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ARLC 2014 - Bradycardias
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ARLC 2014 - Bradycardias

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Arrhythmias in Real Life Course, Khartoum, Sudan, August 2014

Arrhythmias in Real Life Course, Khartoum, Sudan, August 2014

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  • Other definitions, failure to attain 85%, 75%
  • HR 46/min
    Put her on a treadmill reached HR of 137/min
  • 3.4 and 4.8 second pauses
    Patient had acute coronary syndrome with lesion in proximal RCA involving the branch to the SA node, placed a dual chamber pacemaker
  • ACC/AHA guidelines
  • Prolongation of of the PR interval > 200ms, 1:1 conduction, P before every QRS complex, both P and QRS are normal
  • Progressive prolongation of the PR interval terminated in a non conducted P wave
  • Transcript

    • 1. Bradycardias Salah Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA, USA
    • 2. Bradycardias • SA node dysfunction or Sick Sinus Syndrome – Inappropriate sinus bradycardia – Sinoatrial exit Block – Sinus Pause/Arrest – Tachycarda/Bradycardia syndrome – Persistent Atrial Standstill • AV Blocks – First Degree – Second Degree • Mobitz I • Mobitz II • 2:1 Block – Third Degree – High Grade AV Block
    • 3. Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinoatrial exit Block • Sinus Pause/Arrest • Tachycarda/Bradycardia syndrome
    • 4. Causes - Intrinsic • Idiopathic degenerative disease • Coronary Artery Disease • Cardiomyopathy • Hypertension • Infiltrative Disorders (amyloidosis etc..) • Collagen Vascular Disorders (scleroderma etc.) • Inflammatory Processes (myocarditis) • Surgical Trauma • Musculoskeletal disorders (myotonic dystrophy) • Congenital heart disease (postoperative or absence of correction)
    • 5. Causes – Extrinsic - 1 • Medication – BBs, CCBs, digoxin – Clonidine, alpha methyldopa, reserpine – Antiarrhythmics Type • IA (quinidine, procainamide) • IC (flecainide) • III (amiodarone) – Lithium
    • 6. Causes – Extrinsic - 2 • Autonomic influences – High vagal tone – Carotid sinus syndrome – Vasovagal syncope • Electrolyte abnormalities – Hyperkalemia, hypercarbia, hypothyroidism • Increase intracranial pressure • Hypothermia • Sepsis
    • 7. Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
    • 8. Inappropriate Sinus Bradycardia Chronotropic Incompetence • HR<60 that doesn’t increase appropriately with exercise • Usually defined as failure to attain 80% of maximal age predicted HR (MAHR) on exercise testing • MAHR = 220 – Age • e.g. failure to reach a HR of 120 in a 70 year old patient
    • 9. Sinus bradycardia
    • 10. Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
    • 11. Sinus Pause/Arrest • Defined as absence of a sinus beat for >=3 seconds while AWAKE • SA node fails to discharge so no atrial activity occurs
    • 12. Sinus Pause/Arrest
    • 13. Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
    • 14. Sinoatrial Exit Block • SA node discharges an impulse that does NOT result in atrial activity
    • 15. Sinoatrial Exit Block
    • 16. Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
    • 17. Tachycardia-Bradycardia Syndrome • Bradycardia/sinus pauses interspersed with atrial arrhythmias (AFL, A fib, A tach) • Sinus arrest manifests after termination of atrial arrhythmia (spontaneously or after DCCV) • Sinus Node Recovery Time (SNRT) uses the above observation to assess SA node function in EP studies
    • 18. Tachycardia-Bradycardia Syndrome Hurst the Heart 12th Edition
    • 19. Indications for pacing in SND • Class I (recommended) – SND with documented symptoms – SND due to irreversible factors or due to essential drug therapy – Chronotropic incompetence • Class III (NOT recommended) – Asymptomatic
    • 20. Bradycardias • SA node dysfunction or Sick Sinus Syndrome – Inappropriate sinus bradycardia – Sinoatrial exit Block – Sinus Pause/Arrest – Tachycarda/Bradycardia syndrome – Persistent Atrial Standstill • AV Blocks – First Degree – Second Degree • Mobitz I • Mobitz II • 2:1 Block – Third Degree – High Grade AV Block
    • 21. AV Blocks • First Degree • Second Degree – Mobitz I – 2:1 Block – Mobitz II • Third Degree • High Grade AV Block
