Abnormality

of the heart rhythm Can cause syncope, sudden death, palpitations or no symptoms May be classified according to origin or speed

Atrial, supraventricular, ventricular Bradycardia vs tachycardia

 Slow

heart rate

<60 bpm (day) <50 bpm (night) Atrial

Types

Respiratory sinus arrhythmia Sinus bradycardia Sick sinus syndrome (SSS) Types I, II, III

Atrioventricular (AV) block

Bundle branch block

Left and Right

 In

young and healthy adults Cause

Changes in vagal tone during respiration Inhalation increase HR Exhalation decrease HR If HR < 60 bpm during exhalation sign of good autonomic tone benign

Presentation

Workup

 Found

in healthy individuals and athletes Causes

Physiologic - Increased vagal tone Pathologic inferior wall MI, electrolyte disorders, infection, sleep apnea, drugs (beta blockers, digitalis), hypothermia, increased ICP, hypothyroidism, cholestatic jaundice Mostly asymptomatic but may include syncope, dizziness, SOB, chest pain, exercise intolerance Slow regular HR on auscultation and palpation

Presentation

 Workup

and Management

Lab studies related to drug, toxin, electrolytes

Electrolyte, glucose, Ca2+, and Mg levels, thyroid function tests, toxicologic screen Lead 2 ~50 bpm

12 lead ECG for confirmation of diagnosis

Asymptomatic no treatment indicated Symptomatic

Treat underlying cause if due to drugs, endocrine disorder etc IV atropine increase rate by blocking vagal stimulation to SA node Persistent bradycardia - pacemaker

 Umbrella

term for abnormalities of SN impulse formation/propagation e.g. sinus bradycardia, sinus arrest Causes

Intrinsic age related changes (fibrosis), CAD Extrinsic medications, autonomic hyperactivity

 Presentation

If mild asymptomatic With increasing severity due to irregular pulse/organ hypoperfusion

Cerebral irritability, labile mood swings, forgetfulness, dizziness, falls, syncope Cardiac palpitations, angina, CHF, SCD (rare) GI symptoms, oliguria Exercise intolerance, fatigue, SOB

Workup

and Management

Thyroid function, electrolyte testing ECG, Holter monitoring Asymptomatic no treatment reqd Chronic, symptomatic SND pacemaker therapy

1st degree AV block

Prolongation of PR interval >200 ms (normal is 120200ms) Slowed conduction no missed beats Common in healthy hearts

Decreased intensity of S1; short blowing diastolic murmur at apex No treatment if asymptomatic Treat associated/underlying condition if appropriate

 2nd

degree AV block
Progressive prolongation of PR interval until atrial impulse fails to conduct no QRS complex Block originates from AV node

Mobitz I (Wenckebach)

Mobitz II

Unexpected dropped impulse without progressive lengthening of PR interval Block originates in bundle of His

 Causes

Cardioactive drugs exert negative effects on AVN e.g. digoxin, beta blockers, CCBs Inflammatory dx endocarditis, myocarditis, Lyme disease Infiltrative amyloidosis, hemochromatosis, sarcoidosis Metabolic hyperkalemia, hypermagnesemia, Addisons, hyperthyroidism Tumors, trauma, following surgical procedures, EtOH poisoning, acute MI Mobitz I generally asymptomatic syncope, bradycardia Mobitz II lightheaded, dizzy, syncope, chest pain, regularly irregular heartbeat, hypoperfusion

Presentation

 Workup

and Management

Serum electrolytes and ECG monitoring Mobitz I

If asymptomatic no specific therapy reqd Symptomatic atropine and transcutaneous pacing Suspect MI anti-ischemic regimen Drugs decrease dose/discontinue medication

Mobitz II

Avoid AV nodal agents Possible pacemaker implantation

 3rd

degree (complete) AV block

All atrial activity fails to conduct to ventricles

Ventricular pacemaker takes over escape rhythm = 20-40 bpm Can progress to sudden death Causes

Acute MI Cardiac meds beta blockers, CCBs, digitalis Endocarditis, Lyme disease, rheumatic fever

 Presentation

Neck veins cannon a waves, Variable intensity S1, slow pulse If have heart failure rales, S3 gallop, peripheral edema, hepatomegaly CHF

Decreased CO Tachypnea, rales, JVD Hypoperfusion altered mental state, hypotension, lethary

MI - Anxiety, diaphoresis, pale, tachypneic

Workup

and Management

CBC, electrolytes, ECG, CXR If transient IV atropine Chronic block dual chamber pacing

