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Arrhythmias

Arrhythmias. Yasmine Darwazeh FY1 – General Surgery. Objectives. Define bradyarrhythmia and tachyarrythmia Know the most common brady - & tachyarrythmias Recognise them on an ECG. Know the main signs and symptoms, aetiology and treatments of each. What can you see?.

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Arrhythmias

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  1. Arrhythmias YasmineDarwazeh FY1 – General Surgery

  2. Objectives • Define bradyarrhythmia and tachyarrythmia • Know the most common brady- & tachyarrythmias • Recognise them on an ECG. • Know the main signs and symptoms, aetiology and treatments of each.

  3. What can you see?

  4. Types of bradyarrhythmia

  5. Sinus Bradycardia • HR < 60bpm • Causes • Physiological (normal in athletic people) • Iatrogenic (Beta blockers, Ca channel blockers, digoxin, anticholinergics) • Hypothyroidism • Metabolic e.g. hyperkalemia • Hypoxia • Hypothermia • Acute MI/ischemia • Treatment • Remove cause (ie drugs) • Treat cause (ie hypothyroidism)

  6. What can you see?

  7. 1st degree AV node block • PR interval >0.2secs (more than 5 small squares) • Delayed conduction through/near the AVN • Usually asymptomatic • Narrow QRS complex indicates block within AVN • Wide QRS complex indicates His-Purkinje block. • Causes • MI • Myocarditis/endocarditis • SLE • Treatment • Usually benign • Can progress to other forms of AV block • If symptomatic, consider pacemaker

  8. What can you see?

  9. Mobitz type 1 (Wenkebach) • PR interval progressively lengthens until a P wave is not followed by a QRS complex. • Continues as a cycle. • Due to a conduction defect within the AVN • Causes: • Inferior MI • Drugs • Myocarditis • Treatment • None required (unless reversible cause)

  10. What can you see?

  11. Mobitz type 2 • Intermittent non-conducting P waves. • May occur in regular pattern e.g. every 3rd p wave is not followed by a QRS complex (3:1 block) • Causes • Anterior MI • Inflammatory (rheumatic fever, myocarditis) • Autoimmune (SLE, systemic sclerosis) • Hyperkalaemia • Infiltration (sarcoid, haemochromatosis, amyloid) • Treatment • Internal pacing eventually as likely to progress to 3rd degree heart block

  12. What can you see?

  13. Complete AV block • Complete dissociation between atrial & ventricular depolarisations • All impulses from atria blocked by the AVN • Very symptomatic & very syncopal. • Causes • Inferior MI • Drugs (ca channel blockers, beta blockers, digoxin) • Progression of Mobitz 1 & II • Congenital (if mother has SLE) • Lev's disease: idiopathic fibrosis & calcification of conducting system • Treatment • Internal pacing

  14. Adult Bradycardia Algorithm

  15. What can you see?

  16. Sinus tachycardia • HR > 100bpm • Causes: • Intra-cardiac causes  • Ishcaemic heart disease • Valvular heart disease • Heart failure • Cardiomyopathy • Congenital heart disease • Treatment • Treat the cause. • Extra-cardiac causes • Drugs • Alcohol • Stimulants e.g. caffeine • Stress • Hyperthyroidism • Infection/Sepsis

  17. Broad and Narrow Complex tachycardias • Broad Complex Tachyarrhythmias • Ventricular Tachycardia • Torsades de Pointes • Ventricular Fibrillation • Narrow Complex Tachyarrhythmias (SupraventricularTachycardias) • Sinus Tachycardia • Atrial Tachycardia • ReentrantTachycardias (AVNRT and AVRT) • Atrial Fibrillation • Atrial Flutter

  18. What can you see?

  19. Atrial Flutter • SVT, regular • Saw-tooth flutter waves. • Flutter waves rate = 300 bpm • Ventricular rate = 150 bpm or 100 bpm, due to AVN block ratio of 2:1 or 3:1 • Ectopic atrial beat causes a re-entrant circuit within the atria. • Causes • As for AF • Hyperkalaemia • Digoxin toxicity. • Treatment • As for AF (discussed later) • Can be differentiated from Fast AF with vagal manouvres/adenosine.

  20. What can you see?

  21. Ventricular tachycardia • Broad complex tachycardia • Causes • Electrolyte derangement (hypokalaemia, hypomagnesaemia, hypocalcaemia) • Myocardial ischaemia/infarct • Cardiomyopathy • Congenital (HOCM, long QT) • Treatment • Amiodarone • ICDs

  22. What can you see?

  23. Atrial Fibrillation • Atria chaotically fibrillate. • Fibrillation rate between 350 & 600bpm. • Variable impulse conduction through the AVN • Irregularly irregular rhythm • Most common arrhythmia. • 10% of population >80 years old. • Significant morbidity due to thromboembolic disease • Unmanaged = 5% yearly stroke risk.

  24. Atrial Fibrillation • Types • Paroxysmal (acute onset, spontaneous termination within 1 week) • Persistent (>7 days, can be cardioverted) • Permanent (> 1 year not terminated by cardioversion) • Causes • Cardio (HTN, valvular disease, CAD, myositis) • Pulmonary (PE, pneumonia, COPD, lung Ca) • Metabolic (hyperthyroidism) • Infection • Drugs (alcohol, illicit drugs)

  25. AF • Investigations • Bedside – ECG/24 hour tape • Bloods – FBC, U&Es, LFTs, TFTs, coag screen • Imaging – CXR, echo • Management (Rate vs Rhythm) • Rate – • Beta blockers • Digoxin • Rhythm • Cardioversion • Sotalol • Amiodarone (HF)

  26. AF - CHA2DS2-VASc score • Thromboprophylaxis • C – cardiac failure (1) • H – HTN (1) • A - >75 (2, 1 if 65-74) • D – diabetes (1) • S- stroke/TIA (2) • Va – vascular disease • Sc – female (1) 0 = Low Risk 1 = Moderate risk 2 or more = high risk

  27. Summary • Define bradyarrhythmia and tachyarrythmia • Know the most common brady- & tachyarrythmias • Recognise them on an ECG. • Know the main signs and symptoms, aetiology and treatments of each.

  28. Any Questions

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