ECG Conferences – 2012 - 2013ecgtracings.com/uploads/3/4/2/0/34208058/atrialfib_dhrem2012.pdf ·...
Transcript of ECG Conferences – 2012 - 2013ecgtracings.com/uploads/3/4/2/0/34208058/atrialfib_dhrem2012.pdf ·...
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ECG Conferences – 2012 - 2013Steven R. Lowenstein, MD, MPH
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ECG Curriculum
• Inferior MI• Anterior MI• Posterior MI• ST-T depressions• ST-T elevations • Electrocardiography
of shortness of breath
• Atrial Fibrillation• Supraventricular
tachycardias• Wide complex tachycardias• Bradycardias and heart
block• Electrocardiography of
syncope• Wide, ugly QRS rhythms in
critically ill patients
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46 year old female with mild, fleeting right-sided chest pain while at work. She wants to know if “everything is OK.”
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Healthy 25 year old man, presented with nausea, diarrhea, dizziness
Is it Normal Sinus Rhythm?
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AV
Junction
.13 sec delay
Purkinje
Cells
Atrial delay: .03 seconds
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IIIII
AVF
AVR
I
AVL
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Normal Sinus Rhythm
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Junctional (not sinus) rhythms
II
aVF
II
aVR
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25 YEAR OLD MAN WITH GASTROENTERITIS
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Atrial Fibrillation
• Most irregularly irregular rhythms are atrial fibrillation.– Less frequent: Atrial flutter or MAT
• AF is the most common tachycardia encountered in clinical practice.
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ATRIAL FIBRILLATION: The ECG•Irregularly irregular•No distinct, discrete p-waves
•Irregular fibrillatory f-waves (350+ beats/min)
•f-waves vary in rate, intervals, size and shape*
•Ventricular rate = 100 – 170 beats per minute•QRS complex is narrow – unless:
•Pre-existing BBB•Rate-related aberrancy•Accessory Pathway
•Exam: Pulse deficit; no S4 ; Varying S1
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The irregularly irregular tachycardias
• AF: no distinct, discrete p-waves• Atrial flutter: p-waves are distinct, uniform
at a rate that is close to 300• Often slower if anti-arrhythmic drugs
• Atrial tachycardias: uniform, distinct p-waves at a slower rate (140-220)
• MAT: p-waves are distinct, but they vary in size, shape, direction (multi-form)
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•In AF, electrical activity suggestive of p-waves is common
•But even where the R-R interval is long: distinct p-waves cannot be seen, and there is no uniform p-p interval
•“Fib-flutter?”
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Coarse and Fine AF
• The amplitude of the f-waves correlates with duration– Coarse f-waves more common if recent onset.
• f-waves of greater amplitude also seen with atrialmuscle hypertrophy; diminishes with LA fibrosis
– Fine AF (with a quiet baseline, no obvious f-waves) often signifies AF of long duration
– Amplitude of f-waves does not correlate with left atrial size
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Also on the ECG . . . . .
• Markers of other cardiac disease– Left ventricular hypertrophy– Conduction system disease– Evidence of prior myocardial infarction
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85 year old female with mild dyspnea, fatigue
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Atrial Fibrillation• Most common cardiac arrhythmia encountered in clinical
practice• Tied closely to advancing age• Rarely, if ever, a one-time event; it can be expected to
recur at unpredictable intervals.
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•Trigger: PACs arise from atria or muscular tissue of pulmonary veins•Mechanism:•Multiple colliding re-entry wavelets•Enlarged atrium harbors fibrosis and inflammation, perpetuating re-entry•Ongoing electrical and structural remodeling
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AF: Predisposing FactorsAtrial enlargement, stretchpressure overload, fibrosis
• Hypertension• Congestive Heart Failure• Other structural heart
diseases – Valvular heart disease (MS)– Cardiomyopathy
• COPD, pulmonary embolism
• Acute myocardial infarction
Other conditions• Thyrotoxicosis• Hypokalemia,
hypomagnesemia• Hypoxia• Alcohol• Obesity, metabolic
syndrome
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AF: Harbingers
• Left or right atrial enlargement PACs– Hours, days, weeks or months prior to onset
of AF
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Errors in ECG diagnosis of AF
• Computer & human interpretations often wrong.– f-waves are too small or too tall (p-waves)– Ventricular rate is too fast, too slow or too regular– Tremors or electrical artifacts simulate f-waves– AF is confused with sinus tachycardia, MAT,
atrial flutter, AVNRT, multiple PACs– Wide complex AF is mistaken for VT
• Missed Pes and STEMIs
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What determines ventricular response?
