Arrhythmias Flashcards
Sinus Rhythm criteria
- Normal P wave axis and morphology
- Artrial rate 60-100 BPM and regular (<0.16s or <10%)
- P wave upright in I, II, aVF and downright in aVR
Sinus Bradycardia criteria
- Normal P wave axis and morphology
2. Rate < 60 bpm
Sinus Bradycardia causes
- High vagal tone
- Drugs (beta-blockers, verapamil, diltiazem, digitalis, IA, B, C antiarrhythmics, Amiodaronm Sotalol, Lithium, ect)
- Hypothyroidism
- Hypothermia
- Obstructive jaundice
- Hyperkalemia
- Increased ICP
- SSS
Sinus Tachycardia criteria
- Normal P wave axis and morphology
2. Rate > 100 bpm
Sinus Pause or Arrest
PP interval (pause) ≥ 2.0s
Type I SA exit block
- P wave morphology and axis consistent with sinus node origin
- Shortening of PP interval up to pause
- PP pause <2*normal PP interval
- Constant PR interval
Type II SA exit block
- P wave morphology and axis consistent with sinus node origin
- Constant PP interval followed by pause that is +- multiple of normal PP interval
- PP pause <2*normal PP interval
Causes of SA exit block
- Drugs (Digitalis, Quinidine, Flecainide, Propafenone, Procainamide)
- Hyperkalemia
- SA node dysfunction
- Organic heart disease
- MI
- Vagal stimulation
Arrhythmias types
- Bradyarrhythmias
- Tachyarrhythmias
A) Supraventricular Arrhythmias
B) Ventricular Arrhythmias - Premature Complexes and other ventricular arrhythmias
Bradyarrhythmias types
- Sinus Bradycardia
- Disorders of the Sinoatrial Node
- Disorders of AV conduction
Supraventricular Arrhythmias types
- Sinus Tachycardia
- Atrial Tachyarrhythmias
1) Focal Atrial Tachycardia
2) Multifocal Atrial Tachycardia (MAT)
3) Atrial Flutter (AFl)
4) Atrial Fibrillation (AF) - Paroxysmal Supraventricular Tachycardias
1) AV nodal reentry tachycardia (AVNRT)
2) AV Junctional Arrhythmias
3) Tachycardias associated with accessory atrioventricular pathways
Physiologic sinus Tachycardia causes
- Physiologic response to stress (exercise, anxiety, pain, fever)
- Hypovolemia, hypotension
- Anemia
- Thyrotoxicosis
- PE
- Organic heart disease: HF, MI, Myocarditis
Atrial Tachyarrhythmias types
- Inappropriate sinus tachycardia
- Focal Atrial Tachycardia
- Multifocal Atrial Tachycardia (MAT)
- Atrial Flutter (AFl)
- Atrial Fibrillation (AF)
Supraventricular Tachyarrhythmias associated with accessory atrioventricular pathways types
- Orthodromic AV reentral tachycardia (AVRT) 85-95%
- Preexcited tachycardia
1) Antidromic AV reentral tachycardia (AVRT) 5-10%
2) AF with preexcitation
3) AT or AFl with preexcitation
Paroxysmal Supraventricular Tachycardias (PSVT) frequency
- AV nodal reentry tachycardia (AVNRT) 60-70%
- (Orthodromic) AV Reentrant Tachycardia (AVRT) 30%
- Sinus Nodal Reentrant Tachycardia (SNRT) <5%
AV Junctional Arrhythmias types
- AV Junctional Premature Complexes (JPC)
- AV Junctional Escape Complexes
- AV Junctional Rhytm
- AV Junctional Tachycardia = Junctional Ectopic Tachycardia (JET)
Premature Complexes and other ventricular arrhythmias types
- Premature Supraventricular Complexes - atrial or junctional
- Premature Ventricular Complexes (PVC)
- Ventricular Escape Complex(es) or Rhythm
- Accelerated Idioventricular Rhythm (AIVR)
Ventricular Tachyarrhythmias types
- Ventricular Tachycardia (VT)
- Ventricular Flutter
- Ventricular Fibrillation
Ventricular Tachycardia (VT) types
- Monomorphic VT
- Polymorphic VT:
1) Bidirectional
2) Tordase de Pointes
3) Other Polymorphic
Focal Atrial Tachycardia
- ≥3 consecutive ectopic atrial beats (non-sinus P waves)
2. P wave may precede, be buried in or immediately follow the QRS complex
Focal Atrial Tachycardia causes
- Most cases: idiopathic
- Pulmonary disease :COPD/ pneumonia, PE
- Heart disease: Cardiomyopathy, HF, MI, Hypertension
- Drug toxicity: Digoxin, Theophiline, Cocaine
- Alcohol intoxication
- Acute Infection, especially sepsis
