Narrow complex tachycardias

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by Salah Abusin, MD, Cardiology Fellow, Cook County Hospital, Chicago, IL

by Salah Abusin, MD, Cardiology Fellow, Cook County Hospital, Chicago, IL

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  • No P waves  Atrial Fibrillation
  • Narrow Complex  tachycardia  Estimate HR Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval 10x10=100 Identify P waves, variable P wave morphology, variable PP, variable PR intervals No P waves  Atrial Fibrillation Narrow Complex Tachycardia
  • P wave are buried in the QRS complex so cannot be seen on a surface ECG
  • Narrow complex tachycardia  Regular, Rate of 190  No P waves
  • P wave are buried in the QRS complex so cannot be seen on a surface ECG
  • Regular Narrow Complex Tachycardia, ~140/min, short RP, retrograde P wave
  • Narrow complex tachycardia, Regular, 150/min, two P waves to every QRS complex at 300/min,
  • Regular Narrow Complex tachycardia, Long RP, abnormal P wave (biphasic in II, inverted in aVF, upright in III)
  • Re entry underlying heart disease, specturem A fib/flutter, 90-120, 2:1 block, Ablation 75% success Crista terminalis, base of pulmonary vein, ablation if incessant
  • HR 90/min, irregular, narrow complex tachycardia, no P waves  Atrial Fibrillation
  • HR 180/min, narrow complex tachycardia, regular, no P waves  AVNRT
  • HR 150/min, narrow complex tachycardia, regular, atrial rate of 300/min, 2:1 block, saw tooth pattern  atrial flutter Not atrial tachycardia (atrial rate too fast)
  • HR 87/min, narrow complex, regular, 2:1 block, atrial rate of 150/min, Not atrial flutter because atrial rate is much lower than that
  • 110/min, narrow complex tachycardia, irregular, no P waves, coarse baseline  Atrial fibrillation
  • 110/min, narrow complex tachycardia, irregular, atrial rate of 300/min, variable ventricular response, atrial flutter with variable block
  • HR 150/min, narrow complex tachycardia, regular, retrograde P wave, short RP,  AVNRT
  • HR 115/min, narrow complex tachycardia, 2:1 block, atrial rate of 230/min, baseline between the P waves in II, III, aVF
  • 210/min, narrow complex tachycardia, irregular, no P waves, A fib
  • HR 140/min, narrow complex tachycardia, regular, borderline abnormal P, biphasic in II, III, aVF, Long RP  atrial tachycardia

