Danny Haywood FY1 Arrhythmias - PowerPoint Presentation

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Danny HaywoodFY1

Arrhythmias

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Intro

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

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Symptoms/signs

Syncope

Dizziness

Palpitations

Heart Failure

Chest pain

Sudden death

No symptoms

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Investigations

Bedside

ECG

Bloods

TFTs, U+E, FBC, Troponins

Imaging

Echo, CXR

Special tests

Holter monitor

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ARRhYTHMIAS

Bradyarrhythmias vs Tachyarrhythmias

Brady

HR < 60bpm

Tachy

HR > 100bpm

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Bradyarrhythmias

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

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Management

Acute (eg. Secondary to MI)

If symptomatic/clinical deterioration

IV atropine

External (transcutaneous) pacing

Chronic

Mobitz type II or complete AV block

Permanent pacemaker

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Tachyarrhythmias

Narrow complex (Supraventricular) vs Broad complex (Ventricular)

Narrow

QRS <0.12 seconds

Broad

QRS >0.12 seconds

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Narrow complex

Sinus tachycardia

Atrial Fibrillation (AF)

Atrial Flutter

Atrioventricular

nodal re-entry tachycardia (AVNRT)

Atrioventricular

reciprocating tachycardia (AVRT)

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AF

Continuous, rapid activation of atria – due to rapidly depolarising foci within the atriaOften located by pulmonary veinsNo coordinated mechanical action

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AF – 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)

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AF - management

Conservative

Alcohol cessation

Lifestyle factors (diet/exercise/smoking)

Medical

Treat underlying cause

Rate control

vs

rhythm control

Interventional

Catheter ablation

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Rate control

Older age, permanent AF

Bisoprolol/verapamil and Warfarin (CHADSVASc)

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Chadsvasc

 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

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Rhythm 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

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Rhythm 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

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Atrial 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

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Atrial 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

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AVNRT

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.

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avnrt

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AVRT

Accessory pathway (Bundle of Kent most common)Pre-excitation (delta wave) on ECGWolff-Parkinson-White syndrome

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Management 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

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Broad complex tachysVT vs VF

VTUnstable electrical cardioversionStable 1st – Class I Anti-arrhythmics (lidocaine)2nd – Amiodarone3rd – DC cardioversion

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Broad complex tachysVT vs VF

VFCardiac arrestRapid, irregular activity – no cardiac outputUsually provoked by ventricular ectopic beatManagementElectrical defibrillation

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Broad complex tachys

Something to be aware ofSVT with concomitant bundle branch block = broad complex tachy

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Summary

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

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ECGs – test yourself

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A

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B

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C

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D

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E

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F

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G

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H

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I

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J

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K

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L

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Answers

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

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References

All images and ECGs borrowed gratefully from google images

Kumar & Clarke: Clinical Medicine 7

th

Ed

NICE guidelines: AF (CG36)