Arrhythmias:
zero-to-safe.
The first release is not a catalog of squiggles. It is a reusable way to see a rhythm, decide whether it is harming the patient, connect the tracing to electrophysiology, and choose an action that remains safe while uncertainty is still real.
The monitor says “VT.” The patient says nothing.
A 68-year-old with ischemic cardiomyopathy becomes confused and diaphoretic. Pulse 184/min, blood pressure 74/42 mm Hg. The rhythm is regular and wide. You have IV access, pads are going on, and the patient still has a pulse.
What is the decision?
Do not begin with the drug name. Begin with whether this rhythm is causing instability. For causal hypotension and altered mental status with a pulse, prepare immediate synchronized cardioversion; sedate only if feasible without delaying therapy.The master decision tree
Four branches before a drug.
The sequence is deliberately clinical. It protects against two common errors: treating a monitor instead of a patient, and using an AV-nodal drug before recognizing a dangerous wide or pre-excited rhythm.
Think AVNRT/AVRT, atrial tachycardia, flutter with fixed conduction, or sinus tachycardia.
For a stable regular narrow tachycardia: modified Valsalva first, then adenosine when appropriate. Ask whether the rhythm is AV-node dependent or whether adenosine will only reveal atrial activity.
Think AF, flutter with variable conduction, MAT, or frequent ectopy.
Choose rate/rhythm therapy from ventricular function, pressure, congestion, sympathetic state, duration, anticoagulation context, and the precipitating illness.
Treat uncertain wide-complex tachycardia as VT until a safer explanation is established.
Stable regular monomorphic WCT may receive an antiarrhythmic infusion and expert consultation. Adenosine is confined to stable, regular, monomorphic WCT when an AV-node-dependent mechanism is plausible.
Pause: polymorphic VT, pre-excited AF, AF with aberrancy, toxicity, and artifact live here.
Do not reflexively give an AV-nodal blocker. In pre-excited AF it can favor accessory-pathway conduction; sustained polymorphic VT requires immediate unsynchronized shock.
Mechanism anchor
Why width changes risk
A narrow QRS implies rapid, coordinated ventricular depolarization through the native conduction system. A wide QRS can reflect ventricular origin, aberrant supraventricular conduction, pre-excitation, pacing, metabolic conduction delay, or sodium-channel blockade. Surface algorithms modify probability; they do not make uncertainty harmless.
Why regularity changes the drug list
Regularity suggests a repeating circuit or focus. Irregularity can expose competing atrial wavefronts, variable AV conduction, changing ventricular activation, or polymorphism—mechanisms in which a medication that is safe for AVNRT may be ineffective or dangerous.
One case · four lenses
The decision is shared. The responsibilities are not.
Switch lenses on the opening case. Each view adds setting-specific work without changing the core physiology.
Make the next intervention executable and prevent a high-consequence medication error.
- Name the syndrome, not a fragile diagnosis.“Unstable regular wide-complex tachycardia with a pulse” is enough to act safely.
- Build the electrical plan.Confirm sync markers, pads, energy strategy, sedation feasibility, airway support, and a post-conversion 12-lead.
- Prepare the rescue branch.Sustained polymorphic VT → immediate unsynchronized shock. Pulse loss → start CPR and follow arrest rhythm analysis; defibrillate VF/pVT.
- Audit medication before it enters the line.Check QRS/QT, blood pressure, structural disease, renal function, electrolytes, interacting agents, concentration, infusion rate, and stop rules.
Turn a successful conversion into a coherent diagnostic, medication, and follow-up plan.
- Reconstruct the trigger and substrate.Ischemia, scar, HF decompensation, infection, thyroid disease, sleep apnea, electrolyte loss, alcohol, stimulant exposure, and medication changes.
- Reconcile the post-conversion regimen.Separate the acute infusion from chronic recurrence prevention; avoid therapeutic inertia after the indication changes.
- Design telemetry and laboratory monitoring.Specify rhythm endpoints, QT/QRS thresholds, electrolyte targets, renal/hepatic reassessment, and what finding triggers escalation.
