BLOCK 12: Arrhythmia Evaluation and Management
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Learning Objectives By Lesson
Regular Narrow Complex SVTs
  • Describe how to differentiate between narrow complex tachycardias
  • Describe the difference between short and long RP tachycardias
  • Create a differential diagnosis for short and long RP tachycardia
  • Describe the mechanism of action of AV nodal reentrant tachycardia (AVNRT)
  • Describe the electrocardiographic features associated with AV nodal reentrant tachycardia (AVNRT)
  • Describe the eletrocardiographic features associated with accessory pathway mediated-orthodromic reentrant tachycardia (ORT)
Atrial Fibrillation (AF) & Atrial Flutter (AFL)
  • Describe and identify the electrocardiographic features associated with atrial fibrillation (AF)
  • Describe the key mechanistic difference between typical and atypical atrial flutter (AFL)
  • Describe the differences between clockwise (CW) and counter-clockwise (CCW) atrial flutter (AFL)
  • Describe and identify the electrocardiographic features associated with clockwise (CW) and counter-clockwise (CCW) atrial flutter (AFL)
  • Describe and identify the electrocardiographic features to identify atypical atrial flutter (AFL)
AF Classification & Pathophysiology
  • Describe how to classifty atrial fibrillation (AF)
  • Describe the difference between valvular and non-valvular atrial fibrillation (AF)
  • Identify electrophysiological and anatomical factors that influence the initiation and maintenance of atrial fibrillation (AF)
  • Describe the process of atrial electrical remodeling occurs in atrial fibrillation (AF)
Stroke Risk & Anticoagulation in AF
  • Describe how to determine stroke risk in atrial fibrillation (AF)
  • Identify which patients with atrial fibrillation (AF) should be anticoagulated
  • Describe how a rate versus rhythm control approach for atrial fibrillation (AF) alters anticoagulation management
  • Describe the role of aspirin for stroke prevention in atrial fibrillation (AF)
Anticoagulation Selection in AF
  • Identify anticoagulant options to use in atrial fibrillation (AF)
  • Describe the mechanism of action of various direct oral anticoagulants (DOACs)
  • Describe the benefits of using direct oral anticoagulants (DOACs) compared to warfarin in atrial fibrillation (AF)
  • Identify some potential disadvantage of direct oral anticoagulants (DOACs)
  • Identify the proper dosage of various direct oral anticoagulants (DOACs) in atrial fibrillation (AF)
  • Describe when apixaban dose reductions for atrial fibrillation (AF) should be considered
  • Describe the effects of various medications (e.g., verpamil) on different direct oral anticoagulants (DOACs)
  • Identify anticoagulation options for atrial fibrillation (AF) in patients with end-stage renal disease or on dialysis
  • Identify reversal agents for various direct oral anticoagulants (DOACs)
Special Cases of Anticoagulation Use in AF
  • Describe how anticoagulation for atrial fibrillation (AF) should be managed when considering cardioversion
  • Describe how anticoagulation for atrial fibrillation (AF) should be managed in the setting of acute coronary syndrome (ACS)
  • Describe how anticoagulation for atrial fibrillation (AF) should be managed after percutaneous coronary intervention (PCI)
Rate vs. Rhythm Control for AF
  • Describe how to determine between a rate versus rhythm control approach for atrial fibrillation (AF)
  • Identify target heart rates in atrial fibrillation (AF) management
  • Identify clinical scenarios of when to consider a rhythm control approach for atrial fibrillation (AF)
  • Describe how to manage atrial fibrillation (AF) in the acute and chronic settings
  • Identify important lifestyle modifications to consider in atrial fibrillation (AF) management
Rhythm Control Approach for AF
  • Describe how to select a rhythm control approach for atrial fibrillation (AF)
  • Identify antiarrhythmic drug options in atrial fibrillation (AF) as well as their potential side effects
  • Identify antiarrhythmic drugs to avoid and use for atrial fibrillation (AF) in the context of underlying structural heart disease
  • Identify indications for catheter ablation in atrial fibrillation (AF)
  • Identify contraindications for dronedarone in atrial fibrillation (AF) management
  • Identify antiarrhythmic drug options for atrial fibrillation (AF) in hypertrophic cardiomyopathy as well as antiarrhythmic drugs to avoid
Post-Op AF & Ablation Complications
  • Describe how to manage post-operative atrial fibrillation (AF)
  • Describe potential complications of catheter ablation
