Focused Assessment of the Patient with an Acute Arrhythmia
Symptoms?- Of arrhythmia (palpitations, presyncope, syncope)
- Of underlying cardiac disease (chest pain, breathlessness)
Haemodynamically stable? Signs of instability are:
Known arrhythmia?- How diagnosed?
- Previous management?
- Current therapy?
Evidence of ischaemic or other structural heart disease (e.g. history of ACS, Q waves on ECG)?- This makes ventricular tachycardia almost certainly the diagnosis if there is a regular broad complex tachycardia
- Flecainide should be avoided for cardioversion or preventing atrial fibrillation because of the risk of precipitating ventricular arrhythmias
Could LV systolic function be significantly impaired (e.g. exertional breathlessness, large cardiac silhouette on chest X-ray, LV ejection fraction <40% on previous echocardiography)?- If so, avoid high-dose beta-blocker and flecainide
Is there Wolff-Parkinson-White syndrome? This may cause:
- AV re-entrant tachycardia (narrow complex, regular) (conduction forward through the AV node and back via the accessory pathway)
- Fast conduction of atrial fibrillation down the accessory pathway (broad complex, irregular)
- Antidromic tachycardia (broad complex, regular) (conduction forward down the accessory pathway and back via the AV node)
Associated acute or chronic illness?- Acute atrial fibrillation commonly complicates pneumonia and other infection
- Electrolyte disorders (especially of potassium, calcium and magnesium) should be excluded/corrected
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ACS, acute coronary syndrome; AV, atrioventricular; LV, left ventricular.