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Approach to Arrhythmias
Presenter : Dr. Mohammed Jaleel P
Moderator : Prof. Ng Taruni Devi
Regional Institute of Medical Sciences, Imphal
INTRODUCTION
• Arrhythmias are one of the common diseases we used to see
in daily practice
• Fatal sometimes if not treated properly or on time
• Becomes diagnostic challenge sometimes
• In addition to history and examination, ECG is more
important, particularly at the time of symptoms.
Classification of Arrhythmias
Arrhythmias
Tachyarrhythmias
Narrow QRS Wide QRS
Bradyarrhythmias
Narrow QRS Tachyarrthymias
Physiologic sinus tachycardia
• >100 Beats/min, tall P waves in inf leads
• Sympathetic stimulation or vagal withdrawal
Nonphysiologic sinus tachycardia
• Ill defined conditions causing autonomic dysregulations
• Differentiate from sinus tachycardia & focal atrial
tachycardia
• Rx-Beta blockers / CCBs
• Clonidine, Serotonin Reuptake Inhibitors, Ivabradine
Focal Atrial Tachycardia
• Regular atrial tachycardia with defined P wave
• Abrupt onset and offset (diff from sinus tachy)
• AT will not terminate with AV block (from AVRT,AVNRT)
• P wave morphology tells location of focus
• Atrial septum- Narrow p wave
• Left atrium- V1 (monophasic positive), I& avL (negative)
• Superior location – inf leads (positive P)
• Inferior locations – neg p wave
Contd…
• Rx:
• Adenosine, Beta blockers, CCB (improve tolerance by AV block)
• Catheter ablation (recurrent symptomatic)
Multifocal atrial tachycardia
• At least 3 distinct P wave morphologies
• Irregular beats. Rate 100-150 beats/min,
• Clear isoelectric intervals b/w p waves(unlike AF)
• Multiple atrial foci
• In c/c pulmonary disease, a/c illness
• Treat underlying disease ± CCB (Beta blocker avoided)
Mechanisms of various PSVTs
• Regular, Narrow complex tachycardia
• P wave in QRS , slightly before or slightly after QRS
AV nodal re-entry tachycardia (AVNRT)
Approach to cardiac arrhythmias
Junctional tachycardia
• Automaticity within AV node
• Narrow QRS tachycardia, No P wave
• ± VA block --> AV dissociation
AV re-entry tachycardia (AVRT)
• Circulating wavefront reenter atrium
via retrograde conduction through AP
• P wave always follow QRS
• Wide QRS complexes
• Morphology of P wave depending on
pathway location
Paroxysmal supraventricular tachycardia
(PSVT)
• Family of tachycardia including AVRT, AVNRT and atrial
tachycardia.
• Sudden run of 3 or more such beats
• 2nd to 4th decade , mostly women
• Often tolerated, sometimes – angina, pulmonary edema,
hypotension, syncope.
• Unstable- sync DC shock (rarely needed)
Emergency treatment algorithm (stable PSVT)
Atrial flutter
• Neg saw toothed flutter waves in II, III, avF
• Positive P waves in lead V1
• Atrial rate-- 240-300 beats/min
• Usually a/w atrial fibrillation
Approach to cardiac arrhythmias
• Re-entry circuit:
• Common Afl – cavotricuspid isthmus dependent
• Atypical Afl -- not dependent
Atrial flutter and fibrillation
Atrial fibrillation
• Irregular R-R interval
• No p waves
• Normal QRS morphology
Contd…
• Disorganised rapid and irregular atrial activation with loss of
atrial contraction, irregular ventricular rate.
