Bradycardia and Syncope

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1. how are ECG, Holter, exercise tolerance testing, 8. how is tachycardia -differentiate supraventricular and
bradyarrhythmias EPS (sinus node recovery time, sinoatrial syncope treated? ventricular
diagnosed? (AV) conduction time, prolonged -drugs can be given in SVT
recovery/conduction signal problems) -VT needs cardioversion (ICD), drugs
aren't first line
2. how can obstructs venous return to lungs, reducing
-correct the underlying cause
pulmonary preload from the lungs to LA and into LV
-give electrolytes if there is an
emboli cause to get relative hypovolemia
imbalance
syncope?
9. how is the -SA and AV nodes = postganglionic
3. how can narrow QRS complexes (vs. wide in
conduction system sympathetic and parasympathetic
supraventricular ventricular)
innervated? nerves and ganglia
tachycardia be
-bundle of His and distal conducting
identified on
systems = minimally influenced by
ECG?
autonomic tone
4. how does a -implanted device that acts as a generator
10. how long should about 0.4s (2 boxes on ECG,3 boxes
pacemaker with a wire placed toward the apex of the
the QT interval be? would be very long)
work? heart
-contains a battery and solid state 11. sinus bradycardia inferior and posterior MI because of
computer that is programmed differently involving what can RCA involvement (which feeds SA
-placed on right side of the heart to be exacerbated by nodal artery)
prevent thrombosis; flow is more passive, pain or drugs like
less turbulence morphine?
-retrograde conduct toward the base from
12. what are causes of tachycardia or bradycardia
the apex to create ventricular contraction
arrhythmic CO = SV x HR and SV = CO/HR
-generates a spike down toward the RV
syncope? -lower the HR, lower the CO
apex followed by a ventricular
-increase HR, decrease SV
depolarization with a bundle branch block
-lead to decreased cerebral perfusion
5. how does pacing -normally, impulse travels from septum to thus syncope
vary from apex then to base
13. what are causes of -sudden decrease in CO
normal -with a pacemaker, travels apex to base,
cardiogenic -HR below 30 and above 180 bpm
conduction? then septum
syncope? lead to cerebral hypoperfusion (rates
-see a downward spike then a wide
under 30 cannot be supported by
complex on ECG
increased SV, over 180 decreases LV
6. how is -correct the underlying cause, remove filling and decreases SV)
bradycardia medications if necessary
14. what are clinical -abrupt
syncope -if consistent and persistent, a pacemaker
symptoms of brady -no presyncopal symptoms, prodrome
treated? may be necessary
arrhythmic or aura
-no medications available
syncope? -may be repetitive
-give electrolytes if there is an imbalance
-may be necessary to monitor the
7. how is syncope -approach is directed at the underlying heart frequently to find a problem or
treated? cause underlying bradycardia
-try to prevent the episode when
15. what are ECG -short PR (under .12 or <3 small boxes)
symptoms first begin; maximize cerebral
characteristics of -wide QRS
flow
WPW reentry? -delta wave
-medications can be given to blunt
(macro reentry)
sympathetic drive; salt loading,
compression stockings 16. what are examples -breath holding
-pacemaker is necessary in some cases of -coughing
from low HR hypervagotemia? -esophageal and/or nasopharyngeal
stimulation
-increased intracranial pressure
-can be associated with tantrums
17. what are extrinsic -drugs (clonidine, beta blockers, digoxin, 25. what events can LV myocardial restriction, epicardial
causes of CaCB) reduce filling to constriction, pericardial constriction
bradyarrhythmia -hypothermia cause syncope? (stiff muscles, can't receive blood),
in children? -hypervagotemia pericardial tamponade
-neurocardiogenic syncope, sleep
26. what events can pulmonary embolism, pulmonary HTN
18. what are intrinsic -cardiomyopathy (familial, inflammatory reduce preload and (high pressures in lungs), atrial
causes of like myocarditis, pericarditis) cause syncope? myxoma (cause obstruction), mitral
bradyarrhythmia -congenital heart disease (surgical stenosis (decreased SV)
in children? trauma)
27. what events can aortic outflow obstruction, aortic
19. what are Mustard -congenital heart disease repairs where reduce SV/increase valvular stenosis, hypertrophic
and Fontan shunts are created toward the back of the afterload to cause obstruction cardiomyopathy,
repairs? heart to correct blood flow through the syncope? myocardial disease (pump failure)
heart
28. what is a major during fibrillation the patient is
-shunt venous blood back to the correct
difference unconscious
path
between (Vtach often progresses into Vfib)
-lose SA node from cutting into the area
ventricular
surgically
tachycardia and
20. what are the -SA node dysfunction fibrillation?
most common -AV conduction block
29. what is a result of a a relative refractory period occurs, so
causes of
long QT? with a large enough stimulus another
pathologic
action potential can be fired earlier
bradycardia?
