IC1 - Arrhythmia - 2012 EDITED

8/11/2019 IC1 - Arrhythmia - 2012 EDITED

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Arrhythmias

Richard G Sheahan,

ConsultantCardiologist/Electrophysiologist


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ParoxysmalEctopic focus, sudden onset, abrupt cessation

Sustained

Duration of > 30 seconds

Requires intervention to terminate

Non-Sustained

At least 3 beats or < 30 seconds

Spontaneously terminates

Recurrent

Occurs periodically

Periods of no tachycardia are longer than periodsof tachycardia

Terms Describing Tachycardias


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Tachyarrhythmias

Supraventricular Tachycardia

Atrial Flutter

Atrial Fibrillation

Ventricular Tachycardia

Ventricular Fibrillation

Sudden Cardiac Death Premature Atrial & Ventricular

Complexes


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2% VFData source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

34%

Atrial

Fibrillation

18%

Unspecified

6%

PSVT

6%PVCs

4%

Atrial

Flutter

9%

SSS

8%

ConductionDisease

3% SCD

10% VT


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Arrhythmia Symptoms

Palpitations Sudden Onset or Offset

Shortness of Breath

Chest pain

Syncope or Presyncope/Dizziness

Increasing Fatigue

Cough & Sputum Impaired Quality of Life


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Arrhythmia Signs

Pulse Rate Blood Pressure

O2 Saturation

Perfusion, Pale Sweaty & Clammy

Heart Failure


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Tachycardia Recognition

Rate > 100 bpm Regular or Irregular

Narrowcomplex or Broadcomplex

P waves present or absent

Clinical Assessment

Past History


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Arrhythmia

Supraventricular Tachycardia Atrial Flutter

Atrial Fibrillation

Ventricular Tachycardia Ventricular Fibrillation

Sudden Cardiac Death

Premature Atrial & Ventricular Complexes


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Origin: AV Node

Mechanism: Reentry

Rate: 150 - 230 BPM, faster in teenagers

Characteristics: Normal QRS with absent P-waves;

most common SVT in adults

SVT


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Supraventricular Tachycardia

IV Adenosine Rate Control

Beta blockers, Calcium Channel Blockers

(Digoxin)

Rhythm Control Normal Ventricule:

Propafenone, Flecainide, sotalol

Abnormal Ventricule

Amiodarone

Synchronized CardioversionHemodynamically unstable

EP Study & RF Ablation


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AVNRT( atrioventricular nodal re-entrant tachycardia)

Accounts for 80-90% of SVT Abrupt onset and offset

The typical ventricular

rate is 140-300/min

P is usually buried within

the QRS complex

Best identified in V1


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SVT-AVNRT

P

Just learn to recognise SVT, no need to know

AVRT or AVNRT specifically


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AVRT( atrioventricular re-entrant tachycardia)

Reentrant circuit

consists of an

atrioventricular

nodal pathway andaccessory pathway


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SVT-AVRT


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Sinus Tachycardia

Pain Anxiety

Fever

Anaemia

Dehydration

Hyperthyroidism


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Sinus Tachycardia Treatment

Treat the cause

Acute management:

Treatment aimed at restoration of sinus

rhythm

1. Carotid sinus massage

2. IV adenosine

3. IV verapamil


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Sinus Tachycardia Treatment

Long term management:1. Drug therpy

- directed at AVN

- beta-blocker

- calcium channel blocker

- digoxin

- directed at AP

- Class IA/C agents

2. Radiofrequency ablation

3. Treat the underlying causes (if any)


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Arrhythmia

Supraventricular Tachycardia (SVT) Atrial Flutter

Atrial Fibrillation




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Atrial Flutter


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Atrial Flutter Treatment

Anticoagulation for High Risk Patients Rate Control

Beta-blocker, Ca Channel Blocker, (?Digoxin)

Rhythm Control Cardioversion

Antiarrhythmics

Radiofrequency Ablation


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Arrhythmia


Atrial Fibrillation




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Atrial Fibrillation

MOST IMPORTANT RHYTHM AND COMMONEST


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Feinberg WM, Blackshear JL, Laupacis A, et al.Arch Intern Med. 1995;155:469-473

Atrial Fibrillation


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Feinberg WM, Blackshear JL, Laupacis A.Arch Intern Med.1995;155:469-473

Atrial Fibrillation Demographics by

Age


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Atrial Fibrillation Treatment 1

Stroke Prevention Heparin, Warfarin or newer anticoagulants

ASA

Rate Control

Betablockers, Ca Channel blockers, (? Digoxin)

Rhythm Control

Normal Heart: Propafenone, Flecainide, Sotalo

CHF/LVH/CAD: Amiodarone

At i l Fib ill ti T t t 2


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CORE MATERIAL

Synchronized Cardioversion < 48 hours Heparin + Cardioversion

> 48 hours Heparin + TOE +/-Cardioversion

Or Warfarin INR 2.0 -3.0 for > 4 weeks

Pulmonary Vein Isolation Ablation


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Associated Conditions Treat Hyperthyroidism before

cardioversion

Treat sepsis Treat pulmonary embolism

Pacemaker for Bradycardia


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CHADS2Score*

Congestive heart failure 1

History of hypertension 1

Age > 75 1Diabetes 1

Stroke / TIA 2

Warfarin indicated when CHADS2score > 2

* The CHADS2 scores were developed in a study published in The Journal of theAmerican Medical Association in 2001


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Annual Stroke Risk


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Recommendations for Anticoagulation


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Arrhythmia


Atrial Fibrillation




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Origin: Ventricles (Wandering Single Focus)

Mechanism: Reentry with movement in the circui

Initiated by Abnormal Automaticity or

Triggered activity

Characteristics: Wide and irregular QRS Complex that

chan es in axis Tc Normal

Polymorphic VT

*Animation


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Origin: Ventricle

Mechanism: Reentry (movement in focus)

Rate: 200 250 BPM

Characteristics: Associated with Long QT interval;

QRS changes axis & morphologywith alternating positive/negative

complexes

Torsades de Pointes



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CORE


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Ventricular Tachycardia Treatment

Acute Synchronized Cardioversion if unstable

+/- CPR

IV Amiodarone, Beta-blocker, Magnesium

Chronic Correct Reversible Causes

ICD if no 1) Reversible Causes or 2) EF

IC1 - Arrhythmia - 2012 EDITED

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