Rhythm Abnormalities
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Transcript of Rhythm Abnormalities
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Heart (Has Only 2 Problem)
Electrical Mechanical
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Rhythm Abnormalities
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Conduction System Of The Heart
SA node Atria AV node
Ventricles Bundle of HISS
Right
Bundle
Left
Bundle
Anterior
Posterio
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Sinus rhythm- SA node controls the ventricle on a
1 :1 ratio
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Definition of arrythmia
Ventricular activity (QRS) is not regulated by
SA node on a one to one conduction
Interruption in conduction Heart block
Abnormal focus - Atrial tachycardia, VT
Re entry circuit - SVT, Atrial flutter, VT
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Arrhythmias
Reentrant- most common
SVT,AF,A FLUTTER, VT
Automatic-accelerated ectopic rhythm
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Heart Rate
Normal rateFast rate slow rate
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Rhythm
Regular Irregular
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Tachycardia
Sinus Tachycardia Supra ventricularTachycardia
VentricularTachycardia
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Narrow complex tachycardia (NCT)
Broad complex tachycardia (BCT)
Tachycardia
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Bradycardia
Sinus Bradycardia Heart Blocks
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Sick sinus syndrome
Elderly,IHD
SA, SB,TACHY-BRADY
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Sinus Tachycardia
Acute
Exercise
Emotion
Pain
Fever
Infection
Hypovolaemia
Acute heart failure
Acute pulmonaryembolism
Chronic
Pregnancy
Anaemia
Hyperthyroidism
Catecholamine excess
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Sinus Bradycardia
Extrinsic causes
Hypothermia
Hypothyroidism
Raised intracranial pressure
Drugs- Blockers, Digitalis
& other anti arrhythmic
drugs.
Neurally mediatedsyndromes ( carotid sinus
syn, vasovagal syn)
Intrinsic causes
Acute ischemia and
infarction of the sinus node
Chronic degenerativechanges (Sick sinus
syndrome)
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Heart Rate
Normal rateFast rate slow rate
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Ventricular Tachycardia
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Heart Block
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Clinical presentations of Acute Arrhythmias
1. Arrest - VT,VF, Ventricular asystole
2. Breathlessness
3. Chest pain
4. Dizziness
5. Embolic episode
6. Falls
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7. GCS
8. Hypotension
9. Syncope
Clinical presentations of Acute Arrhythmias ct
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Suspected Arrythmia
Immediate assessment
A
B
C
Establish intravenous access
Attach cardiac monitor
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Diagnosis and classification of arrythmia
12 lead ECG
Step 1. L11
or V1
- Sinus rhythm (SR) or Not
P preceding QRS and PR interval equal
If not in SR
Step 2. Heart rate > 100- tachyarrhythmia
< 60 - Bradyarrythmia
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If tachyarrhythmia ( > 100/m)
Step 3. QRS duration< 120 ms - Narrow Complex Tachycardia
> 120 ms - Broad Complex Tachycardia
Narrow complex tachycardia (NCT) is always
Supraventricular in origin
Step 4.Assess whether Regular or Irregular NCT
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Arrythmia
Tachyarrhythmia BradyarrythmiaStep 2
Step 1
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Tachyarrythmia
Narrow QRS Broad QRSStep 3
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Tachyarrythmia
Narrow QRS Broad QRS
IrregularRegular IrregularRegular
Step 3
Step 4
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Tachyarrythmia
Narrow QRS Broad QRS
IrregularRegular IrregularRegular
Step 3
Step 4
Step 5
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Regular narrow-complex tachycardia
1. Atrial flutter with regular AV block
2. Re entrant tachycardia
a) AV nodal (AVNRT)
b) Atrio ventricular(AVRT)
3. Atrial tachycardia
Step 5
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Atrial flutter
Diagnosed only by the presence of Flutter waves onthe ECG (250-350/min)
Re entrant tachycardia
No P wave ( hidden in ST or T waves)
Atrial tachycardia
Abnormal P wave
Regular narrow-complex tachycardia
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Management of Atrial flutter (
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Re - entrant Tachycardia
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Management of Re - entrant tachycardia
(AVNRT / AVRT)
1. Vagal manouevre
Carotid sinus massage
o Not if carotid bruits present
o Not both sides at the same time
Valsalva manoeuvre
Eyeball pressure - SHOULD NEVER BE DONE
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Management of Re - entrant tachycardia(AVNRT/ AVRT)
2. Adenosine
NOT in acute asthmatics
Can use iv verapamil 5-10mg over 2min (but not if on beta blocker)
Warn patient of symptoms (chest pain, SOB,flushing)
Large IV access 6mg, 12mg then 15mg
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Adenosine
Group
Other class of antiarrhythmic
Action
Slows conduction through Av nodeand interrupts AV re-entry pathways
Meabolism
By blood and tissue, deaminated toinosine & subsequently tohypoxanthine .