- Close the loop.Cardiology/EP plan, ischemic evaluation, anticoagulation when relevant, patient teaching, interaction review, and access to prescribed therapy.
Ask whether the arrhythmia is the driver of shock, a consequence of shock, or both.
- Interrogate hemodynamics.Preload, contractility, vascular tone, RV/LV function, mechanical support, ventilator effects, catecholamine exposure, and perfusion markers.
- Model changing PK/PD.Low hepatic flow, AKI/CRRT, acidemia, altered protein binding, cumulative infusions, and active metabolites can change effect within hours.
- Reduce the arrhythmogenic environment.Treat ischemia, hypoxia, acidosis, fever, agitation, pain, electrolyte loss, and unnecessary sympathomimetics or QT/QRS-active drugs.
- Plan for recurrence.Defibrillation readiness, pacing strategy, sedation/sympathetic control, EP escalation, mechanical support, and electrical-storm pathways.
Explain what circuit or focus exists, why this patient developed it, and what proves or changes the diagnosis.
- Build the differential from anatomy.Ventricular scar re-entry, SVT with aberrancy, pre-excitation, focal automaticity, triggered activity, drug/toxin effect, and metabolic conduction delay.
- Use ECG findings as likelihood modifiers.AV dissociation, capture/fusion, concordance, axis, morphology, prior BBB, and comparison with baseline—without pretending any one algorithm is absolute.
- Choose definitive diagnostics.Post-conversion ECG, echo, ischemic workup, medication/toxin history, family history, CMR, ambulatory monitoring, genetics, or EP study as the case warrants.
- Define the endpoint.Acute termination, recurrence suppression, ablation, device therapy, substrate treatment, prognosis, and shared decisions.
Interactive · rhythm-to-action
Choose the next safe move.
These are schematic rhythm strips, not diagnostic tracings. The challenge is to combine the strip with the patient state rather than answer from morphology alone.
Emergency department
Loading case…
Drug atlas preview
Mechanism is a safety tool.
Full monographs arrive in ARR-08. These first cards show the minimum mechanism-to-bedside chain the later atlas will expand.
Adenosine
Transient AV-nodal block. Excellent for AV-node-dependent regular SVT; diagnostic for some atrial rhythms. Never a reflex for irregular/polymorphic WCT or pre-excited AF.
Half-life measured in seconds · caffeine/theophylline oppose · dipyridamole potentiatesProcainamide
Slows conduction and prolongs refractoriness. A rational option for selected stable monomorphic VT or pre-excited AF, constrained by pressure, HF, QRS/QT, kidney function, and cumulative dose.
Parent + active metabolite · renal accumulation · explicit stop rulesAmiodarone
Broad electrophysiologic effects do not make it universally safest. IV hypotension, conversion when anticoagulation matters, long tissue persistence, and major chronic organ toxicity all change the plan.
IV and chronic pharmacology differ · CYP/P-gp interactions · enormous VdMagnesium
2025 AHA: magnesium may be considered for recurrent polymorphic VT associated with long QT (Class 2b, C-LD); direct randomized torsades evidence is absent.
Treat mechanism, not a serum number · pair with trigger removal and correction of hypokalemiaSource-to-practice lab
Read it. See it. Use it. Defend it.
Each object starts with a clinical scaffold, exposes the source’s own words and numbers, and ends with a transfer boundary and teach-back. Quotations are intentionally short; the links take you to full context.
- 01OrientRead the tertiary scaffold.
- 02InterrogateInspect methods and the exact excerpt.
- 03QuantifyRead absolute effects and uncertainty.
- 04TransferName who the result does—and does not—fit.
- 05Teach backDefend the bedside decision without looking.
Clinical pass
Read the excerpt, result, and practice boundary on the tertiary, AHA, REVERT, and PROCAMIO cards.
Evidence pass
Add methods, confidence intervals, and each teach-back before opening the full abstract or manuscript.
