pain and is subsequently admitted to telemetry unit for monitoring. Overnight, the nurse calls you to
the bedside because of tachycardia. His heart rate has been 160 beats per minute for the last 3 minutes. You
race to the bedside, only to find the patient sitting up comfortably. He denies any pain or dyspnea, and says
he feels fine. His BP is 114/72, but the telemetry monitor shows a wide-complex rhythm with a rate of 156,
and you diagnose ventricular tachycardia. What are your next steps?

5. While you are waiting for your orders from the previous question to be carried out, the patient begins to
complain of feeling “woozy”. You check his blood pressure, and discover that it has fallen to 82/60. The tele
monitor still shows ventricular tachycardia with a rate in the 150s-160s. What are your next steps?

6. What type of heart block is described by the following statements?

PR interval prolonged more than 0.2msec (5 small boxes)

No relationship between P waves and QRS

PR interval becomes progressively longer until a beat is blocked

PR interval fixed, but with occasional dropped beats

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7. A nurse calls the on-call intern in the middle of the night because a patient has developed tachycardia, with
rate of 140. The blood pressure is 90/50. The intern orders a stat EKG, then hurries to the floor to examine
the patient. She interprets the wide-complex tachycardia on EKG as ventricular tachycardia, but since the
patient has a pulse she calls her resident for assistance before initiating therapy. The resident studies the EKG
and pronounces this to be supraventricular tachycardia with aberrant conduction. The intern politely but
adamantly disagrees. How should the team proceed?

8. What basic EKG rhythm matches the following statements?

Narrow QRS associated with P waves, rate 60

Chaotic, erratic, wide QRS

Wide QRS not associated with P waves, rate >40 but <100

Narrow QRS not associated with P waves, rate >100

Wide QRS, not associated with P waves, rate 20-40

Wide QRS, not associated with P waves, rate >100

Narrow QRS not associated with P waves, rate >60 but <100

Wide QRS tachycardia with variable amplitude in a repeating pattern

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