-chance for malignant arrhythmia to
21. what causes AV -idiopathic progressive fibrosis of the develop
block? conduction system, common in the 50s,
30. what is atrial -supraventricular tachycardia
accelerated by DM, HTN and
fibrillation? -cannot be captured on ECG--leaves
atherosclerosis
squiggly line
-autonomic dysfunction
-see no baseline, no P waves and
-metabolic dysfunction = more
irregular QRS
pronounced than SA due to the less
-atrial rate is 350-450
spontaneous depolarization;
-chaotic atrial multifocal ectopic
hyperkalemia, hypermagnesimia,
rhythm
hypothyroidism
-drug related 31. what is atrial -supraventricular tachycardia
-infectious, inflammatory flutter? -intraatrial reentry tachycardia
-congenital (iatrogenically induced from -atrial rate is 250-350bpm
surgeries) -gives sawtooth pattern with lots of P
-infiltrative, neoplastic waves on ECG
-degenerative disease -each one stimulates the next
-coronary disease 32. what is AV nodal -supraventricular tachycardia
22. what creates anything that causes a reentry? -atrial flutter within AV nodal reentry
reentry? depolarization/repolarization mismatch -reentry occurs within or just next to
(like electrolyte imbalance, areas that AV node
have a lot of conduction tissue) -sudden development of rapid regular
palpitations
23. what does the -atrial waves are all the same (P waves);
ECG look like PR is normal 33. what is carotid -pressure on the carotid baroreceptor
with paroxysmal -no QRS conduction sinus (carotid massage) leads to activation,
AV block? -leads to syncope hypersensitivity? giving rise to impulses carried via CN9
-needs a pacemaker (glossopharyngeal) to the medulla
-nerves activate nerve fibers to the
24. what drug can be adenosine; blocks the AV node and the
blood vessels, cardiac vagal afferent
given to block reentry circuit so the SA node can
nerve fibers or both
reentry? resume normal sequence
-can lead to sinus arrest or AV block,
vasodilation
-syncope is abnormal
34. what is extrinsic -dysfunction is often reversible 39. what is -results primarily from hypovolemia
bradycardia? -something other than SA node is orthostatic -can also be from disturbances in vascular
providing input (postural) control from medication, peripheral
-autonomic = vasovagal (vomiting), hypotension? neurophathies, or defective postural
carotid hypersensitivity reflexes (consider when neurogenic
-drugs bladder, constipation, heat intolerance,
-hypothyroidism inability to sweat, erectile dysfunction),
-hypoxia multiple system atrophies, post ganglionic
-sleep apnea dysautonomia
-hypothermia
40. what is -supraventricular tachycardia
-increased intracranial pressures
paroxysmal -focus in the atria other than SA node
35. what is intrinsic -diseases of the SA node itself; atrial becomes dominant = ectopic
bradycardia? associated with age, hardening, scarring, tachycardia -atrial rate of 150-250bpm (relatively slow
fibrosis, anything that reduces stimulation (PAT)? tachy arrhythmia)
-degenerative
41. what is reflex -disorder of vascular tone or blood
-MI
syncope? volume
-inflammatory process (pericarditis,
-can be neurocardiogenic, situational
myocarditis, infection, collagen vascular
syncope, or carotid hypersensitivity
diseases)
-senile amyloidosis 42. what is SA -pathologic bradycardia
-iatrogenic (radiation, post surgical, node -can be difficult to distinguish from
congenital heart disease) dysfunction? physiologic sinus bradycardia in young
-myotonic dystrophy and athletic
-trauma -increases in frequency after 60s
-sick sinus syndrome in elderly 43. what is sick -"tachy brady" syndrome
36. what is a beta stimulant that increases atrial rate sinus -found in elderly patients, but can occur in
isoproterenol? syndrome? young
-associated with an increase in fibrous
37. what is Lev acquired complete heart block due to
tissue in the SA node
disease? idiopathic fibrosis and calcification of the
-get such a slow HR from poor generation
electrical conduction system
of depolarization that leads to reflex
-commonly seen in elderly = senile
rebound catecholamine stimulation that
degeneration of the conduction system
causes increased HR
38. what is -vasovagal syncope = sympathetic -fast and slow palpitations
neurocardiogenic withdrawal (vasodilation, hypotensive)
44. what is -cardioinhibitory, vasodepressor or both
syncope? AND increased parasympathetic activity
situational -happens in situations like micturition,
(bradycardia)
