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Bradycardia and Narrow Complex Tachycardia

Bradycardia and Narrow Complex Tachycardia. Smriti Banthia CCU Lecture Series. Conduction System Anatomy. Sinus node is supplied by the RCA in 60% of people and by the LCX in 40%. AV node is supplied by the RCA in 90% and by the LCX in 10% of patients. Right bundle supplied by LAD

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Bradycardia and Narrow Complex Tachycardia

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  1. Bradycardia and Narrow Complex Tachycardia Smriti Banthia CCU Lecture Series

  2. Conduction System Anatomy • Sinus node is supplied by the RCA in 60% of people and by the LCX in 40%. • AV node is supplied by the RCA in 90% and by the LCX in 10% of patients. • Right bundle supplied by LAD • Left bundle supplied by branches of the RCA and LAD Zimetbaum PJ, Josephson ME. NEJM, 2003 Taken from www.baptistoneword.org

  3. Pacemaker? • Progressive shortening of PP interval before it blocks • Pause is less than 2 of the preceding PP intervals

  4. SA Block Type II – Pause approximately 2x PP interval Pacemaker?

  5. WHAT NEXT? 52 year-old obese man who presents with cellulitis. Above seen on telemetry during hospitalization.

  6. Page…. HR 30. WHAT NEXT?

  7. Premature junctional complex Retrograde p wave WHAT IS THIS?

  8. Mobitz II – 2nd Degree AV Block WHAT NEXT? 80 year-old man presents with syncope.

  9. What’s the rhythm? NSR with first degree AV block

  10. Pause duration to meet criteria for pacemaker implantation? 3 seconds

  11. Post cath, holding groin pressure. Pt dizzy now. WHAT NEXT? Sinus Bradycardia. Vagal response. Give Atropine.

  12. What is the rhythm? ATRIAL FIBRILLATION

  13. Management of AF • Maintenance of normal sinus rhythm No treatment Pharmacologic therapy (AAD, anticoagulants) Non-pharmacologic therapy (Ablation, PPM) • Ventricular rate control Pharmacologic therapy (BB, CCB, Digoxin) Non-pharmacologic therapy (AVN ablation) • Reduction of thromboembolic risk

  14. What’s wrong?

  15. AFIB AND STROKE • Leading cause of stroke from embolism • • AF increases stroke risk • ~ 17x Rheumatic heart Dz • ~ 5x in non-valvular • Risk of stroke ~ 5%/yr • • Proportion of strokes attributable to AF increases with age

  16. When Rx Coumadin?

  17. ASA 325 daily ASA or Coumadin Coumadin INR 2-3 Problem: What about pt with prior hx of CVA but no other RF? Classified as moderate risk when in fact may be high risk…. Thus, the ACC/AHA guidelines differ in the following way…

  18. ACC/AHA Guidelines for Anticoagulation

  19. Tachy-Brady Syndrome

  20. WHAT NEXT??? 32 year-old female with palpitations

  21. After Adenosine 6mg IV

  22. Retrograde p waves CSM/Vagal Maneuvers Adenosine BB/CCB Ablation

  23. AVNRT – Mechanism?

  24. Aflutter with variable conduction

  25. MAT

  26. Aflutter with 4:1 Block Most cases of atrial flutter are caused by a large reentrant circuit in the wall of the right atrium EKG Characteristics: Biphasic “sawtooth” flutter waves at a rate of ~ 300 bpm Flutter waves have constant amplitude, duration, and morphology through the cardiac cycle There is usually either a 2:1 or 4:1 block at the AV node, resulting in ventricular rates of either 150 or 75 bpm

  27. Unmasking of Flutter Waves In the presence of 2:1 AV block, the flutter waves may not be immediately apparent. These can be brought out by administration of adenosine.

  28. Atrial Tachycardia

  29. Atrial tachycardia • P wave upright lead V1 and negative in aVL consistent with left atrial focus. • P wave negative in V1 and upright in aVL consistent with right atrial focus. • Adenosine may help with diagnosis if AV block occurs and continued arrhythmia likely atrial tachycardia • 70-80% will also terminate with adenosine.

  30. WHAT IS THIS?

  31. A. Emergent cardioversion for polymorphic VT. • B. I.V. procainamide • C. I.V. lidocaine • D. diltiazem drip to obtain rate control.

  32. WPW epidemiology • Present in 0.3% of the population • Risk of sudden death 1 per 1000 patient-years • Sudden death due to atrial fibrillation with rapid ventricular conduction • Atrial fibrillation often induced from rapid ORT ORT(orthodromic reciprocating tachycardia

  33. Atrial Fibrillation and WPW • AV nodal blocking agents may paradoxically increase conduction over accessory pathway by removing concealed retrograde penetration into accessory pathway. Concealed penetration into the pathway causes intermittent block of pathway conduction

  34. Management of Atrial Fibrillation with WPW • Avoid AV nodal blockers • IV procainamide to slow accessory pathway conduction • Amiodarone if decreased LVEF • DC cardioversion if symptomatic with hypotension

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