"''ARRYTHMIAS''".pptx by Dr. Humna Uzair

Arrhythmias are abnormalities in the rhythm of the heart's electrical system, leading to irregular heartbeats.

Types of Arrhythmias

Classification based on origin:
Supraventricular (atrial) arrhythmias:
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
Ventricular arrhythmias:
Ventricular tachycardia
Ventricular fibrillation
Premature ventricular contractions (PVCs)

1. ARRYTHMIAS DR. HAMNA UZAIR

2. CLASSIFICATION OF ARRYTHMIAS

3. ARRYTHMIAS CAN BE CLASSIFIED ON THE FOLLOWING BASIS: -RATE: TACHYARRYTHMIAS OR BRADYARRYTHMIAS -SITE OF ORIGIN: SUPRAVENTRICULAR OR VENTRICULAR -MECHANISM OF ORIGIN: AUTOMACITY, RE-ENTRY, TRIGGERED -DURATION: ISOLATED PREMATURE BEATS, SUSTAINED, NON-SUSTAINED, COUPLETS

4. CLASSIFICATION ON THE BASIS OF RATE

5. BRADYARRYTHMIAS: SINUS BRADYCARDIA JUNCTIONAL BRADYCARDIA AV BLOCK ATRIAL FLUTTER WITH VARIABLE BLOCK BUNDLE BRANCH BLOCKS ALTHOUGH NOT TRULY BRADYARRYTHMICS

6. TACHYARRYTHMIAS: SUPRAVENTRICULAR TACHYCARDIA [SVT] VENTRICULAR TACHYCARDIA [VT] ATRIAL FIBRILLATION ATRIAL FLUTTER VENTRICULAR FLUTTER PREMATURE ATRIAL CONTRACTIONS

7. BRADYARRYTHMIAS

8. SINUS BRADYCARDIA SINUS BRADYCARDIA IS DEFINED AS HR<60 bpm WITH REGULAR RHYTHM, P-WAVE PRESENT AND NORMAL QRS COMPLEX

9. . CAUSES OF SINUS BRADYCARDIA: -INCREASED AGE -SA NODE PROBLEM [SICK SINUS SYNDROME] -INFLAMMATORY HEART DISEASE e.g PERICARDITIS OR MYOCARDITIS -CONGENITAL HEART DISEASE -INCREASED INTRACRANIAL PRESSURE -MYOCARDIAL INFARCTION -OBSTRUCTIVE SLEEP APNEA

10. . -IATROGENIC -HYPOTHYROIDISM -ATHELETES -PRESSURE ON CAROTID RECEPTOR LIKE TIGHT NECK COLLAR -SUDDEN CONTACT WITH COLD WATER -HYPOTHERMIA -VOMITING/COUGHING AS PER VALSALVA MANEUVER

11. .

12. PHYSIOLOGICAL SINUS BRADYCARDIA IF SINUS BRADYCARDIA IS NOT CAUSING SYMPTOMS, IT IS CALLED AS PHYSIOLOGICAL SINUS BRADYCARDIA. NO NEED TO TREAT THIS BRADYCARDIA

13. PATHOLOGICAL SINUS BRADYCARDIA IF SINUS BRADYCARDIA IS CAUSING SYMPTOMS, IT IS CALLED AS PATHOLOGICAL SINUS BRADYCARDIA. ATROPINE IS USEFUL TREATMENT. RECOMMENDED DOSE OF ATROPINE IN BRADYCARDIA IS 0.5 MG EVERY 3 TO 5 MINUTES FOR THE MAXIMUM TOTAL DOSE OF 3 MG.

14. JUNCTIONAL BRADYCARDIA SINUS RHYTHM, RATE 100/MINT JUNCTION ESCAPE RHYTHM, RATE 75/MINT NO P-WAVE IN JUNCTIONAL BEATS [ INDICATES EITHER NO ATRIAL CONTRACTION OR P-WAVE LOST IN QRS COMPLEX] NORMAL QRS COMPLEXES

15. . .

16. . TREATMENT OF JUNCTIONAL BRADYCARDIA IS NOT USUALLY NECESSARY, BUT TREATMENT OF UNDERLIYING CAUSE[ e.g sinus or atrial bradycardia] MAY BE NEEDED. DISCONTINUATION OF MEDICATION THAT SLOW THE ATRIAL RATE MAY ALLOW THE ATRIAL RATE TO INCREASE AND OVERRIDE THE JUNCTIONAL RHYTHM.