• paroxysmal AF- (<7 days)
• Persistent AF – (>7days, may require cardioversion)
• Permanent AF –(>1 year)
• Risk factors
• ↑Age, HTN, DM, obesity, sleep apnea
• Hyperthyroidism, alcohol, MI
Treatment of AF and Afl
• Unstable new onset AF (severe hypotension, pulmonary edema,
angina) sync: DC Shock
• Stable
 < 48 hrs, not at high risk for stroke  cardioversion can be tried
 >48 hrs  consider anticoagulation (CHA2DS2VASc )
• Rate control- beta blockers , CCB
• Digoxin- (esp with cardiac failure)
• Symptomatic / difficult rate ctrl/ ventricular dysfunction
rhythm control (class I/ class III)
• Catheter / surgical ablation
Approach to cardiac arrhythmias
Approach to cardiac arrhythmias
Wide complex
tachyarrhythmia
Monomorphic QRS
Ventricular
tachycardia
Supraventricular
tachycardia with
aberrancy
Polymorphic QRS
Torsade de
pointes
Ventricular
fibrillation
Classification of wide QRS complex
tachyarrhythmias
• Premature QRS complexes ,Abnormal in shape
• Duration exceeds dominant QRS complex- >120 ms
• ST-T wave large, opposite in direction to deflection of QRS
• Late PVC = compensatory pause
Premature ventricular complexes
Ventricular bigeminy and trigeminy
Ventricular couplet and triplet
Unifocal vs multifocal pvc
PVC which suggest structural heart disease:
• With broad notching and slurred QRS complexes
• PVC with RBBB configuration
• Multifocal PVC
Frequency and severity of arrhythmia – severity of
disease
Treatment
• Treatment approach to patients with PVCs depends on ± of
symptoms and ± underlying structural heart disease
• Beta blocker , CCB as the first-line drug for treatment
• Other options - antiarrhythmic medications or radiofrequency
catheter ablation
• PVCs associated LV dysfunction- Radiofrequency ablation
Accelerated idioventricular rhythm (AIVR)
• Repetitive ventricular rhythm occurring at a rate between 60 and
100 beats per min
• Accelerated ventricular focus that generates an impulse faster
than the sinus node and therefore assumes control
• Fusion beat at onset and termination of arrhythmia
• Common occurs;
• Reperfusion of occluded coronary artery
• Resuscitation
• AV dissociation ±, (PP >RR interval)
• 3 or more abnormaly shaped PVCs
• >120 msec, ST-T vector opposite the major QRS
deflection
• R-R interval regular, or vary
• Atrial activity – independent, or can be depolarized by
ventricles retrogradely (VA association)
• Rates range 100-250 bpm
• Onset : usually sudden
Ventricular tachycardia (V-tach or VT)
Definitions of various v-tachs
• VT: The occurrence of three or more PVC complexes (>
120ms) with a rate of > 120 bpm in succession is called as VT.
• Slow VT - HR >100 & < 120 bpm.
• Non sustained VT : Termination of VT by itself in < 30 sec.
• Sustained VT: for >30 sec. or requiring termination because of
hemodynamical collapse.
Contd…
• Pulseless VT – VT with hemodynamic collapse that
requires defibrillation & treated as VF.
• VT storm – repeated VT episodes requiring the DC shocks.
(≥ 3VT/24hrs)
• VF: Rate >220 bpm
Sustained Monomorphic VT :
ECG of 72yrs old woman with CHD
F C
Fusion beats and capture beats
• Concordance: Chest leads, i.e. leads V1-6 show entirely
positive (R) or entirely negative (QS) complexes, with no RS
complexes seen.
VT (contd…)
• Brugada’s sign– The distance from
the onset of the QRS complex to the
nadir of the S-wave is >100ms
• Josephson’s sign – Notching near the
nadir of the S-wave
• MORRISON’S Sign: complexes with
(Rr’) a taller left rabbit ear. This is the
most specific finding in favour of VT.
