Diagnosis and Management of Arrhythmias

Onn Akbar Ali

MBBS (Adelaide) FRACP

Private RoomsNorth AdelaideAshford HospitalCraigmoreArdrossan

HospitalsAshford Private HospitalsThe Queen Elizabeth Lyell Mc Ewin Hospitals

Outline

• Cardiac Anatomy relevant to ECG

• Recognize normal ECG

• Common

– Brady

– Conduction disease

– Tachy

ArrhythmiasREFER !!

ArrhythmiasREFER !!

Dear Dr Ali,

Re. Mrs Precious binti Anxious

DOB 25/12/1982

Referral valid for 12 months

Patient complains of palpitation , Please manage.

Sincerely

G.P

We prefer to receive letter via Argus

Arrhythmias

Listen carefully (not only the heart sounds) and gives patients time

When symptoms occur and how long does it last?

How long has been? Years months versus recently

How long does it last? Seconds-momentary vs sustained

What’s the symptoms? syncope, collapse or other cardiac symtomps.

How does it terminate? Quick onset and offset

Medications?

Exercise tolerance ? Left heart fa

Family History? Sudden cardiac death, palpitation or Syncope

Diagnosis and Management is based primarily on history , ECG

and Examination

Conducting system

Sinus node

AV node

Left Bundle

Right Bundle

Normal Sinus Rhythm

Rule of sinus rhythm

Every P wave must be followed by QRS complex and every QRS complex must be preceded by P wave

Normal Sinus Rhythm …?

Normal Sinus Rhythm with …?

Normal Sinus Rhythm with …?

Normal Sinus Rhythm with …?

Arrhythmias

Slow

Conduction Disease

SA

1st degree

2nd Degree

3rd Degree

R L

Left anterior (Left axis)

Left Posterior (Right axis)

SA node

AV Node

Left Bundle

Right Bundle

Case study 1 Scenario 1 : 65 year old man ; slow pulse alert on BP

machine ; taxi driver

65 year old man ; well no symptoms

Scenario 1: Sinus Brady without symptoms or conduction disease is often benign

Scenario 2: Lethargic ; tired decreased exercise tolerance; self employed tradesman

SA node

Conduction Disease

AV

1st degree

2nd Degree

3rd Degree

R L

Left anterior (Left axis)

Left Posterior (Right axis)

SA node

AV Node

Left Bundle

Right Bundle

Heart Block

* ***

Case 2: 76 year old with postural dizziness

1st Degree AV Block

– PR Interval > 0.20 s

Sinus rhythm with first degree heart block

2nd Degree AV Block, Type I

• Deviation from NSR

– PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).

2nd Degree AV Block, Type II

• Deviation from NSR

– Regularly a P waves wave not followed by QRS

– For the nerd

Conduction is all or nothing

(no prolongation of PR interval); typically

block occurs in the Bundle of His.

Case 3: 65 on routine check up

Complete Heart Block Note Narrow QRS Complex escape

Case 4: Collapsed at home. Gawler Health Service

AV dissociation

Treatment

• External Pacer

• Isoprenaline infusion

• Temporary Pacing wire

• Permanent Pacemeker

Conduction Disease

SA AV

1st degree

2nd Degree

3rd Degree

Bundle Branch

R

L

65 year old man with recurrent falls and collapse

Case 5: 79 year old man with systolic murmur with syncope

Trifasicular Block

AV nodal disease

Conduction Disease

SA AV

1st degree

2nd Degree

3rd Degree

Bundle Branch

R

L

Left Bundle Branch Block

• Consequence of LBBB

• Significant ?

Fast

Narrow

Irregular Regular

Broad

Regular Irregular

Atrial

fibrillation

Fast

Narrow

Irrgular Regular

Broad

Regular Irregular

Supraventricular Tachycardia

Ventricular Tachycardia

Tachy ArrhythmiasHR >100

Atrial

Atrialcomplex &

narrow QRS

JunctionalNo atrial

complex & narrow QRS

Ventricular

Broad QRS

Supraventricular Arrhythmias

• Atrial Fibrillation ( irregular)

• Atrial Flutter

• Paroxysmal Supraventricular Tachycardia

• Supraventricular Ectopic

SVTAtrial tachycardia

AVNodal reentry

Atrial flutter

Atrial fibrillation

Block AV node and control ventricular

rate

Decision

• Factors

– Symptoms

– Exercise tolerance

– Duration

– Ischemia

– Heart failure

– Mental state ; cerebral perfusion

• Admit or treat

• Referral

– Immediate

– Urgent

– Elective

• Investigate

– Routine blood;TSH

– Echo

– ECG

– CXR

Treatment

• Search underlying cause

– Ischemia

– Thyroid

– Infection

– Comorbidities

– COPD /OSA

– Pulmonary embolus

• Control ventricular rate

• Prevent stroke (A.F)

• Treat complication

– Left heart failure

– Ischemia

Case study

• 75

• DM , HT – Palpitation

• HR 155 BP 150/95

• Coveram ( perindopril &amlodipine 5/5)

• 4 Scenarios

Case 67 female, HT, DM-Palpitation HR 155 BP 150/95

New onset Atrial fibrillation{1} 70 female, HT, DM-Palpitation

Scenario 1

Compensated

• 2 to 3 weeks

• No chest pain; Slightly breathless

• No edema

• No dizziness/no collapse

• BP 160 +

• Can walk to 4 bus stops

• Clear lung

Treatment

• Aspirin ; start warfarin

• Metoprolol 25 mg b.d

• Digoxin 250 mcg 3 stats then half ( 125mcg)

• Bloods (CBP, Euc LFTs, TSH)

• Referral ( Echo)