  • Identify various catheter ablation complications
Management of SVT & Pre-excited AF
  • Describe an acute termination approach for supraventricular tachycardia (SVT)
  • Describe a chronic suppression approach for supraventricular tachycardia (SVT)
  • Identify the role of catheter ablation in supraventricular tachycardia (SVT)
  • Identify hallmark ECG features of pre-excited atrial fibrillation (AF)
  • Describe the risk stratification for symptomatic and asymptomatic patients with ventricular pre-excitation
  • Describe how to manage pre-excited atrial fibrillation (AF)
Wide Complex Tachycardias (WCTs)
  • Define wide complex tachycardias (WCTs)
  • Create a differential diagnosis for wide complex tachycardias (WCTs)
  • Describe the difference between simultaneous and sequential ventricular activation and its general effect on the QRS duration
  • Describe the clinical significance of accurate wide complex tachycardia (WCT) differentiation
Implications of Inaccurate WCT Diagnosis
  • Describe potential clinical implications of ventricular tachycardia (VT) misdiagnosed as supraventricular tachycardia (SVT)
  • Describe potential clinical implications of supraventricular tachycardia (SVT) misdiagnosed as ventricular tachycardia (VT)
AV Dissociation in WCT Differentiation
  • Describe AV dissociation and the electrocardiographic features associated with it
  • Identify AV dissociation on an ECG
  • Describe the utility of AV dissociation in wide complex tachycardia (WCT) differentiation
  • Describe the mechanism behind and electrocardiograpghic features associated with capture beats
  • Identify capture beats on an ECG
  • Describe the mechanism behind and electrocardiograpghic features associated with fusion beats
  • Identify fusion beats on an ECG
  • Describe how to identify artifact in the context of a wide complex tachycardia (WCT)
QRS Axis in WCT Differentiation
  • Describe the utility of QRS axis in differentiation wide complex tachycardias (WCTs)
  • Describe and identify QRS axis ECG clues favoring ventricular tachycardia (VT)
QRS Morphology in WCT Differentiation
  • Describe the utility of QRS morphology in differentiating wide complex tachycardias (WCTs)
  • Describe and identify QRS morphology ECG clues favoring ventricular tachycardia (VT)
  • Describe and identify typical left and right bundle branch block ECG features
  • Describe and identify atypical left and right bundle branch block ECG features
QRS Duration in WCT Differentiation
  • Describe the utility of QRS duration in differentiating wide complex tachycardias (WCTs)
  • Describe QRS durations favoring ventricular tachycardia (VT)
Precordial Lead Concordance in WCTs
  • Describe the utility of precordial lead concordance in differentiating wide complex tachycardias (WCTs)
  • Describe and identify positive and negative precordial lead concordance
Ventricular Activation Velocity in WCTs
  • Describe what is meant by ventricular activation velocity in relation to wide complex tachycardias (WCTs)
  • Describe the utility of ventricular activation velocity in differentiating wide complex tachycardias (WCTs)
  • Describe and identify ventricular activation velocity ECG features favoring ventricular tachycardia (VT)
WCT & Baseline ECG Comparison
  • Describe the utility of wide complex tachycardia (WCT) and baseline ECG comparison in differentiating WCTs
  • Describe and identify wide complex tachycardia (WCT) and baseline ECG comparison features favoring ventricular tachycardia (VT)
WCT Differentiation Algorithms (Pt 1)
  • Describe the utility of, and rationale for, coventional multistep algorithms in differentiating wide complex tachycardias (WCTs)
  • Describe components of the multistep Brugada algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply components of the multistep Brugada algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe components of the multistep Vereckei aVR algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply components of the multistep Vereckei aVR algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe components of the multistep limb lead algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply components of the multistep limb lead algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe notable limitations of conventional multistep algorithms in differentiating wide complex tachycardias (WCTs)
WCT Differentiation Algorithms (Pt 2)
  • Describe the utlity of, and rationale for, the Griffith algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the Griffith algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe notable advantages and limitations of the Griffith algorithm in differentiating wide complex tachycardias (WCTs)
