Approach to the patient with cadiac arrhythmia
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APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA. Masoud Eslami MD Imam Khomeini Hospital. ANY VARIATION FROM THE NORMAL RHYTHM OF THE HEART BEAT IS CALLED ARRHYTHMIA. WHAT IS THE NORMAL RHYTHM OF THE HEART BEAT ?. IT IS CALLED NORMAL SINUS RHYTHM ( NSR )

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APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA

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APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA

Masoud Eslami MD

Imam Khomeini Hospital


ANY VARIATION FROM THE NORMAL RHYTHM OF THE HEART BEAT IS CALLED ARRHYTHMIA


WHAT IS THE NORMAL RHYTHM OF THE HEART BEAT ?

IT IS CALLED NORMAL SINUS RHYTHM

( NSR )

  • THE IMPULSE ORIGINATES IN THE SINUS NODE

  • THE RATE IS BETWEEN 60-100

  • THE P WAVE IS UPRIGHT IN I , II AND aVf , NEGATIVE IN aVr AND POSITIVE IN V3-V6

  • THE PR INTERVAL IS BETWEEN 120-220MS


NSR


ARRHYTHMIAS ARE CLASSIFIED INTO:

1-BRADYARRHYTHMIAS

2-TACHYARRHYTHMIAS


TACHYARRHYTHMIAS

  • ATRIAL TACHYARRHYTHMIAS

  • AV JUNCTIONAL TACHYARRHYTHMIAS

  • VENTRICULAR TACHYARRHYTHMIAS


ATRIAL TACHYARRHYTHMIAS

PREMATURE ATRIAL COPMLEXES

( PAC OR APD )

  • PREMATURE COMPLEXES ARE AMONG THE MOST COMMON CAUSES OF AN IRREGULAR PULSE

  • COMMONLY ARISE IN NORMAL HEARTS,BUT THEY ARE MORE OFTEN ASSOCIATED WITH STRUCTURAL HEART DISEASE AND INCREASE IN FREQUENCY WITH AGE


Premature Beats

Premature Atrial Contraction (PAC)

Origin:Atrium (outside the Sinus Node)

Mechanism:Abnormal Automaticity

Characteristics: An abnormal P-wave occurring

earlier than expected, followed

by compensatory pause


Premature Beats

Premature Junctional Contraction

Origin:AV Node Junction

Mechanism:Abnormal Automaticity

Characteristics:A normally conducted complex with

an absent p-wave, followed by a

compensatory pause


PAC

PACs CAN OCCUR DURING

  • INFECTION

  • INFLAMMATION

  • MYOCARDIAL ISCHEMIA

  • BY MEDICATIONS

  • TENSION STATES

  • TOBACCO

  • ALCOHOL

  • CAFFEINE

THEY CAN PRECIPITATE OR PRESAGE THE OCCURRENCE OF

SUSTAINED SUPRAVENTRICULAR TACHYARRHYTHMIAS


PAC

MANAGEMENT

  • PACs GENERALLY DO NOT REQUIRE THERAPY

  • IN SYMPTOMATIC PATIENTS OR WHEN PACs PRECIPITATE TACHYCARDIAS,TREATMENT WITH DIGITALIS,A BETA BLOCKER,OR A CALCIUM ANTAGONIST CAN BE TRIED


PREMATURE VENTRICULAR COMPLEXES( PVC )

  • PREMATURE OCCURRENCE OF A QRS COMPLEX THAT IS ABNORMAL IN SHAPE AND HAS A DURATION OF MORE THAN 120 ms

  • THE PREVALENCE OF PVC INCREASES WITH AGE

  • SYMPTOMS OF PALPITATIONS OR DISCOMFORT IN THE NECK OR CHEST


Premature Beats

Premature Ventricular Contractions (PVCs)

Origin:Ventricles

Mechanism: Abnormal Automaticity

Characteristics: A broad complex occurring earlier

than expected, followed by a

compensatory pause


PVC Patterns

  • Bigeminy

    • Every other beat

  • Trigeminy

    Every third beat

  • Quadrigemin

    Every fourth beat


Multifocal PVC

  • Origin:Varies within the Ventricle

  • Mechanism: Abnormal Automaticity

  • Characteristics:Each premature beat changes axis;

    implies a different focus origin for

    each beat


PVC

THE IMPORTANCE OF PVC DEPENDS ON THE CLINICAL SETTING

IN THE ABSENCE OF UNDERLYING HEART DISEASE,THE PRESENCE OF PVC HAS NO IMPACT ON LONGEVITY

THE SYMPTOMATIC PATIENT SHOULD BE ASSURED


PVC

  • REASSURANCE AND AVOIDANCE OF POTENTIALLY AGGRAVATING FACTORS ( TOBACCO,COFFEE,CAFFEINE-CONTAINING SOFT DRINKS ),SHOULD BE TRIED FIRST

