Cardiology - Arrhythmias,

pericardial and myocardial

disease
MCQ and SEQ
Classification of arrhythmias
Cardiac arrhythmias are defined as abnormalities of cardiac rhythm
• Based on the heart rate
• Tachyarrhythmia- Heart rate > 100/min
• Bradyarrhythmia- Heart rate < 60/min
• Based on the site of onset
• Supraventricular
• Supraventricular tachyarrhythmias arise from the cardiac tissue above the
ventricles – Narrow QRS complexes
• Ventricular
• These arrhythmias arise from ventricular cardiac tissue – Broad QRS
complexes
Q1 - AF
• T/F regarding atrial fibrillation
• Occurs as a consequence of acute alcohol excess
• The incidence increases with age
• A ‘saw tooth’ P wave in the ECG is characteristic
• Causes a completely irregular pulse which regularizes with exercise
• Increases the risk of stroke and TIA
AF
Q2 - AF
• T/F regarding atrial fibrillation
• In stable patients with AF, immediate electrical cardioversion is the
preferred treatment option
• Digoxin the preferred agent for control of the ventricular rate
• All patients with AF should be commenced on anticoagulation
• Aspirin is an effective alternative for oral anticoagulation in patients
with AF to reduce the risk of stroke and TIA
• A long-term rhythm control strategy has a better outcome than rate
control combined with anticoagulation
Best response Q1.
• A 65-year-old female presents with a history of fatigue and palpitations and
shortness of breath for 4 hours duration. On examination she is vomiting, and is
noted to have a slight tremor, some lid lag and has an irregularly irregular pulse of
140 per minute, with extensive bi basal crepitations. ECG confirms atrial
fibrillation with a rate of approximately 130 per minute. Thyroid function tests
show: Free T4 31.8 pmol/l (9-22) TSH 0.05 mu/l (0.5-4.5)
• Which of the following is the most appropriate initial treatment for this
patient?
• Anticoagulation
• DC cardioversion
• IV amiodarone
• IV digoxin
• IV Metoprolol
Choice of rate control
Best response Q2.
• An 80-year-old woman was admitted to the ward with dizziness. Cardiac
monitoring initially revealed atrial fibrillation with rapid ventricular
response. Her ventricular rate was controlled with beta blocker. An
echocardiogram revealed an enlarged left atrium and an ejection fraction
of 50%. No evidence of diastolic heart dysfunction was noted. She is now
asymptomatic, with blood pressure 130/80 mmHg, heart rhythm
irregularly irregular, and heart rate around 80 beats/min. Which of the
following is the best management strategy of this patient's arrhythmia?

• Electrical cardioversion plus prolonged anticoagulation

• Electrical cardioversion without anticoagulation
• Chemical cardioversion plus prolonged anticoagulation
• Chemical cardioversion without anticoagulation
• Continued rate control plus prolonged anticoagulation.
Q3. SVT
• T/F regarding paroxysmal supraventricular tachycardia
• This is most often due to an accessory pathway connecting the atria
and the ventricles
• Causes a broad complex tachycardia
• Vagal manoeuvres are contraindicated
• Intravenous calcium channel blockers are first line therapy
• Flecainide can be used for rate control in patients with structural
heart disease
Q4. VT vs. SVT
• Which of the following suggest a VT than SVT?
• Broad QRS complex
• Presence of capture beats
• Irregular rhythm
• AV dissociation
• Concordance of voltage complexes in the precordial leads
Q5. – Heart blocks
• T/F regarding complete heart block
• Irregular cannon ‘a’ waves can be seen on the ECG
• Presents with syncopal attacks
• CHB with a narrow ventricular escape rhythm has a poor prognosis
• Dissociation of P waves and QRS complexes on ECG
• Varying intensity of the first heart sound
AV blocks ECG
CHB
Escape rhythms
• Better prognosis with
narrower QRS
Bradycardia
management
Q6. Pericardial disease
• T/F regarding acute pericarditis
• Can occur due to coxsackie viruses
• Causes chest pain, relieved in the seated position
• PR segment depression is seen on the ECG
• Colchicine is used in the treatment
• Hemorrhagic pericardial effusions are seen in patients with uremic
pericarditis
Q7. Pericardial disease
• T/F regarding pericardial disease
• Pulsus paradoxus is seen in large pericardial effusions
• Electrical alternans on the ECG is seen in patients with cardiac
tamponade
• Tuberculosis is a recognized cause of constrictive pericarditis
• Kussmaul’s sign is a feature seen in patients with constrictive
pericarditis
• Pericardiocentesis is the treatment of choice for patients with cardiac
tamponade
Kussmaul’s sign in CP
• Increase in venous distension in the neck with inspiration
• Rigid pericardium – negative IT pressure not transmitted to heart
• No inspiratory increase in RV filling
• Venous backpressure
Video
• https://www.youtube.com/watch?v=795GGACswTA
• https://www.facebook.com/DrShankul/videos/429316941029297/
 A 60-year-old male with a history of hypertension presented with recurrent episodes of palpitations and
progressive shortness of breath over a period of 3 months. On examination he had an irregularly
irregular pulse with a heart rate of 140/min, BP – 120/70, a pansystolic murmur in the mitral area which

SEQ radiated to the axilla, bilateral lower limb edema and a few bilateral basal inspiratory crackles on lung
auscultation. The ECG recorded is given below.

1. What is the ECG diagnosis? (10 marks)

2. Give 2 reasons for your answer in (1). (10 marks)
3. Outline the initial management of this patient (20 marks)
Management
• Stabilization and cardiac monitor
• Rate control
• Diuretics
• Anticoagulation
• The patient subsequently underwent an echocardiogram and was
diagnosed to have mixed mitral valve disease with severe MR and
mild MS. He was started on warfarin and registered for valve
replacement surgery.
• Describe the mechanism of action of warfarin and the rationale to
administer it in this patient (20 marks)
• Outline the important advice you will give this patient regarding
warfarin (20 marks)
Warfarin - MOA
Warfarin patient advice
• Indication
• How to take – same time every day
• Adverse effects
• Interactions
• Food
• Alcohol
• Missed doses
• Monitoring and INR