Intro Conduction system of heart Symptomssigns Investigations Tachy vs Brady Bradyarrhythmias Different types Management Tachyarrhythmias Broad vs narrow Types of each Management of each ID: 775332
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Slide1
Danny HaywoodFY1
Arrhythmias
Slide2Intro
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
Slide3Slide4Symptoms/signs
Syncope
Dizziness
Palpitations
Heart Failure
Chest pain
Sudden death
No symptoms
Slide5Investigations
Bedside
ECG
Bloods
TFTs, U+E, FBC, Troponins
Imaging
Echo, CXR
Special tests
Holter monitor
Slide6ARRhYTHMIAS
Bradyarrhythmias vs Tachyarrhythmias
Brady
HR < 60bpm
Tachy
HR > 100bpm
Slide7Bradyarrhythmias
Type I heart block
1
st
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
Slide8Management
Acute (eg. Secondary to MI)
If symptomatic/clinical deterioration
IV atropine
External (transcutaneous) pacing
Chronic
Mobitz type II or complete AV block
Permanent pacemaker
Slide9Tachyarrhythmias
Narrow complex (Supraventricular) vs Broad complex (Ventricular)
Narrow
QRS <0.12 seconds
Broad
QRS >0.12 seconds
Slide10Narrow complex
Sinus tachycardia
Atrial Fibrillation (AF)
Atrial Flutter
Atrioventricular
nodal re-entry tachycardia (AVNRT)
Atrioventricular
reciprocating tachycardia (AVRT)
Slide11AF
Continuous, rapid activation of atria – due to rapidly depolarising foci within the atriaOften located by pulmonary veinsNo coordinated mechanical action
Slide12AF – 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)
Slide13AF - management
Conservative
Alcohol cessation
Lifestyle factors (diet/exercise/smoking)
Medical
Treat underlying cause
Rate control
vs
rhythm control
Interventional
Catheter ablation
Slide14Rate control
Older age, permanent AF
Bisoprolol/verapamil and Warfarin (CHADSVASc)
Slide15Chadsvasc
C Congestive heart failure (or Left ventricular systolic dysfunction)1 H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)1 A2 Age ≥75 years2 D Diabetes Mellitus1 S2 Prior Stroke or TIA or thromboembolism2 V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)1 A Age 65–74 years1 Sc Sex category (i.e. female gender)1
ScoreRiskAnticoagulation Therapy0LowNo antithrombotic therapy (or Aspirin)1ModerateOral anticoagulant (or Aspirin)2 or greaterHighOral anticoagulant
Slide16Rhythm 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
Slide17Rhythm control
Pharmacological
No structural heart disease
1
st
- Flecainide
2
nd
– Sotalol
3
rd
– Amiodarone
Structural heart disease
Amiodarone
Interventional
Pulmonary vein isolation - catheter ablation
Slide18Atrial Flutter
Organised atrial rhythm, coming from ectopic focus in atria (usually left)Usually 300bpmVentricular rate depends on degree of AV block eg 2:1 = 150bpmSaw tooth pattern
Slide19Atrial 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
Slide20AVNRT
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.
Slide21avnrt
Slide22AVRT
Accessory pathway (Bundle of Kent most common)Pre-excitation (delta wave) on ECGWolff-Parkinson-White syndrome
Slide23Management 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
Slide24Broad complex tachysVT vs VF
VTUnstable electrical cardioversionStable 1st – Class I Anti-arrhythmics (lidocaine)2nd – Amiodarone3rd – DC cardioversion
Slide25Broad complex tachysVT vs VF
VFCardiac arrestRapid, irregular activity – no cardiac outputUsually provoked by ventricular ectopic beatManagementElectrical defibrillation
Slide26Broad complex tachys
Something to be aware ofSVT with concomitant bundle branch block = broad complex tachy
Slide27Summary
Brady vs tachy
Brady
Sinus Brady
1
st
degree heart block
Mobitz I & II
Complete
Tachy
Narrow
Sinus tachy, AF, Flutter, AVNRT, AVRT
Broad
VT, VF,
Remember causes of AF
Slide28ECGs – test yourself
Slide29A
Slide30B
Slide31C
Slide32D
Slide33E
Slide34F
Slide35G
Slide36H
Slide37I
Slide38J
Slide39K
Slide40L
Slide41Answers
Sinus rhythm
AF
Atrial Flutter
VT
VF
1
st
degree heart block
Complete heart block
Mobitz
type II
AVRT
Mobitz
type I
AVNRT
Right bundle branch block
Slide42References
All images and ECGs borrowed gratefully from google images
Kumar & Clarke: Clinical Medicine 7
th
Ed
NICE guidelines: AF (CG36)