ic1 - arrhythmia - 2012 edited
TRANSCRIPT
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Arrhythmias
Richard G Sheahan,
ConsultantCardiologist/Electrophysiologist
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ParoxysmalEctopic focus, sudden onset, abrupt cessation
Sustained
Duration of > 30 seconds
Requires intervention to terminate
Non-Sustained
At least 3 beats or < 30 seconds
Spontaneously terminates
Recurrent
Occurs periodically
Periods of no tachycardia are longer than periodsof tachycardia
Terms Describing Tachycardias
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Tachyarrhythmias
Supraventricular Tachycardia
Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
Sudden Cardiac Death Premature Atrial & Ventricular
Complexes
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2% VFData source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
34%
Atrial
Fibrillation
18%
Unspecified
6%
PSVT
6%PVCs
4%
Atrial
Flutter
9%
SSS
8%
ConductionDisease
3% SCD
10% VT
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Arrhythmia Symptoms
Palpitations Sudden Onset or Offset
Shortness of Breath
Chest pain
Syncope or Presyncope/Dizziness
Increasing Fatigue
Cough & Sputum Impaired Quality of Life
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Arrhythmia Signs
Pulse Rate Blood Pressure
O2 Saturation
Perfusion, Pale Sweaty & Clammy
Heart Failure
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Tachycardia Recognition
Rate > 100 bpm Regular or Irregular
Narrowcomplex or Broadcomplex
P waves present or absent
Clinical Assessment
Past History
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Arrhythmia
Supraventricular Tachycardia Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia Ventricular Fibrillation
Sudden Cardiac Death
Premature Atrial & Ventricular Complexes
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Origin: AV Node
Mechanism: Reentry
Rate: 150 - 230 BPM, faster in teenagers
Characteristics: Normal QRS with absent P-waves;
most common SVT in adults
SVT
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Supraventricular Tachycardia
IV Adenosine Rate Control
Beta blockers, Calcium Channel Blockers
(Digoxin)
Rhythm Control Normal Ventricule:
Propafenone, Flecainide, sotalol
Abnormal Ventricule
Amiodarone
Synchronized CardioversionHemodynamically unstable
EP Study & RF Ablation
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AVNRT( atrioventricular nodal re-entrant tachycardia)
Accounts for 80-90% of SVT Abrupt onset and offset
The typical ventricular
rate is 140-300/min
P is usually buried within
the QRS complex
Best identified in V1
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SVT-AVNRT
P
Just learn to recognise SVT, no need to know
AVRT or AVNRT specifically
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AVRT( atrioventricular re-entrant tachycardia)
Reentrant circuit
consists of an
atrioventricular
nodal pathway andaccessory pathway
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SVT-AVRT
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Sinus Tachycardia
Pain Anxiety
Fever
Anaemia
Dehydration
Hyperthyroidism
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Sinus Tachycardia Treatment
Treat the cause
Acute management:
Treatment aimed at restoration of sinus
rhythm
1. Carotid sinus massage
2. IV adenosine
3. IV verapamil
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Sinus Tachycardia Treatment
Long term management:1. Drug therpy
- directed at AVN
- beta-blocker
- calcium channel blocker
- digoxin
- directed at AP
- Class IA/C agents
2. Radiofrequency ablation
3. Treat the underlying causes (if any)
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Arrhythmia
Supraventricular Tachycardia (SVT) Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
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Atrial Flutter
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Atrial Flutter Treatment
Anticoagulation for High Risk Patients Rate Control
Beta-blocker, Ca Channel Blocker, (?Digoxin)
Rhythm Control Cardioversion
Antiarrhythmics
Radiofrequency Ablation
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Arrhythmia
Supraventricular Tachycardia (SVT) Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
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Atrial Fibrillation
MOST IMPORTANT RHYTHM AND COMMONEST
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Feinberg WM, Blackshear JL, Laupacis A, et al.Arch Intern Med. 1995;155:469-473
Atrial Fibrillation
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Feinberg WM, Blackshear JL, Laupacis A.Arch Intern Med.1995;155:469-473
Atrial Fibrillation Demographics by
Age
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Atrial Fibrillation Treatment 1
Stroke Prevention Heparin, Warfarin or newer anticoagulants
ASA
Rate Control
Betablockers, Ca Channel blockers, (? Digoxin)
Rhythm Control
Normal Heart: Propafenone, Flecainide, Sotalo
CHF/LVH/CAD: Amiodarone
At i l Fib ill ti T t t 2
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Atrial Fibrillation Treatment 2
CORE MATERIAL
Synchronized Cardioversion < 48 hours Heparin + Cardioversion
> 48 hours Heparin + TOE +/-Cardioversion
Or Warfarin INR 2.0 -3.0 for > 4 weeks
Pulmonary Vein Isolation Ablation
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Atrial Fibrillation Treatment 3
Associated Conditions Treat Hyperthyroidism before
cardioversion
Treat sepsis Treat pulmonary embolism
Pacemaker for Bradycardia
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CHADS2Score*
Congestive heart failure 1
History of hypertension 1
Age > 75 1Diabetes 1
Stroke / TIA 2
Warfarin indicated when CHADS2score > 2
* The CHADS2 scores were developed in a study published in The Journal of theAmerican Medical Association in 2001
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Annual Stroke Risk
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Recommendations for Anticoagulation
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Arrhythmia
Supraventricular Tachycardia (SVT) Atrial Flutter
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
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Origin: Ventricles (Wandering Single Focus)
Mechanism: Reentry with movement in the circui
Initiated by Abnormal Automaticity or
Triggered activity
Characteristics: Wide and irregular QRS Complex that
chan es in axis Tc Normal
Polymorphic VT
*Animation
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Origin: Ventricle
Mechanism: Reentry (movement in focus)
Rate: 200 250 BPM
Characteristics: Associated with Long QT interval;
QRS changes axis & morphologywith alternating positive/negative
complexes
Torsades de Pointes
Ventricular Tachycardia
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Ventricular Tachycardia
CORE
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Ventricular Tachycardia Treatment
Acute Synchronized Cardioversion if unstable
+/- CPR
IV Amiodarone, Beta-blocker, Magnesium
Chronic Correct Reversible Causes
ICD if no 1) Reversible Causes or 2) EF