Approach to cardiac arrhythmias
Treatment of VT
• Unstable  sync DC shock
• Stable  trial of adenosine (r/o SVT with aberrancy)
• IV amiodarone is DOC if heart disease present
• Evaluate for underlying heart disease
• r/c VT  antiarrythmic or catheter ablation
• Sustained VT with structural heart dis ICD
Reversible causes of VT
• Hypoxia
• Hypothyroidism/ hyperthyroidism
• Hypokalemia
• Metabolic acidosis
• Hypomagnesemia
• Hypocalcemia
• Drugs
• Alcohol
• Starvation
Approach to cardiac arrhythmias
Wolf Parkinson white syndrome
• Short P-R interval (<0.12s)
• Slurred initial portion of QRS (delta wave)
• Prolonged QRS duration
• Accessory pathway connecting
atrium and ventricle
across valve ring
• Mc- b/w left atrium and free wall
of left ventricle
Contd…
Approach to cardiac arrhythmias
Sustained Polymorphic VT
Torsade de pointes
• Arrhythmia a/w Long QT Syndrome – Polymorphic VT called
TdP.
• The peaks of the QRS complexes appear to "twist" around the
isoelectric line of the recording,
hence the name torsade de pointes or "twisting about the
points."
Approach to cardiac arrhythmias
Contd…
• Prolonged QT interval in the last sinus beat preceding the
onset of the arrhythmia, a ventricular rate of 160 to 250 bpm,
irregular RR intervals
• Torsades de pointes episodes usually are short-lived and
terminate spontaneously. Some times progress to VF
• r/c episodes – IV MgSO4 1-2g.
Idiopathic VT
• Idiopathic VT refers to any VT that is not associated with
structural heart disease
• Outflow tract VT - triggered automatic arrhythmias- RVOT-
LBBB
• Fascicular VT- reentrant arrhythmias within the Purkinje
system- LV- RBBB
• Treatment- beta blockers
CCB- Verapamil
• Not effective/severe symptoms --Catheter ablation
Ventricular fibrillation
• Most frequent mech of sudden cardiac death (SCD).
• Rapid, disorganized ventricular arrhythmia, resulting in no
uniform ventricular contraction, no cardiac output, and no
recordable blood pressure.
• The ECG in VF shows rapid (300 to 400 beats/min), irregular,
shapeless QRST undulations of variable amplitude, morphology
and interval.
• ACLS guideline with defibrillation -> sinus rhythm
• If no reversible cause identified  consider ICD
Approach to cardiac arrhythmias
Approach to cardiac arrhythmias
Approach to cardiac arrhythmias
Sinus bradycardia
• Sinus rhythm.
• Heart rate<60 beats/min
SA node dysfunction
• Sinus pause & Sinus arrest
• Sinus pause of <3sec is common in awake athletes
• Sinus exit block
• Intermittent conduction from SA node
• Can be classified similar to AV blocks
Sick sinus syndrome (SSS)
• Dysfunction of SA node often secondary to senescence of
SAN or surrounding myocardium
Sinus pause
2nd degree Sinus block
1st degree AV block
All P waves are conducted
• Each P followed by QRS
• PR interval is uniformly prolonged (>200 ms)
Second degree AV block
Intermittently droped QRS complexes
(mobitz type 1)-Wenckebach pattern
• PR interval progressively lengthens until 1P wave is not conducted
• PR interval after nonconducted beat is shorter
• Ratio of number of P wave to QRS as nomenclature
Contd…
Mobitz type II
• PR intervals of conducted beats are constant
• Occasional P waves without following QRS
3rd degree (complete) heart block
No stimuli transmitted from atria to ventricle
• Independent atrial and ventricular activity
Junctional escape rhythm
• No P wave apparent
• Heart rate 40-60 beats/min
• Regular Narrow QRS complexes
Ventricular escape rhythm
• No P wave (rarely neg P after QRS)
• Ventricular rate <40 beats/min
• regular Wide QRS complexes
Atrial fibrillation with slow ventricular
response
• No P wave
• Irregular narrow QRS complexes
• Ventricular rate <60beats/min
Conclusion
• Arrhythmias are one of the commonly encountered problems
in clinical practice
• Cardiac arrhythmias result from abnormality of impulse
generation or conduction or both
• ECG can differentiate between most of the arrhythmias.
