Tachyarrhythmia: Pearls for ECG Diagnosis - PowerPoint PPT Presentation

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Tachyarrhythmia: Pearls for ECG Diagnosis
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Tachyarrhythmia: Pearls for ECG Diagnosis

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  1. Tachyarrhythmia: Pearls for ECG Diagnosis Arjun V. Gururaj, MD Cardiac Arrhythmia and EP Nevada Heart and Vascular Center

  2. Initial Evaluation • Hemodynamic stability • History of CAD or previous MI • History of syncope • Depressed LV function • Baseline ECG • Characteristics of the tachycardia • Narrow complex • Wide complex • Other morphologic clues

  3. Should you use electrical therapy? • Acute hemodynamic collapse • Acute cardiac ischemia or infarction • Tachycardia induced congestive heart failure • Beware atrial fibrillation (CVA risk) • Follow ACLS protocols in most cases

  4. What’s the rhythm? • To treat effectively means knowing the differential diagnoses • Use patient clues • ALWAYS obtain a proper 12-lead ECG • ECG “quick look” • Narrow or wide complex? • Regularity? • Possible preexcitation? • Ischemic changes?

  5. Narrow Complex Tachycardia • Differential diagnoses • Sinus tachycardia • Atrial tachycardia • AV nodal reentrant tachycardia • Orthodromic AV reciprocating tachycardia (CMT) • Atrial fibrillation/flutter • Unusual VTs • Look for P-waves • Let the PR-RP relationship help you

  6. Looking at the PR-RP intervals • Long RP tachycardia • Sinus tachycardia • Atrial tachycardia • Some AVRTs • Junctional tachycardia • Aytypical AVNRT • Short RP tachycardia • Typical AVNRT • Most AVRTs • Atach with long PR interval PR RP RP PR RP<PR (Short RP) RP>PR (Long RP)

  7. Acute therapies for SVT • Many SVTs depend on the AV node for perpetuation (e.g. AVNRT, AVRT, etc) • Try affecting AV nodal conduction to terminate the tachycardia • Valsalva • CSM • Adenosine • Beta-blockers, Ca channel antagonists

  8. “pseudo-R’”

  9. AV Nodal Reentrant Tachycardia (AVNRT) • Most common reentrant SVT • May achieve rates >200 bpm • Look for the psuedo-R’ in V1 or NO P wave AT ALL! • AV node dependent! • Most common type (>90%) is the slow-fast variety (typical)

  10. Initiation of AVNRT

  11. Atrial tachycardia • Can be an incessant rhythm • Rate: usually <220 bpm • Does not need the AV node for perpetuation • Adenosine response: • Transient AV block WITHOUT termination • Transient AV block WITH termination (40%) • Use your knowledge of the AV node to make the diagnosis

  12. Atrioventricular Reciprocating Tachycardia (AVRT) • Can be orthodromic (most common) or antidromic (very uncommon) • Needs AV node to perpetuate rhythm • Always associated with an AV bypass tract • May mimic AVNRT and atrial tachycardia • Can be short or long RP

  13. Therapies II • Some atrial tachycardias (about 40%) can be terminated with adenosine • Atrial flutter and fibrillation are not terminated by changing AV nodal conduction • Consider rate control • Electrical or chemical cardioverision • RF ablation