  • Describe the utlity of, and rationale for, the Bayesian algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the Bayesian algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe notable advantages and limitations of the Bayesian algorithm in differentiating wide complex tachycardias (WCTs)
  • Describe the utlity of, and rationale for, the single-crtierion R-wave-to-peak-time (RWPT) algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the single-crtierion R-wave-to-peak-time (RWPT) algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe notable advantages and limitations of the single-crtierion R-wave-to-peak-time (RWPT) algorithm in differentiating wide complex tachycardias (WCTs)
WCT Differentiation Algorithms (Pt 3)
  • Describe the utlity of, and rationale for, point-based scoring methods for differentiating wide complex tachycardias (WCTs)
  • Describe the utlity of, and rationale for, the point-based VT Score algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the point-based VT Score algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe the utlity of, and rationale for, the point-based Pachon scoring algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the point-based Pachon scoring algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe the utlity of, and rationale for, the point-based Basel algorithm for differentiating wide complex tachycardias (WCTs)
  • Apply the point-based Basel algorithm for differentiating wide complex tachycardias (WCTs)
  • Describe notable advantages and limitations of the point-based scoring methods in differentiating wide complex tachycardias (WCTs)
ECG Features Favoring SVT with Aberrancy
  • Describe ECG feautres favoring supraventricular tachycardia (SVT) with aberrancy over ventricular tachycardia (VT)
  • Identify ECG feautres favoring supraventricular tachycardia (SVT) with aberrancy over ventricular tachycardia (VT)
Wide Complex Tachycardia (WCT) Management
  • Describe an approach wide complex tachycardia (WCT) management based on the patient's clinical status
  • Identify the appropriate management for an unresponsive patient with a wide complex tachycardia (WCT)
  • Identify the appropriate management for an unstable patient with a wide complex tachycardia (WCT)
  • Identify the appropriate management for a stable patient in a supraventricular wide complex tachycardia
  • Identify the appropriate management for a stable patient in ventricular tachycardia
General Indications for Pacemakers
  • Identify various aspects of the electrical conduction of the heart
  • Describe the general variation in pacemaker indications along the conduction system of the heart
  • Identify pacemaker indications for sinus node dysfunction
  • Identify pacemaker indications for varying degrees of AV block
  • Identify contraindications for pacing in AV block
  • Describe what is meant by bifascicular block
  • Describe the general prognosis of bifascicular block
  • Identify pacemaker indications for bifascicular block
Special Indications for Pacemakers
  • Describe indications for pacemaker implantation after cardiac surgery
  • Describe indications for pacemaker implantation after trancatheter aortic valve replacement (TAVR)
  • Describe indications for pacemaker implantation for AV block after acute myocardial infarction
  • Describe indications for pacemaker implantation after cardiac transplant
  • Describe the different conduction defects risks for patients with hypertrophic cardiomyopathy undergoing myectomy or alcohol septal ablation
  • Describe indications for pacemaker implantation in adult congenital heart disease
  • Describe indications for pacemaker implantation in epilepsy
  • Describe indications for pacemaker implantation in carotid sinus syndrome
  • Describe indications for pacemaker implantation in vasovagal syncope
ICD Indications for SCD Prevention (Pt 1)
  • Define primary and secondary suddent cardiac death (SCD) prevention
  • Describe the clinical benefit for implantable cardioverter defibrillator (ICD) candidates
  • Identify primary implantable cardioverter defibrillator (ICD) indications based on ejection fraction, etiology, and NYHA functional class
  • Identify primary implantable cardioverter defibrillator (ICD) indications after acute myocardial infarction with or without revascularization
  • Identify primary implantable cardioverter defibrillator (ICD) indications for non-ischemic cardiomyopathy (NICM)
  • Describe general ethical considerations for device therapy