17. ATRIOVENTRICULAR BLOCKS

18. IST DEGREE HEART BLOCK NORMAL PR INTERVAL IS 0.12 TO 0.20 SECONDS IST DEGREE HEART BLOCK IS PR INTERVAL GREATER THAN 0.20 SECONDS APPROPRIATELY CALLING 0.36 SECONDS OR 9 SMALL BOXES WITHOUT ATRIAL OR VENTRICULAR DISRUPTION.

19. . .

20. SECON DEGREE HEART BLOCK MOBITZ TYPE 1 [ WENCKEBACH ] BLOCK MOBITZ TYPE 2 BLOCK

21. MOBITZ TYPE 1 BLOCK PROGRESSIVE LENGHTENING OF PR INTERVAL ONE NONCONDUCTED P WAVE NEXT CONDUCTED BEAT HAS SHORTER PR INTERVAL THAN PRECEEDING CONDUCTED BEAT AS WITH ANY OTHER RHYTHM, A P WAVW MAY ONLY SHOW ITSELF AS A DISTORTION OF T WAVE.

22. . .

23. MOBITZ TYPE 2 BLOCK PR INTERVAL OF THE CONDUCTED BEAT IS CONSTANT ONE P WAVE IS NOT FOLLOWED BY A QRS COMPLEX

24. . .

25. THIRD DEGREE HEART BLOCK [COMPLETE HEART BLOCK] P WAVE RATE 90/MINT NO RELATIONSHIP BETWEEN P WAVES AND QRS COMPLEXES QRS COMPLEX RATE IS 36/MINT ABNORMAL SHAPE OF QRS COMPLEXES, BECAUSE OF ABNORMAL SPREAD OF DEPOLARIZATION FROM VENTRICULAR FOCUS.

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28. TREATMENT OF HEART BLOCKS IST DEGREE HEART BLOCK USUALLY DOES NOT REQUIRE TREATMENT 2 ND DEGREE DEGREE HEART BLOCK REQUIRES INITIAL PACING AS SOON AS IS RECOGNIZED, ESPECIALLY MOBITZ TYPE 2; BECAUSE IT CAN DETERIORATES INTO 3 RD DEGREE HEART BLOCK.

29. . PACING CAN BE TEMPORARY OR PERMANENT DEPENDING UPON ITS REQUIREMENT AND CIRCUMSTANCES. COMPLETE AV BLOCKS CAN BE REVERSIBLE IN SOME CASES OF ACUTE INFERIOR WALL MYOCARDIAL INARCTION; SO IN THESE CASE, TEMPORARY PACEMAKERS ALLOW AV NODE TO HEAL OVER TIME.

30. ATRIAL FLUTTER WITH VARIABLE BLOCK ATRIAL FLUTTER WITH 2:1 BLOCK IS COMMON AMONG ALL ATRIAL FLUTTER WITH AN ATRIAL RATE OF 250/MINT, AND IN 2:1 BLOCK, GIVING VENTRICULAR RATE OF 125/MINT THE FIRST 2 P WAVES ASSOCIATED WITH EACH QRS COMPLEX CAN BE MISTAKEN FOR T WAVE OF THE PRECEDING BEAT, BUT P WAVES CAN BE IDENTIFIED BY THEIR REGULARITY IN THIS TRACE, T WAVES CANT BE CLEARLY IDENTIFIED

31. ATRIAL FLUTTER WITH 2:1 BLOCK .

32. . .

33. CAROTID SINUS PRESSURE HAS INCREASED THE BLOCK MAKING IT OBVIOUS THAT UNDERLYING RHYTHM IS ATRIAL FLUTTER .

34. TACHYARRYTHMIAS

35. SINUS TACHYCARDIA HEART RATE GREATER THAN 100 BPM, WITH NORMAL P-WAVE, NORMAL SHAPE OF QRS COMPLEX, WITH REGULAR RHYTHM IS SINUS TACHYCARDIA.

