rhythm abnormalities

8/12/2019 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



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Causes


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.



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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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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



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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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rhythm abnormalities

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