Multifocal Atrial Tachycardia (MAT) ECG criteria
- Atrial rate >100bpm
- Ectopic P waves with ≥3 morphologies
(with ectopic P waves RAE and LAE cannot be determined -> requires presence of sinus rhythm)
Multifocal Atrial Tachycardia (MAT) causes
- Pulmonary disease -> most frequently
- HF
- Electrolyte or acid balance abnormalities
Atrial Tachycardia (FAT + MAT) treatment
- Treat underlying cause
- Rate control -> β-blocker or non-d CCB
- Catheter ablation
Paroxysmal Supraventricular Tachycardias (PSVT) ECG criteria
- Regular rhythm >100bpm
- P wave not easily indentified (may precede the QRS -> retrograde atrial activation, may be buried in the QRS [pseudo S in II, III, aVF, pseudo r’ in V1] or may follow the QRS complex)
- QRS narrow or with BBB
- Onset and termination of SVT are sudden
AVNRT Atrioventricular Nodal Reentrant Tachycardia
- Paroxysmal, usually initiated by APC
- Two AV nodal pathways -> slow (α) and fast (β)
- Three types: slow-fast α->β (typical, most common), fast-slow β->α (atypical) and slow-slow -> if conduction AV is by slow -> RP < 0.5 RR, if fast RP > 0.5 RR
- P wave usually not visible
Orthodromic AVRT (AV Reentrant Tachycardia)
- Occurs with WPW syndrome and bypass tracts -> antegrade conduction through AV node
- HR 150-250 bpm
- Regular rhythm
- Narrow QRS complex
- P wave usually follows QRS complex (or is buries within)
Antidromic AVRT (AV Reentrant Tachycardia)
- Retrograde conduction through AV node, antegrade through accessory pathway
- HR 150-250 bpm
- Regular rhythm
- Wide QRS complex
- Sort PR interval
Acute Treatment of AVNRT and orthrodromic AVRT
A) Hemodynamically unstable: electrical cardioversion
B) Hemodynamically stable:
Vagal maneuvers -> IV adenosine -> IV β-blocker or non-d CCB -> electrical cardioversion
Long-term Treatment of AVNRT and orthrodromic AVRT
- Infrequent and mild episodes -> vagal maneuvers
- Catheter ablation
- Second line: β-blocker or non-d CCB
Acute Treatment of antidromic AVRT
A) Hemodynamically unstable: electrical cardioversion
B) Hemodynamically stable:
Ic class: Flecainide or Propafenone or
Ia class Procainamide or III class Ibutilide
consider electrical cardioversion
Causes of WPW syndrome
- AVRT 80%
- AF 15%
- AFl 5%
- Other (rare): MAT, FAT
Ventricular preexcitation ecg criteria
- PR interval duration < 0.12 s
- Delta wave at the beginning of the QRS complex
- QRS > 0.12 s
- Changes in ST segment and T wave -> usually opposite side of the QRS complex
WPW = preexcitation + tachycardia
Junctional rhythm/ tachycardia
- HR: Junctional rhythm 40-60 bpm
Accelerated Junctional rhythm 60-100 bpm
Junctional Tachycardia >100 bpm - Regular rhythm (usually)
- Narrow QRS complex unless aberrant conduction
- P wave either hidden within QRS complex or immediately before/ after
- P wave inverted in II, III and aVF leads
Junctional rhythm/ tachycardia treatment
A) Acute episodes: β-blocker or non-d CCB
B) Long term:
1. Treat underlying cause
2. Consider Flecainide, Propafenone, β-blocker or non-d CCB
3. Consider catheter ablation
Atrial Flutter ECG
- F waves at a rate 240-340 bpm
- Typical -> inverted in leads II, III, aVF, upright in V1, inverted in V6
- Atypical with upright F waves in leads II, III, aVF, inverted in V1, upright in V6
- Rate and regularity of QRS complexes depend on AV conductions -> 2:1, 4:1 etc
- Treatment same as AF
Atrial Fibrillation ECG
- P waves absent
- Totally irregular atrial activity -> fibrillatory (f) waves -> frequency >350/min
- Ventricular rhythm is irregularly irregular
Atrial Fibrillation Classification
- Paroxysmal (intermittent, napadowe) AF -> terminates spontaneously or with intervention within seven days of onset
- Persistent AF (przetrwałe) -> fails to self-terminate within seven days
- Long-standing persistent AF (przetrwałe długo trwające) -> has lasted for more than 12 months.