Four-lens pass
Read every card, then explain how the same evidence changes ED action, ICU rescue, medicine follow-up, and physician diagnosis.
Figure lab 01 · original visualization
Three trials, three different questions.
Bars use the published percentages, but the endpoint and population determine what each picture means. A larger bar is not automatically a stronger or more transferable conclusion.
Technique changes the effect.
- Absolute benefit
- 26 percentage points
- Approximate NNT
- 4
- Adjusted OR
- 3.7 (95% CI 2.3–5.8)
Read benefit and harm together.
Major cardiac adverse events
Tachycardia terminated by 40 minutes
Near-equal totals can conceal different workflows.
- Absolute difference
- 4 points (95% CI 0–9)
- Drug alone converted
- 52%
- Strategy p value
- 0.07
| Trial | Population | Endpoint | Comparison | Result |
|---|---|---|---|---|
| REVERT | Stable adult SVT | Sinus rhythm at 1 minute | Modified vs standard Valsalva | 43% vs 17% |
| PROCAMIO | Tolerated regular WCT | Major cardiac adverse events | Procainamide vs amiodarone | 9% vs 41% |
| PROCAMIO | Tolerated regular WCT | Termination by 40 minutes | Procainamide vs amiodarone | 67% vs 38% |
| RAFF2 | Selected stable acute AF | Conversion to sinus rhythm | Drug–shock vs shock-only | 96% vs 92% |
Commit an interpretation before revealing the debrief
REVERT: the clinically useful measure is the 26-point absolute benefit and NNT near 4—not a claim that every SVT is 3.7 times more likely to convert.
PROCAMIO: both the adverse-event and termination signals favor procainamide, but the sample is small and the transfer boundary excludes unstable, polymorphic, and pulseless rhythms.
RAFF2: both bundled strategies converted most eligible patients. A nonsignificant 4-point difference is not proof of equivalence; workflow, sedation, preference, and eligibility still matter.
verified excerpts · each 20 words or fewer
Key reading cards
Reading progress is stored only on this device.
01 Wide QRS Complex TachycardiaTertiary scaffold · Foundation
“Wide complex tachycardia is a dysrhythmia with a long list of potential causes”
Continuing Education Activity · 13 quoted words
A broad, open-access clinical review that organizes the differential before the learner enters individual trials and guidelines.
No comparative effect estimate; its job is orientation, vocabulary, and differential diagnosis.
Start with patient stability, then treat width and regularity as probability-changing features rather than a final diagnosis.
Tertiary reviews compress nuance and can age. Verify management-changing claims against the current guideline and direct evidence below.
Teach-back prompt
Before opening the answer: Name four causes of wide-complex tachycardia that would change the medication plan.
Expert response: Examples include ventricular tachycardia, pre-excited AF, sodium-channel blockade, hyperkalemia, SVT with aberrancy, pacing, and artifact. The point is to connect each cause to a different hazard or rescue pathway.
02 Sustained polymorphic ventricular tachycardiaCurrent guideline · ED + ICU
“Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation”
Adult ALS: polymorphic VT discussion · 13 quoted words
Current emergency guidance derived from systematic, scoping, and focused evidence reviews.
Immediate unsynchronized shock for sustained polymorphic VT is Class 1, B-NR. Magnesium for recurrence with long QT is Class 2b, C-LD.
Shock sustained polymorphic VT without waiting for synchronization, even when a pulse is present; address the substrate after energy.
A recommendation is not a randomized comparison. The guideline notes that randomized evidence for drug management of polymorphic VT is absent.
Teach-back prompt
Before opening the answer: Why is this an unsynchronized-shock pathway, and what additional action begins if the patient loses a pulse?
Expert response: Beat-to-beat QRS variation makes reliable synchronization impractical. If pulse loss occurs, begin CPR and follow arrest rhythm analysis; defibrillate VF or pulseless VT.
