Arrhythmias

• Arrhythmias


  Abnormal heart rhythms
• Ectopic beats (spontaneous treatment rate)
• Treatment for ectopic beats

  1. Beta blocker if needed
• Blood pooling - clots
• AF (atrial fibrillation) valves not emptying
• Ventricular rate / sinus by the control
• Acute AF


  Life-threatening haemodynamic instability
• Emergency treatment for acute AF


  Electrical cardioversion
• Acute AF onset < 48 hours (rate or rhythm)
• Acute AF onset > 48 hours (rate)
• Treatments for acute AF


  1. Cardioversion (rhythm)

  2. Pharmacological (flecainide/amiodarone)

  3. Electrical (IV anticoagulation (rule out left atrial thrombus))
• Maintenance treatments for AF

  • Rate control monotherapy
  • Rhythm control
  • B-blocker (not sotalol)
  • Rate limiting calcium channel blockers (diltiazem/verapamil)
  • Digoxin (sedentary + non-paroxysmal AF)
  • Dual therapy
• AF > 48 hrs electrical better than pharmacological
• Clotting risk - anticoagulation 3 weeks before + 4 weeks after
• Post cardioversion

  1. Chug treatment with B-blocker

  2. SPAF (Sotalol, profenone, amiodarone, flecainide) can be used at least 4 wks before up to 12 months after
• Paroxysmal Af


  Episodes of symptomatic DAF
• Treatment for paroxysmal Af

  1. B-blocker

  2. SPAF

  3. When required flecainide/propafenone "pill in pocket"
• SPAF


  Symptomatic paroxysmal atrial fibrillation
• Treatment for atrial flutter

  1. Favour non-pharmacological treatment (e.g. catheter ablation)
  2. Rate control with beta-blockers/calcium channel blockers
  3. Rhythm control with direct current cardioversion or pharmacological cardioversion
  4. Anticoagulation for 3 weeks if AF > 48 hours or high stroke risk
• Paroxysmal supraventricular tachycardia


  • Non-treatment (self-limiting)
  • Reflex vagal stimulation (ECG monitoring)
  • Valsalva manoeuvre
  • Cold water immersion (face)
  • Carotid sinus massage
  • IV verapamil
  • Catheter ablation
• Treatment for pulseless/ventricular fibrillation


  1. Direct current cardioversion

  2. IV amiodarone

  3. Repeat cardioversion
• Treatment for unstable sustained ventricular tachycardia


  Direct current cardioversion
• Treatment for non-sustained ventricular tachycardia


  1. Beta-blocker

  2. Maintenance therapy if high risk of cardiac events
• Implantable cardioverter defibrillator


  Indicated for high risk of cardiac events
• Anti-arrhythmic drug classes


  • Class I (membrane-stabilising)
  • Class III (potassium channel blockers)
  • Amiodarone (multiple mechanisms)
• Torsade de pointes is a drug-induced ventricular tachycardia caused by QT prolongation, often due to hypokalemia or severe bradycardia
• Treatment for torsade de pointes


  1. Magnesium sulphate

  2. Beta-blocker (not sotalol)

  3. Atrial/ventricular pacing
• Stroke Prevention


  • Congestive HF
  • Hypertension
  • Age 75+
  • Diabetes
  • Stroke/TIA
  • Vascular disease
• Thromboprophylaxis not needed for men = 0, women = 1