Brady Arrhythmias

Raja Selvaraj

Organization of this talk

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

Normal rhythm

  • Origin
  • Rate
  • AV conduction

Normal rhythm

conduction_system_normal.jpg

Arrhythmias

  • Not a normal rhythm
  • Bradyarrhythmia
  • Tachyarrhythmia

Bradyarrhythmias

  • Abnormal rhythm with a slow heart rate (<60 bpm in adults)
  • Sinus node disease (too few P waves)
  • Atrioventricular block (too few QRS, P > QRS)

Sinus node disease

sa_junction.png

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

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 ?
  • Symptoms
  • 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

SA wenckebach block

second_degree_type1_sa_block.png

Middle aged female wih syncope

second_degree_type2_block.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

AV block or sinus bradycardia

infra_his_ECG.jpg

56 yr old female, with one episode of syncope

chb_torsades1.png

CHB - Life threatening condition

chb_torsades2.png

Pacing - temporary

tpi.jpg

Pacing - permanent

ppi.jpg

Pacing for CHB

pacing_chb.jpg

Summary

  • Abnormalities of rhythm are an important class of heart disorders
  • Bradyarrhythmias - Slow rate
  • Can be asymptomatic, affect daily life or even be life threatening in some patients
  • Important to differentiate benign forms from malignant forms
  • Repetitive exposure to ECGs, management of individual patients