Arrhythmias

Richard G Sheahan,
Consultant
Cardiologist/Electrophysiologist
Paroxysmal
Ectopic focus, sudden onset, abrupt cessation
Sustained
Duration of > 30 seconds
Requires intervention to terminate
Non-Sustained
At least 3 beats or < 30 seconds
Spontaneously terminates
Recurrent
Occurs periodically
Periods of no tachycardia are longer than periods
of tachycardia
Terms Describing Tachycardias
Tachyarrhythmias
Supraventricular Tachycardia
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
Sudden Cardiac Death
Premature Atrial & Ventricular
Complexes
2% VF
Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
34%
Atrial
Fibrillation
18%
Unspecified
6%
PSVT
6%
PVCs
4%
Atrial
Flutter
9%
SSS
8%
Conduction
Disease
3% SCD
10% VT
Arrhythmia Symptoms
Palpitations Sudden Onset or Offset
Shortness of Breath
Chest pain
Syncope or Presyncope/Dizziness
Increasing Fatigue
Cough & Sputum
Impaired Quality of Life
Arrhythmia Signs
Pulse Rate
Blood Pressure
O2 Saturation
Perfusion, Pale Sweaty & Clammy
Heart Failure

Tachycardia Recognition
Rate > 100 bpm
Regular or Irregular
Narrow complex or Broad complex
P waves present or absent
Clinical Assessment
Past History
Arrhythmia
Supraventricular Tachycardia
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
Sudden Cardiac Death
Premature Atrial & Ventricular Complexes


Origin: AV Node
Mechanism: Reentry
Rate: 150 - 230 BPM, faster in teenagers
Characteristics: Normal QRS with absent P-waves;
most common SVT in adults
SVT
Supraventricular Tachycardia
IV Adenosine
Rate Control
Beta blockers, Calcium Channel Blockers
(Digoxin)
Rhythm Control
Normal Ventricule:
Propafenone, Flecainide, sotalol
Abnormal Ventricule
Amiodarone
Synchronized Cardioversion
Hemodynamically unstable
EP Study & RF Ablation
AVNRT( atrioventricular nodal re-entrant tachycardia)
Accounts for 80-90% of SVT
Abrupt onset and offset
The typical ventricular
rate is 140-300/min
P is usually buried within
the QRS complex
Best identified in V1

SVT-AVNRT

P
Just learn to recognise SVT, no need to know
AVRT or AVNRT specifically

AVRT( atrioventricular re-entrant tachycardia)
Reentrant circuit
consists of an
atrioventricular
nodal pathway and
accessory pathway
SVT-AVRT
Sinus Tachycardia
Pain
Anxiety
Fever
Anaemia
Dehydration
Hyperthyroidism
Sinus Tachycardia Treatment
Treat the cause
Acute management:
Treatment aimed at restoration of sinus
rhythm
1. Carotid sinus massage
2. IV adenosine
3. IV verapamil


Sinus Tachycardia Treatment
Long term management:
1. Drug therpy
- directed at AVN
- beta-blocker
- calcium channel blocker
- digoxin
- directed at AP
- Class IA/C agents
2. Radiofrequency ablation
3. Treat the underlying causes (if any)


Arrhythmia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation

Atrial Flutter
Atrial Flutter Treatment
Anticoagulation for High Risk Patients
Rate Control
Beta-blocker, Ca Channel Blocker, (?Digoxin)
Rhythm Control
Cardioversion
Antiarrhythmics
Radiofrequency Ablation

Arrhythmia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation

Atrial Fibrillation
MOST IMPORTANT RHYTHM AND COMMONEST

Feinberg WM, Blackshear JL, Laupacis A, et al. Arch Intern Med. 1995;155:469-473
Atrial Fibrillation
Feinberg WM, Blackshear JL, Laupacis A. Arch Intern Med. 1995;155:469-473
Atrial Fibrillation Demographics by
Age
Atrial Fibrillation Treatment 1
Stroke Prevention
Heparin, Warfarin or newer anticoagulants
ASA
Rate Control
Betablockers, Ca Channel blockers, (? Digoxin)
Rhythm Control
Normal Heart: Propafenone, Flecainide, Sotalol
CHF/LVH/CAD: Amiodarone

Atrial Fibrillation Treatment 2
CORE MATERIAL
Synchronized Cardioversion
< 48 hours Heparin + Cardioversion

> 48 hours Heparin + TOE +/-
Cardioversion
Or Warfarin INR 2.0 -3.0 for > 4 weeks

Pulmonary Vein Isolation Ablation
Atrial Fibrillation Treatment 3
Associated Conditions
Treat Hyperthyroidism before
cardioversion
Treat sepsis
Treat pulmonary embolism
Pacemaker for Bradycardia
CHADS
2
Score*
Congestive heart failure 1
History of hypertension 1
Age > 75 1
Diabetes 1
Stroke / TIA 2

Warfarin indicated when CHADS
2
score > 2
* The CHADS
2
scores were developed in a study published in The Journal of the
American Medical Association in 2001
Annual Stroke Risk
Recommendations for Anticoagulation
Atrial Flutter vs. Atrial Fibrillation
CORE
Atrial Flutter

Summary of Disease Characteristics
Underlying
Mechanism
Pattern

Atrial Rate

Ventricular Rate

Rhythm

Atrial Fibrillation
Multiple wavelet reentry
Multiple/single focus
firing
Wavy baseline

400 BPM

Varies w/conduction

Grossly Irregular
Reentry via macro
reentrant circuit
Saw tooth baseline

250 to 320 BPM

Varies w/conduction

Usually regular
Arrhythmia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation

Origin: Ventricles (Single Focus)
Mechanism: Reentry Initiated by abnormal
Automaticity or Triggered activity
Characteristics: Rapid, wide, and regular QRS
ECG Characteristics
Monomorphic VT
*
Animation
Origin: Ventricles (Wandering Single Focus)
Mechanism: Reentry with movement in the circuit
Initiated by Abnormal Automaticity or
Triggered activity
Characteristics: Wide and irregular QRS Complex that
changes in axis QTc Normal
Polymorphic VT
*
Animation
Origin: Ventricle
Mechanism: Reentry (movement in focus)
Rate: 200 250 BPM
Characteristics: Associated with Long QT interval;
QRS changes axis & morphology
with alternating positive/negative
complexes
Torsades de Pointes
Ventricular Tachycardia
CORE
Ventricular Tachycardia Treatment
Acute
Synchronized Cardioversion if unstable
+/- CPR
IV Amiodarone, Beta-blocker, Magnesium
Chronic
Correct Reversible Causes
ICD if no 1) Reversible Causes or 2) EF <
35%
Arrhythmia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation

Ventricular Fibrillation
CORE
Ventricular Fibrillation Treatment
Acute
Defibrillation
CPR & ACLS
IV Amiodarone, Beta-blocker, Magnesium
Chronic
Correct Reversible Causes
ICD if 1) no Reversible Causes 2) EF < 35%