03 When atrial fibrillation is causing instabilityCurrent guideline · ED + physician
“In patients with hemodynamic instability attributable to AF, immediate electrical cardioversion should be performed to restore sinus rhythm”
Electrical cardioversion recommendations · 18 quoted words
Multidisciplinary evidence synthesis for adults across the atrial-fibrillation continuum.
Immediate synchronized cardioversion when instability is attributable to AF is Class 1, C-LD.
The causal word matters: treat AF immediately when it is driving the instability.
AF can also be a marker of sepsis, hemorrhage, PE, ACS, or another shock state. Cardioversion does not replace simultaneous causal evaluation.
Teach-back prompt
Before opening the answer: A septic patient has AF at 160/min and hypotension. What observations would make AF more likely to be the driver rather than a compensatory response?
Expert response: Look for temporal coupling, disproportionate rate, loss of atrial contribution in a preload-dependent patient, worsening with rhythm onset, and hemodynamic improvement with rate/rhythm intervention—while treating sepsis in parallel.
04 Flecainide and use dependenceExpert pharmacology synthesis · Pharmacology
“This use-dependent property enables flecainide to effectively block the activation front, contributing to the termination of atrial fibrillation”
Flecainide: use-dependent sodium-channel block · 18 quoted words
Expert consensus integrating ion-channel mechanisms, PK/PD, selection, monitoring, interactions, and proarrhythmia.
This is a mechanistic statement, not a comparative clinical effect estimate.
At faster activation rates, less time is available for flecainide to dissociate from sodium channels, strengthening blockade.
The same mechanism can cause rate-related QRS widening and proarrhythmia. Mechanistic plausibility does not erase patient-selection restrictions.
Teach-back prompt
Before opening the answer: What would exercise-related QRS widening reveal about flecainide’s channel-binding behavior?
Expert response: It demonstrates use dependence: faster rates increase the fraction of blocked channels because there is less diastolic time for drug dissociation.
05 REVERT: do the maneuver correctlyPrimary randomized trial · ED pharmacist
“We have shown that a simple, cost-free, well-tolerated postural modification to the standard Valsalva manoeuvre is highly effective”
Discussion · 18 quoted words
Multicenter randomized, assessor-blinded trial in 10 UK EDs; 428 primary-analysis encounters with stable SVT.
Sinus rhythm at one minute: 43% modified versus 17% standard; absolute difference 26 percentage points; approximate NNT 4; adjusted OR 3.7 (95% CI 2.3–5.8).
A correctly performed modified Valsalva belongs before adenosine in an appropriate stable regular narrow-complex SVT pathway.
The intervention was not blinded to clinicians or patients and does not apply to instability, AF/flutter, irregular rhythms, or undifferentiated WCT.
Teach-back prompt
Before opening the answer: Calculate the absolute benefit and NNT, then name the rhythm and stability checks required before using the result.
Expert response: The absolute benefit is about 26 percentage points and NNT is about 4. Confirm a stable patient with a compatible regular SVT; exclude rhythms and states in which a vagal-first pathway is inappropriate.
06 A newer, smaller Valsalva trialNew primary trial · Evidence critique
“Sinus rhythm was restored in 10 of 38 patients (26.3%) in the modified Valsalva group”
Abstract: Results · 15 quoted words
Single-center, open-label, pragmatic randomized trial in 75 adults with stable PSVT in an Indian tertiary ED.
Modified 26.3% versus standard 16.2%; 95% CI for the absolute difference −8.2% to 28.4%; not statistically significant.
The direction of effect remained favorable, but the estimate was imprecise and smaller than REVERT’s.
A small single-center trial with a confidence interval spanning harm and substantial benefit cannot establish equivalence or erase the larger trial.
Teach-back prompt
Before opening the answer: Why does ‘not statistically significant’ fail to prove that the two maneuvers are equivalent?
Expert response: Failure to reject no difference is not proof of equality. The wide confidence interval shows that the study cannot distinguish modest harm, no effect, or clinically important benefit.