Right bundle branch block (RBBB)

ECG widened QRS (>0.12 s); deep S waves in lead I and V6, tall late R waves in V1/V2 (like bunny ears/M pattern) Causes isolated congenital anomaly, or assoc with cardiac/pulmonary conditions Presentation wide physiological splitting of S2

 Left

bundle branch block (LBBB)

ECG widened QRS (>0.12 s), deep S wave in V1, tall late R waves in 1 and V6, abnormal Q wave Causes CAD, LV outflow obstruction Clinical reverse splitting of S2, assoc with left ventricular disease

 Premature

Atrial Complexes (PACs)

Arises from the atria Causes

Excess adrenergic stimulation, drugs, EtOH, tobacco, ischemia

ECG early P waves (differ in morphology from normal P waves from sinus node), normal QRS Presentation

Normal heart found in 50% of pts on Holter monitoring Diseased heart ischemic precusor may have palpitations Asymptomatic no treatment, monitor Symptomatic beta blockers

Management

 Premature

Ventricular Complexes (PVCs)

Early beat fires from ventricles Causes

Hypoxia, electrolyte disturbances, stimulants, caffeine, medications

ECG slower conduction since from ventricles wider QRS; P wave buried in QRS Presentation

Can be asymptomatic Hypotension, diminished pulse, hypoxia, cannon a waves in JVP, sympathetic activation (if catecholamines are cause)
Asymptomatic no treatment Symptomatic beta blockers Risk sudden death if recurrent PVCs + heart disease implantable cardiac defibrillator (ICD)

Management

 Fast

heart rate

>100 bpm Atrial

Types

Atrial fibrillation Atrial flutter Multifocal Atrial Tachycardia

Paroxysmal Supraventricular Tachycardia Wolff-Parkinson-White Syndrome Ventricular

Ventricular tachycardia Ventricular fibrillation

ECG rate >100 bpm, regular rhythm, normal P waves, shorter PRI and QRS

Mainly in young women Persistent increase in resting HR unrelated to or out of proportion with level of physical/emotional stress Cause generally secondary phenomenon exercise, emotion, PE, infection Management

Beta blockers slow sinus rate Ivabradine (If channel blocker) if BB not tolerated

Multiple foci in atria fire continuously atrial rate ~400 bpm but impulses not all conducted to ventricles ventricular rate 75-175 bpm irregularly irregular pulse Causes - raised atrial P, increased atrial muscle mass, atrial fibrosis, inflammation and infiltration of atrium

Classic rheumatic heart disease, thyrotoxicosis, EtOH Most common HTN, heart failure

Symptoms

Fatigue, exertional dyspnea, palpitations, dizziness, angina, syncope, blood stasis (2to ineffective contraction) thrombi emboli

 Management

Treat underlying cause alcohol toxicity, chest infection, hyperthyroidism Cardioversion

Minimize risk of thromboembolism by fully anticoagulating Warfarin (INR of 2-3) or dabigatran (150 mg 2x daily for 3 weeks before)

Long term management

Rate control AV nodal slowing agents + oral anticoagulants

Indicated for: Have permanent form improve with decreased HR or are >65 years with recurrent atrial tachyarrhythmias Failed cardioversion Combo of digoxin, beta blockers or nondihydropyridine calcium channel blockers (verapamil or diltiazem) Only digoxin if elderly non-ambulant Considered controlled if resting HR <110 bpm If symptoms persist resting HR of 60-80 and exercise of <110 bpm For younger, symptomatic and active patients If no significant heart disease any class 1a, 1c or III drug Reserve amiodarone until others have failed Heart failure or LVH amiodarone only CAD sotalol or amiodarone PAF (paroxysmal atrial fib) left atrial ablation

Rhythm control antiarrhythmic drugs + DC cardioversion + oral anticoagulants

 Indications

a fib related to rheumatic mitral stenosis or with mechanical heart valve Score with CHADS2 CHF, HTN, Age >75, Diabetes, Previous stroke/TIA

If score >2 then need oral anticoag If score <2 then use CHADS2VASc Vascular dx, Age 65-74 and female

Score >2 need anticoag; 1=aspirin or consideration for anticoag; 0=no need

Warfarin

dose to maintain INR of 2-3 Dabigatran 150 mg 2x daily or 110 mg 2x daily for >75 yrs

Organized atrial rhythm with atrial rate of 250-350 bpm ventricular rate one half/one third atrial rate usually travels down the lateral wall of the RA, through the eustachian ridge between the tricuspid annulus and IVC then up the interatrial septum CCW flutter

Causes
Most common COPD Heart disease RHD, CAD, CHF ASD

ECG

Carotid massage increase block saw-tooth baseline - QRS complex appearing after every second or third "tooth" (P wave). Saw-tooth flutter waves are best seen in the inferior leads (II, III, aVF) .

