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

ARLC 2014 - Bradycardias ARLC 2014 - Bradycardias Presentation Transcript

  • Bradycardias Salah Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA, USA
  • 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
  • Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinoatrial exit Block • Sinus Pause/Arrest • Tachycarda/Bradycardia syndrome
  • 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)
  • Causes – Extrinsic - 1 • Medication – BBs, CCBs, digoxin – Clonidine, alpha methyldopa, reserpine – Antiarrhythmics Type • IA (quinidine, procainamide) • IC (flecainide) • III (amiodarone) – Lithium
  • Causes – Extrinsic - 2 • Autonomic influences – High vagal tone – Carotid sinus syndrome – Vasovagal syncope • Electrolyte abnormalities – Hyperkalemia, hypercarbia, hypothyroidism • Increase intracranial pressure • Hypothermia • Sepsis
  • Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
  • 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
  • Sinus bradycardia
  • Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
  • 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
  • Sinus Pause/Arrest
  • Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
  • Sinoatrial Exit Block • SA node discharges an impulse that does NOT result in atrial activity
  • Sinoatrial Exit Block
  • Sinoatrial Node dysfunction • Inappropriate sinus bradycardia • Sinus Pause/Arrest • Sinoatrial exit Block • Tachycarda/Bradycardia syndrome
  • 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
  • Tachycardia-Bradycardia Syndrome Hurst the Heart 12th Edition
  • 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
  • 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
  • AV Blocks • First Degree • Second Degree – Mobitz I – 2:1 Block – Mobitz II • Third Degree • High Grade AV Block
  • 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
  • First degree AV block
  • Management • Usually no specific therapy is required
  • 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
  • Second Degree – Mobitz I P P P P P P
  • 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
  • Management • Usually do not require permanent pacing
  • 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
  • High Grade AV Block
  • PP PP Second Degree Heart Block 2:1 Block
  • Management • Usually require permanent pacing especially if symptomatic due to high likelihood of progression to high grade AV block and third degree AV block
  • 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
  • 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
  • Third Degree AV block P P P P P P P P P PP
  • 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)
  • 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
  • Management • Usually require permanent pacing
  • Acclerated Idioventricular rhythm
  • Acclerated Idioventricular rhythm • Regular Wide complex rhythm • 60-110/min • AV dissociation • Benign phenomenon • Causes – Normal – Coronary reperfusion – Digoxin toxicity
  • Problems
  • 3rd degree AV block, junctional escape
  • Second Degree Mobitz I
  • P P P P P P P P P P P 3rd degree AV block, junctional escape
  • P P P P P P P P P P 3rd degree AV block, junctional escape or high grade AV block
  • 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
  • Sinus arrest with ventricular escape
  • Sinus arrhythmia
  • 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
  • Atrial Fibrillation with 3rd degree AV block & junctional escape
  • Single Chamber Ventricular Pacing at 45/min with complete heart block
  • Dual Chamber Pacing with marked anterolateral ST depression
  • Sick Sinus Syndrome Sinus pauses with interspersed short runs of Atrial Fibrillation
  • Thank You