danny haywood fy1 arrhythmias. intro conduction system of heart symptoms/signs investigations tachy...
TRANSCRIPT
INTRO
• Conduction system of heart• Symptoms/signs• Investigations• Tachy vs Brady• Bradyarrhythmias• Different types• Management
• Tachyarrhythmias• Broad vs narrow• Types of each• Management of each
• Summary• Some example ECGs
SYMPTOMS/SIGNS
• Syncope• Dizziness• Palpitations• Heart Failure• Chest pain• Sudden death• No symptoms
INVESTIGATIONS
• Bedside• ECG
• Bloods• TFTs, U+E, FBC, Troponins
• Imaging• Echo, CXR
• Special tests• Holter monitor
BRADYARRHYTHMIAS
• Type I heart block• 1st degree heart block• Prolonged PR interval > 0.2 seconds
• Type II heart block• Mobitz type 1 – Wenckebach• Gradually increased PR intervals until missed QRS
• Mobitz type 2• Intermittently P wave not followed by QRS• May be pattern eg 2:1, 3:1 ratio of P waves to QRS complexes
– no increase in PR interval
• Type III heart block• Complete heart block• No correlation between P waves and QRS complexes
MANAGEMENT
• Acute (eg. Secondary to MI)• If symptomatic/clinical deterioration• IV atropine• External (transcutaneous) pacing
• Chronic• Mobitz type II or complete AV block• Permanent pacemaker
TACHYARRHYTHMIAS
• Narrow complex (Supraventricular) vs Broad complex (Ventricular)
• Narrow • QRS <0.12 seconds
• Broad • QRS >0.12 seconds
NARROW COMPLEX
• Sinus tachycardia• Atrial Fibrillation (AF)• Atrial Flutter• Atrioventricular nodal re-entry tachycardia
(AVNRT)• Atrioventricular reciprocating tachycardia (AVRT)
AF
• Continuous, rapid activation of atria – due to rapidly depolarising foci within the atria• Often located by pulmonary veins
• No coordinated mechanical action
AF – CAUSES
• ATRIAL PhIB• A – Alcohol• T – Thyroid disease• R – Rheumatic heart disease• I – Ischaemic heart disease• A – Atrial myxoma• L – Lung pathology (pneumonia, PE)
• Ph – Pheochromocytoma• I – Idiopathic• B – Blood pressure (hypertension)
AF - MANAGEMENT
• Conservative• Alcohol cessation• Lifestyle factors (diet/exercise/smoking)
• Medical• Treat underlying cause• Rate control vs rhythm control
• Interventional• Catheter ablation
CHADSVASC C
Congestive heart failure (or Left ventricular systolic dysfunction)
1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
1
A2 Age ≥75 years 2
D Diabetes Mellitus 1
S2 Prior Stroke or TIA or thromboembolism 2
V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)
1
A Age 65–74 years 1
Sc Sex category (i.e. female gender) 1
Score Risk Anticoagulation Therapy
0 Low
No antithrombotic therapy (or Aspirin)
1 ModerateOral anticoagulant (or Aspirin)
2 or greater High Oral anticoagulant
RHYTHM CONTROL
• Cardioversion• Pharmacological vs DC• younger, symptomatic, physically active patients• Congestive heart failure• Paroxysmal AF• failure of rate control
• < 48 hours• Cardioversion + heparin
• > 48hrs – TOE/anti-coagulation (3 weeks)• risk of failure?• High – 4 weeks sotalol/amiodarone then electrical.• Low - electrical
RHYTHM CONTROL
• Pharmacological• No structural heart disease• 1st - Flecainide• 2nd – Sotalol• 3rd – Amiodarone
• Structural heart disease• Amiodarone
• Interventional• Pulmonary vein isolation - catheter ablation
ATRIAL FLUTTER
• Organised atrial rhythm, coming from ectopic focus in atria (usually left)• Usually 300bpm• Ventricular rate depends on degree of AV block eg
2:1 = 150bpm• Saw tooth pattern
ATRIAL FLUTTER
• Management• Conservative• Vagal manoeuvres
• Medical – similar to AF• Acute
• DC cardioversion or IV adenosine (<48 hours)• > 48 hours - 3 weeks anticoag then cardiovert
• Chronic• Pill in pocket• Regular anti-arrhythmics
• Interventional• Radiofrequency catheter ablation
AVNRT
• 2 pathways within the AV node1) short refractory period + slow conduction2) long refractory period + fast conduction
• Normally conducts through fast pathway• If premature atrial beat, fast pathway still
refractory (long refractory period) therefore travels down slow pathway and back up the fast pathway.
AVRT
• Accessory pathway (Bundle of Kent most common)• Pre-excitation (delta wave) on ECG• Wolff-Parkinson-White syndrome
MANAGEMENT OF SVTS
• Haemodynaically unstable• Electrical cardioversion
• Conservative• Vagal manoeuvres• Valsalva, carotid massage, cold water
• Medical• Adenosine (acute)• Anti-arrhythmics (regular and pill-in-pocket)
• Interventional• Catheter ablation
BROAD COMPLEX TACHYSVT VS VF
• VT• Unstable • electrical cardioversion
• Stable • 1st – Class I Anti-arrhythmics (lidocaine)• 2nd – Amiodarone• 3rd – DC cardioversion
BROAD COMPLEX TACHYSVT VS VF
• VF• Cardiac arrest• Rapid, irregular activity – no cardiac output• Usually provoked by ventricular ectopic beat• Management• Electrical defibrillation
BROAD COMPLEX TACHYS
• Something to be aware of• SVT with concomitant bundle branch block = broad
complex tachy
SUMMARY
• Brady vs tachy• Brady• Sinus Brady• 1st degree heart block• Mobitz I & II• Complete
• Tachy• Narrow
• Sinus tachy, AF, Flutter, AVNRT, AVRT
• Broad• VT, VF,
• Remember causes of AF
ANSWERS
A. Sinus rhythmB. AFC. Atrial FlutterD. VTE. VFF. 1st degree heart blockG. Complete heart blockH. Mobitz type III. AVRTJ. Mobitz type IK. AVNRTL. Right bundle branch block