syncope? cough, swallowing (rarely), valsalva,
-vasodepressor = associated with
defecation
sympathetic withdrawal alone
-sympathetic and parasympathetic event
-common; accounts for half of all
-pass out from transient increase in vagal
syncope episodes
tone
-preceded by presyncope; precipitated
by situations (alcohol, heat, pain, 45. what is -preceded by presyncopal picture
emotions, crowds) tachyarrhythmic (dizziness, lightheadedness, palpitations)
-not a lot of sympathetic tone so don't syncope? -can occur abruptly
feel tachycardia, flushing -usually has some anxiety associated
-motionless with muscle relaxation, -supraventricular or ventricular
maintain sphincter control (in contrast to 46. what is the ANS -parasympathetic = vagal stimulation leads
seizure) function in to slowing of HR; too slow causes
syncope? bradycardia, sympathetic withdrawal,
vasodilation (cannot maintain normal
vascular tone), reduced SV and cerebral
perfusion causing syncope
-sympathetic = tachycardia, reduced SV,
reduced cerebral perfusion
47. what is the cause cerebrovascular disease; usually 56. what is Wolff- -supraventricular tachycardia
of neurologic symptoms of focal cerebral ischemia, Parkinson-White -macro atrial ventricular reentry
syncope? diplopia, ataxia, dysarthria, sensory tachycardia? (initiated from atria, but associated with
disturbances; anything that inhibits rapid conduction down the accessory
perfusion pathway)
-often due to bilateral carotid stenosis,
57. what pulse level >160, <30
vertebrobasilar insufficiency, basilar
will decrease
artery migraine
cerebral perfusion
48. what is the ECG LVH = large QRS complexes enough to cause
morphology of syncope?
aortic stenosis?
58. what supplies AV nodal artery and first septal
49. what is the ECG RVH, right axis deviation blood to the AV perforator branches from the LAD
morphology of node?
congenital heart
59. what supplies the septal perforators of the LAD and
disease?
blood to the the posterior descending artery
50. what is the ECG LVH, left axis deviation bundle branches?
morphology of
60. what volume reduced preload, reduced
hypertrophic
dependent factors afterload/pump failure, reduced filling,
obstructive
cause syncope? reduced stroke volume
cardiomyopathy?
61. what will atropine decrease vagal components and
51. what is the ECG Q waves (scar tissue) or ST
do? increase HR; can sometimes help AV
morphology of abnormalities (ischemia)
block
ischemic
cardiomyopathy? 62. when does -doesn't normally happen
syncope occur in -occurs with heart disease leading to
52. what is the most ischemic cardiomyopathy
supraventricular decreased CO, cerebrovascular
frequent cause of
tachycardia? disease, disorder of vascular tone or
Vtach?
blood volume, rapid ventricular rate
53. what is the pacemaker implantation; pharmacology affecting CO/SV
primary treatment is limited (isoproterenol or
63. when is carotid -to break supraventricular tachycardia
therapeutic atropine acutely; theophylline for
massage used? and reentry by creating a stop
intervention for chronic)
-used as a first therapeutic intervention
bradyarrhythmia?
-cannot be used it there are signs of
54. what is transient -acquired and persistent failure of AV carotid disease
AV block? conduction
64. where does the SA -right coronary artery 55-60%
-fatigue, chronotropic incompetence,
nodal artery arise? -left circumflex 40-45%
exercise intolerance, syncope
-rare in the healthy adult population but 65. which medications -beta blockers
common in young (they have increased are useful in -serotonin uptake inhibitors
vagal tone) treating syncope? -hydrofludrocortisone (promotes
-associated with degenerative heart peripheral vasoconstriction)
disease -alpha agonists
-disopyramide (vagolytic anti-
55. what is ventricular -usually associated with structural heart
arrhythmic), transdermal scopolamine
tachycardia? disease (aortic stenosis, hypertrophic
(caution with ventricular arrhythmia) =
obstructive cardiomyopathy, congenital
for vasovagal syncope
heart disease, ischemic
-avoid vasodilators, diuretics
cardiomyopathy)
-common cause of syncope 66. which medications anything that elongates the QT interval,
-can occur from abnormalities in can cause such as anti arrhythmics, tricyclic
repolarization (long QT syndrome) torsade? antidepressants, erythromycin
*can also be caused by genetic long
QT syndrome
67. which tachycardia syncope is worse: supraventricular or ventricular? ventricular; can be lethal and requires cardioversion