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# ARLC 2014 - Narrow complex tachycardias

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

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• Narrow Complex  tachycardia  Estimate HR
Calculate HR in irregular rhythm, multiply by10 the number of complexes in a 6 second interval
11x10=110
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
• ### ARLC 2014 - Narrow complex tachycardias

1. 1. Arrhythmias in Real Life Narrow Complex Tachycardias Salaheldin Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA ,USA
2. 2. Outline • Types • Mechanism of Tachyarrhythmias • ECG Interpretation & Acute Management • Algorithm for Management of NCTs • Problems
3. 3. Types Atrial Tissue • Sinus Tachycardia • Atrial Tachycardia • Multifocal Atrial Tachycardia • Atrial Flutter • Atrial Fibrillation • Sinus Node Reentry Tachycardia • Inappropriate Sinus Tachycardia AV Junction (Supraventricular) • AV nodal Reentry Tachycardia • AV Reentry Tachycardia Pre Excitation Syndromes • WPW • Permanent Junctional Reentry tachycardia • Mahaim tachycardia • Lown-Ganong- Levine Syn.
4. 4. Mechanisms of tachyarrhythmias 1. Automaticity 2. Triggered Activity 3. Reentry
5. 5. Automaticity • Normal – SA Node – AV Node • Abnormal – Idioventricular rhythm
6. 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. 7. Triggered Activity Delayed After Depolarization • Early – Prolonged QT – Torsades de Pointes • Late – Digoxin Toxicity
8. 8. Regular Narrow Complex Tachycardia No P Waves Atrial Fibrillation Irregular Multifocal Atrial Tachycardia Atrial Flutter with variable block P Waves present
9. 9. aVR aVL aVF V1 V2 V3 V4 V5 V6 EFINAID:00436354522-SEP-201001:46:49COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Atrialfibrillationwithrapidventricularresponse V100Hz005D12SL233CID:1 Referredby:ConfirmedBy:PAYMANSATTARM.D. BPM124Vent.rate ms*PRinterval ms72QRSduration msQT/QTc290/416 -649*P-R-Taxes 2yr) Indian hnician:STEPHAN0021 tind:234783934 1-1928 Page1of1 EID:84EDT:18:0127-SEP-2010ORDER:ACCOUNT:00023478393 Atrial Fibrillation
10. 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. 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. Hurst's the Heart, 12th Edition
12. 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. 13. Multifocal Atrial Tachycardia II III aVL aVF V2 V3 V1 II V5 25mm/s 10mm/mV 100Hz 005D 12SL 233 CID: 31 EID:34 EDT: 09:14 16-M PP PPP P P
14. 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. 15. Causes • COPD • Cor pulmonale • Hypoxia • Heart Failure • Postoperative State • Sepsis • Pulmonary Edema
16. 16. Management • Treatment of the underlying cause • Correction of electrolytes (K, Mg) • AV nodal blocking agents • Anticoagulation depending on stroke risk
17. 17. Regular Narrow Complex Tachycardia No P Waves AV nodal Reentry tachycardia, AVNRT Irregular P Waves present Identify P wave morphology/rate Relationship between P and QRS Identify RP interval
18. 18. AV nodal Reentry Tachycardia
19. 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. 20. Mechanism of AVNRT
21. 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. 22. Regular Narrow Complex Tachycardia No P Waves Irregular P Waves present Identify P wave morphology/rate Relationship between P and QRS Identify RP interval
23. 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. 24. Long RP Interval EID:89EDT:18:1406-OCT-2010 RR RP RP interval > ½ RR interval
25. 25. Short RP interval V3V6 EID:34EDT:09:5114-JUN-2008ORD RR RP RP interval < ½ RR interval