• Normal ventricular rate is ~110 – 170
Determinants:• Intrinsic delay of AV node• Modified by:
– Balance of sympathetic –parasympathetic tone
– Drugs– Fibrosis (with aging)
• Slow ventricular response – MEDICATIONS
• Calcium channel blockers• Beta blockers• Digitalis
– Sclero-degenerative conduction disease (SSS)
– Hypothermia• Very fast response (> 200)
– ↑Sympathetic tone:• Thyrotoxicosis• Fever • Hypoxia, sepsis, GI bleeding
– Accessory pathway
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70 YEAR OLD MAN WITH COPD, PRESENTS WITH 2 DAYS OF FEVER, CP, ↑COUGH, SPUTUM AND SOB; Temp was 39.8° C.
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Rapid Atrial Fibrillation: Hemodynamic Consequences
• Rapid rate (shortened diastole)• Loss of regular, organized atrial systoles
(5-40% of cardiac output)• Many patients have pre-existing LV
dysfunction (hypertension, CHF)• If pronged: Ventricular dysfunction
• Tachycardia-induced cardiomypoathy– Remodeling begins in 24-48 hours if heart rate > 130
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89 year old female with weakness. Unknown medical history, denies meds.
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66 year old man found unconsious
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AF with wide beats
• Pre-existing BBB (left or right)• Rate-related (functional) BBB
– Rate-related aberrancy below AV node– Typical pattern of BBB (usually right) at fast
rates• Pre-excitation (accessory pathway that
bypasses the AV node)
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93 year old female (presented to Rose ED)
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27 year-old female presents with the sudden-onset of palpitations, chest tightness, and lightheadedness approximately one hour prior to arrival … She became increasingly lethargic during her initial evaluation. BP was 88/54.
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42 year old man with complaint of “fast heart beat,” mild dizziness and SOB
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67 yo man with SSCP and SOB. Hx hypertension.
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Review Tracings
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90 year old female presented to ED with 1 day SOB and chest pain. History of CHF and CAD. BP: 144/87 Pulse: 124. Management?
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66 year old female, history of multiple myeloma, DVTs, PEs. Presented with syncope, shortness of breath, mild chest pain.
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38 y.o. man presented with 3 hours substernal chest pain (like “shoe on my chest”) and palpitations. At triage, BP = 115/70, then 100/80.
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After electrical cardioversion
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64 y.o. female has history of renal insufficiency, CHF and hypertension. Presented with 3 days of exertional dyspnea.
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89 yo man with dyspnea and confusion
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E.D. Management
Electrical cardioversion is treatment of choice only for:
– Hypotension or organ hypo-perfusion– Severe congestive heart failure– Active myocardial ischemia (symptomatic or
ECG)– Pre-excitation and AF
• In these circumstances, the need to restore NSR takes precedence over the need to anti-coagulate
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ED Management: The non-emergent patient
• Avoid cardioversion unless anticoagulated– Conversion of AF to NSR --- by EC or drugs --- may
cause embolization of atrial thrombi unless patient has adequate anticoagulation
• Rate control (and treatment of precipitating illness) is the recommended initial treatment for all stable patients.
• After rate control, up to 50% of patients will convert to NSR “naturally” within 24 hours
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Final management points• Recent-onset AF often converts to NSR
– Spontaneously or with treatment of underlying conditions
• Know how to select rate-control drugs• Only choose rhythm conversion if known < 48 hours• It is worth ordering TSH and free T4 • There is no need to admit to “rule out MI”
– Unless clinical or ECG evidence of ACS, angina• If hypotension is present with AF and moderate
ventricular response ( < 130), find another cause– PE, Acute MI, sepsis, hypovolemia
• Do not hesitate to use EC in patients who truly need it.