2. BASICS
• NORMAL SINUS RYTHM: when
every heart beat originates with
depolarisation of sinus node.
• ARRYTHMIA/ DYSRYTHMIA Any
disturbance in rate, regularity, site
of origin, or conduction of the
cardiac electrical impulse
3.
4. PRECIPITATING FACTORS FOR ARRYTHMIAS
• HYPOXIA : myocardium deprived of O2 – irritable myocardium. Pulm disorders, copd,
• embolus.
• ISCHEMIA & IRRITABILITY: ANGINA, MYOCARDIAL INFARCTIONS, MYOCARDITIS( Viral
SYMPATHETIC STIMULATION : enhanced sympathetic tone ( hyperthyroid, nervousness, exercise)
• DRUGS : Many drugs cause arrhythmias…
• ELECTROLYTE IMBALANCE: K, Ca , Mg.
• STRECTH : Hypertrophy & enlargement of ATRIA & VENTRICLES
• ( VALVULAR HEART Ds, CARDIOMYOPATHY, CHF)
5. CLINICAL MANIFESTATIONS
• ASYMPTOMATIC
• PALPITATIONS awareness of ones own heart beat
• SYNCOPE : symptoms of decreased cardiac output. ( light headedness.)
• CHEST PAIN: rapid heartbeat can inc O2 demand of myocardium, cause ANGINA.
• CHF sudden onset of arrhythmias in underlying heart ds precipitate CHF
• DEATH: sudden death… ( post MI Pt increase risk of sudden death 2* arrhythmias)
monitoring continuous rhythm imp,,
IN OP SETTINGS,,, RHYTHM STRIPS, HOLTER 24- 48, EVENT MONITORS.
11. • BETA BLOCKERS — For patients with symptomatic inappropriate sinus tachycardia, we
suggest a trial of beta blockade, rather than non-dihydropyridine CCB, as the initial medical
therapy. start long-acting metoprolol 25 to 50 mg daily.
• IVABRADINE — For patients with persistently symptomatic inappropriate sinus tachycardia,
ivabradine (5 mg to 7.5 mg twice daily) with or without a beta adrenergic receptor blocker
• 2015 ACC/AHA/HRS guideline for the treatment of supraventricular tachycardia both support
the use of ivabradine for inappropriate sinus tachycardia
16. RX
• radiofrequency ablation (RFA). In all available studies, catheter ablation is
superior to rate-control and rhythm-control strategies with antiarrhythmic
drugs.
19. MANAGEMENT OF ACUTE AF (<48 HRS)
• Haemodynamically unstable : hypotension/heart failure/chest pain/syncope
Use DC Cardioversion
Haemodynamically stable :
Rate control : If significant tachycardia
Rhythm control : Flecainide, Propafenone (cl-I) Amiodarone, Sotalol (cl-III)
Anticoagulant : LMWH
20.
21. RATE CONTROL VS RHYTHM CONTROL
• RHYTHM CONTROL AS PREFERRED THERAPY
• ? First episode afib
• Reversible cause (alcohol)
• Symptomatic patient despite rate control
• Patient unable to take anticoagulant (falls, bleeding, noncompliance)
• CHF precipitated or worsened by afib
• ? Young afib patient (to avoid chronic electrical and anatomic remodeling that
occurs with afib
• RATE CONTROL AS PREFERRED THERAPY
• Age > 65, less symptomatic, hypertension
• Recurrent afib
• Previous antiarrhythmic drug failure
• Unlikely to maintain sinus rhythm (enlarged LA)
22. AMIODARONE
•Large volume of distribution
& long half life
•Contraindications
•Sinus bradycardia
•Heart block
•Adverse effects
•Short term : Skin
reactions,Brady, hypotension,
•Long term :
• Pulmonary fibrosis, alveolitis,
pneumonitis
• Liver dysfunction..monitor LFT
• Hypo or Hyperthyroidism (check
TFT before starting)
• Peripheral neuropathy, myopathy,
Cerebellar dysfunction.
29. CAROTID MASSAGE
• Check for carotid bruit before massage.
• At the level of cricoid cartilage,at the angle of mandible the carotid sinus is situated.
• Gentle pressure is applied over the carotid sinus for 10-15 seconds.