26. 26. Regular Narrow Complex Tachycardia No P Waves P Waves present P wave morphology Atrial rate Relationship between P and QRS RP interval Atrial rate >200 Flutter waves Atrial Flutter Short RP Abnormal P wave Atrial tachycardia With AV delay Long RP interval Abnormal P wave Atrial tachycardia Short RP Retrograde P wave AVNRT, AVRT Long RP interval Retrograde P wave Atypical AVNRT
27. 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. 28. V5 V6 Page1of1 EID:34EDT:09:5114-JUN-2008ORDER:ACCOUNT:0 RR PPPP RP AV node reentry tachycardia, AVNRT
29. 29. V6 Page1of1 EID:34EDT:09:0811-SEP-2009ORDER:ACCOUN P P P P P P Atrial Flutter
30. 30. Atrial Flutter • Regular Narrow Complex Tachycardia • F 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. 31. Mechanism of Atrial Flutter • Typical F waves inverted F waves in II, III, aVF Page1 EID:34EDT:09:0811-SEP-2009ORDER:
32. 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. 33. aVR aVL aVF V1 V2 V3 V4 V5 V6 TTYID:00271403019-OCT-201006:20:38COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Atrialflutterwith2to1blockAVB mV100Hz005D12SL233CID:1 Referredby:ConfirmedBy:BOSKOMARGETAMD BPM156Vent.rate ms116PRinterval ms96QRSduration msQT/QTc260/419 21528-76P-R-Taxes 61yr) 9 chnician:SHEILALOVE stind:235171493 Page1of1 EID:1080EDT:20:2627-OCT-2010ORDER:ACCOUNT:0002358098 P P P P RR RP Atrial Tachycardia
34. 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. 35. Management • AV nodal blocking agents • Some are amenable to Radiofrequency ablation
36. 36. ECG Problems
37. 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. 38. aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00262456728-JUL-201117:06:30COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Atrialfibrillationwithprematureventricularoraberrantlyconductedcomplexes Inferiorinfarct,ageundetermined Anteriorinfarct,ageundetermined Twaveabnormality,considerlateralischemiaordigitaliseffect AbnormalECG NopreviousECGsavailable 005D12SL233CID:1 Referredby:ConfirmedBy:PAYMANSATTARM.D. BPM92Vent.rate ms*PRinterval ms92QRSduration msQT/QTc346/427 26111*P-R-Taxes n:SHAWNTEWILLIAMS 0197424773 Page1of1 EID:89EDT:09:2605-AUG-2011ORDER:ACCOUNT:000706386349 • Regularity of rhythm • P wave present or absent Atrial Fibrillation
39. 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. 40. V4 V5 V6 Page1of1 EID:5EDT:15:2127-AUG-2010ORDER:ACCOUNT:000234091080 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS AVNRT
41. 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. 42. • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Flutter aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00034559908-APR-200903:24:28COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Sinustachycardia Leftposteriorfascicularblock CannotruleoutInferiorinfarct(citedonorbefore18-APR-2008) Anteriorinfarct(citedonorbefore02-DEC-2007) WhencomparedwithECGof20-DEC-200813:44, Significantchangeshaveoccurred ConfirmedbyKELLYMD,RUSSELL,F(1006),editorJAMES,MAMIE(34)on16-Apr-200915:20:27 D12SL233CID:1 Referredby:ConfirmedBy:RUSSELL,FKELLYMD BPM153ent.rate ms208Rinterval ms84RSduration msT/QTc306/488 59141*R-Taxes TEPHANBARBER 162456 Page1of1 EID:34EDT:15:2016-APR-2009ORDER:ACCOUNT:000221162456
43. 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. 44. aVR aVL aVF V1 V2 V3 V4 V5 V6 LEEID:00112599815-NOV-201011:05:43COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** UnusualPaxis,possibleectopicatrialrhythm Hz005D12SL233CID:1 Referredby:CARDIOLOGYConfirmedBy:BOSKOMARGETAMD BPM87Vent.rate ms288PRinterval ms104QRSduration msQT/QTc390/469 5342258P-R-Taxes ) ian:ROSALINDMCDANIEL :ACT#236367140 5 Page1of1 EID:89EDT:17:3119-JAN-2011ORDER:ACCOUNT:000236367140 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Tachycardia with 2:1 Block
