Arrhythmias

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Raja Selvaraj. Professor of Cardiology, JIPMER

https://rajaselvaraj.in/talk/arrhythmias_mbbs_2020/1 raja@rajaselvaraj.in

17-06-2020

Organization of this talk

  • Normal rhythm
  • Arrhythmias - Introduction
  • Case illustrations
  • Management - interspersed

What do you know?

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  1. Bradycardia 2. Tachycardia
  2. Normal rate 4. I don't know

What do you know - What is the abnormality?

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  1. First degree heart block
  2. Second degree heart block
  3. Third degree heart block
  4. I don't know

What do you know - Which is present in this ECG?

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  1. Preexcitation 2. Atrial fibrillation
  2. Both 4. None

Arrhythmias

  • Lack of rhythm
  • Not normal rhythm

Normal rhythm

  • Origin
  • Rate
  • AV conduction

Normal rhythm

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Arrhythmias - Classification

  • Bradyarrhythmia
  • Tachyarrhythmia

Bradyarrhythmias - Causes

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Bradyarrhythmias

  • Sinus node disease (too few P waves)
  • Atrioventricular block (too few QRS, P > QRS)

Sinus node disease

  • Sinus arrest
  • Sinus bradycardia
  • Sino-atrial block
    • Second degree type I
    • Second degree type II

Atrioventricular block

First degree

Second degree type I

Second degree type II

Third degree

Tachyarrhythmias - Causes

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Tachyarrhythmias

  • Supraventricular tachycardia
  • Ventricular tachycardia

Supraventricular tachycardia

Sinus tachycardia

Atrial tachycardia

Atrial flutter

Atrioventricular nodal reentrant tachycardia

Atrioventricular reentrant tachycardia

Atrial fibrillation

Ventricular tachycardia

Premature ventricular complexes

Ventricular tachycardia

Ventricular fibrillation

ECG display

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Rate

  • 300 / large squares
  • 1500 / small squares

Axis

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Axis

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30 year old male - ECG done for pre-employment check up

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P wave axis

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60 year old female, complains of presyncopal episodes

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Bradycardia - symptoms

  • Giddiness
  • Syncope
  • Fatigue
  • Breathlessness
  • Death

Young male, asymptomatic

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Management of sinus bradycardia

  • Rule out underlying cause
  • Drugs ?
  • Physiological ?
  • Pacemaker implantation

Drugs

  • Atropine
  • Isoprenaline
  • Orciprenaline
  • Long acting theophylline

55 year old male, asymptomatic, referred for abnormal ECG

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AV Conduction block - degrees

  • First: All P waves conducted
  • Second: Some P waves conducted
  • Third: No P waves conducted

Young male, found to have irregular pulse

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Second degree AV block - Mobitz types

  • Type 1 - Progressive PR prolongation before block
  • Type 2 - Fixed PR interval of conducted beats

RR interval in Wenckebach block

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Middle aged female with syncope

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Middle aged female with syncope

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Mobitz types - implications

  • Type 1
    • Block above His
    • Usually benign
  • Type 2
    • Block at or below His
    • Usually needs treatment

Atrioventricular conduction system

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70 year old male, fainted at home

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Pacing - temporary

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Pacing - permanent

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Pacing for CHB

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Clinical examination in bradycardia

How can you differentiate sinus dysfunction from atrioventricular block?

  1. Pulse rate
  2. Second heart sound
  3. JVP

Rapid pulse in pre-operative patient

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Sinus tachycardia

  • Fever
  • Stress
  • Hypovolemia
  • Hyperthyroidism
  • Inappropriate sinus tachycardia

10 year old boy referred from pediatric OPD for irregular pulse

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Premature atrial beats

  • Benign in absence of structural heart disease
  • "Missed beats"
  • Rarely need treatment

Supraventricular tachycardia and AV junction

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65 year old female with COPD and palpitations

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Vagal maneuvers in narrow QRS tachycardia

  • Carotid sinus massage
  • Straining / gag reflex
  • Eyeball pressure
  • Diving reflex

Adenosine

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Atrial tachycardia

What will be the response to adenosine?

Middle aged hypertensive male with fatigue

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12 lead ECG - same arrhythmia ? Something else?

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After adenosine bolus

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Atrial flutter

  • Classic example of macroreentry
  • Can be treated with AV blocking drugs
  • Rhythm control by ablation

Macroreentry

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Middle aged female with palpitations

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PSVT

  • Paroxysmal supraventricular tachycardia
  • Reentry using two pathways in AV node or AV node and AP
  • Response to adenosine?

Reentry

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AVNRT - Pseudo r`

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Another patient - ECG after termination of tachycardia

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WPW syndrome

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Radiofrequency ablation

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Elderly lady with dizziness

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Atrial fibrillation

  • Commonest arrhythmia
  • With or without structural heart disease
  • Loss of atrial pump function
  • High ventricular rate
  • Thromboembolism
  • Rate versus rhythm control

Middle aged male with previous myocardial infarction

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Palpitations and presyncope

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Ventricular arrhythmias

  • Idiopathic
  • Structural heart disease
  • Risk of sudden death
  • Drugs
    • Lignocaine
    • Amiodarone

Young female with recurrent syncope

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Patient in CCCU

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Defibrillator

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Implantable defibrillator

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Summary

  • Abnormalities of rhythm are an important class of heart disorders
  • May present as slow rate or rapid rate
  • Can be life threatening in some patients
  • Wide variability in presentation, evaluation and management
  • Repetitive exposure to ECGs, management of individual patients

Questions / Comments / Feedback