diagonosis and management of arrhythmia final dr. onn akbar ali adelaide hilton 2012
TRANSCRIPT
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Diagnosis and Management of Arrhythmias
Onn Akbar Ali
MBBS (Adelaide) FRACP
Private RoomsNorth AdelaideAshford HospitalCraigmoreArdrossan
HospitalsAshford Private HospitalsThe Queen Elizabeth Lyell Mc Ewin Hospitals
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Outline
• Cardiac Anatomy relevant to ECG
• Recognize normal ECG
• Common
– Brady
– Conduction disease
– Tachy
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ArrhythmiasREFER !!
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ArrhythmiasREFER !!
Dear Dr Ali,
Re. Mrs Precious binti Anxious
DOB 25/12/1982
Referral valid for 12 months
Patient complains of palpitation , Please manage.
Sincerely
G.P
We prefer to receive letter via Argus
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Arrhythmias
Listen carefully (not only the heart sounds) and gives patients time
When symptoms occur and how long does it last?
How long has been? Years months versus recently
How long does it last? Seconds-momentary vs sustained
What’s the symptoms? syncope, collapse or other cardiac symtomps.
How does it terminate? Quick onset and offset
Medications?
Exercise tolerance ? Left heart fa
Family History? Sudden cardiac death, palpitation or Syncope
Diagnosis and Management is based primarily on history , ECG
and Examination
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Conducting system
Sinus node
AV node
Left Bundle
Right Bundle
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Normal Sinus Rhythm
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Rule of sinus rhythm
Every P wave must be followed by QRS complex and every QRS complex must be preceded by P wave
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Normal Sinus Rhythm …?
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Normal Sinus Rhythm with …?
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Normal Sinus Rhythm with …?
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Normal Sinus Rhythm with …?
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Arrhythmias
Slow
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Conduction Disease
SA
1st degree
2nd Degree
3rd Degree
R L
Left anterior (Left axis)
Left Posterior (Right axis)
SA node
AV Node
Left Bundle
Right Bundle
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Case study 1 Scenario 1 : 65 year old man ; slow pulse alert on BP
machine ; taxi driver
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65 year old man ; well no symptoms
Scenario 1: Sinus Brady without symptoms or conduction disease is often benign
Scenario 2: Lethargic ; tired decreased exercise tolerance; self employed tradesman
SA node
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Conduction Disease
AV
1st degree
2nd Degree
3rd Degree
R L
Left anterior (Left axis)
Left Posterior (Right axis)
SA node
AV Node
Left Bundle
Right Bundle
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Heart Block
* ***
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Case 2: 76 year old with postural dizziness
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1st Degree AV Block
– PR Interval > 0.20 s
Sinus rhythm with first degree heart block
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2nd Degree AV Block, Type I
• Deviation from NSR
– PR interval progressively lengthens, then the impulse is completely blocked (P wave not followed by QRS).
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2nd Degree AV Block, Type II
• Deviation from NSR
– Regularly a P waves wave not followed by QRS
– For the nerd
Conduction is all or nothing
(no prolongation of PR interval); typically
block occurs in the Bundle of His.
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Case 3: 65 on routine check up
Complete Heart Block Note Narrow QRS Complex escape
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Case 4: Collapsed at home. Gawler Health Service
AV dissociation
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Treatment
• External Pacer
• Isoprenaline infusion
• Temporary Pacing wire
• Permanent Pacemeker
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Conduction Disease
SA AV
1st degree
2nd Degree
3rd Degree
Bundle Branch
R
L
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65 year old man with recurrent falls and collapse
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Case 5: 79 year old man with systolic murmur with syncope
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Trifasicular Block
AV nodal disease
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Conduction Disease
SA AV
1st degree
2nd Degree
3rd Degree
Bundle Branch
R
L
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Left Bundle Branch Block
• Consequence of LBBB
• Significant ?
