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APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA

APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA. Masoud Eslami MD Imam Khomeini Hospital. ANY VARIATION FROM THE NORMAL RHYTHM OF THE HEART BEAT IS CALLED ARRHYTHMIA. WHAT IS THE NORMAL RHYTHM OF THE HEART BEAT ?. IT IS CALLED NORMAL SINUS RHYTHM ( NSR )

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APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA

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  1. APPROACH TO THE PATIENT WITH CADIAC ARRHYTHMIA Masoud Eslami MD Imam Khomeini Hospital

  2. ANY VARIATION FROM THE NORMAL RHYTHM OF THE HEART BEAT IS CALLED ARRHYTHMIA

  3. WHAT IS THE NORMAL RHYTHM OF THE HEART BEAT ? IT IS CALLED NORMAL SINUS RHYTHM ( NSR ) • THE IMPULSE ORIGINATES IN THE SINUS NODE • THE RATE IS BETWEEN 60-100 • THE P WAVE IS UPRIGHT IN I , II AND aVf , NEGATIVE IN aVr AND POSITIVE IN V3-V6 • THE PR INTERVAL IS BETWEEN 120-220MS

  4. NSR

  5. ARRHYTHMIAS ARE CLASSIFIED INTO: 1-BRADYARRHYTHMIAS 2-TACHYARRHYTHMIAS

  6. TACHYARRHYTHMIAS • ATRIAL TACHYARRHYTHMIAS • AV JUNCTIONAL TACHYARRHYTHMIAS • VENTRICULAR TACHYARRHYTHMIAS

  7. ATRIAL TACHYARRHYTHMIAS PREMATURE ATRIAL COPMLEXES ( PAC OR APD ) • PREMATURE COMPLEXES ARE AMONG THE MOST COMMON CAUSES OF AN IRREGULAR PULSE • COMMONLY ARISE IN NORMAL HEARTS,BUT THEY ARE MORE OFTEN ASSOCIATED WITH STRUCTURAL HEART DISEASE AND INCREASE IN FREQUENCY WITH AGE

  8. Premature Beats Premature Atrial Contraction (PAC) Origin: Atrium (outside the Sinus Node) Mechanism: Abnormal Automaticity Characteristics: An abnormal P-wave occurring earlier than expected, followed by compensatory pause

  9. Premature Beats Premature Junctional Contraction Origin: AV Node Junction Mechanism: Abnormal Automaticity Characteristics: A normally conducted complex with an absent p-wave, followed by a compensatory pause

  10. PAC PACs CAN OCCUR DURING • INFECTION • INFLAMMATION • MYOCARDIAL ISCHEMIA • BY MEDICATIONS • TENSION STATES • TOBACCO • ALCOHOL • CAFFEINE THEY CAN PRECIPITATE OR PRESAGE THE OCCURRENCE OF SUSTAINED SUPRAVENTRICULAR TACHYARRHYTHMIAS

  11. PAC MANAGEMENT • PACs GENERALLY DO NOT REQUIRE THERAPY • IN SYMPTOMATIC PATIENTS OR WHEN PACs PRECIPITATE TACHYCARDIAS,TREATMENT WITH DIGITALIS,A BETA BLOCKER,OR A CALCIUM ANTAGONIST CAN BE TRIED

  12. PREMATURE VENTRICULAR COMPLEXES( PVC ) • PREMATURE OCCURRENCE OF A QRS COMPLEX THAT IS ABNORMAL IN SHAPE AND HAS A DURATION OF MORE THAN 120 ms • THE PREVALENCE OF PVC INCREASES WITH AGE • SYMPTOMS OF PALPITATIONS OR DISCOMFORT IN THE NECK OR CHEST

  13. Premature Beats Premature Ventricular Contractions (PVCs) Origin: Ventricles Mechanism: Abnormal Automaticity Characteristics: A broad complex occurring earlier than expected, followed by a compensatory pause

  14. PVC Patterns • Bigeminy • Every other beat • Trigeminy Every third beat • Quadrigemin Every fourth beat

  15. Multifocal PVC • Origin: Varies within the Ventricle • Mechanism: Abnormal Automaticity • Characteristics: Each premature beat changes axis; implies a different focus origin for each beat

  16. PVC THE IMPORTANCE OF PVC DEPENDS ON THE CLINICAL SETTING IN THE ABSENCE OF UNDERLYING HEART DISEASE,THE PRESENCE OF PVC HAS NO IMPACT ON LONGEVITY THE SYMPTOMATIC PATIENT SHOULD BE ASSURED