07 PROCAMIO: comparative drug evidencePrimary randomized trial · ED + critical care
“Procainamide therapy was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 min”
Abstract: Conclusions · 20 quoted words
Multicenter, randomized, open-label comparison; 74 enrolled and 62 analyzed with tolerated regular wide-QRS tachycardia, probably monomorphic VT.
Major cardiac adverse events: 9% procainamide versus 41% amiodarone. Termination by 40 minutes: 67% versus 38%.
For carefully selected tolerated monomorphic WCT, procainamide has stronger direct comparative evidence than amiodarone.
Small, open-label, 12 exclusions from the principal analysis, and not powered for mortality. Do not extrapolate to unstable, polymorphic, or pulseless VT.
Teach-back prompt
Before opening the answer: Would you transfer this result to LVEF 15%, SBP 92 mm Hg, CKD, and QTc 510 ms? Defend the plan.
Expert response: No automatic transfer. Hypotension, severe HF, renal accumulation, and prolonged QT narrow or remove the procainamide option; reassess stability and prepare electrical therapy with expert input.
08 RAFF2: two workable acute-AF strategiesPrimary randomized trial · ED pharmacist
“Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm”
Abstract: Interpretation · 16 quoted words
Partial-factorial randomized trial at 11 Canadian academic EDs; 396 selected adults with stable acute AF.
Conversion: 96% drug–shock versus 92% shock-only; absolute difference 4% (95% CI 0–9; p=0.07). Procainamide alone converted 52%.
Either pathway can work for selected stable recent-onset AF; procainamide may avoid sedation and shock in about half.
This compared bundled strategies, did not establish statistical equivalence, and excluded unstable or secondary-AF presentations.
Teach-back prompt
Before opening the answer: How should prior response, sedation risk, ED resources, patient preference, and time-to-disposition alter the choice?
Expert response: Use shared, context-specific selection. High sedation risk or limited procedural resources may favor a drug-first attempt; prior drug failure, patient preference, or a need for rapid predictable conversion may favor shock-first when eligible.
09 EAST-AFNET 4: rhythm control as prognosisPrimary randomized trial · Internal medicine
“Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care”
Abstract: Conclusions · 16 quoted words
International, randomized, open-label trial with blinded outcome assessment; 2,789 patients with AF diagnosed within one year plus cardiovascular conditions.
Composite event rates: 3.9 versus 5.0 per 100 person-years; HR 0.79 (96% CI 0.66–0.94). Rhythm-therapy-related serious adverse events: 4.9% versus 1.4%.
For selected early-AF patients, rhythm control can be a prognostic strategy rather than symptom rescue alone.
Not an acute ED cardioversion trial. Therapy was heterogeneous, the trial was open-label and stopped early, and the composite cannot be assigned to one drug or ablation.
Teach-back prompt
Before opening the answer: Which new AF patients leaving the ED merit an explicit early-rhythm-control referral instead of a rate-control-only plan?
Expert response: Patients within a year of diagnosis who resemble the trial population and have cardiovascular risk or disease merit an intentional rhythm-control discussion, alongside anticoagulation and comorbidity management—not an automatic prescription for one intervention.
Watch · simulate · inspect
A curated media shelf, with a job for every click.
These are outbound resources, not endorsements of every statement they contain. Predict before opening; teach back afterward. Current guidance outranks an older demonstration when they differ.
Modified Valsalva Maneuver
JAMA Network / JN Learning
- Before opening
- Predict the exact strain, repositioning, and leg-raise sequence before pressing play.
- Afterward
- Teach the maneuver back as an executable order, including patient selection and monitoring.
Access: Public player; an auto-generated transcript is available but may contain errors.
Boundary: Copyrighted AMA content. Link out only; do not copy, download, or embed.
Link checked 2026-07-16Synchronised cardioversion
Resuscitation Council UK
- Before opening
- Name the four setup checks you expect before shock delivery.
- Afterward
- Identify the sync-marker, safety, sedation, and re-synchronization steps shown.
Access: Full transcript and contrast controls are available.
