Prof .Dr.K.H.NOORUL AMEEN’S unit M6

Dr.G ARUN KUMAR

• 45 YEAR OLD DIABETIC PRESENTED TO OPD WITH EPISODES OF PALPITATION ON AND OFF FOR 6 MONTHS

• NO H/O CHEST PAIN , SYNCOPE

• NO H/O ANY DRUG INTAKE(BUT FOR OHA)

Lead 2 rhythm strip

Whats the diagnosis ?

Whats the next investigation you would do ?

Drugs causing this pattern?

• RATE – 88/MIN

• RHYTHM – REGULARLY IRREGULAR

• P WAVE - NORMAL MORPHOLOGY

• PR INTERVAL – 180 ms

• QRS NORMAL IN SINUS BEAT BUT WIDE AND BIZZARE AFTER EVERY 2 NORMAL SINUS BEAT(VENTRICULAR ECTOPIC)

• RBBB PATTERN

IMP: VENTRICULAR PREMATURE BEAT WITH COMPLETE COMPENSATORY PAUSE (VENTRICULAR TRIGEMINY) PROBABLY OF LEFT VENTRICULAR ORIGIN

NORMAL RR INTERVAL 720 ms

2 TIMES RR INTERVAL (pre ectopic + post ectopic interval = 2 sinus interval) 1440ms

COMPENSATORY PAUSE

VENTRICULAR PREMATURE BEAT

• THEY ARE PREMATURE AND OCCUR BEFORE NEXT NORMAL BEAT IS EXPECTED

• THEY ARE USUALLY WIDE, BIZZARE IN APPEARANCE DUE TO THEIR ECTOPIC FOCUS AND THE COURSE OF DEPOLARISATION IS ALSO ABNORMAL

• THE T WAVE AND QRS COMPLEX POINT IN OPPOSITE DIRECTION

RELATION TO SINUS P WAVE

VENTRICULAR EXTRASYSTOLE MAY MANIFEST

1. BEFORE THE FOLLOWING SINUS DISCHARGE

2. AT THE TIME OF SINUS DISCHARGE

3. RELATIVELY LATE ie AFTER SINUS P WAVE BUT BEFORE THE NORMAL QRS (END DIASTOLIC VENTRICULAR ES). SOMETIMES THIS TYPE OF IMPULSES INVADE THE VENTRICLES AT THE SAME TIME AS SINUS IMPULSE THEREBY RESULTING IN A VENTRICULAR FUSION BEAT

4.RETROGRADE CONDUCTION OF VENTRICULAR EXTRASYSTOLE PRODUCE A PREMATURE INVERTED P WAVE FOLLOWING A WIDE QRS

FREQUENCY

• WHEN ISOLATED VPBs ARISE AFTER EVERY SINUS BEAT- VENTRICULAR BIGEMINY

• WHEN ISOLATED VPBs ARISE AFTER EVERY 2 SINUS BEATS- VENTRICULAR TRIGEMINY

• VPBs OCCURING 2 IN A ROW – PAIR OR COUPLET

• VPBs OCCURING 3 OR MORE IN A ROW - VT

VENTRICULAR BIGEMINY

COUPLET

MORPHOLOGY

• LV ORIGIN - RBBB PATTERN • RV ORIGIN - LBBB PATTERN• IVS ORIGIN - LBBB PATTERN

COUPLING INTERVAL

• INTERVAL BETWEEEN ECTOPIC BEAT AND PRECEEDING SINUS BEAT(IS SAME FOR VPBs ARISING FROM SAME FOCUS)

INTERPOLATED VENTRICULAR EXTRASYSTOLE

• THIS TYPE OCCURS

1. WITHOUT A COMPENSATORY PAUSE

2.DURING SLOW SINUS RHYTHM

3.SINUS BEAT FOLLOWING THE ES HAS A

LONGER PR INTERVAL

UNIFORM AND MULTIFORM VPB

• MULTIFOCAL VENTRICULAR EXTRASYSTOLES AND EXTRASYSTOLES IN PAIRS ARE ALWAYS ABNORMAL

• UNIFOCAL VENTRICULAR EXTRAYSTOLES ARE USUALLY INDICATIVE OF CARDIAC DISEASE

IF OCCURS IN CROPS

IF THEY OCCUR IN BIGEMINAL RHYTHM

IF THEY OCCUR IN ASSO. CARDIAC DISEASE

IF AGE >40

IF THEY ARE PRECIPITATED BY EXERCISE

R ON T PHENOMENON

• VPBs THAT FALL ON THE PEAK OF T WAVE OF SINUS BEAT MAY PRECIPITATE VT OR VF.

• THIS USUALLY OCCUR WITH VPBs WITH SHORT COUPLING INTERVAL WHICH ALMOST OCCUR IN THE SETTING OF ANY ACUTE INSULT TO HEART (eg ACUTE MI)

CAUSES OF VPB

• ANXIETY• EXCESS CAFFEINE INTAKE• AMINOPHYLLINE• EPINEPHRINE• ISOPROTERENOL• DIGITALIS(V.BIGEMINY)• VALVULAR,HYPERTENSIVE,ISCHEMIC HEART

DISEASE • ACUTE MI• HYPOKALEMIA,HYPOMAGNESIMIA, HYPOXEMIA OF

ANY CAUSE

GRADING

CLINICAL FEATURES

• ASYMPTOMATIC• PALPITATIONS,MISSED OR EXTRA BEAT

TREATMENT

USE OF ANTIARRHYTHMICS IN ISOLATED VPBs AND SHORT RUN VT HAVE NOT SHOWN ANY IMPROVED SURVIVAL

USE OF BETA BLOCKERS HAS BEEN HELPFUL IN ABOLISHING VPBs IN PATIENT WITH STEMI AND IN PREVENTION OF VF

AT PRESENT PHARMACOTHERAPY IS RESERVED ONLY FOR PATIENT WITH SUSTAINED VENTRICULAR ARRHYTHMIAS

USE OF PROPHYLACTIC ANTI ARRHYTHMICS IS CONTRAINDICATED IN THE ABSENCE OF CLINICALLY IMPORTANT VT

REF : SHAMROTH GOLDBERGER HARRISON