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Program Information. Arrhythmias – Part 2. Karima Sajadi, MD Sarah A. Stahmer MD Cooper University Hospital. Regular Wide-Complex Tachyarrhythmias. Ventricular tachycardia Pacemaker-mediated tachycardia Sinus tachycardia with pre-exisitng BBB Sinus tachycardia with rate-dependent BBB.

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  1. Program Information

  2. Arrhythmias – Part 2 Karima Sajadi, MD Sarah A. Stahmer MD Cooper University Hospital

  3. Regular Wide-Complex Tachyarrhythmias Ventricular tachycardia Pacemaker-mediated tachycardia Sinus tachycardia with pre-exisitng BBB Sinus tachycardia with rate-dependent BBB

  4. Ventricular Tachycardia (VT) Defined as 3 consecutive beats at a rate >100 bpm ECG recognition: Rate >100 bpm QRS duration >120 msec ECG criteria vary Brugada criteria are the most accurate ECG should be correlated with clinical presentation, history, and comparison with old ECG if possible!

  5. ECG Criteria for VT • Step 1: Is there an absence of RS complex in V1-V6? • If yes, then it is VT • Step 2: Is the interval from the onset of the R wave to the nadir of the S wave greater than 100 msec in any precordial leads • If yes, then it is VT • Step 3: Is there any AV dissociation? • If yes, then it is VT • Step 4: Are morphology criteria for VT present? (see next slide) • If yes, then it is VT

  6. Right bundle type requires waveforms from both V1 and V6 Morphology Criteria for VT

  7. Morphology Criteria for VT Left bundle type requires any of the below morphologies Adapted from Brugada et al. A new approach to the differential diagnosis of regular tachycardia with a wide QRS complex. Circulation 1991; 83:1649-59.

  8. VT

  9. VT • Causes: • Usually a complications of CAD (ischemia, scar tissue) • Medications: Digoxin, TCAs, Type I antiarrhythmics, sympathomimetics, Electrolytes imbalance (low or high K) • Can occur in healthy individuals! • Can be the first presentation of an organic heart disease

  10. VT • Treatment: • In patients with diminished LV function: Amiodarone • In patients with preserved LV function: DC cardioversion • Amiodarone, Procainamide The combination of antiarrhythmic drugs is strongly discouraged due to their limited efficacy and a pro-arrhythmic potential

  11. Pacemaker-Mediated Tachycardia • Mechanism: • reentrant tachycardia • occurs when pacer senses a retrograde atrial depolarization and triggers ventricular pacing • usually initiated by a PVC, which is conducted retrograde to the atria and is subsequently sensed by the pacer

  12. Pacemaker-Mediated Tachycardia • ECG recognition: • regular, wide complex tachycardia • pacer spikes present on ECG • Treatment: magnet application that converts a pacer into DOO mode and terminates the rhythm. It will not recur once magnet is removed

  13. Pacer Mediated Tachycardia

  14. Pacemaker Mediated Tachycardia after magnet applied

  15. SVT with Pre-existing BBB • Can be with either right or left bundle branch block • Old ECG is helpful to determine whether it is a pre-existing or new BBB

  16. SVT with Pre-existing LBBB

  17. NSR with Pre-existing LBBB

  18. SVT with Rate-dependent BBB • Mechanism: • As HR increases, the cycle length shortens • Normally there should be a decrease of refractoriness • In affected bundle, this does not happen • Could be an indication of an early bundle branch disease • ECG recognition: • absent or incomplete BBB at NSR • BBB with tachycardia

  19. Absent RBBB at NSR

  20. Rate-dependent RBBB

  21. Irregular Wide-Complex Tachyarrhythmias • Polymorphic ventricular tachycardia – torsade de pointes • Ventricular Fibrillation

  22. Torsade de Pointes • Type of polymorphic VT • ECG recognition: • each QRS complex varies in amplitude and polarity • they appear to twist around the isoelectric line • Mechanism: • abnormal repolarization, such as QT prolongation (congenital or acquired) • when premature beat falls on the preceding T wave, it precipitates this rhythm

  23. Torsade de Pointes

  24. Ventricular Fibrillation • Mechanism: • myocardium is unable to generate synchronous ventricular contractions • can be fatal if not terminated abruptly • ECG recognition: • unmistakable in appearance - chaotic, irregular, and disorganized ventricular complexes without any discrete P waves or QRS complexes

  25. Ventricular Fibrillation • Treatment: defibrillation, Amiodarone

  26. Conclusion • This concludes part 2 of the arrhythmia presentation. • Continue to Arrhythmias Part 3 for the final installment of this lecture. • Cases studies and references for this section are found at the end of Arrhythmias Part 3.

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