Transcript

  • 1. Arrhythmias in Real LifeNarrow Complex Tachycardias Salah Abusin, MBBS, MRCP (UK), ABIM Cardiology Fellow Chicago, IL,USA
  • 2. Outline• Types• Mechanism of Tachyarrhythmias• ECG Interpretation & Acute Management• Algorithm for Management of NCTs• Problems
  • 3. Types Atrial Tissue AV Junction (Supraventricular)• Sinus Tachycardia • AV nodal Reentry Tachycardia• Atrial Tachycardia • AV Reentry Tachycardia• Multifocal Atrial Tachycardia Pre Excitation Syndromes• Atrial Flutter • WPW• Atrial Fibrillation • Permanent Junctional Reentry• Sinus Node Reentry Tachycardia tachycardia• Inappropriate Sinus Tachycardia • Mahaim tachycardia • Lown-Ganong- Levine Syn.
  • 4. Mechanisms of tachyarrhythmias1. Automaticity2. Triggered Activity3. Reentry
  • 5. Automaticity • Normal – SA Node – AV Node • Abnormal – Idioventricular rhythm
  • 6. Reentry • Requires the presence of two pathways – One slow, the other fast – Unidirectional block in one of the pathways – Slow conduction down the unblocked pathway allowing the other pathway to recover and maintain the circuit
  • 7. Triggered Activity Delayed After Depolarization• Early – Prolonged QT – Torsades de Pointes• Late – Digoxin Toxicity
  • 8. Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAtrial Fibrillation Multifocal Atrial Tachycardia Atrial Flutter with variable block
  • 9. Atrial Fibrillation
  • 10. Atrial Fibrillation• Irregular Narrow Complex Tachycardia• The commonest sustained arrhythmia• Absence of P waves• Atrial activity appears as irregular baseline or f (fibrillatory) waves• Usual ventricular rate 100-180 in the absence of therapy• If HR < 100 without medical treatment suspect underlying conductive tissue disease
  • 11. Types• Paroxysmal – self-terminating episodes that generally last <7 days (most <24 hours)• Persistent – generally lasts >7 days and often requires electrical or pharmacologic cardioversion.• Permanent – failed cardioversion or when further attempts to terminate the arrhythmia are deemed futile. Hursts the Heart, 12th Edition
  • 12. Causes• Ischemic Heart Disease• Hypertensive Heart Disease• Other organic heart disease/cardiomyopathy• Mitral Valve disease• ASD• WPW• Lung Disorders (Acute e.g. PE, Chronic e.g. COPD)• Post Surgical e.g. CABG• Thyrotoxicosis• Alcohol
  • 13. II aVL V2 III aVF V3 V1 P P P P P P P II V525mm/s 10mm/mV 100Hz 005D 12SL 233 CID: 31 EID:34 EDT: 09:14 16-M Multifocal Atrial Tachycardia
  • 14. Multifocal Atrial Tachycardia (MAT)• Irregular Narrow Complex Tachycardia• >= 3 P wave morphologies• Varying PP, PR, RR intervals• P waves may be blocked• P waves may conduct with aberrancy• Unstable rhythm usually progresses to atrial fibrillation
  • 15. Causes• COPD• Cor pulmonale• Hypoxia• Heart Failure• Postoperative State• Sepsis• Pulmonary Edema
  • 16. Management• Treatment of the underlying cause• Correction of electrolytes (K, Mg)• AV nodal blocking agents• Anticoagulation depending on stroke risk
  • 17. Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAV nodal Reentry Identify P wave morphology/ratetachycardia, AVNRT Relationship between P and QRS Identify RP interval
  • 18. AV nodal Reentry Tachycardia
  • 19. AVNRT• Regular Narrow Complex Tachycardia• Usual rate 150-250• Abrupt onset and offset• Variable relation to P wave – P wave buried in the QRS – Short RP interval – Atypical AVNRT Long RP• Usually no underlying heart disease
  • 20. Mechanism of AVNRT
  • 21. Management• Acute Episode – Vagal Maneuvers • Valsalva, carotid sinus massage, – IV adenosine – IV/PO Betablockers, Calcium Channel Blockers – DC Cardioversion• Prevention – PO Betablockers, Calcium Channel Blockers – Radiofrequency Ablation
  • 22. Narrow Complex TachycardiaIrregular Regular No P Waves P Waves present Identify P wave morphology/rate Relationship between P and QRS Identify RP interval
  • 23. RP Interval• Distance from the R wave to the NEXT P wave• Short if RP interval < ½ RR interval• Long if RP interval > ½ RR interval
  • 24. Long RP IntervalRP interval > ½ RR interval RR RP
  • 25. Short RP intervalRP interval < ½ RR interval RR RP
  • 26. Regular Narrow Complex Tachycardia P wave morphology Atrial rate Relationship betweenNo P Waves P Waves present P and QRS RP interval Atrial rate >200 Short RP Long RP interval Flutter waves Abnormal P wave Abnormal P wave Atrial Flutter Atrial tachycardia Atrial tachycardia With AV delay Short RP Long RP interval Retrograde P wave Retrograde P wave AVNRT, AVRT Atypical AVNRT
  • 27. Definition of normal P• Duration 0.08 to 0.11 (2-3 small squares)• Axis (0-75)• Upright in II, III, aVF• Upright/biphasic in III, aVL, V1, V2• Amplitude <2.5mm in II (2.5 small squares)• Amplitude in V1 positive <1.5mm (1.5 small sq) negative <1mm (1 small sq)• PR interval 0.12 – 0.2 (3-5 small squares)
  • 28. RR P P P P RPAV node reentry tachycardia, AVNRT
  • 29. F F F F F Atrial Flutter
