CARDIAC CARDIAC ARRHYTHMIASARRHYTHMIAS

Diagnosis and ManagementDiagnosis and ManagementDr. Asadullah Khan Soomro

Diploma Cardiology Royal Brompton

National Heart &Lung Institute

University of London

King Fahad Hofuf Hospital

Email; hssbasadsoomro@gmail.com

IntroductionIntroductionCCardiac arrhythmias leading to ardiac arrhythmias leading to

sudden cardiac death is estimated to sudden cardiac death is estimated to claim claim 2,50,0002,50,000 lives annually or lives annually or 2525 lives per million people per week in Unites lives per million people per week in Unites States.States.

IIn more than n more than 80%80% of cases sudden of cases sudden death is caused by abrupt onset of death is caused by abrupt onset of ventricular tachycardia and may progress ventricular tachycardia and may progress to ventricular fibrilation.to ventricular fibrilation.

• Family physicians &nurses working at primary, secondary and tertiary care hospital, are usually confronted with cardiac rhythm problems, which need to be high litened with regards to practical diagnosis and management, which is based not only on electrocardiogram but thorough history and physical examination indeed,

History of ArrhythmiasHistory of Arrhythmias• 1903 – Willem Einthoven developed

electrocardiogram.

• 1876 – Marey discover extra systoles

• 1827 – Robert Adams was first to recognize atrial fibrillation as a sign of mitral stenosis.

• 1867 – Cotton described first supraventricular tachycardia.

• 1761 – Morgagni recognized CHB as most ancient arrhythmias.

• 1862 – Panum induced ventricular tachycardia.

• 1909 – First ECG of V.T. in man was published by Thomas Lewis.

• 1842 – Ventricular fibrillation was first described by Erichsen.

• 1902 – Mackenzie described sick sinus syndrome.

• 1928 – Paul Dudley white discover WPW syndrome.

Major Arrhythmias and AV BlocksMajor Arrhythmias and AV Blocks

Arrhythmias Interpretation

Sinus P wave of normal shape in front of each QRS with regular R.R. interval

Nodal P waves may be absent or if present occur after QRS and are inverted

Atrial P waves of unusual shape, abnormal number of P waves per QRS, absent P waves

Ventricular Wide, bizarre-looking QRS

A.V. Blocks Interpretation

1st degree Prolongation of PR interval (> .20)

2nd degree

Type I (Wenckebach)

Type II

2:1, 3:1 AV block

Progressive prolong P-R interval with drop QRS

Some P waves are not conducted but conducted beats have normal constant PR interval.

Third degreeP waves and QRS complexes are entirely independent “complete AV dissociation”

Regular R-R with slow heart rate.

Causes of Cardiac Causes of Cardiac ArrhythmiasArrhythmias

Coronary artery diseaseCoronary artery diseaseRheumatic heart diseaseRheumatic heart disease

Congenital heart defectsCongenital heart defects

CardiomyopathiesCardiomyopathies

Pericardial diseasesPericardial diseases

HypertensionHypertension

MiscellaneousMiscellaneous

CardiacCardiac ArrhythmiasArrhythmiasSymptomaticSymptomatic______________________

AsymptomaticAsymptomatic

Structural heartStructural heartDiseaseDisease

__________________________

Normal heartNormal heart

Normal Normal E.F. >50%E.F. >50%

Normal heart sizeNormal heart size

________________________EnlargedEnlarged

heart sizeheart size

Cardiac originCardiac origin________________________Non-cardiacNon-cardiac

originorigin

Regular rhythm Irregular rhythmREGULAR RHYTHMREGULAR RHYTHM

a. a. Normal rateNormal rate

Sinus rhythm

Non-sinus (pacemaker)

b. Rapid rateb. Rapid rate

Sinus tachycardia

Supraventricular tachycardia

Ventricular tachycardia

c. Slow ratec. Slow rate

Sinus bradycardia

AV nodal rhythm

AV block

Analysis of ArrhythmiasAnalysis of Arrhythmias

Analysis of ArrhythmiasAnalysis of ArrhythmiasThere are different ways of approaching

arrhythmias, the choice depends upon the level of understanding of the reader.