• ECG recording to be present.
• In case of no response – try on the other side.
• Simultaneous pressure not to be applied both sides.
• Alternative manuevres are valsalva,gag reflex,ice water pouring over the face.
• IF EVIDENCE OF CAROTID @ Ds do not perform carotid massage.
30. • If SVT is suspected to be AVNode dependent – drug of choice is adenosine and CCBs verapamil
and diltiazem.
• But digoxin,BBs,CCBs better control of ventricular response in atrial tachycardias
• Class I agents to be combined with AV nodal blocking drugs – to eliminate 1:1 conduction of
atrial to ventricles.
31. • Pre-excitation syndromes seen on ECG when patient in sinus rhythm (WPW changes). These are
lost when AVRT is established
• Short PR, delta wave, widened QRS
• Anatomical re-entrant pathway (Bundle of Kent). Circus movement between the AV node and
accessory pathway.
• May be triggered by PAC or PVC
• Circus movement may by orthodromic or antidromic
33. PREMATURE VENTRICULAR CONTRACTION (PVC)
• The ectopic beat is not preceded by a p-wave
• Irregular rhythm due to ectopic beat
• Rate will be determined by the underlying rhythm
• QRS is wide and may be bizarre in appearance
• Caused by a irritable focus within the ventricle which fires prematurely
• Must identify an underlying rhythm
34. PREMATURE VENTRICULAR CONTRACTION (PVC)
• Classify as UNIFOCAL, OR MULTIFOCAL PVC’S
• UNIFOCAL-originating from same area of the ventricle; distinguished by same
morphology
• MULTIFOCAL-originating from different areas of the ventricle; distinguished by
different morphology
45. IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD)
•ICD therapy compared with conventional AAD associated with mortality
reduction of 23-55% depending on risk group.
•Current ICD options:
• Single chamber
• Dual chamber
• Biventricular cardiac resynchronization
• Multilevel shock discharge for VT or VF
Complications:
Inappropriate shock discharge
Defibrillator storm
Infections
Exacerbation of HF
46. LONG QT SYNDROME
• Long QT syndrome (LQTS) is a rare congenital and inherited or acquired heart condition in
which delayed repolarization of the heart following a heartbeat increases the risk of episodes
of torsades de pointes (TdP, a form of irregular heartbeat that originates from the ventricles)
• QTc is prolonged if > 440ms in men or
• > 460ms in women.
• QTc > 500 is associated with increased risk of torsades de pointes.
• a normal QT is less than half the preceding RRinterval.
50. TREATMENT
• Beta-adrenergic blocking agents are the drugs of choice to treat long QT syndrome and include
the following medications:
• Propranolol, Nadolol, Metoprolol, Atenolol
• SURGICAL OPTION
• Surgical intervention in patients with long QT syndrome may include the following procedures:
• Implantation of cardioverter-defibrillators
• Placement of a pacemaker
• Left cervicothoracic stellectomy
• FAMILY HISTORY,, AVOID EXERCISES, AVOID DRUGS
51. TORSADES DE POINTES
• Torsades de pointes is a specific form of polymorphic VT in patients with a
long QT interval. It is characterized by rapid, irregular QRS complexes,
• which appear to be twisting around the ECG baseline.
• This arrhythmia may cease spontaneously or degenerate into ventricular
fibrillation.
53. RX
MAGNESIUM
decreasing the influx of calcium, thus lowering the amplitude of EADs.
Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be
repeated in 5-15 minutes.
• Because of the danger of hypermagnesemia (depression of neuromuscular function), the
patient requires close monitoring.
LONG-TERM TREATMENT
• Beta-adrenergic antagonists at maximally tolerated doses are used as a first-line long-
term therapy in congenital long QT syndrome. Propranolol is used most extensively
• Implantable cardioverter-defibrillators (ICDs) are useful in instances when torsade
recurs despite treatment with beta-blockers, pacing, and possibly left thoracic
sympathectomy.
55. • VENTRICULAR FIBRILLATION
• No discernable p-waves
• No regularity
• Unable to determine rate
• Multiple irritable foci within the ventricles all firing simultaneously
• May be coarse or fine
• This is a deadly rhythm
• Patient will have no pulse
• begin CPR & resustication.