  • 30. Atrial Flutter• Regular Narrow Complex Tachycardia• Flutter waves conducting ~ 300/min• Usually 2:1 block with a ventricular response of 150/min• Same causes as atrial fibrillation• No baseline in II, III, aVF• Discrete P waves in V1
  • 31. Mechanism of Atrial Flutter • Typical F waves inverted F waves in II, III, aVF
  • 32. Management• Similar to atrial fibrillation – Requires anticoagulation• More Difficult to control rate with medical treatment compared to atrial fibrillation• Usually requires DC Cardioversion• Radiofrequency ablation highly successful in restoration and maintenance of sinus rhythm
  • 33. RR RPP P P P Atrial Tachycardia
  • 34. Atrial tachycardia• Atrial rate is 100-240 i.e. slower than atrial flutter• Usually 1:1 conduction without medical treatment• Not terminated by vagal maneuvers• Mechanism – Intra atrial reentry – Automatic – ectopic focus – triggered
  • 35. Management• AV nodal blocking agents• Some are amenable to Radiofrequency ablation
  • 36. ECG PROBLEMS
  • 37. Problem 1• 68 year old Nigerian male with PMH of HTN, DM comes to Cardiology clinic for a routine check up• He takes metoprolol in addition to Lisinopril for Blood Pressure Control• HR 70/min, irregular, BP 150/70
  • 38. • Regularity of rhythm• P wave present or absent Atrial Fibrillation
  • 39. Problem 2• 62 year old female with known ESRD on HD via left AV fistula developed sudden onset of palpitations during dialysis; feels her HR racing• HR 170/min, BP 130/80• Clinical Examination revealed rapid regular heart beat, mild LE edema, left AV fistula
  • 40. • Regularity of rhythm• P wave present or absent•• RP interval P wave morphology/rate AVNRT• Relationship between P and QRS
  • 41. Problem 3• 59 year old African American Male, with DM, HTN, Obesity presents to his internist with two weeks history of shortness of breath on exertion• HR 140/min, BP 140/90• JVP difficult to assess due to obesity• Chest clear, mild LE edema (unchanged according to patient)
  • 42. • Regularity of rhythm• P wave present or absent Atrial• RP interval• P wave morphology/rate Flutter• Relationship between P and QRS
  • 43. Problem 4• 74 year old African American Female with remote history of ASD repair and Pulmonary Hypertension comes for follow up• She takes metoprolol for hypertension• HR 80/min, BP 120/70
  • 44. • Regularity of rhythm• P wave present or absent Atrial• RP interval Tachycardia• P wave morphology/rate• Relationship between P and QRS with 2:1 Block
  • 45. Problem 5• 52 year old Middle Eastern Female with known non ischemic cardiomyopathy is admitted with heart failure exacerbation• HR 105/min, BP 100/60• JVP raised, bibasal crackles, and bilateral LE edema 2+
  • 46. • Regularity of rhythm•• P wave present or absent RP interval Atrial• P wave morphology/rate Fibrillation• Relationship between P and QRS
  • 47. Problem 6• 54 year old White Male with PMH of a known arrhythmia comes for routine follow up• He takes metoprolol XL 200mg once daily• HR 110/min, irregular, BP 130/70
  • 48. • Regularity of rhythm• P wave present or absent Atrial Flutter• RP interval with variable Block• P wave morphology/rate• Relationship between P and QRS
  • 49. Problem 7• 49 year old male with no PMH, presents to the Emergency Room with sudden onset of palpitations, headache• HR 145/min, BP 140/90
  • 50. • Regularity of rhythm• P wave present or absent• RP interval•• P wave morphology/rate Relationship between P and QRS AVNRT
  • 51. Problem 8• 36 year old African American Male with no PMH comes for a routine outpatient visit to his primary care doctor• HR 115/min, BP 120/80
  • 52. • Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate Tachycardia• Relationship between P and QRS with 2:1 Block
  • 53. Problem 9• 61 year old Hispanic female with no PMH, presents to the Emergency Room with fatigue, loss of weight, palpitations, and feeling warm all the time.• HR 200/min, BP 120/80
  • 54. • Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate Fibrillation• Relationship between P and QRS
  • 55. Problem 10• 48 year old male with severe obesity, a chronic skin disorder, and chronic LE edema is sent to hospital from this primary care doctor after he finds his HR to be very fast• HR 141/min, BP 130/70• In the ER an ECG was performed• Due to concerns for Pulmonary Embolism (PE), a CT Pulmonary Angiogram was performed and was reported as negative for PE
  • 56. • Regularity of rhythm• P wave present or absent• RP interval Atrial• P wave morphology/rate Tachycardia• Relationship between P and QRS
  • 57. • Diagnosed with probable ectopic atrial tachycardia• No response to IV adenosine• No response to IV esmolol• NO response to IV amiodarone• Started becoming more breathless
  • 58. • Performed DC Cardioversion 50J Biphasic, then 200 with no response• At second attempt at DC Cardioversion 200J reverted to Sinus rhythm
  • 59. THANK YOU