For rhythm analysis, ask the following questions.

• Is the rhythm regular?• If so, is the rate normal, rapid, slow?

• If irregularRegularly irregular?Irregularly irregular?

Arrhythmias EvaluationArrhythmias Evaluation• Asymptomatic

•Symptomatic PalpitationDizzinessNausea/vomitingSyncopeAnginaDyspnoeaNeurological defecit

Arrhythmias EvaluationArrhythmias Evaluation

• Thorough Physical Examination Pulse (Regular, irregular)Blood pressureJVP, TemperatureCarotidsThyroid glandPre-cordial (Palpation, Auscultation)

Arrhythmias EvaluationArrhythmias Evaluation• Investigations

Routine, renal function, electrolytesThyroid function test, drug level12 lead ECG with rhythm stripX-ray chestECG at time of symptom24 hour Holter monitoringStress testEchocardiogramStress thalliumCardiac catheter, angiogramElectrophysiological studies

IRREGULAR RHYTHMIRREGULAR RHYTHM

a. Regular irregulara. Regular irregular

Sinus arrhythmias

Bigeminy, trigeminy

Wenckebach

b. Irregularly irregularb. Irregularly irregular

Atrial fibrillation

Atrial flutter with block

Ventricular fibrillation

c. Infrequent irregularlyc. Infrequent irregularly

PVC, APC

AV dissociation

2nd degree block

Analysis of ArrhythmiasAnalysis of Arrhythmias

Sinus tachycardiaSinus tachycardiaIt is usually a physiological response

but may be precipitated by sympathomimetic drugs or endocrine disturbance.

• Rate rarely exceed 200/min.• Each P wave is followed by QRS.• P wave morphology and axis are normal.• Height of P wave may increase PR shorten.• With fast tachycardia P wave merged in T

wave.

Causes of Sinus TachycardiaCauses of Sinus Tachycardia• Physiological.

– Exertion, anxiety and pain.

• Pathological. – Fever, anaemia, hypovolaemia, hypoxia.

• Endocrine.– Thyrotoxicosis, pheochromocytoma.

• Pharmacological.• Adrenaline, salbutamol, alcohol, coffeine.

Supra-ventricular Supra-ventricular tachycardiatachycardia

From the atria or SA node:• Sinus tachycardia.• Atrial fibrilation.• Atrial flutter.• Atrial tachycardia.

From the atrio-ventricular node:• Atrioventricular Re-entrant tachycardia.• Atrio-ventricular nodal Re-entrant

tachycardia.

ECG characteristic of Atrial ECG characteristic of Atrial ArrhythmiasArrhythmias

Sinus tachycardia.• P wave have normal morphology.

• Atrial rate 100-200 beats/min.

• Regular ventricular rhythm.

• Atrial tachycardia• Abnormal P wave morphology

• Atrial rate 250-350 beats/min.

Atrial FibrillationAtrial Fibrillation• P waves absent baseline f (fibrillation)

waves.• Atrial rate 350-600 beats/min.• Irregular ventricular rhythm.• Ventricular rate 100-180/min.

• Atrial flutter• Saw toothed flutter F waves• Atrial rate 250-350/min.• Regular rhythm

ECG Characteristics of ECG Characteristics of vventricular Tachycardiaentricular Tachycardia

• Rate is normally 120-300 beats/min.

• Rhythm is almost regular

• A positive QRS in AVR

• Usually right bundle morphology

• QRS is bizarre

• Broad QRS > .14 sec

• Presence of capture or infusion beats

Broad Complex TachycardiaBroad Complex TachycardiaVentricular.Regular:• Monomorphic V.T.

• Fasicular tachycardia.

• Rt. Ventricular outflow tract tachycardia.

Irregular:• Torsades de-points tachycardia

• Polymorphic V.T.

Broad Complex Broad Complex TachycardiaTachycardia

Supra-ventricular:

• Bundle branch block with aberrant conduction.

