tachyarrhythmia gaurav panchal. arrhythmogenesis impulse formation –automaticity – inappropriate...
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Tachyarrhythmia
Gaurav Panchal
Arrhythmogenesis
• Impulse formation – Automaticity – inappropriate Tachy / brady;
accelerated Ventricular rate after MI. – Triggered activity i.e. Long QT, CPVT
• Impulse conduction – Block –
• Without re entry – SA/AV/ BBB• With re entry – WPW, AVNRT,
– Reflection • Both
– Interaction between automatic foci– Interaction between automaticity and conduction
Presentations
• Mode of presentation – Clinic vs Emergency
• Palpitations – Mode of onset – rest vs exercise – Mode of termination – Severity of symptoms
• Syncope • Dizziness / presyncope • SOB
Evaluate
• Drug history
• F/H
• Assess – HR, BP, ECG
• Effect of respiration, CSM
Case 1
• 24 year old female with palpitations – – fast, regular, – usually at rest, – subsides after holding breath or pouring cold
water on face, – usually lasts 25 min to 1 hour. – No presyncope / syncope / SOB
• QRS– >120ms = Broad Complex Tachycardia– <120ms = Narrow Complex Tachycardia
• P-QRS relation• Abnormal pattern of beats
– QRS morphology – normal / abnormal– P wave morphology – normal / abnormal
• Origin or termination of arrhythmia – P / QRS
SVT
• 90% reentrant, 10 % not reentrant
• 60% AV nodal reentrant tachycardia (AVNRT)
• 30% orthodromic reciprocating tachycardia (ORT)
• 10% Atrial tachycardia
• 2 to 5% involve WPW syndrome
Differential Dx of Regular SVT
• Short RP tachycardia– AV nodal reentrant tachycardia– AVRT– atrial tachycardia when associated with slow
AV nodal conduction
AVNRT
• Responds to vagal maneuvers in 1/3 cases
• Very responsive to AV nodal blocking agents such as beta blockers, CA channel blockers, adenosine.
• Recurrences are the norm on medical therapy
• Catheter ablation 95% successful with 1% major complication rate
• 2 pathways within or limited to perinodal tissue– anterograde conduction
down fast pathway blocks with conduction down slow pathway, with retrograde conduction up fast pathway.
• May have very short RP interval with retrograde P wave visible as an R’ in lead V1 or psuedo-S wave in inferior leads in 1/3 of cases . No p wave seen in 2/3
Management
• Vagal manoeuvres
• Pharmacological – Acute management – adenosine, flecainide,
amiodarone – Prevention – flecainide, propranolol, sotalol,
amiodarone
• RFA
Case 2
• 64 year old male with palpitations – acute onset for 12 hours – fast, regular, associated with dizziness on standing up. No syncope or SOB.
Management
• Cardioversion – Pharmacological – DCCV
• Ablation
• Rate control – Beta blockers– Amiodarone
• Anticoagulation
Narrow Complex Tachycardia
Regular Irregular
Irregularly Irregular:•Afib•Multifocal Atach
Regularly Irregular:•Aflutter with variable response•Atach with var response
P before QRS:Sinus tachyAtachAflutter with 1:1 AV
No p wave:SVTAtach?very fast AFIB
P>QRS:Aflutter
68 year old male collapse while on coffee table.
Management
• Acute stabilisation– Hemodynamically unstable – Hemodynamically stable – amiodarone,
lidocaine– Correct predisposing factors
• K+, hypotension, ischemia,
• Long term care – Anti-arrhythmic – beta blocker, amiodarone – ICD
• Cardiomyopathies– Ischaemic – DCM– HCM– ARVC
• TOF • Inherited arrhythmias
– CPVT– Brugada– Long QT – Short QT
• Idiopathic – Outflow tract – Annular – Fascicular
• Questions