36. CAUSES OF SINUS TACHYCARDIA CAFFEINE ALCOHOL NICOTINE COCAINE HYPERTHYROIDISM FEVER ANXIETY

37. . ANEMIA HYPOTENSION MYOCARDIAL INFARCTION HERAT FAILURE LUNG DISEASE LIKE COPD/ASTHMA PAIN

38. TREATMENT OF SINUS TACHYCARDIA ELIMINATE POTENTIAL TRIGGER CAROTID SINUS MASSAGE CARDIOSELECTIVE B-BLOCKERS LIKE METOPROLOL,BISOPROLOL OR NON-CARDIOSELECTIVE LIKE PROPRANALOL, CALCIUM CHANNEL BLOCKERS LIKE VERAPAMIL OR IVABRADINE. VALSALVA MANEUVER

39. SUPRAVENTRICULAR TACHYCARDIA HEART RATE GREATER THAN 200/MINT NO APPRECIATION OF P-WAVE REGULAR RHYTHM NORMAL SHAPE OF QRS COMPLEXES BUT NARROW DUE TO INCREASED RATE

40. VENTRICULAR TACHYCARDIA NO P WAVE REGULAR QRS COMPLEXES, RATE 200/MINT BROAD QRS COMPLEXES, DURATION GREATER THA 280 MILLISECONDS, WITH ABNORMAL SHAPE NO IDENTIFIABLE T WAVES

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42. VENTRICULar fibrillation No QRS COMPLEX IS IDENTIFIED, AND THE ECG IS COMPLETELY DISTORTED WITHOUT IDENTIFICATION P AND T WAVES

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44. ATRIAL FIBRILLATION NO P WAVES IRREGULAR BASELINE IRREGULAR QRS COMPLEXES, RATE VARYING BETWEEN 75/MINT TO 190/MINT, CAN BE LABELLED AS SVR AND FVR RESPECTIVELY. NARROW QRS COMOPLEXES OF NORMAL SHAPE NORMAL T WAVES

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46. JUNCTIONAL [NODAL] TACHYCARDIA NO P WAVES REGULAR QRS COMPLEXES, RATE 200/MINT NARROW QRS COMPLEXES NORMAL T WAVES

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48. RIGHT BUNDLE BRANCH BLOCK WITH SINUS RHYTHM SINUS RHYTHM, RATE 60/MINT NORMAL PR INTERVAL NORMAL CARDIAC AXIS WIDE QRS COMPLEX, >160ms RSR PATTERN IN V1 AND DEEP S-WAVES IN LEAD V6 NORMAL ST SEGMENT AND T WAVES

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50. LEFT BUNDLE BRANCH BLOCK WITH SINUS RHYTHM SINUS RHYTHM, RATE 100/MINT NORMAL PR INTERVAL NORMAL CARDIAC AXIS WIDE QRS COMPLEXES, > 160ms M PATTERN IN QRS COMPLEX, BEST SEEN IN LEADS I,aVL,V5 AND V6 INVERTED T WAVES IN LEADS I,II,aVL

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52. TYPES OF CARDIOVERSION PHARMACOLOGICAL CARDIOVERSION ELECTRICAL CARDIOVERSION

53. PHARMACOLOGICAL CARDIOVERSION PHARMACOLOGICAL CARDIOVERSION INCLUDES ANTIARRYTHMIC DRUGS THERE ARE 5 CLASSES OF THESE DRUGS, AMONG WHICH CLASS I DRUGS ARE FURTHER SUBDIVIDED INTO 1A, 1B, AND 1C.

54. CLASS IA DRUGS QUINIDINE: TEST DOSE IS 200 MG FOR A-FIB------300-400MG PO 6 HOURLY FOR PSVT-----400-600MG EVERY 2 TO 3 HOURS UNTIL PAROXYSM TERMINATE MAINTAINENCE DOSE IS 200-400MG EVERY 6 HOURLY

55. CLASS IA DRUGS CONTD…… PROCAINAMIDE-------0.5-1 GRAM IM EVERY 4-8 HOURLY DISOPYRAMIDE--------300 MG PO INITIALLY, THEN 150-300 MG EVERY 6 HOURLY

56. CLASS IB DRUGS LIDOCAINE-----1-1.5MG/KG SLOW IV BOLUS OVER 2 TO 3 MINTS, IF IV NOT POSSIBLE, IO/ET CAN BE GIVEN AS 2-3.75mg/kg DILUTED IN 5-10 ML NORMAL SLAINE OR STERILE WATER MEXILETINE --------200-300 MG PO INITIALLY OR EVERY 8 HOURLY

