6. Reentry
• Requires the presence
of two pathways
– One slow, the other fast
– Unidirectional block in
one of the pathways
– Slow conduction down
the unblocked pathway
allowing the other
pathway to recover and
maintain the circuit
10. Atrial Fibrillation
• Irregular Narrow Complex Tachycardia
• The commonest sustained arrhythmia
• Absence of P waves
• Atrial activity appears as irregular baseline or f
(fibrillatory) waves
• Usual ventricular rate 100-180 in the absence of
therapy
• If HR < 100 without medical treatment suspect
underlying conductive tissue disease
11. Types
• Paroxysmal
– self-terminating episodes that generally last <7 days
(most <24 hours)
• Persistent
– generally lasts >7 days and often requires electrical or
pharmacologic cardioversion.
• Permanent
– failed cardioversion or when further attempts to
terminate the arrhythmia are deemed futile.
Hurst's the Heart, 12th Edition
12. Causes
• Ischemic Heart Disease
• Hypertensive Heart Disease
• Other organic heart disease/cardiomyopathy
• Mitral Valve disease
• ASD
• WPW
• Lung Disorders (Acute e.g. PE, Chronic e.g. COPD)
• Post Surgical e.g. CABG
• Thyrotoxicosis
• Alcohol
14. Multifocal Atrial Tachycardia
(MAT)
• Irregular Narrow Complex Tachycardia
• >= 3 P wave morphologies
• Varying PP, PR, RR intervals
• P waves may be blocked
• P waves may conduct with aberrancy
• Unstable rhythm usually progresses to atrial
fibrillation
16. Management
• Treatment of the underlying cause
• Correction of electrolytes (K, Mg)
• AV nodal blocking agents
• Anticoagulation depending on stroke risk
17. Regular
Narrow Complex Tachycardia
No P Waves
AV nodal Reentry
tachycardia, AVNRT
Irregular
P Waves present
Identify P wave morphology/rate
Relationship between P and QRS
Identify RP interval
19. AVNRT
• Regular Narrow Complex Tachycardia
• Usual rate 150-250
• Abrupt onset and offset
• Variable relation to P wave
– P wave buried in the QRS
– Short RP interval
– Atypical AVNRT Long RP
• Usually no underlying heart disease
22. Regular
Narrow Complex Tachycardia
No P Waves
Irregular
P Waves present
Identify P wave morphology/rate
Relationship between P and QRS
Identify RP interval
23. RP Interval
• Distance from the R wave to the NEXT P wave
• Short if RP interval < ½ RR interval
• Long if RP interval > ½ RR interval
26. Regular Narrow Complex Tachycardia
No P Waves P Waves present
P wave morphology
Atrial rate
Relationship between
P and QRS
RP interval
Atrial rate >200
Flutter waves
Atrial Flutter
Short RP
Abnormal P wave
Atrial tachycardia
With AV delay
Long RP interval
Abnormal P wave
Atrial tachycardia
Short RP
Retrograde P wave
AVNRT, AVRT
Long RP interval
Retrograde P wave
Atypical AVNRT
27. Definition of normal P
• Duration 0.08 to 0.11 (2-3 small squares)
• Axis (0-75)
• Upright in II, III, aVF
• Upright/biphasic in III, aVL, V1, V2
• Amplitude <2.5mm in II (2.5 small squares)
• Amplitude in V1 positive <1.5mm (1.5 small sq)
negative <1mm (1 small sq)
• PR interval 0.12 – 0.2 (3-5 small squares)
30. Atrial Flutter
• Regular Narrow Complex Tachycardia
• F waves conducting ~ 300/min
• Usually 2:1 block with a ventricular response
of 150/min
• Same causes as atrial fibrillation
• No baseline in II, III, aVF
• Discrete P waves in V1
31. Mechanism of Atrial Flutter
• Typical F waves inverted
F waves in II, III, aVF
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EID:34EDT:09:0811-SEP-2009ORDER:
32. Management
• Similar to atrial fibrillation
– Requires anticoagulation
• More Difficult to control rate with medical
treatment compared to atrial fibrillation
• Usually requires DC Cardioversion
• Radiofrequency ablation highly successful in
restoration and maintenance of sinus rhythm
34. Atrial tachycardia
• Atrial rate is 100-240 i.e. slower than atrial flutter
• Usually 1:1 conduction without medical
treatment
• Not terminated by vagal maneuvers
• Mechanism
– Intra atrial reentry
– Automatic – ectopic focus
– triggered
35. Management
• AV nodal blocking agents
• Some are amenable to Radiofrequency
ablation
37. Problem 1
• 68 year old Nigerian male with PMH of HTN,
DM comes to Cardiology clinic for a routine
check up
• He takes metoprolol in addition to Lisinopril
for Blood Pressure Control
• HR 70/min, irregular, BP 150/70
39. Problem 2
• 62 year old female with known ESRD on HD
via left AV fistula developed sudden onset of
palpitations during dialysis; feels her HR racing
• HR 170/min, BP 130/80
• Clinical Examination revealed rapid regular
heart beat, mild LE edema, left AV fistula
41. Problem 3