  • MILD ANXIOLYTIC DRUGS OR BETA-BLOCKERS ARE PREFERRED


Paroxysmal Supraventricular Tachycardia (PSVT)

  • Usually at a rate of 150-250 bpm

  • No organic heart disease in the majority

  • Presentations

    • Palpitations

    • Chest discomfort,dyspnea, lightheadedness

    • Frank syncope

    • SCD


AV Nodal Reentrant Tachycardia

  • The most common form of paroxysmal supraventricular tachycardia (about 70%)

  • More common in women (66%)

  • Usually a regular narrow QRS complex tachycardia

  • No P wave is usually evident during the tachycardia. Retrograde P waves may occasionally be seen at the end of QRS.


AVNRT

Origin: AV Node

Mechanism: Reentry

Rate: 150 - 230 BPM, faster in teenagers

Characteristics:Normal QRS with absent P-waves;

most common SVT in adults


AVNRT


Atrium

Slow Pathway

Fast Pathway

His Bundle

Longitudinal Dissociation Within AV Node


AVNRT


Wolff-Parkinson-White(WPW) Syndrome


AV Reentrant Tachycardia

  • Incorporates a bypass tract as part of the tachycardia circuit.

  • Surface ECG:

    • Manifest with short PR interval and delta wave (preexcitation)

    • Concealed with normal ECG

  • Prevalence of ECG pattern: 0.1% to 0.3%.


Wolff-Parkinson-White

Origin: Outside the AV Node

Mechanism:Reentry

Rate:180-260 BPM – can be faster

Characteristics:Short PR Interval (< 120 ms),wide

QRS (> 110 ms), obvious delta wave


Pre-excitation


Pre-excitation


AVRT Types


AVRT

  • Mechanism: Reentry

  • Rate: 180 - 260 BPM, sometimes faster

  • Characteristics:Extra electrical pathway to ventricles

    Wolf-Parkinson-White (WPW)

    Syndrome is most common


AVRT


PSVTTreatment

  • Vagal maneuvers particularly carotid sinus massage

  • AV nodal blocking drugs

    • Adenosine

    • Verapamil

    • Propranolol

    • Digoxin

  • DC cardioversion if hypotensive

  • Radiofrequency ablation


Atrial Flutter

  • Regular atrial tachyarrhythmia with atrial rate between 250-350 bpm.

  • Flutter waves are seen as saw-tooth like atrial activity


Atrial Flutter

  • Typically the ventricular rate is half the atrial rate, but the ventricular response may be 4:1, 1:1, etc.

  • Atrial Flutter is a form of atrial reentry localized to right atrium.


Atrial Flutter Circuit


Atrial Flutter with 2:1 Conduction


Atrial Flutter with 4:1 Conduction


Atrial Flutter

  • More common in men (4.7:1)

  • Most often in patients with organic heart disease

  • Usually less long-lived than AF and may convert to AF.

  • Control of ventricular rate is difficult in atrial flutter

  • The most effective treatment is DC cardioversion


Atrial Fibrillation

  • The most common sustained arrhythmia

  • Incidence increases progressively with age.

  • Prevalence: 0.4% of overall population

  • Mortality ratedouble that of control

  • Hypertension and CAD, the most frequent underlying heart diseases

  • AF is characterized by disorganized atrial activity without discrete P waves


Atrial Fibrillation


Atrial Fibrillation

  • Undulating baseline or atrial deflections of varying amplitude and frequency ranging from 350 to 600 bpm.

  • Irregularly irregular ventricular response.


Atrial Fibrillation with Rapid Ventricular Response


Atrial Fibrillation

  • Morbidity related to:

    • Excessive ventricular rate

    • Pause following cessation of AF

    • Systemic embolization

    • Loss of atrial kick

    • Anxiety secondary to palpitations

    • Irregular ventricular rate


Atrial Fibrillation

  • Persistent AF usually in patients with cardiovascular disease

    • Valvular heart disease

    • Hypertensive heart disease

    • Congenital heart disease

  • Paroxysmal AF may occur with acute hypoxia, hypercapnia or metabolic or hemodynamic derangements

  • Normal people with emotional stress or surgery or acute alcoholic intoxication

  • Lone AF


Atrial Fibrillation

  • Therapeutic Goals:

    • Control of ventricular rate

    • Restoration and maintenance of sinus rhythm

    • Prevention of thromboembolism


Radiofrequency Ablation


RFA


Electrophysiologic Study


Loss of Delta


Ventricular Tachycardia (VT)