ICD Indications for SCD Prevention (Pt 2)
  • Identify primary implantable cardioverter defibrillator (ICD) indications in hypertrophic cardiomyopathy (HCM)
  • Identify primary implantable cardioverter defibrillator (ICD) indications in long QT syndrome (LQTS)
  • Identify primary implantable cardioverter defibrillator (ICD) indications in various disorders based on ejection fraction
  • Identify primary implantable cardioverter defibrillator (ICD) indications in arrhythmogenic right ventricular cardiomyopathy (ARVC)
Cardiac Resynchronization Therapy (CRT) Indications
  • Describe the rationale and purpose for cardiac resynchronization therapy (CRT)
  • Define left ventricular dyssynchrony
  • Describe the hemodynamic effects associated with left ventricular dyssynchrony
  • Describe the clinical and hemodyamic benefits of cardiac resynchronization therapy (CRT)
  • Describe and identify clinical indications for cardiac resynchronization therapy (CRT)
Brugada Syndrome (BrS)
  • Describe the diagnostic critiera for Brugada syndrome
  • Describe the genetic basis for Brugada syndrome
  • Describe and identify type 1 Brugada ECG pattern
  • Describe and identify type 2 Brugada ECG pattern
  • Describe how the PR interval duration can increase the yield of genetic testing
  • Describe lifestyle modifications for patients with Brugada syndrome
  • Identify indications for implantable cardioverter defibrillator (ICD) implantation in Brugada syndrome
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
  • Describe the pathophysiology of catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Identify triggers of catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Describe how to diagnose catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Describe the clinical presentation of catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Describe the ECG features associated with catecholaminergic polymorphic ventricular tachycardia (CPVT) during exercise stress testing
  • Identify characteristic settings in which bidirectional ventricular tachycardia (VT) might occur
  • Describe a management approach for catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Describe the role of implantable cardioverter defibrillator (ICD) therapy in catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Describe a screening approach for catecholaminergic polymorphic ventricular tachycardia (CPVT)
  • Idenitfy independent cardiac event predictors in catecholaminergic polymorphic ventricular tachycardia (CPVT)
Long QT Syndrome (LQTS)
  • Describe how to diagnose long QT syndrome (LQTS)
  • Describe the role of exercise stress testing in the diagnosis of long QT syndrome (LQTS)
  • Describe the clinical presentation of long QT syndrome (LQTS)
  • Describe hallmark features associated with Jervell and Lange-Nielsen syndrome
  • Describe hallmark features associated with Romano-Ward syndrome
  • Describe hallmark features associated with Anderson-Tawil syndrome
  • Describe what is considered a prolonged QTc interval in males and females
  • Describe how to accurately measure the QT interval, including in the setting of irregular rhythms (e.g., sinus arrhythmia, atrial fibrillation)
  • Describe how heart rate affects QT interval
  • Describe and identify T wave morphologies associated with long QT syndrome type 1, 2, and 3 phenotypes
  • Identify general QTc interval measurement cutoffs for a long QT syndrome (LQTS) screening program
  • Describe the role of genetic screening in long QT syndrome (LQTS)
  • Describe a management approach for long QT syndrome (LQTS)
  • Describe the role of implantable cardioverter defibrillator (ICD) therapy in long QT syndrome (LQTS)
Antiarrhythmic Drug (AAD) Classification
  • Describe and identify different aspects of a cardiomyocyte action potential
  • Describe and identify different aspects of a pacemaker cell action potential
  • Assign antiarrhythmic drugs (AADs) to their associated Vaughan-Williams class
  • Describe the differences in kinetics amongst class I antiarrhythmic drugs (AADs)
  • Describe the mechanism of action of each antiarrhythmic drug (AAD) class
  • Identify the action potential phases each antiarrhythmic drug (AAD) class effects 
  • Describe the effect of each antiarrhythmic drug (AAD) class on the action potential
  • Describe the effect of each antiarrhythmic drug (AAD) class on the ECG
Antiarrhythmic Proarrhythmia Mechanisms
  • Define proarrhythmia in relation to antiarrhythmic drugs (AADs)
  • Describe three proarrhythmia mechanisms of antiarrhythmic drugs (AADs)
  • Identify key components for scar-mediated reentry arrhythmias
