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Arrhythmias

Clinical Discipline(s)/Organ System(s)
Cardiology, Cardiovascular System
Progress Test Topic(s)
Cardiovascular, Seriously ill patient
Description
A 64 year old NZ European man is brought to the Emergency Department by ambulance. He had collapsed, temporarily lost consciousness and was observed to become pale at the time of collapse. When the ambulance crew arrived, it was noted that his pulse rate was very rapid.
Applied Science for Medicine 
   - Structure of cardiac myocytes
   - Normal cardiac electrophysiology including ion channel activity during cardiomyocyte depolarization
   - Normal ECG and how it correlates with the cardiac cycle; how a 12 level ECG is generated from 10 leads; calculate the QTc interval
   - Principles of drug distribution, metabolism and excretion; concentration-time relationships, individual variability in response to drugs; pharmacogenetic variability; monitoring drug therapy, drug interactions, rational approach to prescribing
   - Vaughan-Williams classification of anti-arrhythmic drugs
   - Pharmacology of amiodarone, sotalol, lignocaine and membrane stabilisers, warfarin
Clinical and Communication Skills 
   - History from a patient or witness following a syncopal episode; indication for hospital admission
   - Take a thorough medication history
   - Examination of a patient post syncope; recognise signs of haemodynamic compromise
   - Perform an ECG; identify atrial fibrillation and flutter, supraventricular tachycardia, left and right bundle branch block, ventricular tachycardia and fibrillation, Wolff-Parkinson-White syndrome, first-, second type 1-, second type 2- and third-degree heart blocks, atrial and ventricular ectopy
   - Indications for Holter monitor, echocardiogram, cardiac MRI, electrophysiology studies
   - Differential diagnosis of syncope
   - Causes of narrow complex and broad complex tachycardias
   - Pharmacological and non-pharmacological management of tachyarrhythmias and bradyarrhythmias
   - Management of atrial fibrillation: rate vs rhythm control, use of anticoagulation; preparation required for elective cardioversion
   - Role of the anticoagulant clinic and pharmacist
   - Complications of atrial fibrillation
   - Management of pulseless ventricular tachycardia and ventricular fibrillation
   - Indications for, and methods of cardioversion
   - Prescribe drugs safely, effectively and economically; write prescriptions that take into account the needs of individual patients; prescribe high risk medications (e.g. warfarin)
Personal and Professional Skills 
   - Taking a collateral history
   - Competence and decision-making
   - Patient education, including anticoagulant counselling
Population Health 
   - Epidemiology of syncope and atrial fibrillation
   - Epidemiology of stroke in those with atrial fibrillation
   - Access to healthcare resources: implantable defibrillators
Conditions to be considered relating to this scenario
Common
vasovagal syncope, heart block (first, second and third-degree), sustained and non-sustained ventricular tachycardia, AV nodal re-entrant tachycardia, AV reentrant tachycardia, Stokes-Adams attack, orthostatic hypotension, hypoglycaemia, drug induced, aortic stenosis, atrial fibrillation, mitral stenosis, emotional trauma
Less common but 'important not to miss'
vertebrobasilar artery TIA, Wolff-Parkinson-White syndrome, ruptured abdominal aortic aneurysm, hypertensive encephalopathy, epilepsy, Brugada syndrome, polymorphic ventricular tachycardia, subarachnoid haemorrhage, hypertrophic obstructive cardiomyopathy
Uncommon
tachy-brady syndrome, sick sinus syndrome, multifocal atrial tachycardia, subclavian steal syndrome