Arrhythmias

arrhythmia.jpg

Raja Selvaraj. Professor of Cardiology, JIPMER

https://rajaselvaraj.in/talks/arrhythmias_mbbs_2020_with_notes.html raja@rajaselvaraj.in

17-06-2020

Organization of this talk

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

What do you know?

challenge1_nsr.jpg

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

What do you know - What is the abnormality?

challenge_2.jpg

  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?

challenge_3.png

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

Arrhythmias

  • Lack of rhythm
  • Not normal rhythm

Normal rhythm

  • Origin
  • Rate
  • AV conduction

Normal rhythm

normal.gif

Arrhythmias - Classification

  • Bradyarrhythmia
  • Tachyarrhythmia

Bradyarrhythmias - Causes

brady_causes.png

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

supra_vt.png

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

ecg_display.png

Rate

  • 300 / large squares
  • 1500 / small squares

Axis

lead_vectors.png

Axis

quadrants.png

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

normal_sinus.jpg

P wave axis

normal_p_axis.jpg

60 year old female, complains of presyncopal episodes

sinus_bradycardia.jpg

Bradycardia - symptoms

  • Giddiness
  • Syncope
  • Fatigue
  • Breathlessness
  • Death

Young male, asymptomatic

sablock.jpg

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

first_degree_av_block.jpg

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

second_degree_type1_av_block.jpg

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

second_degree_type1_av_block.jpg

Middle aged female with syncope

second_degree_type2_block.png

Middle aged female with syncope

second_degree_type2_block_m.png

Mobitz types - implications

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

Atrioventricular conduction system

av_conduction.gif

70 year old male, fainted at home

complete_av_block.png

Pacing - temporary

tpi.jpg

Pacing - permanent

ppi.jpg

Pacing for CHB

pacing_chb.jpg

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

sinus_tachy.jpg

Sinus tachycardia

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

10 year old boy referred from pediatric OPD for irregular pulse

pac.png

Premature atrial beats

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

Supraventricular tachycardia and AV junction

essential_parts.gif

65 year old female with COPD and palpitations

atrial_tachycardia.jpg

Vagal maneuvers in narrow QRS tachycardia

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

Adenosine

adenosine.jpg

Atrial tachycardia

What will be the response to adenosine?

Middle aged hypertensive male with fatigue

atrial_flutter.jpg

12 lead ECG - same arrhythmia ? Something else?

atrial_flutter2.png

After adenosine bolus

atrial_flutter2_adenosine.png

Atrial flutter

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

Macroreentry

flutter_circuit.jpg

Middle aged female with palpitations

psvt.jpg

PSVT

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

Reentry

reentry.jpg

AVNRT - Pseudo r`

pseudo_r.jpg

Another patient - ECG after termination of tachycardia

wpw.png

WPW syndrome

wpw_schematic.jpg

Radiofrequency ablation

rf_ablation.jpg

Elderly lady with dizziness

atrial_fibrillation.png

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

pvc.png

Palpitations and presyncope

ventricular_tachycardia.jpg

Ventricular arrhythmias

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

Young female with recurrent syncope

torsades.jpg

Patient in CCCU

ventricular_fibrillation.png Treatment ?

Defibrillator

defibrillator.jpg

Implantable defibrillator

aicd.jpg

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