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Fast
Narrow
Irregular Regular
Broad
Regular Irregular
Atrial
fibrillation
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Fast
Narrow
Irrgular Regular
Broad
Regular Irregular
Supraventricular Tachycardia
Ventricular Tachycardia
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Tachy ArrhythmiasHR >100
Atrial
Atrialcomplex &
narrow QRS
JunctionalNo atrial
complex & narrow QRS
Ventricular
Broad QRS
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Supraventricular Arrhythmias
• Atrial Fibrillation ( irregular)
• Atrial Flutter
• Paroxysmal Supraventricular Tachycardia
• Supraventricular Ectopic
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SVTAtrial tachycardia
AVNodal reentry
Atrial flutter
Atrial fibrillation
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Block AV node and control ventricular
rate
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Decision
• Factors
– Symptoms
– Exercise tolerance
– Duration
– Ischemia
– Heart failure
– Mental state ; cerebral perfusion
• Admit or treat
• Referral
– Immediate
– Urgent
– Elective
• Investigate
– Routine blood;TSH
– Echo
– ECG
– CXR
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Treatment
• Search underlying cause
– Ischemia
– Thyroid
– Infection
– Comorbidities
– COPD /OSA
– Pulmonary embolus
• Control ventricular rate
• Prevent stroke (A.F)
• Treat complication
– Left heart failure
– Ischemia
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Case study
• 75
• DM , HT – Palpitation
• HR 155 BP 150/95
• Coveram ( perindopril &amlodipine 5/5)
• 4 Scenarios
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Case 67 female, HT, DM-Palpitation HR 155 BP 150/95
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New onset Atrial fibrillation{1} 70 female, HT, DM-Palpitation
Scenario 1
Compensated
• 2 to 3 weeks
• No chest pain; Slightly breathless
• No edema
• No dizziness/no collapse
• BP 160 +
• Can walk to 4 bus stops
• Clear lung
Treatment
• Aspirin ; start warfarin
• Metoprolol 25 mg b.d
• Digoxin 250 mcg 3 stats then half ( 125mcg)
• Bloods (CBP, Euc LFTs, TSH)
• Referral ( Echo)
• Re assess 2 -3 days ; INR ;education; chase blood ;CXR
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New onset Atrial fibrillation {2}70 female, HT, DM-Palpitation
De Compensated Treatment
• 2 weeks
• Chest pain on stairs
• Orthopneic; PND
• Mild edema
• BP 150/50
• Ex tolerance- 20 m from 1 km
• Mild creps &murmur
• Aspirin -Warfarin
• Metoprolol 12.5 mg tds
• Digoxin 250 mcg ;3 then half
• Frusemide 60 then 40 mg
• Imdur 60 mg
• Stop amlodipine
• Blood CXR
• Review 2 days
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Atrial fibrillation 1. Control ventricular rate-
Low dose beta blocker & digoxin --the best combination
1. Prevent stroke – start warfarin – don’t procrastinate-
2. Don’t wait for cardiologist-don’t panic-Low dose beta blocker has few contraindication
3. Pulmonary embolus and stroke causes serious morbidity and mortality
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Atrial fibrillationwhen to refer to
ANE
1. Hopeless patient
1. Home alone; no english
2. Very poor ex tolerance
3. Dizziness
4. Overt LVF
5. You don’t have time
( wife rang you 3 times already; ; kids to pick up from school)
6. Other organ failure or comorbidities
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75 female; DM & HT routine ECG{3}
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• 75 female; DM & HT routine ECG
75 female; DM & HT routine ECG {4}
Left Bundle Branch Block and Fast AF: Refer
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ManagementAim
1. Control ventricular rate
2. Prevent stroke
3. Look for underlying cause
4. Identify and treat complication
Control ventricular rate
1. Beta blocker (metoprolol 25 bd or tds best)
2. Digoxin
3. Calcium Channel blocker
Regulate Rhythm
1. Flecainide (cardiologist)
2. Amiodarone (short term)
3. Sotalol
Prevent stroke
1. Aspirin
2. Warfarin
3. Dabigatran direct thrombin in
4. Rivaroxaban F XA inh
CHAD or CHAD-Vasc score
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Warfarin vs dabigatran vsRivaroxaban vs Aspirin vs
nothing
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Acute Palpitation – Gawler ANE70 HT; COPD ; DM
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Acute onset narrow complex Regular tachycardia
{ ANE}
• Carotid sinus massage
• Ice
• Valsalva
• Adenosine
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Adenosine for uncertain SVT
• Atrial flutter 2:1 vs AVNRT ?
