Phase 2 Michelle Mair The Peer Teaching Society is not liable for false or misleading information…

Phase 2

Michelle Mair

Cardiovascular 2

The Peer Teaching Society is not liable for false or misleading information…

Arrhythmias:- Atrial fibrillation- Atrial flutter- Heart block- Sinus tachycardia- SVTs- Ventricular ectopics- Prolonged QT syndrome- Aberrant pathways


Aims


ECGs

1) Heart Rate 2) Heart Rhythm

3) Cardiac axis4) P waves

5)P-R interval6) QRS complex7) ST segment

8) T waves


Cardiac axis


I

IIIII

AVLAVR

AVF

Normal Axis

Positive

Positive

Positive

Cardiac axis


I

IIIII

AVLAVR

AVF

Right Axis Deviation

Negative

Positive

Positive

Cardiac axis


I

IIIII

AVLAVR

AVF

Left Axis Deviation

Positive

Negative

Negative


Atrial Fibrillation• Irregularly irregular rhythm • Varying rate• Absent p waves

http://nl.ecgpedia.org/images/6/64/Afib_ecg.jpg


Atrial Fibrillation

Types:

1. Paroxysmal= spontaneous termination within 7 days, most commonly

in 48 hours

2. Persistent= not self-limiting, lasting longer than 7 days or prior to

cardioversion

3. Permanent= long standing (over 1 year) not terminated by

cardioversion


Atrial Fibrillation

Causes:

• Hypertension

• Coronary artery disease

• Valve disease (especially mitral valve)

• Hyperthyroidism

• Infection

• Idiopathic


Atrial Fibrillation

Presentation:

• Asymptomatic

• Palpitations

• Breathlessness/dyspnoea

• Dizziness/syncope

• Chest discomfort

• Stroke/TIA


Atrial Fibrillation

Investigations:

• ECG

• Bloods: FBC, TFTs, LFTs, U&Es (coagulation screen)

• CXR

• Echo


Atrial Fibrillation

Complications:

• Stroke/ TIA – increased six-fold

• Heart failure

• Cardiomyopathy


Atrial Fibrillation

Management:

1) Rate control- beta-blockers or rate-limiting sodium channel blocker e.g.

Verapamil

2) Rhythm control- pharmacological or electrical cardioversion

- left atrial ablation

- pace and ablate strategy

3) Thromboprophylaxis- use CHA2DS2-VASc score

- warfarin therapy

- apixiban, dibigitran, rivaroxiban

Atrial Flutter• ‘saw tooth’ pattern• Atrial rates of 240-340



Atrial Flutter

Causes:

• Coronary heart disease

• Atrial dilatation

• Open heart surgery

• Hypertension

• COPD

• Obesity

• Thyrotoxicosis


Atrial Flutter

Presentation:

• Asymptomatic

• Palpitations

• Fatigue

• Dyspnoea

• Syncope

• Heart failure

• TIA


Atrial Flutter

Investigations:

• ECG

• CXR

• TFTs, FBC, ESR, U&Es, LFTs, clotting

• Echo


Atrial Flutter

Management:

• Catheter radiofrequency ablation

• Electrical/Pharmacological cardioversion

• Anti-coagulants


Heart Block

Types:

1) First degree = prolonged P-R interval [>200ms]

2) Second degree

3) Third degree = both present but no association between P wave and QRS complex

Mobitz I (Wenckebach) = gradual progressive P-R prolongation before a QRS complex is dropped

Mobitz II = same P-R interval followed by absent QRS complex


Heart Block

First degreeMobitz I Mobitz II Third degree

a) b)

c) d)


Heart Block

First degreeMobitz I

Mobitz II

Third degree

a) b)

c) d)


Heart Block

Causes:

First degree:- Athletes- Myocarditis- Hypokalaemia- Hypomagnesaemia- Medications

Second degree:- Athletes- Post MI- Lyme disease- Medications

Third degree:- Complication of heart

surgery- Coronary heart

disease- Radiotherapy- Infection- Hypertension- Medications


Heart Block

Symptoms

First degree:- asymptomatic

Mobitz I:- light-headedness- dizziness- syncope

Mobitz II:- chest pain- shortness of breath- tiring on exertion- postural hypotension

Third degree:- light-headedness - dizziness - fainting - fatigue (extreme tiredness) - chest pain - slow heart beat (bradycardia)


Heart Block

Management:

• Transcutaneous pacing

• Pacemaker


Supraventricular Tachycardia

Supraventricular = above the ventricle

• SA node overridden and another part of the heart triggers faster

impulses

Types:

• Atrio-ventricular nodal re-entry tachycardia

• Atrial tachycardia

• Wolff-Parkinson White syndrome

The heart rate must be FAST and REGULAR


SVT

Atrio-ventricular nodal re-entry tachycardia

• Most common

• Seen in people aged 20-30

• Electrical short circuit in centre of the heart

• Usually no underlying cause


SVT

Atrial tachycardia

• Arises from anywhere in the atria

• Usually no underlying cause


SVT

Wolff-Parkinson White syndrome

• Accessory pathway between atria and ventricles

• Congenital abnormality

• May get palpitations, severe dizziness or syncope


SVT

Presentation:

• Tachycardia

• Palpitations

• Dizziness

• Breathlessness

• Chest discomfort

• Asymptomatic


SVT

Management:

• Self-resolving

• Adenosine

• Long term digoxin, beta-blocker, verapamil

• Catheter ablation



Sinus Tachycardia

Normal heart rate: 60-100bpm

Causes: • Pain• Exercise• Fever• Anxiety• Dehydration• Anaemia• Sepsis• Heart failure• Hyperthyroidism• MI• PE• Stimulant use


Sinus Tachycardia

Treatment:

• Treat underlying cause


Questions

A 51 year old gentleman is complaining of palpitations. He is a smoker and

you find his blood pressure is 145/92. He has an underactive thyroid for

which he take Levothyroxine. His ECG shows an irregularly irregular

rhythm.

Name this condition………………………………………What his main risk factor for developing this?………………………………………….What is the first line treatment of this condition?………………………………………….Give the class of drug suitable for this…………………………………………Give a complication of this condition?..........................................................


Questions

A man comes into hospital looking very unwell. His vital signs are: -Temp :39.5- SpO2 : 95% on air- BP: 110/65- HR: 135bpmHe is found to have a pneumonia causing sepsis

List 4 other cause of sinus tachycardia………………………………………………..………………………………………………...………………………………………………..……………………………………………….


Questions

You are asked to review a ECG of a lady admitted to your ward. You notice that the P-R interval is irregular and that after every now and then there is an absent QRS complexYou diagnose heart block

Which type of heart block does she have?…………………………………………………………

Give 2 symptoms that she might be experiencing………………………………………………………….

What treatment does she require?………………………………………………………….

Phase 2 Michelle Mair The Peer Teaching Society is not liable for false or misleading information…

Documents

misleading information

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misleading information

cardioversion slide

rivaroxiban slide

atrial flutter causes

atrial ablation pace

cardiac axis