Treatment like A. fib

 In

pts with severe pulmonary disease (COPD) ECG variable P wave morphology; variable PR/RR intervals

At least 3 diff. morphologies for dx

Workup

Vagal maneuvers/adenosine show AV block

Improve oxygenation/ventilation If LV fxn good CCBs, beta blockers, digoxin, amiodarone, flecainide, propafenone No LV fxn digoxin, diltiazem, amiodarone Electric cardioversion ineffective

Treatment

AV nodal reentrant tachycardia

Two pathways (one fast and the other slow) within the AV node - reentrant circuit is within the AV node Most common cause

ECG

narrow QRS complexes with no P waves (P waves are buried within the QRS complex). circuit is short/conduction rapid, so impulses exit to activate atria and ventricles simultaneously

Causes

IHD; digoxin toxicity, AV node reentry, atrial flutter with rapid ventricular response, AV reciprocating tachycardia (accessory pathway), Excessive caffeine/EtOH

 Treatment

Stimulate vagal delay block reentry

Valsalva maneuver, carotid massage, immerse head in cold water Pharm IV adenosine DOC short acting, decrease SA/AV nodal activity

Acute treatment

CI - asthma

If have LV fxn - IV verapamil/IV esmolol DC cardioversion if pharm ineffective

Prevention

Digoxin (DOC) or verapamil/beta blockers

If recurrent/symptomatic radiofrequency catheter ablation

 accessory

conduction pathway premature ventricular excitation - lacks the delay seen in the AV node ECG delta wave deflection before QRS, short PRI, narrow complex Treatment

Radiofrequency catheter ablation of one arm of the reentrant loop (i.e. , of the accessory pathway) is an effective treatment. Avoid drugs active on the AV node (e.g. , digoxin) because they may accelerate conduction through the accessory pathway. Type lA or IC antiarrhythmics are better choices.

 rapid

and repetitive firing of three or more PVCs in a row, at a rate ~100-250 bpm AV dissociation (P waves indep. of QRS) Originate below bundle of His Causes

CAD with prior MI - most common cause Active ischemia, hypotension Cardiomyopathies Congenital defects Prolonged QT syndrome Drug toxicity

 ECG

wide/bizarre QRS

Monomorphic all QRS same Polymorphic all QRS different

Presentation

Palpitations, dyspnea, lightheadedness, angina, impaired consciousness (e.g. syncope) May present with sudden cardiac death Signs of cardiogenic shock may be present. Asymptomatic if rate is slow Physical findings - cannon a waves in the neck (2 to AV dissociation atrial contraction during ventricular contraction); varying intensity S1

 Treatment

ID and treat underlying causes If hemodynamically stable/systolic BP>90 IV amiodarone, procainamide, sotalol If unstable cardioversion + amiodarone for sinus rhythm If asymptomatic/non-sustained dont need to treat If underlying heart disease ICD placement Pharm 2nd line treatment amiodarone (DOC)

 Multiple

foci in the ventricles fire rapidly chaotic quivering of the ventricles no CO Oft begins with VT Causes

IHD most common Antiarrhythmic drugs (esp. if cause torsades de pointes) A. fib with rapid vent. rate in pts with WPW Cant measure BP, no pulse/heart sounds, unconscious, can lead to SCD

Presentation

 ECG

No identifiable P waves/QRS complexes very irregular Medical Emergency! Immediate defibrillation and CPR

Treatment

Give 3 sequential shocks to establish new rhythm. Assess rhythm between each shock Give Epinephrine (1 mg IV) decreases defib threshold, increase BF Defib again after 30-60 s Try amiodarone then shocking 2nd line lidocaine, bretylium, procainamide

If persist continue CPR, intubation

If above fails

Long term amiodarone or implantable defi

 Agabegi,

Elizabeth and Agabegi, Steven. Step Up to Medicine. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins. 2008. Pg. 1830. Kumar and Clarks Clinical Medicine. Ed. By Clark, Michael and Kumar, Parveen. 8th Ed. Edinburgh: Elsevier. 2012. Pg. 697-714. Thaler, Malcom. The Only EKG Book Youll Ever Need. 6th Ed. Philadelphia: Lippincott Williams & Wilkins. 2010. Print.