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Adenosine for SVT
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Adenosine in AF/ Aflutter
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60 ;HT otherwise well
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Atrial Flutter
Curable (80 -90%)
with ablation & very
amenable to
cardioversion
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Acute palpitation , hemodynamically stable
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Therapy
I.V
• Adenosine ( 6,12,18,24)
• IV metoprolol
• IV verapamil
• ( 5 mg in 10 mls ) ; 1 mg /min assess each min
• NO VERAPAMIL IN A.S /CARDIOMEGALY /LVF/ Murmur
ORAL
1. Metoprolol 25 bd
2. Atenolol 25
3. Verapamil 80 tds
4. Digoxin load and 62.5 mcg (AF/Flutter)
Play simple and safe
Consider IV amiodarone
(hypotension)
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Case study- my heart stops!
• 40 year old litigation lawyer
• Palpitations
• My heart stops and starts again
• Dizziness
• Throat
• Treadmill 3 x week and pump class
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40 Female healthy , irregular pulse
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What would you do?
1. Reassurance
2. Reassurance , Echo and Holter
3. Exercise stress test ? Ischemia
4. Stress Echocardiography
5. Cardiology review now ( hotline)
6. Cardiology review next 3 weeks
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FAST
Narrow
Irregular
A.F
Treat
Regular
SVT/A. Flutter
Treat
Broad
Regular
Ventricular Tachycardia-
000
Irregular
Fax to cardiologist
Regular narrow complex rhythm at
150 bpm ~~ Atrial flutter 2:1block
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70 y.o no symptoms , driver license check , no med. Exam :Irregular pulse
Atrial Fibrillation
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35 y.o female palpitation.
• SVT eg. AVJRT
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35 y.o female with palpitation
• Gawler Hospital
• Initial BP 125/90
• Given IV verapamil 5 mg total no result
• Another GP : IV amiodarone 300 mg rapid push ( please don’t do this !) (he has just left)
• BP now 85 mm Hg feels drained but conscious.
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Now What?
Who wants to be a Hero ?
• Dial a friend
• 50 -50
• Ask the audience ( Husband is a lawyer)
• Adrenaline
• Metaraminol ( Aramine)
• Fluid
• Its not my fault
• Call ambulance ( remember, you
are in hospital)
• DC shock
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DC shocks
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• DC shock delivered on R wave ( R on T phenomenon) resulting in VF
• Now patient is fully unconscious ….
– Husband: “what happening” –
– Doc to Nurse –what have you done?
R
T
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Learn your buttons !!!
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Tachycardia with hemodynamic instability
• Ensure not sinus tachycardia
• DC shocks with or without sedation
• Please sync
• Prepare for post shock bradycardiahypotension LVF ( CPR , atropine , adrenaline)
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Broad Complex Regular Tachycardia
• Ventricular Tachycardia
• Ventricular Fibrillation
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Broad-Fast-Monomorphic
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Ventricular Tachycardia
[1] Stable
• Palpitation BP 125 sys
• Mild chest tightness
• Clear Lung no LVF
• Previous Inf MI 20 years ago
• What do you do
• Blood – Panic
– Shocks
– Amiodarone
– Lignocaine
[2] BP 85 Concious
• Palpitation
• Breathless
• Crepitation
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Ventricular Tachycardia
Impulse is originating in the ventricles
(wide QRS).
Take your own pulse
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