45. 45. Problem 5 • Patient presenting with palpitations
46. 46. • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Fibrillation
47. 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. 48. aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00409125524-APR-200905:06:35COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** AtrialflutterwithvariableA-Vblock Pulmonarydiseasepattern NonspecificTwaveabnormality ConfirmedbyKELLYMD,RUSSELL,F(1006),editorJAMES,MAMIE(34)on28-Apr-200911:55:41 ReconfirmedbyKELLYMD,RUSSELL,F(1006),editorJAMES,MAMIE(34)on28-Apr-200911:56:58 05D12SL233CID:1 Referredby:CCUConfirmedBy:RUSSELL,FKELLYMD BPM109Vent.rate ms128PRinterval ms100QRSduration msQT/QTc294/395 2476260P-R-Taxes :RONALDVANN 1576820 Page1of1 EID:34EDT:11:5628-APR-2009ORDER:ACCOUNT:000221576820 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Flutter with variable Block
49. 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. 50. aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00469085508-NOV-201011:24:15COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Supraventriculartachycardia Rightwardaxis JunctionalSTdepression,probablyabnormal NopreviousECGsavailable 05D12SL233CID:16 Referredby:ConfirmedBy:PAYMANSATTARM.D. BPM145Vent.rate ms256PRinterval ms98QRSduration msQT/QTc272/422 4097*P-R-Taxes :SHARONMOORE 236192233 Page1of1 EID:82EDT:10:2517-NOV-2010ORDER:ACCOUNT:000236192233 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS AVNRT
51. 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. 52. aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00226100431-JAN-201115:45:41COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** UnusualPaxis,possibleectopicatrialtachycardia Rightbundlebranchblock AbnormalECG 05D12SL233CID:1 Referredby:ConfirmedBy:MICHAELSHAPIROMD BPM115Vent.rate ms200PRinterval ms172QRSduration msQT/QTc346/478 17148258P-R-Taxes :SHAWNTEWILLIAMS Page1of1 EID:53EDT:12:4518-JUN-2011ORDER:ACCOUNT:000701556979 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Tachycardia with 2:1 Block
53. 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. 54. aVR aVL aVF V1 V2 V3 V4 V5 V6 ID:00467869621-JUN-201017:31:36COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Atrialfibrillationwithrapidventricularresponse CannotruleoutAnteriorinfarct,ageundetermined ST&Twaveabnormality,considerinferiorischemiaordigitaliseffect NopreviousECGsavailable 005D12SL233CID:1 Referredby:ConfirmedBy:NAJAMULANSARI BPM216Vent.rate ms*PRinterval ms70QRSduration msQT/QTc208/394 24461*P-R-Taxes n:MARYPARKER IN232491415 Page1of1 EID:1080EDT:17:2928-JUN-2010ORDER:ACCOUNT:000232491415 • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Fibrillation
55. 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. 56. • Regularity of rhythm • P wave present or absent • RP interval • P wave morphology/rate • Relationship between P and QRS Atrial Tachycardia
57. 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. 58. • Performed DC Cardioversion 50J Biphasic, then 200 with no response • At second attempt at DC Cardioversion 200J reverted to Sinus rhythm
59. 59. aVR aVL aVF V1 V2 V3 V4 V5 V6 HEID:00439763214-SEP-201001:31:23COOKCOUNTYHOSPITAL ***AgeandgenderspecificECGanalysis*** Normalsinusrhythm Leftaxisdeviation Incompleteleftbundlebranchblock AbnormalECG WhencomparedwithECGof12-SEP-201017:03, MANUALCOMPARISONREQUIRED,DATAISUNCONFIRMED z005D12SL233CID:1 Referredby:ConfirmedBy:ASMIMULANSARI BPM89Vent.rate ms146PRinterval ms120QRSduration msQT/QTc374/455 73-5417P-R-Taxes an:SHEILALOVE Page1of1 EID:89EDT:16:2107-OCT-2010ORDER:ACCOUNT:000234
60. 60. THANK YOU