    • 22. First Degree AV Block • PR interval > 200msec • If QRS is normal, block is usually at the level of the AV node • If QRS shows bundle branch block, block maybe in His-Purkinje System
    • 23. First degree AV block
    • 24. Management • Usually no specific therapy is required
    • 25. Second Degree Heart Block Mobitz I or Wenchebach • Progressive Prolongation of the PR interval and shortening of the RR interval until a P wave is blocked • RR interval containing the non conducted P wave is less than two PP intervals • PR interval longer after the non conducted P wave • Grouped beating
    • 26. Second Degree – Mobitz I P P P P P P
    • 27. Causes • Normal • Athletes • Medications • Myocardial Infarction (inferior wall) • Acute rheumatic fever • Myocarditis Features • Usually asymptomatic • Usually narrow QRS complex  block at AV node • The presence of bundle branch block suggests the possibility of block below the AV node in His Purkinje system
    • 28. Management • Usually do not require permanent pacing
    • 29. Second Degree – Mobitz II • Constant PR interval with intermittent nonconducted P wave and no evidence for PACs • RR interval between non conducted P waves is equal to two PP intervals • Each QRS is preceded by multiple P waves • 3:1, 4:1 also called high grade AV block • Other variations include 3:2 • 2:1 block maybe Mobitz I or Mobitz II
    • 30. High Grade AV Block
    • 31. PP PP Second Degree Heart Block 2:1 Block
    • 32. Management • Usually require permanent pacing especially if symptomatic due to high likelihood of progression to high grade AV block and third degree AV block
    • 33. Differentiating mechanism of 2:1 block Feature Mobitz I Mobitz II QRS duration Narrow Wide Response to increasing HR & AV conduction i.e. exercise, atropine Improves Worsens Response to decreasing HR & AV conduction i.e. carotid sinus massage Worsens Improves Acute MI Inferior Anterior
    • 34. Third Degree AV block • Atrial impulses consistently fail to reach the ventricles, resulting in atrial and ventricular rhythms that are independent of each other • PR interval varies • PP and RR intervals are constant • Ventriculophasic sinus arrhythmia – PP interval containing QRS is shorter than PP interval without a QRS complex
    • 35. Third Degree AV block P P P P P P P P P PP
    • 36. Escape Rhythms • Junctional – Usually narrow (may be wide if underlying BBB) – 40-60/min • Ventricular Escape Rhythm – Wide complex – 30-40/min (range 20-50)
    • 37. Causes • Myocardial Infarction – Inferior wall, usually transient, associated with a stable junctional escape rhythm – Anterior wall, usually permanent • Degenerative Disease • Infiltrative Disease (amyloid, sarcoid) • Endocarditis (Aortic Root abscess) • Hyperkalemia • Medication • Post Cardiac Surgery
    • 38. Management • Usually require permanent pacing
    • 39. Acclerated Idioventricular rhythm
    • 40. Acclerated Idioventricular rhythm • Regular Wide complex rhythm • 60-110/min • AV dissociation • Benign phenomenon • Causes – Normal – Coronary reperfusion – Digoxin toxicity
    • 41. Problems
    • 42. 3rd degree AV block, junctional escape
    • 43. Second Degree Mobitz I
    • 44. P P P P P P P P P P P 3rd degree AV block, junctional escape
    • 45. P P P P P P P P P P 3rd degree AV block, junctional escape or high grade AV block
    • 46. Problem • 50 year old female with no PMH presents with acute onset of shortness of breath on exertion of 4 days duration • HR 50/min, BP 140/80 • Initial ECG sinus bradycardia • TropI 1.2
    • 47. Sinus arrest with ventricular escape
    • 48. Sinus arrhythmia
    • 49. Problem • 65 year old male presented with 4 day history of shortness of breath on exertion, orthopnea and PND • HR 50/min, regular, BP 150/70
    • 50. Atrial Fibrillation with 3rd degree AV block & junctional escape
    • 51. Single Chamber Ventricular Pacing at 45/min with complete heart block
    • 52. Dual Chamber Pacing with marked anterolateral ST depression
    • 53. Sick Sinus Syndrome Sinus pauses with interspersed short runs of Atrial Fibrillation
    • 54. Thank You

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