Boundary: The older 120-J example is a device/scenario demonstration, not a universal current energy recommendation; pair it with the 2025 AHA algorithm.
Link checked 2026-07-16Manual External Defibrillation, Cardioversion, and Pacing
University of Florida Center for Safety, Simulation & Advanced Learning Technologies
- Before opening
- Write the device sequence for synchronized cardioversion from memory.
- Afterward
- Repeat locally using the text pathway: pads → rhythm → sync → energy → clear → shock → reassess → re-sync if needed.
Access: Free non-CME WebGL simulator; desktop-oriented and drag-heavy. The local text pathway is the keyboard alternative.
Boundary: Use for equipment logic, not as a substitute for device-specific training or current protocols.
Link checked 2026-07-16Marion-Arnsdorf ECG Project
University of Chicago Medicine
- Before opening
- Choose one mechanism—automaticity, triggered activity, or re-entry—and sketch it first.
- Afterward
- Explain how that mechanism predicts onset, regularity, response to AV-nodal blockade, and recurrence.
Access: JavaScript is required. Learning units combine electrophysiology diagrams with rhythm examples.
Boundary: No reuse license was visible; link to the original rather than copying its images.
Link checked 2026-07-16Arrhythmia Quiz
University of Utah ECG Learning Center
- Before opening
- Use the same sequence every time: rate → regularity → P–QRS relation → width → patient context.
- Afterward
- Record one morphology clue you over-weighted and one clinical clue you under-weighted.
Access: Image-based questions include AVNRT, AF, flutter, VT, and a ladder diagram.
Boundary: Licensed CC BY-ND-NC; link-only avoids creating an unauthorized derivative.
Link checked 2026-07-162025 Electrical Cardioversion Algorithm
American Heart Association
- Before opening
- Predict the starting-energy rows and the point at which synchronization no longer applies.
- Afterward
- Turn the algorithm into a bedside preparation checklist rather than memorizing one number.
Access: Graphic PDF plus a linked long-description companion.
Boundary: Confirm the specific defibrillator’s recommended energy and local protocol.
Link checked 2026-07-16Baseline assessment · six decisions
Explain the answer you choose.
Score is secondary. Every item exposes why each alternative fails and when it would become appropriate.
Evidence dossier
Hierarchy is only one axis.
A meta-analysis is not automatically more useful than a direct trial, and a guideline is not a study design. Each source is judged by question, risk of bias, directness, precision, applicability, recency, and corrections.
- SynthesisSystematic review / meta-analysis
- ExperimentRandomized trial
- ObservationCohort / case-control
- SignalsCase series / reports / pharmacovigilance
- MechanismHuman physiology / translational evidence
seed records · verified links and identifiers
Scope: initial guideline spine and practice-shaping studies. This is a documented scoping set, not yet a completed systematic review.
1 Part 9: Adult Advanced Life Support — 2025 AHA Guidelines for CPR and ECCGuideline · current emergency algorithm · Recommendation-specific
Acute tachyarrhythmia, bradycardia, cardioversion, polymorphic VT, and arrest pathways.
- Citation
- Wigginton JG, et al. Circulation. 2025;152(suppl 2):S538–S577.
- DOI / identifier
- 10.1161/CIR.0000000000001376
2 Part 10: Adult and Pediatric Special Circumstances of Resuscitation — 2025 AHA GuidelinesGuideline · toxicology/special circumstances · Recommendation-specific
Hyperkalemia, pregnancy, pulmonary embolism, and arrhythmogenic drug/toxin emergencies.
- Citation
- Cao D, et al. Circulation. 2025;152(suppl 2):S578–S672.
- DOI / identifier
- 10.1161/CIR.0000000000001380
3 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial FibrillationGuideline · multidisciplinary synthesis · Recommendation-specific
US framework for AF staging, stroke prevention, rate/rhythm control, acute illness, and ablation.
- Citation
- Joglar JA, et al. Circulation. 2024;149:e1–e156.