• Re assess 2 -3 days ; INR ;education; chase blood ;CXR

New onset Atrial fibrillation {2}70 female, HT, DM-Palpitation

De Compensated Treatment

• 2 weeks

• Chest pain on stairs

• Orthopneic; PND

• Mild edema

• BP 150/50

• Ex tolerance- 20 m from 1 km

• Mild creps &murmur

• Aspirin -Warfarin

• Metoprolol 12.5 mg tds

• Digoxin 250 mcg ;3 then half

• Frusemide 60 then 40 mg

• Imdur 60 mg

• Stop amlodipine

• Blood CXR

• Review 2 days

Atrial fibrillation 1. Control ventricular rate-

Low dose beta blocker & digoxin --the best combination

1. Prevent stroke – start warfarin – don’t procrastinate-

2. Don’t wait for cardiologist-don’t panic-Low dose beta blocker has few contraindication

3. Pulmonary embolus and stroke causes serious morbidity and mortality

Atrial fibrillationwhen to refer to

ANE

1. Hopeless patient

1. Home alone; no english

2. Very poor ex tolerance

3. Dizziness

4. Overt LVF

5. You don’t have time

( wife rang you 3 times already; ; kids to pick up from school)

6. Other organ failure or comorbidities

75 female; DM & HT routine ECG{3}

• 75 female; DM & HT routine ECG

75 female; DM & HT routine ECG {4}

Left Bundle Branch Block and Fast AF: Refer

ManagementAim

1. Control ventricular rate

2. Prevent stroke

3. Look for underlying cause

4. Identify and treat complication

Control ventricular rate

1. Beta blocker (metoprolol 25 bd or tds best)

2. Digoxin

3. Calcium Channel blocker

Regulate Rhythm

1. Flecainide (cardiologist)

2. Amiodarone (short term)

3. Sotalol

Prevent stroke

1. Aspirin

2. Warfarin

3. Dabigatran direct thrombin in

4. Rivaroxaban F XA inh

CHAD or CHAD-Vasc score

Warfarin vs dabigatran vsRivaroxaban vs Aspirin vs

nothing

Acute Palpitation – Gawler ANE70 HT; COPD ; DM

Acute onset narrow complex Regular tachycardia

{ ANE}

• Carotid sinus massage

• Ice

• Valsalva

• Adenosine

Adenosine for uncertain SVT

• Atrial flutter 2:1 vs AVNRT ?

Adenosine for SVT

Adenosine in AF/ Aflutter

60 ;HT otherwise well

Atrial Flutter

Curable (80 -90%)

with ablation & very

amenable to

cardioversion

Acute palpitation , hemodynamically stable

Therapy

I.V

• Adenosine ( 6,12,18,24)

• IV metoprolol

• IV verapamil

• ( 5 mg in 10 mls ) ; 1 mg /min assess each min

• NO VERAPAMIL IN A.S /CARDIOMEGALY /LVF/ Murmur

ORAL

1. Metoprolol 25 bd

2. Atenolol 25

3. Verapamil 80 tds

4. Digoxin load and 62.5 mcg (AF/Flutter)

Play simple and safe

Consider IV amiodarone

(hypotension)

Case study- my heart stops!

• 40 year old litigation lawyer

• Palpitations

• My heart stops and starts again

• Dizziness

• Throat

• Treadmill 3 x week and pump class

40 Female healthy , irregular pulse

What would you do?

1. Reassurance

2. Reassurance , Echo and Holter

3. Exercise stress test ? Ischemia

4. Stress Echocardiography

5. Cardiology review now ( hotline)

6. Cardiology review next 3 weeks

FAST

Narrow

Irregular

A.F

Treat

Regular

SVT/A. Flutter

Treat

Broad

Regular

Ventricular Tachycardia-

000

Irregular

Fax to cardiologist

Regular narrow complex rhythm at

150 bpm ~~ Atrial flutter 2:1block

70 y.o no symptoms , driver license check , no med. Exam :Irregular pulse

Atrial Fibrillation

35 y.o female palpitation.

• SVT eg. AVJRT

35 y.o female with palpitation

• Gawler Hospital

• Initial BP 125/90

• Given IV verapamil 5 mg total no result

• Another GP : IV amiodarone 300 mg rapid push ( please don’t do this !) (he has just left)

• BP now 85 mm Hg feels drained but conscious.

Now What?

Who wants to be a Hero ?

• Dial a friend

• 50 -50

• Ask the audience ( Husband is a lawyer)

• Adrenaline

• Metaraminol ( Aramine)

• Fluid

• Its not my fault

• Call ambulance ( remember, you

are in hospital)

• DC shock

DC shocks

• DC shock delivered on R wave ( R on T phenomenon) resulting in VF

• Now patient is fully unconscious ….

– Husband: “what happening” –

– Doc to Nurse –what have you done?

R

T

Learn your buttons !!!

Tachycardia with hemodynamic instability

• Ensure not sinus tachycardia

• DC shocks with or without sedation

• Please sync

• Prepare for post shock bradycardiahypotension LVF ( CPR , atropine , adrenaline)

Broad Complex Regular Tachycardia

• Ventricular Tachycardia

• Ventricular Fibrillation

Broad-Fast-Monomorphic

Ventricular Tachycardia

[1] Stable

• Palpitation BP 125 sys

• Mild chest tightness

• Clear Lung no LVF

• Previous Inf MI 20 years ago

• What do you do

• Blood – Panic

– Shocks

– Amiodarone

– Lignocaine

[2] BP 85 Concious

• Palpitation

• Breathless

• Crepitation

Ventricular Tachycardia

Impulse is originating in the ventricles

(wide QRS).

Take your own pulse