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Indication
Paroxysmal SVTs, WPW Syndrome Side effect
Facial flushing
BronchospasmTransient rhythm disturbances
Chest Pain
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Caution.
AF/Atrial flutter with accessaory
pathways
Contra-indication
Bronchoconstrictive or
bronchospastic diseases.
Hypersensitivity.
2ndor 3rddegree AV block, sick sinus
syndrome.
M t f R t t t h di
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Management of Re - entrant tachycardia
(AVNRT/ AVRT)ct
3.Flecainide 2mg/Kg ( 30-60) min if adenosine fails.
4. DC cardioversion
If haemodynamic instability and no response toadenosine or flecainide
DC seldom required in Re-entrant tachycardia
5. To prevent recurrence - Flecainide or B-blocker
6. Consider Ablation for all Re-entrant
tachycardias
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Irregular narrow-complex tachycardia
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Step 5
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Atrial fibrillation
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AF
Normal sinus Rhythm
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Atrial Fibrillation
Fast Irregularly Irregular pulse
Symptoms
Palpitation
Breathlessness
Signs
Fast irregularly Irregular pulse
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Types of AF
Paroxysmal
Persistent
Permanent
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AF
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AF
If reverts to
sinus
rhythm(SR)
Spontaneously
)
within 7 days
Reverts to
SR withtreatment
Persistent
No
reversion
permanent
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Consequences
Haemodynamic instability(rate& rhythm)
Thrombus formation ( rhythm)
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Assess effect
Blood pressure
Cardiac Failure
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TREATMENT
REVERSION OF RHYTHM/RATE COTROL
ANTICOAGULATION
Rh th t l
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Rhythm control
Cardio version
Electrical Drugs
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Cardioversion
ECG Evidence of Acute MI
Hypotension
Hemodynamic Instability
WPW Syndrome Drugs
Try if less than 24 to 48 hours
Amiodarone
Rate control
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Rate control
Acute AF
Beta Blocker- IV Atenolol 5 mg over
5 min
Calcium Channel Blocker-Verapamil
5- 10 mg over 5 min
Digoxin IV loading dose 1 mg over
2h
Rate Control
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Rate Control
Chronic AF
Drug of choice - Beta Blocker -Atenolol
Calcium Channel Blocker-Verapamil,Ditiazem,
Digoxin
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Anticoagulation
Apply CHAD S2
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Anti coagulation
CHAD S2 0-1 Aspirin
CHAD S2 2-3 Aspirin /Warfarin
CHAD S2
3 or above Warfarin
INR
Target INR 2-3
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Anticoagulation
CHAD S2 Score
CCF 1
Hypertension 1
Age over 75 1 Diabetes Mellitus 1
Stroke or TIA 2
Not applicable in Valvular heart(eg Mitral stenosis)
Needs anti coagulation
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Valvular Heart Disease
anticoagulation
Warfarin (No CHAD S2)
Lone AF -No anticoagulation
Flecainide (c/iCoronary Heart disease)
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Flecainide (c/iCoronary Heart disease)
Maintain Sinus Rhythm withAtenolol,
Sotalol,
Amiodarone
Classification of Atrial fibrillation
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Classification of Atrial fibrillation
AcuteAtrial fibrillation (within 7 days)
ChronicAtrial fibrillation
Paroxysmal
Persistent
Permanent
Management of acute Atrial fibrillation
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a age e t o acute t a b at o
if < 48 hrs of onset
1. DC cardioversion if haemodynamic compromise
2. IV Flecainide 2mg/kg over 30-60 min if
echocardiography normal.