• 59 year old African American Male, with DM,
HTN, Obesity presents to his internist with
two weeks history of shortness of breath on
exertion
• HR 140/min, BP 140/90
• JVP difficult to assess due to obesity
• Chest clear, mild LE edema (unchanged
according to patient)
42. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Flutter
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
ID:00034559908-APR-200903:24:28COOKCOUNTYHOSPITAL
***AgeandgenderspecificECGanalysis***
Sinustachycardia
Leftposteriorfascicularblock
CannotruleoutInferiorinfarct(citedonorbefore18-APR-2008)
Anteriorinfarct(citedonorbefore02-DEC-2007)
WhencomparedwithECGof20-DEC-200813:44,
Significantchangeshaveoccurred
ConfirmedbyKELLYMD,RUSSELL,F(1006),editorJAMES,MAMIE(34)on16-Apr-200915:20:27
D12SL233CID:1
Referredby:ConfirmedBy:RUSSELL,FKELLYMD
BPM153ent.rate
ms208Rinterval
ms84RSduration
msT/QTc306/488
59141*R-Taxes
TEPHANBARBER
162456
Page1of1
EID:34EDT:15:2016-APR-2009ORDER:ACCOUNT:000221162456
43. Problem 4
• 74 year old African American Female with
remote history of ASD repair and Pulmonary
Hypertension comes for follow up
• She takes metoprolol for hypertension
• HR 80/min, BP 120/70
46. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Fibrillation
47. Problem 6
• 54 year old White Male with PMH of a known
arrhythmia comes for routine follow up
• He takes metoprolol XL 200mg once daily
• HR 110/min, irregular, BP 130/70
53. Problem 9
• 61 year old Hispanic female with no PMH,
presents to the Emergency Room with fatigue,
loss of weight, palpitations, and feeling warm
all the time.
• HR 200/min, BP 120/80
55. Problem 10
• 48 year old male with severe obesity, a
chronic skin disorder, and chronic LE edema is
sent to hospital from this primary care doctor
after he finds his HR to be very fast
• HR 141/min, BP 130/70
• In the ER an ECG was performed
• Due to concerns for Pulmonary Embolism (PE),
a CT Pulmonary Angiogram was performed
and was reported as negative for PE
56. • Regularity of rhythm
• P wave present or absent
• RP interval
• P wave morphology/rate
• Relationship between P and QRS
Atrial
Tachycardia
57. • Diagnosed with probable ectopic atrial
tachycardia
• No response to IV adenosine
• No response to IV esmolol
• NO response to IV amiodarone
• Started becoming more breathless
58. • Performed DC Cardioversion 50J Biphasic, then 200
with no response
• At second attempt at DC Cardioversion 200J reverted
to Sinus rhythm
Narrow Complex tachycardia Estimate HR
Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval
11x10=110
No P waves Atrial Fibrillation
Narrow Complex tachycardia Estimate HR
Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval
10x10=100
Identify P waves, variable P wave morphology, variable PP, variable PR intervals
No P waves Atrial Fibrillation
Narrow Complex Tachycardia
P wave are buried in the QRS complex so cannot be seen on a surface ECG
Narrow complex tachycardia Regular, Rate of 190 No P waves
P wave are buried in the QRS complex so cannot be seen on a surface ECG
Regular Narrow Complex Tachycardia, ~140/min, short RP, retrograde P wave
Narrow complex tachycardia, Regular, 150/min, two P waves to every QRS complex at 300/min,
Regular Narrow Complex tachycardia, Long RP, abnormal P wave (biphasic in II, inverted in aVF, upright in III)
Re entry underlying heart disease, specturem A fib/flutter, 90-120, 2:1 block, Ablation 75% success
Crista terminalis, base of pulmonary vein, ablation if incessant
HR 90/min, irregular, narrow complex tachycardia, no P waves Atrial Fibrillation
HR 180/min, narrow complex tachycardia, regular, no P waves AVNRT
HR 150/min, narrow complex tachycardia, regular, atrial rate of 300/min, 2:1 block, saw tooth pattern atrial flutter
Not atrial tachycardia (atrial rate too fast)
HR 87/min, narrow complex, regular, 2:1 block, atrial rate of 150/min,
Not atrial flutter because atrial rate is much lower than that
110/min, narrow complex tachycardia, irregular, no P waves, coarse baseline Atrial fibrillation
110/min, narrow complex tachycardia, irregular, atrial rate of 300/min, variable ventricular response, atrial flutter with variable block
HR 150/min, narrow complex tachycardia, regular, retrograde P wave, short RP, AVNRT
HR 115/min, narrow complex tachycardia, 2:1 block, atrial rate of 230/min, baseline between the P waves in II, III, aVF
210/min, narrow complex tachycardia, irregular, no P waves, A fib
HR 140/min, narrow complex tachycardia, regular, borderline abnormal P, biphasic in II, III, aVF, Long RP atrial tachycardia