• Rate, QRS width, regularity of R-R interval and P wave all
are important in approaching arrhythmias.
References …
• Harrisons principles of internal medicine, 20th edition
• Goldberger’s clinical electrocardiography, 9th edition
• UpToDate,
THANK YOU
Prepared by: Dr. Mohammed Jaleel P
Dept. of General Medicine
Regional Institute of Medical Sciences, Imphal
pmjaleelvld@gmail.com
Ph.: 9633882581

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Approach to cardiac arrhythmias

  • 1. Approach to Arrhythmias Presenter : Dr. Mohammed Jaleel P Moderator : Prof. Ng Taruni Devi Regional Institute of Medical Sciences, Imphal
  • 2. INTRODUCTION • Arrhythmias are one of the common diseases we used to see in daily practice • Fatal sometimes if not treated properly or on time • Becomes diagnostic challenge sometimes • In addition to history and examination, ECG is more important, particularly at the time of symptoms.
  • 5. Physiologic sinus tachycardia • >100 Beats/min, tall P waves in inf leads • Sympathetic stimulation or vagal withdrawal
  • 6. Nonphysiologic sinus tachycardia • Ill defined conditions causing autonomic dysregulations • Differentiate from sinus tachycardia & focal atrial tachycardia • Rx-Beta blockers / CCBs • Clonidine, Serotonin Reuptake Inhibitors, Ivabradine
  • 7. Focal Atrial Tachycardia • Regular atrial tachycardia with defined P wave • Abrupt onset and offset (diff from sinus tachy) • AT will not terminate with AV block (from AVRT,AVNRT) • P wave morphology tells location of focus • Atrial septum- Narrow p wave • Left atrium- V1 (monophasic positive), I& avL (negative) • Superior location – inf leads (positive P) • Inferior locations – neg p wave
  • 8. Contd… • Rx: • Adenosine, Beta blockers, CCB (improve tolerance by AV block) • Catheter ablation (recurrent symptomatic)
  • 9. Multifocal atrial tachycardia • At least 3 distinct P wave morphologies • Irregular beats. Rate 100-150 beats/min, • Clear isoelectric intervals b/w p waves(unlike AF) • Multiple atrial foci • In c/c pulmonary disease, a/c illness • Treat underlying disease ± CCB (Beta blocker avoided)
  • 11. • Regular, Narrow complex tachycardia • P wave in QRS , slightly before or slightly after QRS AV nodal re-entry tachycardia (AVNRT)
  • 13. Junctional tachycardia • Automaticity within AV node • Narrow QRS tachycardia, No P wave • ± VA block --> AV dissociation
  • 14. AV re-entry tachycardia (AVRT) • Circulating wavefront reenter atrium via retrograde conduction through AP • P wave always follow QRS • Wide QRS complexes • Morphology of P wave depending on pathway location
  • 15. Paroxysmal supraventricular tachycardia (PSVT) • Family of tachycardia including AVRT, AVNRT and atrial tachycardia. • Sudden run of 3 or more such beats • 2nd to 4th decade , mostly women • Often tolerated, sometimes – angina, pulmonary edema, hypotension, syncope. • Unstable- sync DC shock (rarely needed)
  • 17. Atrial flutter • Neg saw toothed flutter waves in II, III, avF • Positive P waves in lead V1 • Atrial rate-- 240-300 beats/min • Usually a/w atrial fibrillation
  • 19. • Re-entry circuit: • Common Afl – cavotricuspid isthmus dependent • Atypical Afl -- not dependent Atrial flutter and fibrillation
  • 20. Atrial fibrillation • Irregular R-R interval • No p waves • Normal QRS morphology