57. CLASS IC DRUGS FLECAINIDE------50 MG PO BD PROPAFENONE-----150 MG PO EVERY 8 HOURLY

58. CLASS II DRUGS THIS CLASS INCLUDES B-BLOCKERS PROPRANOLOL-----10-30 MG PO EVERY 6-8 HOURLY OR 1-3 MG AT 1MG/MINT INITIALLY; REPEAT EVERY 2-5 MINT TO TOTAL OF 5 MG IF REQUIRED OTHER DRUGS INCLUDE METOPROLOL,NADOLOL,TIMOLOL,ESMOLOL,ACEBUTOLOL

59. CLASS III DRUGS AMIODARONE---- 150 MG IV BOLUS IN 10 MINTS INITIALLY IBUTILIDE-----1 MG IV INFUSION, CAN BE REPEATED AFTER 10 MINTS SOTALOL------80 MG PO BD ----NA IN PAKISTAN DOFETILIDE----NA IN PAKISTAN BRETYLIUM----NA IN PAKISTAN

60. CLASS IV DRUGS IT INCLUDES CALCIUM CHANNEL BLOCKERS SPECIFICALLY VERAPAMIL VERAPAMIL-----2.5-5mg IV OVER 2 MINTS, 5-10mg DOSE CAN BE REPEATED AFTER 15 TO 30 MINTS ORAL FORM AVAILABLE AS 240 MG STRENGTH IN CAPSULE AND 80 MG STRENGTH IN TABLET FORM

61. CLASS V DRUGS ADENOSINE-----6 MG IV OVER 1-3 SECONDS FOLLOWED BY RAPID FLUSH OF 20 ML NS, IF NO CONVERSION WITHIN 1-2 MINTS GIVE 12 MG IV, REPEAT SECOND TIME IF NECESSARY NOT TO EXCEED TOTAL OF 30 MG DIGOXIN CAN CONTROL VENTRICULAR RESPONSE IN A-FIB OR A-FLUTTER WITH DOSE OF 0.125 MG TO 0.5 MG PER DAY

62. ELECTRICAL CARDIOVERSION ELECTRICAL CARDIOVERSION IS A PROCEDURE IN WHICH AN ELECTRIC CURRENT IS USED TO RESET THE HEART’S RHYTHM BACK TO ITS NORMAL SINUS RHYTHM. THE LOW VOLTAGE ELECTRICAL CURRENT ENTERS THE BODY THROUGH ELECTRICAL PADS APPLIED TO CHEST WALL STARTING FROM LOW VOLTAGE E.g CARDIOVERSION OF PULSELESS V-TACH SHOULD START FROM 50-100 JOULES INITIALLY, AND THEN 200, 250 OR 360 JOULES SUBSEQUENTY

63. INTERPRET ECG PATTERN AND SUGGEST TREATMENT

64. . RHYTHM SHOWN IN ECG IS VENTRCULAR TACHYCARDIA. TREATMENT OPTION DEPENDS ON THE PRESENCE OR ABSENCE OF PULSE IF PULSE PRESENT, GO FOR PHARMACOLOGICAL CARDIOVERSION AT IST INSTANCE IF PULSELESS PATIENT, IMMEDIATELY GO FOR DC CARDIOVERSION

65. E CG FROM 20 YEARS OLD FEMALE STUDENT WITH NON-SEPCIFIC CHEST PAIN, NO ABNORMALITIES ON EXAMINATION. INTERPRET ECG AND SUGGEST MANAGEMENT

66. . THIS IS PERFECTLY NORMAL RECORD OF ECG. DESCRIPTION OF PAIN DOES’NT SOUND LIKE CARDIAC PAIN, MOREOVER HER AGE AND GENDER ARE NOT IN THE RISK FACTORS RANGE THIS PAIN SOUNDS MUSCULAR, AND SHE ONLY NEEDS RE-ASSURANCE AND ANALGESICS.

67. ECG FROM 60 YR OLD MAN WHO NOTICED DIZZINESS AND CHEST DISCOMFORT ON CLIMBING HILLS

68. . ECG SHOWS LBBB. IN THE PRESENCE OF LBBB, ECG CANNOT BE INTERPRETED ANY FURTHER, SO ITS OT POSSIBLE TO COMMENT ON PRESENCE OR ABSENCE OF ISCHEMIA. STORY SOUNDS LIKE ANGINA WHILE DOING EXERTION. WHEN ANGINA COMBINED WITH DIZZINESS, ALWAYS THINK OF AORTIC STENOSIS; AS LBBB IS COMMON IN AORTIC STENOSIS.

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