• Atrial tachycardia with pre-excitation.

ECG in WPW ECG in WPW SyndromeSyndrome

•Short PR interval

•Delta wave

•Wide initial QRS

Classification of Wolff Parkinson Classification of Wolff Parkinson “white syndrome”“white syndrome”

Type A (dominant R in V1).Maybe confused with.• Rt. Bundle branch block.• Rt. Ventricular hypertrophy.• Posterior myocardial infarction.

Type B (negative QRS in V1)Maybe confused with.• Left bundle branch block.• Anterior myocardial infarction.

CONCLUSIONCONCLUSION• Cardiac arrhythmias due to coronary artery

disease is the most frequent cause of death and disability all over the world and in the Kingdom of Saudi Arabia indeed.

• Atrial fibrillation is the most common sustained rhythm abnormality encountered at primary to tertiary care levels, is the main precipitant of heart failure syndrome. And is one of the commonest cause of thrombo-embolic Stroke.

• Prompt diagnosis is possible only if precise history is taken along with thorough physical examination and off course concrete investigations too.

• Management of arrhythmias includes various factors, however it needs to be individualized, from low cost digoxin to highly expensive automatic implantable cardio-verter and defibrillator.

GoalsGoals• Symptoms relief• Prevention of tachycardia induced

LV dysfunction• Improved exercise capacity• Improved quality of life• Reduction in embolic risk• Improved survival

Management of Cardiac Management of Cardiac ArrhythmiasArrhythmias “Options”“Options”

• Medical

• Surgical correction

• Radio frequency ablation

• Pacemaker

• Automatic implantable

Cardioverter / defibrillator

Management of Atrial ArrhythmiasManagement of Atrial Arrhythmias• Paroxysmal Atrial Atrial Fibrillation

Tachycardia “Ask” - new onset / chronic

- Re-assurance - possible cause- Carotid massage - haemodynamic

stability- Valsalva maneuver - Heart / function- Ice chewing- Monitor the rhythm Successful – OK

unsuccessfull _ Narrow QRS- I/V Verapamil 5mg.

Management of Cardiac Management of Cardiac ArrhythmiasArrhythmias

• Depend upon AgeSymptomsOrganic heart diseaseNon cardiac pathologyHaemodynamic stabilityLab resultsTechnological observation

Most common arrhythmias, prevalence

is 1%-1.5% increase with age 10% over 70 years of age.

Atrial Fibrillation

Paroxysmal Persistent Permanent

• Paroxysmal Atrial FibrillationIf the current episode has been present for less than 7 days and there is

history of 1 or more episode of self terminating.

• Recent Onset Atrial FibrillationWhen the current symptomatic episode

is the first by history and its duration is longer than 48 hours and less than 7 days.

• Chronic Atrial FibrillationIf the current episode has lasted for

seven or more days (≥7 days).

Causes of Atrial FibrillationCauses of Atrial Fibrillation• Ischaemic heart disease.• Hypertensive heart disease.• Rheumatic heart disease.• Thyrotoxicosis.• Alcohol misuse (acute or chronic).• Sick sinus syndrome.• Post cardiac surgery.• Chronic pulmonary disease.• Idiopathic (lone).

Atrial FibrillationAtrial FibrillationHemodynamically Stable/unstable

• Acute Infarction• Pulmonary edema Referral• Chronic course• Known precipitating cause• Drug non compliance• No Digoxin before – digitalize• Uncontrolled rate, add β block / Verapamil• If large heart Amiodarone• Control hypertension and diabetes

Atrial FibrillationAtrial Fibrillation• Hemodynamically Stable• Rate controlled / increased• Chronic course• Known etiology• Drug non compliance• Drug adjustment / Addition

Ventricular TachycardiaVentricular TachycardiaIt is defined as three or more ventricular

extrasystoles in succession at rate of > 120/min. It may be self terminating or “sustained” if it last longer than 30 seconds. It could be monomorphic (commonest) or polymorphic.

Monomorphic VT usually occurs after myocardial infarction and is a sign of extensive myocardial damage.

