Arrhytmia Highlight : Point of Interest

Prof. Idris Idham , MD, PhD, FIHA,FESC,FACC,FAsCC,FSCAI

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 Introduction
• Cardiac arrhytmia is an abonormality of the heart rhytm
• Bradycardia- heart rate slow (<60 beats/min)
• Tachycardia- heart rate fast (>60 beats/min)

• Cardiac arrhythmias can predispose to the

development of lethal stroke or life threatening
condition that may result in sudden cardiac
death

• 300.000-400.000 people die suddenly each

year in US—> 80% are caused by VF in the
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context of ichemic heart disease

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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
 Mechanism of Arrythmia
(Arrhythmogenesis)
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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
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Classification

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 Classification
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Lily, Leonard S. Pathophysiology of Heart Disease. 5th Edition .2011
 Supraventricular arrythmias

• Sinus tachycardia
• Atrial fibrilation (AF)
Atrial • Atrial flutter (AFL)
origin • Multifocal atrial tachycardia (MAT)
• Atrial tachycardia

AV node • AV nodal reentry tachycardia (AVNRT)

dependent • AV reciprocating tachycardia (AVRT)
• Junctional ectopic tachycardia (JET)
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ACC/AHA/ESC guidelines for the Management of Patient with supraventricular arrhytmias.Circulation. 2003
 AV Nodal Reentry
Tachycardia (AVNRT)
• Re-entrant SVT utilizing the approaches to the AV nodes
and the compact AV node itself

• AV node ( in some people)

• Fast pathway, slower recovery

• Slow pathway, faster recovery

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 AVNRT mechanism
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AVNRT
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 Atrioventricular Reentry
Tachycardia (AVRT)
• AVRT is a form of paroxysmal
supraventricular tachycardia
• A reentry circuit is formed by
the normal conduction system
and the accessory pathway
resulting in circus movement
• AVRT are divided into
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orthodromic and antidromic

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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701 antedromic (right) AVRT
 AVRT mechanism
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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
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Lily, Leonard S. Pathophysiology of Heart Disease. 5th Edition .2011
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 Antidromic AVRT

Orthodromic
AVRT
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 Ventricular arrythmias

• Premature Ventricular Contraction (PVC)

• Ectopic ventricular beat
• Non life threatening and usually asymptomatic
• Ventricular Tachycardia (VT)
• A life threatening situation
• >3 consecutive PVCs occuring at a rate >100 beats/ min
• Could be monomorphic or polymorphic
• Ventricular Fibriliation
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• results in hemodynamic collapse,syncope,and cardiac arrest.

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 Premature Ventricular Contraction (PVC)
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 Monomorphic PVC

Polymorphic PVC
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 Ventricular Tachycardia

• Mechanism of VT are disorder of

impulse formation ( enhanced
automoaticity or triggered activiy)
and conduction
• Occurence of a series of three or
more consecutive, abnormally
shaped PVCs whose duration
exceeds 120 m
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 Ventricular Tachycardia

• Regular
• Wide
• No identifiable P wave
• Rate >150x/min
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 Ventricular Fibrilation

• Irregular
• Wide
• No P wave
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 Torsade De Pointes

• Form of polymorphic VT
with the variation of QRS
amplitude
• Irregular
• Wide
• No p wave
• Migrating QRS axis
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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-
701
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 Diagnosis of cardiac arrythmias

• History & Physical examination

• palpitation? presyncope? syncope? shortness of breath?

• ECG

• Exercise test
• Px who have symtoms with arrythmia induced by exercise
(syncope,sustained palpitations should be considered for stress testing)

• Upright Tilt-table testing

• To identify patient who have vasodepressor or cardioinihbitory response as
a cause of syncope
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ECG abnormalities in resting rhytm

that suggest potential for arrhythmia

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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
 Diagnosis of cardiac arrythmias
Long term ECG recording (Ambulatory ECG)

• Indication
• To evaluate unexplained syncope,near
syncope, or episodic dizziness
• Unexplained recurrent palpitation
• To asses the adequacy of rate control in
AF patients
• To screen for asymptomatic PVC or non
sustained VT in HCM, long QT syndrome,
or brugada
• To asses silent MI
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MCrawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography : executive summary and recommendations. A report of the American College of Cardiology/ American Heart Association task force on practice guideline. Ciruculation 1
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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
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 Types of ambulatory ECG
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 Types of ambulatory ECG
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 Diagnosis of cardiac arrythmias
Electrophysiology study(EPS)

• Function : To diagnose and to treat cardiac

arrythmia
• EPS provide information about cardiac
automoaticity and conduction (sinus node,AV
node, and His-Purkinje function )
• EPS—>detect arrythmia causes of syncope
and distinguish VT from SVT with abberancy
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Miller JZD. Diagnosis of cardiac arrhytmias. Braunwald’s heart disease. 2012; 1: 687-701
 Therapy
Antiarrythmic drug
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 ACC/AHA/ESC guidelines for the Management of Patient with supraventricular arrhytmias.2003

Response of narrow complex tachycardia

with adenosine
regular narrow QRS
complex tachycardia

IV adenosine

Gradual slowing Persistent atrial

No change in rate then reacceleration sudden termination tachycardia with
of rate transient high
grade AV block

• inadequate dose • Sinus

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• Consider VT tachycardia
(fascicular or •AVNRT
• Focal AT
• AVRT • Atrial flutter
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high septal • Nonparoxysmal
• Focal reentry • AT
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origin) junctional
tachycardia
 Electrical therapy
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If VT pulseless or VF—>DC shock
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 ICD
(implantable cardioverter-defibrilator)
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 When to consider ICD (implantable
cardioverter-defibrilator)?
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 Summary

• Cardiac arrythmia is abnormality of heart rhytm, consist of

tachyarrythmia and bradyarrythmia
• Cardiac arrythmia can lead to life threatening condition that
may result in cardiac death
• Evaluation of the patient with arrythmia could be done with
histroy taking, physical examniation,ECG,ambulatory
ECG,exercise testing
• Therapy of cardiac arrythmia consist of pharmacotherapy
and electrical therapy
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