- DOI / identifier
- 10.1161/CIR.0000000000001193
- Correction / erratum
- Correction DOI 10.1161/CIR.0000000000001207; PMID 38153996.
4 2024 ESC Guidelines for the management of atrial fibrillationGuideline · international synthesis · Recommendation-specific
AF-CARE framework and an explicit international comparison to US recommendations.
- Citation
- Van Gelder IC, et al. Eur Heart J. 2024;45:3314–3414.
- DOI / identifier
- 10.1093/eurheartj/ehae176
- Correction / erratum
- Later correction indexed as PMID 40622753.
5 2018 ACC/AHA/HRS Bradycardia and Cardiac Conduction Delay Guideline — Executive SummaryGuideline · bradycardia/conduction · Recommendation-specific
Sinus node disease, AV block, pacing decisions, and reversible causes.
- Citation
- Kusumoto FM, et al. Circulation. 2019;140:e333–e381.
- DOI / identifier
- 10.1161/CIR.0000000000000627
6 2015 ACC/AHA/HRS Guideline for Adult Supraventricular TachycardiaGuideline · supraventricular tachycardia · Recommendation-specific
AVNRT/AVRT, focal atrial tachycardia, pre-excitation, acute therapy, and ablation.
- Citation
- Page RL, et al. Circulation. 2016;133:e506–e574.
- DOI / identifier
- 10.1161/CIR.0000000000000311
7 2019 ESC Guidelines for Supraventricular TachycardiaGuideline · international comparison · Recommendation-specific
Updated SVT diagnosis, acute treatment, ablation, pregnancy, and special contexts.
- Citation
- Brugada J, et al. Eur Heart J. 2020;41:655–720.
- DOI / identifier
- 10.1093/eurheartj/ehz467
8 2022 ESC Guidelines for Ventricular Arrhythmias and Prevention of Sudden Cardiac DeathGuideline · ventricular arrhythmias · Recommendation-specific
Ventricular arrhythmias, electrical storm, structural disease, genetic evaluation, devices, and ablation.
- Citation
- Zeppenfeld K, et al. Eur Heart J. 2022;43:3997–4126.
- DOI / identifier
- 10.1093/eurheartj/ehac262
9 REVERT: modified versus standard Valsalva for supraventricular tachycardiaRandomized controlled trial · Moderate · direct for stable SVT
Shows why the postural modification belongs before medication in a stable regular narrow-complex pathway.
- Citation
- Appelboam A, et al. Lancet. 2015;386:1747–1753.
- DOI / identifier
- 10.1016/S0140-6736(15)61485-4
10 PROCAMIO: procainamide versus amiodarone for tolerated wide-QRS tachycardiaRandomized controlled trial · Low–moderate · small open-label trial
Practice-shaping comparative evidence, taught with its small sample and setting limitations visible.
- Citation
- Ortiz M, et al. Eur Heart J. 2017;38:1329–1335.
- DOI / identifier
- 10.1093/eurheartj/ehw230
11 RAFF2: electrical versus drug–shock cardioversion for acute atrial fibrillationRandomized controlled trial · Moderate · ED acute AF population
ED rhythm-control strategy, procainamide, and electrical cardioversion in selected recent-onset AF.
- Citation
- Stiell IG, et al. Lancet. 2020;395:339–349.
- DOI / identifier
- 10.1016/S0140-6736(19)32994-0
12 EAST-AFNET 4: early rhythm-control therapy in atrial fibrillationRandomized controlled trial · High for enrolled early-AF population
Changes the longitudinal frame from symptom rescue alone to selected early rhythm control.
- Citation
- Kirchhof P, et al. N Engl J Med. 2020;383:1305–1316.
- DOI / identifier
- 10.1056/NEJMoa2019422
13 EHRA Practical Compendium of Antiarrhythmic DrugsExpert consensus · pharmacology compendium · Consensus plus drug-specific evidence
Current drug-mechanism, selection, safety, interaction, and monitoring backbone; paired with correction DOI 10.1093/europace/euag041.