  • Describe how slow conduction can contribute to scar-mediated reentry arrhythmias
  • Describe how class I and III antiarrhythmic drugs (AADs) can influence conduction in scar-mediated reentry arrhythmias
  • Describe how prolonged repolarization can be proarrhythmic
  • Describe the mechanism for pause-dependent polymorphic ventricular tachycardia (VT)
  • Describe how intracellular calcium overload can be proarrhythmic
  • Describe the mechanism for pause-independent bidirectional ventricular tachycardia (VT)
  • Identify triggers for intracellular calcium overload arrhythmias
  • Describe the differential diagnosis for bidirectional ventricular tachycardia (VT)
  • Describe the mechanism for digoxin-induced bidirectional ventricular tachycardia (VT)
  • Identify an electrolyte abnormality that can potentiate the effect of digoxin
  • Describe the mechanism for catecholaminergic polymorphic ventricular tachycardia (CPVT)
Antiarrhythmic Rate Dependence
  • Describe the modulated receptor hypothesis of cardiac ion channels
  • Describe the difference between use dependence and reverse-use dependence
  • Identify antiarrhythmic drugs (AADs) with use dependence properties
  • Identify antiarrhythmic drugs (AADs) with reverse-use dependence properties
  • Describe the mechanism of action of class Ic antiarrhythmic drugs (AADs)
  • Describe the mechanism of action of class III antiarrhythmic drugs (AADs)
  • Describe the clinical utility of class Ic antiarrhythmic drugs (AADs)
  • Describe the clinical utility of class III antiarrhythmic drugs (AADs)
  • Describe the proarrhythmic risk of class 1c antiarrhythmic drugs (AADs)
  • Describe the proarrhythmic risk of class 1c antiarrhythmic drugs (AADs)
  • Describe how to monitor class 1c antiarrhythmic drugs (AADs)
  • Describe how to monitor class 1c antiarrhythmic drugs (AADs)
  • Describe the rate dependence of amiodarone
  • Describe the clinical utility of class Ib antiarrhythmic drugs (AADs) during myocardial ischemia
Antiarrhythmic Metabolism & Interactions
  • Identify major routes of antiarrhythmic drug (AAD) elimination
  • Identify renally eliminated antiarrhythmic drugs (AADs)
  • Identify antiarrhythmic drugs (AADs) that act as  metabolizers and inhibitors of cytochrome P450 2D6
  • Identify antiarrhythmic drugs (AADs) that act as  metabolizers, inhibitors, and inducers of cytochrome P450 3A4
  • Describe the effects from co-administration of amiodarone with warfarin, digoxin, tacrolimus, and cyclosporine
  • Identify drugs to avoid co-administering with class Ia and III antiarrhythmic drugs (AADs) due to their QT prolonging effects
Antiarrhythmic Selection & Monitoring
  • Describe the antiarrhythmic drug (AAD) selection approach for atrial fibrillation (AF) management
  • Identify the ideal patient candidate in which a class Ic antiarrhythmic drug (AAD) might be considered for atrial fibrillation (AF) management
  • Identify the ideal patient candidate in which dofetilide or sotalol might be considered for atrial fibrillation (AF) management
  • Identify the ideal patient candidate in which amiodarone might be considered for atrial fibrillation (AF) management
  • Describe the antiarrhythmic drug (AAD) selection approach for ventricular tachycardia (VT) management
  • Describe the baseline and follow-up monitoring approach for class Ic antiarrhythmic drugs (AADs) flecianide and propafenone
  • Describe the baseline and follow-up monitoring approach for class III antiarrhythmic drugs (AADs) dofetilide, sotalol, and amiodarone
Syncope Terms & Definitions
  • Define loss of consciousness
  • Define and differentiate between syncope, presyncope, and unexplained syncope (syncope of undetermined etiology)
  • Create a differential diagnosis for loss of consciousness
  • Differentiate between non-cardiac syncope and cardiac syncope
  • Identify syncope mimickers
  • Define and differentiate epilepsy, cataplexy, psychogenic syncope, and syncope related to metabolic disorders
Commotio Cordis
  • Describe what commotio cordis refers to and how it occurs
  • Identify patients at risk of commotio cordis
  • Identify influencing factors of commotio cordis
  • Describe the general management approach of commotio cordis
  • Describe the prognosis of commotio cordis
Contributors: Anthony Kashou, MD; Mahmoud Ismayl, MD; Khalid Saeed Al-Asad, MD; Adnan Halboni, MD; Adolfo Martinez Salazar, MD; Nandan Anavekar, MBBCh
Last updated: January 2023.
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Teachers
Anthony Kashou, MD
Anthony Kashou, MD
The EKG Guy | USA
GCU Education Team
Physician Educators