Ventricular ArrhythmiasVentricular ArrhythmiasMiddle Age / Elderly• Asymptomatic/Atypical symptoms• Positive risk factors• Positive family history of sudden death• Normal ECG• Normal echocardiogram• Stress test positive for myocardial

ischaemia and arrhythmias

• Early re-vascularization

Management of ventricular Management of ventricular ArrhythmiasArrhythmias

• Young age• Asymptomatic ectopics• No structural heart disease• No family history sudden death

Reassurance

Ventricular ArrhythmiasVentricular Arrhythmias• Symptomatic (syncope, angina, heart failure).• Sustained / unsustained VT rapid / slow• Nitrates, β blockers, K, Mg supplement,

xylocaine.• ECG + X-ray chest (PA/ lat.)• Echocardiogram• Structural heart disease (congenital,

acquired)• Depressed /preserved systolic function• Above 40 years cardiac cath & coronary

angiogram.

-Valve replacement with or without Coronary Artery by pass Surgery”

- Pacemaker implantation

- Automatic implantable cardioverter defibrilator

Cardiac Arrhythmias Cardiac Arrhythmias and Pregnancyand Pregnancy

• Paroxysmal Atrial tachycardia• Atrial fibrillation (RHD)Rapid rate

Hypotension

Heart failureCardioversion

(followed by β blockers, Verapamil

Cardiac Arrhythmias and Cardiac Arrhythmias and PregnancyPregnancy

Rapid rate

Normotension

No heart failure• Reassurance• Carotid massage• Valsalva• Β blockers/Verapamil/Digitalization• Look for etiology/precipitating factors

Causes of Re-admission in Causes of Re-admission in Patients with arrhythmiasPatients with arrhythmias

• Myocardial ischaemia

• Infections

• Poor compliance

• Inadequate drug treatment

• Iatrogenic factors

• Inadequate discharge planning

• Poor social/family support

Orally Available Anti-Arrhythmic Orally Available Anti-Arrhythmic DrugsDrugs

Class IIa: Quinidine, Procainamide, Disopyramide

Ib: Moricizine, Mexiletine

Ic: Propafenone, Flecainide, Cibenzoline

Class II: β-adrenergic receptor antagonist

Class III: Amiodarone, Sotalol, Dofetilide

Class IV: Verapamil, Diltiazem

Antiarrhythmic TherapyAntiarrhythmic TherapyAntiarrhythmic drug therapy is frequently

very frustrating for both the patient and physician. The recommended approach to therapy is to begin with relatively low dosage i.e. lowest dosage with reasonably chance of producing a favourable response and titrating the dose upward as needed. Dose titration should be guided by clinical response and drug level at appropriate time.

Selection of Initial DoseSelection of Initial Dose• The success or failure of drug depends in part

on the selection of drug, too low an initial dosage can prolong the patient’s risk of arrhythmia recurrence and increase the duration of the patient’s hospitalization and ultimate increase cost of treatment.

• Too high a dose can put the patient at risk of cardiac and noncardiac toxicity of drugs. Therefore, individualization of treatment is necessary to optimize the chances of achieving a satisfactory result in treatment.

Drugs MonitoringDrugs Monitoring

• Digoxin (K. level, renal functions, toxicity)

• B-blockers/ Ca antagonists• Amiodarone, (Thyroid, lungs,

eyes, liver)• Warfarine (PT, INR)

Electronic DevicesElectronic DevicesA. Immediate

–Cardioversion

–Defibrillation

–Temporary pacemaker

B. Long term– Permanent pacemaker

– Implantable cardioverted / defibrillator

Risk to Benefit Ratio of Risk to Benefit Ratio of DrugsDrugs

• Benefits– Symptom

reduction• Haemodynamic• Nausance

– Sudden cardiac death

RisksRisksCardiacCardiac

ProarrhythmiaProarrhythmia

Negative Negative ionotrophyionotrophy

Non-cardiacNon-cardiac

Adverse effectsAdverse effects

Organ toxicityOrgan toxicity