  • 21. Contd… • Disorganised rapid and irregular atrial activation with loss of atrial contraction, irregular ventricular rate. • paroxysmal AF- (<7 days) • Persistent AF – (>7days, may require cardioversion) • Permanent AF –(>1 year) • Risk factors • ↑Age, HTN, DM, obesity, sleep apnea • Hyperthyroidism, alcohol, MI
  • 22. Treatment of AF and Afl • Unstable new onset AF (severe hypotension, pulmonary edema, angina) sync: DC Shock • Stable  < 48 hrs, not at high risk for stroke  cardioversion can be tried  >48 hrs  consider anticoagulation (CHA2DS2VASc ) • Rate control- beta blockers , CCB • Digoxin- (esp with cardiac failure) • Symptomatic / difficult rate ctrl/ ventricular dysfunction rhythm control (class I/ class III) • Catheter / surgical ablation
  • 25. Wide complex tachyarrhythmia Monomorphic QRS Ventricular tachycardia Supraventricular tachycardia with aberrancy Polymorphic QRS Torsade de pointes Ventricular fibrillation Classification of wide QRS complex tachyarrhythmias
  • 26. • Premature QRS complexes ,Abnormal in shape • Duration exceeds dominant QRS complex- >120 ms • ST-T wave large, opposite in direction to deflection of QRS • Late PVC = compensatory pause Premature ventricular complexes
  • 30. PVC which suggest structural heart disease: • With broad notching and slurred QRS complexes • PVC with RBBB configuration • Multifocal PVC Frequency and severity of arrhythmia – severity of disease
  • 31. Treatment • Treatment approach to patients with PVCs depends on ± of symptoms and ± underlying structural heart disease • Beta blocker , CCB as the first-line drug for treatment • Other options - antiarrhythmic medications or radiofrequency catheter ablation • PVCs associated LV dysfunction- Radiofrequency ablation
  • 32. Accelerated idioventricular rhythm (AIVR) • Repetitive ventricular rhythm occurring at a rate between 60 and 100 beats per min • Accelerated ventricular focus that generates an impulse faster than the sinus node and therefore assumes control • Fusion beat at onset and termination of arrhythmia • Common occurs; • Reperfusion of occluded coronary artery • Resuscitation
  • 33. • AV dissociation ±, (PP >RR interval)
  • 34. • 3 or more abnormaly shaped PVCs • >120 msec, ST-T vector opposite the major QRS deflection • R-R interval regular, or vary • Atrial activity – independent, or can be depolarized by ventricles retrogradely (VA association) • Rates range 100-250 bpm • Onset : usually sudden Ventricular tachycardia (V-tach or VT)
  • 35. Definitions of various v-tachs • VT: The occurrence of three or more PVC complexes (> 120ms) with a rate of > 120 bpm in succession is called as VT. • Slow VT - HR >100 & < 120 bpm. • Non sustained VT : Termination of VT by itself in < 30 sec. • Sustained VT: for >30 sec. or requiring termination because of hemodynamical collapse.
  • 36. Contd… • Pulseless VT – VT with hemodynamic collapse that requires defibrillation & treated as VF. • VT storm – repeated VT episodes requiring the DC shocks. (≥ 3VT/24hrs) • VF: Rate >220 bpm
  • 37. Sustained Monomorphic VT : ECG of 72yrs old woman with CHD
  • 38. F C Fusion beats and capture beats
  • 39. • Concordance: Chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
  • 40. VT (contd…) • Brugada’s sign– The distance from the onset of the QRS complex to the nadir of the S-wave is >100ms • Josephson’s sign – Notching near the nadir of the S-wave • MORRISON’S Sign: complexes with (Rr’) a taller left rabbit ear. This is the most specific finding in favour of VT.
