Bhubaneswar / 15.10.06

1. Bhubaneswar / 15.10.06

2. Cardiac Arrhythmias in ICU Dr. P.K.Sahoo Cardiologist Kalinga Hospital Bhubaneswar

4. Cardiac arrhythmias do not necessarily mean structural heart disease

5. CARDIAC Myocardial Ischaemia Valvular problems CHF NON CARDIAC Hypoxemia Hypercapnia Hypotension Electrolyte imbalance (K;Ca;Mg) Drug toxicity Conditions provoking arrhythmias

6. When you suspect arrhythmia in ICU • 12 lead ECG • Long rhythm strip II;aVf or V1 • Double ECG voltage • ↑ paper speed to 50mm/s

7. Arrhythmias in ICU • Tachyarrhythmias (>100/min) # Narrow QRS complex # Wide QRS complex • Bradyarrhythmias ( <60/min)

8. Clinical classification of arrhythmias • Heart rate (increased/decreased) • Heart rhythm (regular/irregular) • Site of origin (supraventricular / ventricular) • Complexes on ECG (narrow/broad)

9. Narrow QRS complex tachycardias • Atrial premature beats • Sinus Tachycardia (100-150) • PSVT (150-250) • Atrial tachycardia with blocks (150-250) • Atrial flutter (250-350) • Atrial fibrillation (>350) • Multifocal atrial tachycardia

10. 36 year old woman with asthma has ‘thumping in chest’

11. 48yr.M; febrile • Sinus tachycardia • Remove precipitating cause • BB if symptomatic

12. 60yr. F. COPD; Resp. failure • More than 3 different P wave shapes with varying PR interval

13. 60yr. F. COPD; Resp. failure Multifocal Atrial Tachycardia (Chaotic Atrial Tachycardia) • Treat underlying lung disease • Verapamil

14. ECG in Supraventricular Tachycardia Atrial Flutter Atrial Fibrillation

15. Relationship between P & QRS in supraventricular Tachycardia (PR & RP interval) AVNRT AVRT Typical (Slow-Fast) Re-entry : PR > RP, Atypical reentry (Fast-Slow), Sinus & Atrial tachycardias : PR < RP

16. ECG in AV Nodal Reentrant Tachycardia (AVNRT) • QRS is • Regular (180-200/min) • Narrow (<120ms), • No distinct P wave or retrograde P just after QRS

17. WPW Syndrome Sinus Rhthm Short PR, Delta wave. Wide QRS, Normal terminal QRS, Secondary ST/T changes AVRT QRS is Regular (180-200/min) Narrow (<120ms), Distinct retrograde P wave after QRS (RP<PR) AF with Accessory pathway

18. Non- Paroxismal Junctional Tachycardia Increased automaticity of a focus in AV junction (70 – 130 /min) Retrograde P may precede QRS (High Junctional/Coronary sinus rhythm) may coincide or may folow QRS (low junctional rhythm)

19. Wide QRS Tachycardia

20. Underlying Arrhythmia of Sudden Cardiac Death Primary VF 8% Torsades de Pointes 13% VT 62% Bradycardia 17% Bayés de Luna A. Am Heart J. 1989;117:151-159.

21. Underlying Causes of Fatal Arrhythmias Other* Cardiomyopathy 80% Coronary Artery Disease *ion-channel abnormalities, valvular or congenital heart disease, other causes

22. Rhythm Strip During Episodeof Sudden Death • VT degenerates into VF in 30 sec to 3 minutes • 4 minutes into collapse,VF is identified in 90%, asystole identified in 10% • As more time elapses,asystole and EMD areidentified in 60% of victims 6:02 AM 6:05 AM 6:07 AM 6:11 AM

23. The ‘Dying Heart’ !!

24. Wide QRS Tachycardia • Ventricular Premature beats • Ventricular Tachycardia • Ventricular Fibrillation • Torsades de pointes • SVT with aberrancy

25. Cardiac ArrhythmiaPremature Ventricular Contraction

26. 50 yr. M. post CABG presents with palpitations ; (haemodynamically stable)

27. Misconceptions about VT • MISDIAGNOSIS Haemodynamic stable wide QRS tachycardia cannot be VT • UNDERDIAGNOSIS Unexplained syncope : ? Bradyarrhthmia / ??VT

28. 80% of wide QRS tachycardias are VT

29. VT : manifestations • Syncope / Near syncope • Wide QRS tachycardia • Sudden Cardiac Death ( VF)

30. ECG diagnosis of VT

31. VT : Morphological types • UNCHANGING : Monomorphic • CHANGING : Polymorphic # Repetitive – Torsades de Pointes # Alternate complexes – Bidirectional VT # Stable but changing : RBB  LBB

32. Monomorphic VT:uniform QRS for all complexes

33. Polymorphic VT:beat to beat variation in QRS morphology

34. MONOMORPHIC CAD DCM RV dysplasia No structural disease # RBB pattern # LBB pattern POLYMORPHIC Prolonged QT( Torsades de pointes) # Congenital # Acquired Normal QT # Ischaemic (Acute) # Others VT : common causes

35. VT : How long does it last ? • SUSTAINED : # >30sec. # Requiring termination due to haemodynamic instability • NON SUSTAINED : # <30 secs # Stops spontaneously

36. ECG in Ventricular Tachycardia (VT) Non-sustained VT (< 30 sec) Sustained VT (≥ 30 sec)

37. Non sustained polymorphic VT

38. Polymorphic VT degenerating to VF

39. Polymorphic VT in ICU :search for a cause of prolonged QT interval

40. Polymorphic VT : prolonged QT PHARMACOLOGICAL AGENTS Quinidine, Erythromycin,Chloroquine, Amantadine,TCA,phenothiazines, Organophosporous insecticides, Antihistaminics ( astemizole, terfenadine) ELECTROLYTE ABNORMALITIES Hypo Mg;K;Ca

41. Is it Ventricular Tachycardia (VT) or Supraventricular tachycardia with abberrancy (SVTab) ?

42. Wide QRS Tachycardia Supraventricular Tachycardia withAberration,BBB, Accessory pathway Ventricular tachycardia Capture & Fusion beats, AV Dissociation / VA association QRS > 140 msec, Superior QRS axis, Concordant pattern of QRS Capture & Fusion beats AV Dissociation 2:1 VA block

43. Bed side approach : VT vs SVTab

44. In an ICU setting assume it to be VT rather than SVTab

45. Specific Types of VT Verapamil sensitive VT RBBB,LAD, Normal Heart Arrhythmogenic RV Dysplasia VT with LBBB morphology

46. Specific Types of VT Long QT Syndromes Drugs, Electrolyte, Genetic (Jarvell & Lange-Nielsen syndrome, Romano-Ward Syndrome) Torsades de pointes Brugada Syndrome Risk of MalignantVentricular Arrhythmia & Sudden death

47. 60 year old man with recurrent blackouts

48. Malignant Ventricular Arrhythmia Ventricular Flutter Ventricular Fibrillation

49. Finally : a bad one !!!

50. Rhythm Management .