Bradycardia and Narrow Complex Tachycardia Smriti Banthia CCU Lecture Series.
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Transcript of Bradycardia and Narrow Complex Tachycardia Smriti Banthia CCU Lecture Series.
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Bradycardia and Narrow Bradycardia and Narrow Complex TachycardiaComplex Tachycardia
Smriti BanthiaSmriti BanthiaCCU Lecture SeriesCCU Lecture Series
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• Sinus node is supplied by the RCA in 60% of people and by the LCX in 40%.
• AV node is supplied by the RCA in 90% and by the LCX in 10% of patients.
• Right bundle supplied by LAD
• Left bundle supplied by branches of the RCA and LAD
Zimetbaum PJ, Josephson ME. NEJM, 2003Taken from www.baptistoneword.org
Conduction System Anatomy
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Pacemaker?
• Progressive shortening of PP interval before it blocks
• Pause is less than 2 of the preceding PP intervals
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Pacemaker?
SA Block Type II – Pause approximately 2x PP interval
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WHAT NEXT?
52 year-old obese man who presents with cellulitis. Above seen on telemetry during hospitalization.
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Page…. HR 30. WHAT NEXT?
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WHAT IS THIS?
Premature junctional complex
Retrograde p wave
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WHAT NEXT?
80 year-old man presents with syncope.
Mobitz II – 2nd Degree AV Block
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What’s the rhythm?
NSR with first degree AV block
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Pause duration to meet criteria for pacemaker implantation?
3 seconds
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Post cath, holding groin pressure. Pt dizzy now. WHAT NEXT?
Sinus Bradycardia.
Vagal response. Give Atropine.
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What is the rhythm?
ATRIAL FIBRILLATION
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Management of AF
• Maintenance of normal sinus rhythmNo treatmentPharmacologic therapy (AAD, anticoagulants)Non-pharmacologic therapy (Ablation, PPM)
• Ventricular rate controlPharmacologic therapy (BB, CCB, Digoxin)Non-pharmacologic therapy (AVN ablation)
• Reduction of thromboembolic risk
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What’s wrong?
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• Leading cause of stroke from embolism
• AF increases stroke risk
~ 17x Rheumatic heart Dz
~ 5x in non-valvular
Risk of stroke ~ 5%/yr
• Proportion of strokes attributable to AF increases with age
AFIB AND STROKE
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When Rx Coumadin?
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ASA 325 dailyASA or Coumadin
Coumadin INR 2-3
Problem: What about pt with prior hx of CVA but no other RF? Classified as moderate risk when in fact may be high risk…. Thus, the ACC/AHA guidelines differ in the following way…
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ACC/AHA Guidelines for Anticoagulation
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Tachy-Brady Syndrome
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32 year-old female with palpitations
WHAT NEXT???
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After Adenosine 6mg IV
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Retrograde p waves
CSM/Vagal Maneuvers
Adenosine
BB/CCB
Ablation
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AVNRT – Mechanism?
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Aflutter with variable conduction
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MAT
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Aflutter with 4:1 Block
Most cases of atrial flutter are caused by a large reentrant circuit in the wall of the right atrium
EKG Characteristics: Biphasic “sawtooth” flutter waves at a rate of ~ 300 bpm
Flutter waves have constant amplitude, duration, and morphology through the cardiac cycle
There is usually either a 2:1 or 4:1 block at the AV node, resulting in ventricular rates of either 150 or 75 bpm
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Unmasking of Flutter Waves
In the presence of 2:1 AV block, the flutter waves may not be immediately apparent. These can be brought out by administration of adenosine.
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Atrial Tachycardia
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Atrial tachycardia
• P wave upright lead V1 and negative in aVL consistent with left atrial focus.
• P wave negative in V1 and upright in aVL consistent with right atrial focus.
• Adenosine may help with diagnosis if AV block occurs and continued arrhythmia likely atrial tachycardia
• 70-80% will also terminate with adenosine.
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WHAT IS THIS?
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•A. Emergent cardioversion for polymorphic VT.
•B. I.V. procainamide
•C. I.V. lidocaine
•D. diltiazem drip to obtain rate control.
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WPW epidemiology• Present in 0.3% of the
population• Risk of sudden death 1
per 1000 patient-years• Sudden death due to
atrial fibrillation with rapid ventricular conduction
• Atrial fibrillation often induced from rapid ORT
ORT(orthodromic reciprocating tachycardia
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Atrial Fibrillation and WPW
• AV nodal blocking agents may paradoxically increase conduction over accessory pathway by removing concealed retrograde penetration into accessory pathway. Concealed penetration into the
pathway causes intermittent block of pathway conduction
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Management of Atrial Fibrillation with WPW
• Avoid AV nodal blockers
• IV procainamide to slow accessory pathway conduction
• Amiodarone if decreased LVEF
• DC cardioversion if symptomatic with hypotension