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Arrhythmias

Arrhythmias. Danny Haywood FY1. Intro. Conduction system of heart Symptoms/signs Investigations Tachy vs Brady Bradyarrhythmias Different types Management Tachyarrhythmias Broad vs narrow Types of each Management of each Summary Some example ECGs. Symptoms/signs. Syncope

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Arrhythmias

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  1. Arrhythmias Danny Haywood FY1

  2. Intro • Conduction system of heart • Symptoms/signs • Investigations • TachyvsBrady • Bradyarrhythmias • Different types • Management • Tachyarrhythmias • Broad vs narrow • Types of each • Management of each • Summary • Some example ECGs

  3. Symptoms/signs • Syncope • Dizziness • Palpitations • Heart Failure • Chest pain • Sudden death • No symptoms

  4. Investigations • Bedside • ECG • Bloods • TFTs, U+E, FBC, Troponins • Imaging • Echo, CXR • Special tests • Holter monitor

  5. ARRhYTHMIAS • Bradyarrhythmias vs Tachyarrhythmias • Brady • HR < 60bpm • Tachy • HR > 100bpm

  6. Bradyarrhythmias • Type I heart block • 1st degree heart block • Prolonged PR interval > 0.2 seconds • Type II heart block • Mobitz type 1 – Wenckebach • Gradually increased PR intervals until missed QRS • Mobitz type 2 • Intermittently P wave not followed by QRS • May be pattern eg 2:1, 3:1 ratio of P waves to QRS complexes – no increase in PR interval • Type III heart block • Complete heart block • No correlation between P waves and QRS complexes

  7. Management • Acute (eg. Secondary to MI) • If symptomatic/clinical deterioration • IV atropine • External (transcutaneous) pacing • Chronic • Mobitz type II or complete AV block • Permanent pacemaker

  8. Tachyarrhythmias • Narrow complex (Supraventricular) vs Broad complex (Ventricular) • Narrow • QRS <0.12 seconds • Broad • QRS >0.12 seconds

  9. Narrow complex • Sinus tachycardia • Atrial Fibrillation (AF) • Atrial Flutter • Atrioventricular nodal re-entry tachycardia (AVNRT) • Atrioventricular reciprocating tachycardia (AVRT)

  10. AF • Continuous, rapid activation of atria – due to rapidly depolarising foci within the atria • Often located by pulmonary veins • No coordinated mechanical action

  11. AF – Causes • ATRIAL PhIB • A – Alcohol • T – Thyroid disease • R – Rheumatic heart disease • I – Ischaemic heart disease • A – Atrial myxoma • L – Lung pathology (pneumonia, PE) • Ph – Pheochromocytoma • I – Idiopathic • B – Blood pressure (hypertension)

  12. AF - management • Conservative • Alcohol cessation • Lifestyle factors (diet/exercise/smoking) • Medical • Treat underlying cause • Rate control vs rhythm control • Interventional • Catheter ablation

  13. Rate control • Older age, permanent AF • Bisoprolol/verapamil and Warfarin (CHADSVASc)

  14. Chadsvasc

  15. Rhythm control • Cardioversion • Pharmacological vs DC • younger, symptomatic, physically active patients • Congestive heart failure • Paroxysmal AF • failure of rate control • < 48 hours • Cardioversion + heparin • > 48hrs – TOE/anti-coagulation (3 weeks) • risk of failure? • High – 4 weeks sotalol/amiodarone then electrical. • Low - electrical

  16. Rhythm control • Pharmacological • No structural heart disease • 1st - Flecainide • 2nd – Sotalol • 3rd – Amiodarone • Structural heart disease • Amiodarone • Interventional • Pulmonary vein isolation - catheter ablation

  17. Atrial Flutter • Organised atrial rhythm, coming from ectopic focus in atria (usually left) • Usually 300bpm • Ventricular rate depends on degree of AV block eg 2:1 = 150bpm • Saw tooth pattern

  18. Atrial Flutter • Management • Conservative • Vagal manoeuvres • Medical – similar to AF • Acute • DC cardioversion or IV adenosine (<48 hours) • > 48 hours - 3 weeks anticoag then cardiovert • Chronic • Pill in pocket • Regular anti-arrhythmics • Interventional • Radiofrequency catheter ablation

  19. AVNRT • 2 pathways within the AV node 1) short refractory period + slow conduction 2) long refractory period + fast conduction • Normally conducts through fast pathway • If premature atrial beat, fast pathway still refractory (long refractory period) therefore travels down slow pathway and back up the fast pathway.

  20. avnrt

  21. AVRT • Accessory pathway (Bundle of Kent most common) • Pre-excitation (delta wave) on ECG • Wolff-Parkinson-White syndrome

  22. Management of SVTs • Haemodynaically unstable • Electrical cardioversion • Conservative • Vagal manoeuvres • Valsalva, carotid massage, cold water • Medical • Adenosine (acute) • Anti-arrhythmics (regular and pill-in-pocket) • Interventional • Catheter ablation

  23. Broad complex tachysVT vsVF • VT • Unstable • electrical cardioversion • Stable • 1st – Class I Anti-arrhythmics (lidocaine) • 2nd – Amiodarone • 3rd – DC cardioversion

  24. Broad complex tachysVT vs VF • VF • Cardiac arrest • Rapid, irregular activity – no cardiac output • Usually provoked by ventricular ectopic beat • Management • Electrical defibrillation

  25. Broad complex tachys • Something to be aware of • SVT with concomitant bundle branch block = broad complex tachy

  26. Summary • Brady vs tachy • Brady • Sinus Brady • 1st degree heart block • Mobitz I & II • Complete • Tachy • Narrow • Sinus tachy, AF, Flutter, AVNRT, AVRT • Broad • VT, VF, • Remember causes of AF

  27. ECGs – test yourself

  28. A

  29. B

  30. C

  31. D

  32. E

  33. F

  34. G

  35. H

  36. I

  37. J

  38. K

  39. L

  40. Answers • Sinus rhythm • AF • Atrial Flutter • VT • VF • 1st degree heart block • Complete heart block • Mobitz type II • AVRT • Mobitz type I • AVNRT • Right bundle branch block

  41. References • All images and ECGs borrowed gratefully from google images • Kumar & Clarke: Clinical Medicine 7th Ed • NICE guidelines: AF (CG36)

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