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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

APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA

Masoud Eslami MD

Imam Khomeini Hospital



What is the normal rhythm of the heart beat
WHAT IS THE NORMAL RHYTHM OF THE HEART BEAT ? CALLED

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 CALLED


Arrhythmias are classified into
ARRHYTHMIAS ARE CLASSIFIED INTO: CALLED

1-BRADYARRHYTHMIAS

2-TACHYARRHYTHMIAS


Tachyarrhythmias
TACHYARRHYTHMIAS CALLED

  • ATRIAL TACHYARRHYTHMIAS

  • AV JUNCTIONAL TACHYARRHYTHMIAS

  • VENTRICULAR TACHYARRHYTHMIAS


Atrial tachyarrhythmias
ATRIAL TACHYARRHYTHMIAS CALLED

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 Beats CALLED

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 beats1
Premature Beats CALLED

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 CALLED

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 CALLED

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 VENTRICULAR COMPLEXES CALLED ( 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 beats2
Premature Beats CALLED

Premature Ventricular Contractions (PVCs)

Origin: Ventricles

Mechanism: Abnormal Automaticity

Characteristics: A broad complex occurring earlier

than expected, followed by a

compensatory pause


Pvc patterns
PVC Patterns CALLED

  • Bigeminy

    • Every other beat

  • Trigeminy

    Every third beat

  • Quadrigemin

    Every fourth beat


Multifocal pvc
Multifocal PVC CALLED

  • Origin: Varies within the Ventricle

  • Mechanism: Abnormal Automaticity

  • Characteristics: Each premature beat changes axis;

    implies a different focus origin for

    each beat


PVC CALLED

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 CALLED

  • 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
Paroxysmal Supraventricular Tachycardia (PSVT) CALLED

  • 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
AV Nodal Reentrant Tachycardia CALLED

  • 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 CALLED

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
AVNRT CALLED


Longitudinal dissociation within av node

Atrium CALLED

Slow Pathway

Fast Pathway

His Bundle

Longitudinal Dissociation Within AV Node


Avnrt1
AVNRT CALLED


Wolff parkinson white wpw syndrome
Wolff-Parkinson-White CALLED (WPW) Syndrome


Av reentrant tachycardia
AV Reentrant Tachycardia CALLED

  • 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 CALLED

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




Avrt types
AVRT Types CALLED


AVRT CALLED

  • Mechanism: Reentry

  • Rate: 180 - 260 BPM, sometimes faster

  • Characteristics: Extra electrical pathway to ventricles

    Wolf-Parkinson-White (WPW)

    Syndrome is most common


AVRT CALLED


Psvt treatment
PSVT CALLED Treatment

  • Vagal maneuvers particularly carotid sinus massage

  • AV nodal blocking drugs

    • Adenosine

    • Verapamil

    • Propranolol

    • Digoxin

  • DC cardioversion if hypotensive

  • Radiofrequency ablation


Atrial flutter
Atrial Flutter CALLED

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

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


Atrial flutter1
Atrial Flutter CALLED

  • 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 flutter2
Atrial Flutter CALLED

  • 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
Atrial Fibrillation CALLED

  • 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 fibrillation2
Atrial Fibrillation CALLED

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

  • Irregularly irregular ventricular response.



Atrial fibrillation3
Atrial Fibrillation CALLED

  • 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 fibrillation4
Atrial Fibrillation CALLED

  • 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 fibrillation5
Atrial Fibrillation CALLED

  • Therapeutic Goals:

    • Control of ventricular rate

    • Restoration and maintenance of sinus rhythm

    • Prevention of thromboembolism



RFA CALLED




Ventricular tachycardia vt
Ventricular Tachycardia (VT) CALLED

  • 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
Mechanisms of VT CALLED

  • 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
DEFINITION CALLED

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



Sustained vs nonsustained
Sustained vs. Nonsustained CARDIOLOGIST

  • 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 CARDIOLOGISTNSVT DO NOT CAUSE SYMPTOMS

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


Classification
Classification CARDIOLOGIST

  • Ventricular Tachycardia

    • Monomorphic

      • Idiopathic VT

      • Bundle branch reentry tachycardia

      • Ventricular flutter

      • Ventricular fibrillation

    • Polymorphic

      • Torsades de pointes (TdP)


Monomorphic VT CARDIOLOGIST

  • Origin: Ventricles (Single Focus)

  • Mechanism: Reentry Initiated by abnormal

    Automaticity or Triggered activity

  • Characteristics: Rapid, wide, and regular QRS


Monomorphic vt
Monomorphic VT CARDIOLOGIST

  • 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 CARDIOLOGIST


Ecg recognition1
ECG Recognition CARDIOLOGIST


Polymorphic vt
Polymorphic VT CARDIOLOGIST

  • Heart rate: Variable

  • Rhythm: Irregular

  • Mechanism:

    • Reentry

    • Triggered activity

  • Recognition:

    • Wide QRS with phasic variation

    • Torsades de pointes


Polymorphic VT CARDIOLOGIST

  • 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 recognition2
ECG Recognition CARDIOLOGIST


Torsades de pointes tdp
Torsades de Pointes (TDP) CARDIOLOGIST

  • Heart rate: 200 - 250 bpm

  • Rhythm: Irregular

  • Recognition:

    • Long QT interval

    • Wide QRS

    • Continuously changing QRS morphology


Torsades de Pointes CARDIOLOGIST

  • 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
Ventricular Flutter CARDIOLOGIST

  • 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
Ventricular Fibrillation CARDIOLOGIST

  • Heart rate: Chaotic, random and asynchronous

  • Rhythm: Irregular

  • Mechanism: Multiple wavelets of reentry

  • Recognition:

    • No discrete QRS complexes

  • Treatment:

    • Defibrillation


Ventricular Fibrillation (VF) CARDIOLOGIST

Origin: Ventricle

Mechanism: Multiple Wavelets of reentry

Characteristics: Irregular with no discrete QRS


External electroshock
External electroshock CARDIOLOGIST


Paddle sites
Paddle sites CARDIOLOGIST


Vf or pulseless vt
VF CARDIOLOGISTor 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 CARDIOLOGIST


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