  • 42. Treatment of VT • Unstable  sync DC shock • Stable  trial of adenosine (r/o SVT with aberrancy) • IV amiodarone is DOC if heart disease present • Evaluate for underlying heart disease • r/c VT  antiarrythmic or catheter ablation • Sustained VT with structural heart dis ICD
  • 43. Reversible causes of VT • Hypoxia • Hypothyroidism/ hyperthyroidism • Hypokalemia • Metabolic acidosis • Hypomagnesemia • Hypocalcemia • Drugs • Alcohol • Starvation
  • 45. Wolf Parkinson white syndrome • Short P-R interval (<0.12s) • Slurred initial portion of QRS (delta wave) • Prolonged QRS duration • Accessory pathway connecting atrium and ventricle across valve ring • Mc- b/w left atrium and free wall of left ventricle
  • 49. Torsade de pointes • Arrhythmia a/w Long QT Syndrome – Polymorphic VT called TdP. • The peaks of the QRS complexes appear to "twist" around the isoelectric line of the recording, hence the name torsade de pointes or "twisting about the points."
  • 51. Contd… • Prolonged QT interval in the last sinus beat preceding the onset of the arrhythmia, a ventricular rate of 160 to 250 bpm, irregular RR intervals • Torsades de pointes episodes usually are short-lived and terminate spontaneously. Some times progress to VF • r/c episodes – IV MgSO4 1-2g.
  • 52. Idiopathic VT • Idiopathic VT refers to any VT that is not associated with structural heart disease • Outflow tract VT - triggered automatic arrhythmias- RVOT- LBBB • Fascicular VT- reentrant arrhythmias within the Purkinje system- LV- RBBB • Treatment- beta blockers CCB- Verapamil • Not effective/severe symptoms --Catheter ablation
  • 53. Ventricular fibrillation • Most frequent mech of sudden cardiac death (SCD). • Rapid, disorganized ventricular arrhythmia, resulting in no uniform ventricular contraction, no cardiac output, and no recordable blood pressure. • The ECG in VF shows rapid (300 to 400 beats/min), irregular, shapeless QRST undulations of variable amplitude, morphology and interval. • ACLS guideline with defibrillation -> sinus rhythm • If no reversible cause identified  consider ICD
  • 57. Sinus bradycardia • Sinus rhythm. • Heart rate<60 beats/min
  • 58. SA node dysfunction • Sinus pause & Sinus arrest • Sinus pause of <3sec is common in awake athletes • Sinus exit block • Intermittent conduction from SA node • Can be classified similar to AV blocks Sick sinus syndrome (SSS) • Dysfunction of SA node often secondary to senescence of SAN or surrounding myocardium
  • 61. 1st degree AV block All P waves are conducted • Each P followed by QRS • PR interval is uniformly prolonged (>200 ms)
  • 62. Second degree AV block Intermittently droped QRS complexes (mobitz type 1)-Wenckebach pattern • PR interval progressively lengthens until 1P wave is not conducted • PR interval after nonconducted beat is shorter • Ratio of number of P wave to QRS as nomenclature
  • 63. Contd… Mobitz type II • PR intervals of conducted beats are constant • Occasional P waves without following QRS
  • 64. 3rd degree (complete) heart block No stimuli transmitted from atria to ventricle • Independent atrial and ventricular activity
  • 65. Junctional escape rhythm • No P wave apparent • Heart rate 40-60 beats/min • Regular Narrow QRS complexes
  • 66. Ventricular escape rhythm • No P wave (rarely neg P after QRS) • Ventricular rate <40 beats/min • regular Wide QRS complexes
  • 67. Atrial fibrillation with slow ventricular response • No P wave • Irregular narrow QRS complexes • Ventricular rate <60beats/min
  • 68. Conclusion • Arrhythmias are one of the commonly encountered problems in clinical practice • Cardiac arrhythmias result from abnormality of impulse generation or conduction or both • ECG can differentiate between most of the arrhythmias. • Rate, QRS width, regularity of R-R interval and P wave all are important in approaching arrhythmias.
  • 69. References … • Harrisons principles of internal medicine, 20th edition • Goldberger’s clinical electrocardiography, 9th edition • UpToDate,
  • 71. Prepared by: Dr. Mohammed Jaleel P Dept. of General Medicine Regional Institute of Medical Sciences, Imphal pmjaleelvld@gmail.com Ph.: 9633882581