  17. PVC • REASSURANCE AND AVOIDANCE OF POTENTIALLY AGGRAVATING FACTORS ( TOBACCO,COFFEE,CAFFEINE-CONTAINING SOFT DRINKS ),SHOULD BE TRIED FIRST • MILD ANXIOLYTIC DRUGS OR BETA-BLOCKERS ARE PREFERRED

  18. Paroxysmal Supraventricular Tachycardia (PSVT) • Usually at a rate of 150-250 bpm • No organic heart disease in the majority • Presentations • Palpitations • Chest discomfort,dyspnea, lightheadedness • Frank syncope • SCD

  19. AV Nodal Reentrant Tachycardia • The most common form of paroxysmal supraventricular tachycardia (about 70%) • More common in women (66%) • Usually a regular narrow QRS complex tachycardia • No P wave is usually evident during the tachycardia. Retrograde P waves may occasionally be seen at the end of QRS.

  20. AVNRT Origin: AV Node Mechanism: Reentry Rate: 150 - 230 BPM, faster in teenagers Characteristics: Normal QRS with absent P-waves; most common SVT in adults

  21. AVNRT

  22. Atrium Slow Pathway Fast Pathway His Bundle Longitudinal Dissociation Within AV Node

  23. AVNRT

  24. Wolff-Parkinson-White(WPW) Syndrome

  25. AV Reentrant Tachycardia • Incorporates a bypass tract as part of the tachycardia circuit. • Surface ECG: • Manifest with short PR interval and delta wave (preexcitation) • Concealed with normal ECG • Prevalence of ECG pattern: 0.1% to 0.3%.

  26. Wolff-Parkinson-White Origin: Outside the AV Node Mechanism: Reentry Rate: 180-260 BPM – can be faster Characteristics: Short PR Interval (< 120 ms),wide QRS (> 110 ms), obvious delta wave

  27. Pre-excitation

  28. Pre-excitation

  29. AVRT Types

  30. AVRT • Mechanism: Reentry • Rate: 180 - 260 BPM, sometimes faster • Characteristics: Extra electrical pathway to ventricles Wolf-Parkinson-White (WPW) Syndrome is most common

  31. AVRT

  32. PSVTTreatment • Vagal maneuvers particularly carotid sinus massage • AV nodal blocking drugs • Adenosine • Verapamil • Propranolol • Digoxin • DC cardioversion if hypotensive • Radiofrequency ablation

  33. Atrial Flutter • Regular atrial tachyarrhythmia with atrial rate between 250-350 bpm. • Flutter waves are seen as saw-tooth like atrial activity

  34. Atrial Flutter • Typically the ventricular rate is half the atrial rate, but the ventricular response may be 4:1, 1:1, etc. • Atrial Flutter is a form of atrial reentry localized to right atrium.

  35. Atrial Flutter Circuit

  36. Atrial Flutter with 2:1 Conduction

  37. Atrial Flutter with 4:1 Conduction

  38. Atrial Flutter • More common in men (4.7:1) • Most often in patients with organic heart disease • Usually less long-lived than AF and may convert to AF. • Control of ventricular rate is difficult in atrial flutter • The most effective treatment is DC cardioversion

  39. Atrial Fibrillation • The most common sustained arrhythmia • Incidence increases progressively with age. • Prevalence: 0.4% of overall population • Mortality ratedouble that of control • Hypertension and CAD, the most frequent underlying heart diseases • AF is characterized by disorganized atrial activity without discrete P waves

  40. Atrial Fibrillation

  41. Atrial Fibrillation • Undulating baseline or atrial deflections of varying amplitude and frequency ranging from 350 to 600 bpm. • Irregularly irregular ventricular response.

  42. Atrial Fibrillation with Rapid Ventricular Response

  43. Atrial Fibrillation • Morbidity related to: • Excessive ventricular rate • Pause following cessation of AF • Systemic embolization • Loss of atrial kick • Anxiety secondary to palpitations • Irregular ventricular rate

  44. Atrial Fibrillation • Persistent AF usually in patients with cardiovascular disease • Valvular heart disease • Hypertensive heart disease • Congenital heart disease • Paroxysmal AF may occur with acute hypoxia, hypercapnia or metabolic or hemodynamic derangements • Normal people with emotional stress or surgery or acute alcoholic intoxication • Lone AF

  45. Atrial Fibrillation • Therapeutic Goals: • Control of ventricular rate • Restoration and maintenance of sinus rhythm • Prevention of thromboembolism

  46. Radiofrequency Ablation

  47. RFA

  48. Electrophysiologic Study

  49. Loss of Delta

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