Atrial arrhythmia

دورة ECG Course 1

1. Atrial Arrhythmias Rami alkhatib

2. outlines Premature atrial contraction Wandering pacemaker Sinus tachycardia SVT Atrial flutter Atrial fibrillation

3. W a n d e r in g P a c e ma k e r • P a c em a k er s i t es t r a n s f e r s f r o m t he S A N o de t o o t her s i t es in t he a t r ium a nd t he • A V jun ct i o n a nd b a c k t o t he S A N o de

4. • • R a t e : N o rmal ( 60 – 10 bpm) R h y th m : I r r e gula r . W a v es : A t l e a s t th r e e di f f e r e n t f o rms, d e t e rmin e d b y f o c us in a t r ia b y f o c us P R I nt e r v a l: V ariabl e ; d e t e rmin e d Q R S : N o rmal • •

5. P r ea m a tu r e A t r i a l C o n t r act i o n ( P A C ’ S ) • T he a t r i a l impulse fi r es e ar li e r t h a n e xpe c t ed; a f t e r w a r ds n or m a l s inus r h y t hm • u s u a lly c o n t inue s .

6. P A C ’ S • R a t e : D e p e nds o n r a t e o f und er l y ing r h y thm R h y th m : I r r e gular wh e n e v e r a P A C o cc u r s . P W a v es : P r e s e n t; in the P AC , n o rmal, m a y h a v e a di f f e r e n t s hap e . P R I nt e r v a l: V ari e s in the P A C ; o th e r wi s e normal Q R S : N o rmal • • •

7. A tr i a l T a c hy c a r d i a • The S A n o de impul s e is o v e rr idden b y t he r a t e . w a v e a nd t he T w a v e m a y be s een. m o r e r a pid a t r i a l • •

8. • • R at e: 15 –250 bpm R h y th m: R egul a r P W a v es: N or m a l ( up r ig h t a nd uni f or m) but di f f er in s h a pe f r o m s inus P w a v es P R I nt e r v a l: M a y be s h or t ( <0 . 12 s e c ) in r a pid r a t es . Q R S : N or m a l • • •

9. S U P R A VE N T R I C U L A R T A CH Y C A R D I A ( S V T ) • P w a v es m a y n o t be seen d ue t o t he e x t r emely r a pid r a t e.

10. A T R IA L F L U TTER • • The A V n o de c o ndu ct s impul s es t o t he v e n t r i c les a t a 2 : 1 , 3 : 1 , 4 : 1 , o r g r e a t er r a t io ( r a r ely 1 : 1 ) .

11. • I f v e n tr i cu l a r he a r t r a t e is l e ss th a n 10 = C o n tro ll e d A - fl u t t er or A -f l u t t e r wi t h c o n tro ll e d v e n tr i cu l a r re s p on s e . • I f v e n tr i cu l a r he a r t r a t e is g re a t e r th a n 10 = U n c o n tro ll e d A - fl u t t er or A -f l u t t e r wi t h R V R (r ap id v e n tr i cu l a r re s p on s e )

12. • R at e: A t r i a l: 25 –350 bpm; v e n t r i c ula r : v ar i a bl e . R h y th m: A t r i a l: r egula r ; v e n t r i c ula r : v ar i a ble P W a v es: Flu t t er w a v es h a v e a s a w - t oo t hed a ppe a r a n c e, so me m a y n o t be v i s ible bu r ied in t he Q R S. P R I n t e r v a l: V ar i a ble Q R S : U s u a lly n or m a l • • •

13. A T R IA L F I B R I LL A T I O N • R a pid ele ct r i c a l dis c h a r g e c o mes f r o m mul t iple a t r i a l e c t o pic f o c i. • No o r g a n i z ed a t r i a l dep o l ar i z a t i o n a r e d e t e c t a ble.

14. A t ri a l Fibril l a t ion R h y t h m : I rr e gu l ar R a t e : Unab l e t o me asu re a tr i a l ; v e n tr i c u l ar c ondu ct i o n d e p e nd s o n A V P w a ve s : F i br ill a t o r y wa v e s ( c oa r s e o r f i n e ) P R I : Unab l e t o b e me asu r e d Q R S : N a rr o w ( < 0.12 s e c ) ; s o m e t ime s w i de

15. • I f v e n tr i cu l a r he a r t r a t e is g re a t e r th a n 10 = U n c o n tro ll e d A - fib or A -f ib wi t h R V R (r ap id v e n tr i cu l a r re s p on s e )

16. At r i al F l u tt e r Ca n c oun t t he # of f lu tt e r wa v e s (P wa v e s) At r i a l F i br i l l a ti o n ( Af i b ) U nabl e t o c oun t th e # o f w a v es

17. Fibri ll at ion v s. F l ut t er ? • • • On e f o c u s - o r g a ni z ed R a t e: 200 - 4 bp m A tr i a l C a r di a c Ou t pu t • Mul t i- f o c a l or i g in s - c h a ot ic R a t e: >400 bp m IRR E G UL A R - R A tr i a l C a r di a c Ou t pu t i s l o s t • • • i s c om p r om is ed At r i a con t r i bu t e ~ 20% of t he t o t al C ard i ac ou t pu t : A- F i b i s non - l e t hal

18. References Huff, J. (2006). ECG workout: Exercises in arrhythmia interpretation. Lippincott Williams & Wilkins. Hampton, J. R. (2013). 150 ECG problems. Elsevier Health Sciences. Khan, M. G. (2008). Rapid ECG interpretation. Springer Science & Business Media