  • Originates in the ventricles

  • Can be life threatening

  • Most patients have significant heart disease

    • Coronary artery disease

    • A previous myocardial infarction

    • Cardiomyopathy


Mechanisms of VT

  • Reentrant

    • Reentry circuit (fast and slow pathway) is confined to the ventricles and/or bundle branches

  • Automatic

    • Automatic focus occurs within the ventricles

  • Triggered activity

    • Early afterdepolarizations (phase 3)

    • Delayed afterdepolarizations (phase 4)


DEFINITION

THREE OR MORE CONSECUTIVE VENTRICULAR PREMATURE DEPOLARIZATIONS,UP TO A MAXIMUM DURATION OF 30 SECONDS BEFORE SPONTAEOUS TERMINATION


  • IT REPRESENTS A COMMON MANAGEMENT PROBLEM FOR THE CARDIOLOGIST

  • MOST TACHYARRHYTHMIAS COME TO OUR ATTENTION BECAUSE OF THE SYMPTOMS THEY PRODUCE


Sustained vs. Nonsustained

  • Sustained VT

    • Episodes last at least 30 seconds

    • Commonly seen in adults with prior :

      • Myocardial infarction

      • Chronic coronary artery disease

      • Dilated cardiomyopathy

  • Non-sustained VT

    • Episodes last at least 3 beats but < 30 seconds


  • IN CONTRAST,MOST INSTANCES OF NSVT DO NOT CAUSE SYMPTOMS

  • RATHER IT DERIVES ITS IMPORTANCE FROM THE PROGNOSTIC SIGNIFICANCE IT CARRIES IN SOME PATIENT POPULATIONS


Classification

  • Ventricular Tachycardia

    • Monomorphic

      • Idiopathic VT

      • Bundle branch reentry tachycardia

      • Ventricular flutter

      • Ventricular fibrillation

    • Polymorphic

      • Torsades de pointes (TdP)


Monomorphic VT

  • Origin: Ventricles (Single Focus)

  • Mechanism:Reentry Initiated by abnormal

    Automaticity or Triggered activity

  • Characteristics:Rapid, wide, and regular QRS


Monomorphic VT

  • Heart rate: 100 bpm or greater

  • Rhythm: Regular

  • Mechanism

    • Reentry

    • Abnormal automaticity

    • Triggered activity

  • Recognition

    • Broad QRS

    • Stable and uniform beat-to-beat appearance


ECG Recognition


ECG Recognition


Polymorphic VT

  • Heart rate: Variable

  • Rhythm: Irregular

  • Mechanism:

    • Reentry

    • Triggered activity

  • Recognition:

    • Wide QRS with phasic variation

    • Torsades de pointes


Polymorphic VT

  • Origin: Ventricles (Wandering Single Focus)

  • Mechanism:Reentry with movement in the circuit

    Initiated by Abnormal Automaticity or

    Triggered activity

  • Characteristics:Wide and irregular QRS Complex that

    changes in axis


ECG Recognition


Torsades de Pointes (TDP)

  • Heart rate: 200 - 250 bpm

  • Rhythm: Irregular

  • Recognition:

    • Long QT interval

    • Wide QRS

    • Continuously changing QRS morphology


Torsades de Pointes

  • Origin:Ventricle

  • Mechanism:Reentry (movement in focus)

  • Rate: 200 – 250 BPM

  • Characteristics:Associated with Long QT interval;

    QRS changes axis & morphology

    with alternating positive/negative

    complexes


Ventricular Flutter

  • Heart rate: 300 bpm

  • Rhythm: Regular and uniform

  • Mechanism: Reentry

  • Recognition:

    • No isoelectric interval

    • No visible T wave

    • Degenerates to ventricular fibrillation

  • Treatment: Cardioversion


Ventricular Fibrillation

  • Heart rate: Chaotic, random and asynchronous

  • Rhythm: Irregular

  • Mechanism: Multiple wavelets of reentry

  • Recognition:

    • No discrete QRS complexes

  • Treatment:

    • Defibrillation


Ventricular Fibrillation (VF)

Origin:Ventricle

Mechanism: Multiple Wavelets of reentry

Characteristics:Irregular with no discrete QRS


External electroshock


Paddle sites


VF or Pulseless VT

  • Defibrilate(Monophasic:360j),(Biphasic:200j).If unsuccesful>>>CPR for 5 cycle>>>>Defibrilate,If

  • Unsuccesful>>>Intubation+1mg iv Epinephrine+CPR If unsuccesful>>>Defibrilate,If unsuccesful>>>>>>>>>>>>

  • Iv amiodarone + iv Bicarbonate +CPR,If unsuccesful>>>

  • Defibrilate,If unsuccesful>>>>Repeat epinephrine,CPR and DEFIBRILATION.

    Braunwald 2012


AED


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