- Citation
- Merino JL, et al. Europace. 2025;27:euaf076; corrected March 2026.
- DOI / identifier
- 10.1093/europace/euaf076
- Correction / erratum
- March 2026 correction DOI 10.1093/europace/euag041.
14 FDA approval of intranasal etripamil (Cardamyst) for adult PSVT self-treatmentRegulatory review + randomized trials · Approved indication; post-guideline
A living-evidence example: contemporary approved therapy that is not integrated into the older US/ESC SVT guidelines.
- Citation
- US Food and Drug Administration. Drug Trials Snapshot: Cardamyst. December 2025.
- DOI / identifier
- FDA approval record; RAPID trial DOI 10.1016/S0140-6736(23)00776-6
15 Effectiveness of the Valsalva manoeuvre for reversion of SVTSystematic review · Limited by heterogeneous, older studies
Evidence-synthesis layer used alongside, not as a substitute for, the later REVERT trial.
- Citation
- Smith GD, et al. Cochrane Database Syst Rev. 2015;CD009502.
- DOI / identifier
- 10.1002/14651858.CD009502.pub3
16 Wide QRS Complex TachycardiaTertiary clinical review · Orientation layer · verify management claims
Open-access scaffold for WCT definitions, mechanisms, differential diagnosis, and initial evaluation.
- Citation
- Obando MA, Marra EM. StatPearls [Internet]. Updated June 26, 2023.
- DOI / identifier
- Bookshelf ID NBK559054; PMID 32644480
17 Modified versus standard Valsalva for PSVT in an Indian emergency departmentRandomized controlled trial · new evidence · Low–moderate · small single-center trial
A current, imprecise replication signal used to teach confidence intervals, external context, and why one small trial does not erase REVERT.
- Citation
- Arora S, et al. Indian Heart J. 2026. Online ahead of print.
- DOI / identifier
- 10.1016/j.ihj.2026.02.004
Arrhythmias release map
One hard decision every 4–5 days.
The module grows in focused releases, then recombines into cumulative capstones. Older material resurfaces at 2, 7, 21, 45, and 90 days.
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ARR-00
available
Baseline diagnostic assessment
Find the exact gaps in recognition, ECG logic, pharmacology, and bedside decisions.
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ARR-01
active
Electrical foundations & rhythm classification
Conduction, action potentials, re-entry, automaticity, ECG intervals, and the pulse–stability–width–regularity framework.
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ARR-02
next
The unstable rhythm & electrical therapies
Causal instability, synchronized versus unsynchronized energy, pacing, reversible causes, and post-conversion care.
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ARR-03
queued
Atrial fibrillation & flutter
Acute rate/rhythm control, cardioversion, stroke prevention, precipitants, HF, sepsis, and pre-excitation.
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ARR-04
queued
Regular narrow-complex tachycardia
Sinus tachycardia, AVNRT, AVRT, atrial tachycardia, vagal maneuvers, adenosine, and AV nodal drugs.
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ARR-05
queued
Wide-complex tachycardia & monomorphic VT
Safe presumptive management, electrical therapy, antiarrhythmics, ischemia, and structural heart disease.
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ARR-06
queued
Polymorphic VT, torsades & QT
QT measurement, congenital versus acquired causes, drug stacks, electrolytes, magnesium, and recurrence prevention.
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ARR-07
queued
Bradyarrhythmias & AV block
Localization, reversible causes, atropine, vasoactive support, pacing, poisoning, and post-MI contexts.
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ARR-08
queued
Antiarrhythmic pharmacology atlas
Ion-channel mechanisms, state/use dependence, PK/PD, metabolites, interactions, organ dysfunction, and proarrhythmia.
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ARR-09
queued
Complex contexts
ACS, HF, shock, sepsis, renal/hepatic failure, pregnancy, older adults, postoperative states, and toxicology.
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ARR-10
queued
Four-lens capstone
A patient moving from ED to ICU to medicine to discharge, followed by unseen transfer cases and teach-back.