- Permanent AF (utrwalone) -> decision to no longer pursue a rhythm control strategy
Atrial Fibrillation symptom classifications
EHRA I - No symptoms
EHRA II - Mild symptoms -> normal daily activity not affected
EHRA III - Severe symptoms -> normal daily activity affected
EHRA IV - Disabling symptoms -> normal daily activity discontinued
AF Treatment general
4S -> structured characterization of AF ABC -> treatment Anticoagulation Better symptom control Comorbidities
Newly diagnosed Paroxysmal Atrial Fibrillation acute treatment
- Hemodynamically unstable -> Emergency cardioversion (360 J)
- Stable patients with acceptable symptoms:
- > rate control and anticoagulation and wait for spontaineous return of sinus rhythm
- > if symptoms prolong -> consider cardioversion (electrical or pharmacological): - Unacceptable symptoms
rhythm control in Newly diagnosed Atrial Fibrillation
- Check OAC (Oral Anticoagulation) status -> if on procede to early or delayed cardioversion
if not on OAC -> start OAC and - Check AF episode duration:
-> <48h either early cardioversion or wait for spontaineous return of sinus rhythm - if not - delayed cardioversion (within 48h)
-> >48h - elective cardioversion after 3 weeks of OAC
AF treatment rate control
- None comorbidieties or HT or HFpEF-> bblocker or NDCC
- HFrEF -> bblocker
- Severe COPD or Asthma: NDCC
- Preexitation
2nd line:
bblocker or NDCC or Digoxin
3rd line -> consider ablation
Drugs used in rhythm control AF
- Patients without significant Heart Disease -> Flecainide, Propafenone, Vernakalant
- HFrEF -> Amiodarone
4S-AF scheme
Stroke risk -> CHA2DS2-VASc + HAS-BLED
Symptom severity -> EHRA
Severity of AF burden
Substrate severity
Anticoagulation in AF
NOAC -> prefered
VKA (treatment goals: INR 2-3)
Premature Ventricular Complexes (PVC) ECG
- wide, notched QRS >0.12 s (almost always)
- Premature relative to the normal RR interval
- not preceded by a P wave
- ST-T changes in opposite direction to the QRS
Ventricular Escape Complex(es) or Rhythm
- > occurs as a secondary phenomenon in responce to decreased sinus impulse formation (e.g. AV block, pause after termination of AF)
1. Single beat or regular or slightly irregular ventricular rhythm
2. Rate of 30-40 bpm
3. Wide, notched QRS >0.12 s
Ventricular Parasystole
- > caused by the presence and function of a secondary pacemaker in the heart, which works in parallel with the SA node
1. Frequent usually uniform VPC at a rate 30-55 bpm with nonfixed coupling with normal rhythm
2. Morphology: VPC-like: wide, notched QRS >0.12 s
3. Fusion beats
Accelerated Idioventricular Rhythm (AIVR)
- > between Ventricular Escape Rhythm (<50bpm) and VT (>100 bpm)
1. Regular or slightly irregular ventricular rhythm
2. rate of 50-100 (80) bpm
3. QRS morphology VPC-like: wide, notched QRS >0.12 s
4. lack of P waves or AV dissociation
Ventricular Tachycardia (VT)
- ⩾ 3 VPC at rate >100 bpm
- TYPES:
1) Monomorphic VT
2) Bidirectional VT
3) Polymorphic VT
4) torsade de pointes
- > differentiate with SVT with bundle blocks
Ventricular Flutter ECG
- Regular sinusoidal waveform without clear definition of the QRS and T waves
- Absence of an isoelectric line
- Rate over 250-350 beats/min
Ventricular Fibrillation ECG
- Extremely rapid and irregular ventricular rhythm
- Chaotic and irregular deflections of varing amplitude and contour
- Absence of P waves, QRS complexes and T waves
- Rate over 300 beats/min