If > 48 hrs
1. Early Cardioversion after TOE
or2. Delayed Cardioversion after 4 weeks of warfarin
Echocardiography in AF
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Echocardiography in AF
Identify the cause - Mitral valve, myocardial or pericardial
Assess LV size and Function - H/T, IHD, cardiomyopathy
Assess atrial size /clot
R t t l i At i l fib ill ti (Af)
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Rate-control in Atrial fibrillation (Af)
Try rate control first for patients with Persistent Af:
> 65 years
Duration > 1 year
Hypertension with LVH
Dilated LA > 5 cm
Unsuitable for cardioversion
D t hi t t l
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Drugs to achieve rate control
Verapamil / Diltiazem Avoid if IHD, LV impairment
Beta blocker Usual CI should be observed
Digoxin
Amiodarone
Rh th t l i At i l fib ill ti
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Rhythm control in Atrial fibrillation
Acute AF
AF < 6 months
< 65 years
Structurally normal heart
? Non ischaemic LV dysfunction
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Cardioversion
Cardioversion is performed as part of a rhythm-control
treatment strategy
There are two types of cardioversion: electrical (ECV) and
pharmacological (PCV)
Cardioversion of AF is associated with increased risk of stroke
in the absence of antithrombotic therapy
Not all attempts at ECV or PCV are successful
Patient choice is important
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Maintaining Sinus Rhythm in A fibrillation
Normal Heart /No CHD Mild LVH/CHD Significant LVH/HF
Flecanide/Propafenone
Disopyramide Sotalol
Beta blocker/
Amiodarone
Digoxin not useful for maintaining SR
B d C l T h di
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Broad Complex Tachycardia
Clinically
Any cardiac rhythm >100 /min, with QRS
duration of >0.12s
Electro physiologically
Mostly ventricular in origin, involving
automatic focus or re-entry circuit within theventricles
Broad Complex Tachycardia
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Broad Complex Tachycardia
Causes
Ventricular Tachycardia
Supraventricular arrythmia with aberrantconduction (BBB)
WPW with antidromic pathway
Default diagnosis is VT. Other diagnoses should only be made on
the basis of definite evidence, including adenosine test.
Ventricular Tachycardia
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Ventricular Tachycardia
Monomorphic Ventricular Tachycardia (>120/min)
Accelerated Idioventricular rhythm (< 120/min)
Polymorphic Ventricular Tachycardia
a. Acute MI or ischaemiab. Long QT interval (Torsades)
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VT SVT
P/H IHD,drugs
VA dissociation
QRS>140ms
QRS>160ms
Left axis with RBBB
Concordance
Fusion or Capturebeat
No cardiac history
-
-
-
-
-
-
BP does not help to differentiate VT/SVT
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AF with LBBB
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AF with LBBB
Assessment of patient with BCT
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Assessment of patient with BCT
Immediate assessment
A
B
C
Establish intravenous access
Attach cardiac monitor (ideally with printout)
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Management of VT (2)
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Management of VT (2)
If patient notcompromised
2. If LV not impaired give iv lignocaine
100mg over 2 min, then infuse at 4mg/min for 30 min,
2mg/min for 2hr, 1mg/min for 24hr
3. If evidence of cardiac failure or poor LV function give iv
amiodarone
300mg over 1 hr, 900mg over 24 hrs via central line
Management of VT (3)
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Management of VT (3)
If patient notcompromised
Second-Line drugs
Beta-blockers (avoid in heart failure)
Mexiletine (do not use in cardiogenic shock) Procainamide (can cause torsade)
Causes of VT
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Causes of VT
1. IHD
2. Cardiomyopathy
3. Arrythmogenic RV dysplasia
4. Brugada syndrome
5. Congenital Heart disease
Causes of Torsades de pointes (TDP)
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Congenital long QT syndromes
1. Jervell and Lange-Nielsen syndrome
2. Romano-Ward syndrome
Acquired long QT syndromes
1. Bradycardia
2. ElectrolytesHypokalaemia, Hypomagnesaemia3. Drugs
Drugs causing long QT Syndromes
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Drugs causing long QT Syndromes
AntiarrythmicsSotalol, Amiodarone, disopyramide
H1-receptor antagonists - Terfenadine, astemizole
Cholinergic antagonists Cisapride
Antibiotics - Erythromycin, clarithromycin
Antifungals - Ketoconazole, itraconazole
Psychotropic agents - Haloperidol, phenothiazines
Tricyclic and tetracyclic antidepressants
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Long QT Syndrome
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Long QT Syndrome
ECG in Torsades de pointes
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CG o sades de po tes
Paroxysms of 5-20 beats, with a heart rate of200/min
Sustained episodes occasionally can be seen
Complete 180 twist of QRS complexes within 10-12beats
Torsade occurring in the setting of acquired long QTis preceded by pauses in almost all cases
Torsades de points
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Torsades de points
Management of Torsades de points
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Give all patients iv magnesium
isoprenaline infusion can help suppress TDP
Overdrive atrial pacing (if no AV block) at rate
of 100 bpm is treatment of choice
DC cardioversion if sustained
Management of Torsades de points
Ventricular Fibrillation
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ICD
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