Samir rafla ecg arrhythmia for medical students- 70 slides


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Samir Rafla- ECG Arrhythmia_For Medical Students- 70 slides

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Samir rafla ecg arrhythmia for medical students- 70 slides

  1. 1. Arrhythmia for Medical Students Samir Rafla, FACC, FESC Prof. of Cardiology Alexandria University
  2. 2. The pathways of Conduction
  3. 3. Anatomy of the AV node (fast and slow pathways) and the triangle of Koch Anatomy of the AV node
  4. 4. Normal electrical activation of the heart Sinus node AV - node right and left branch ECG (62/min)
  5. 5. Normal ECG
  6. 6. Classification of arrhythmia: - Rapid, regular. Sinus tachycardia, supraventricular tachycardia, atrial flutter, ventricular tachycardia. - Rapid, irregular. Sinus arrhythmia, multiple ectopic beats whether atrial or ventricular, atrial fibrillation. - Slow, regular. Sinus bradycardia, nodal rhythm, complete heart block. - Slow, irregular. Slow atrial fibrillation.
  7. 7. Tachycardia Rhythm disturbances regular irregular QRS narr ow QRS wide Sinus tachycardia AVNRT WPW (orthodrom) AT VT SVT with branch block WPW (antidrom) Atrial fib (TAA) Atrial flutter; Sinus tachycardia with SVES VF VT (polymorph) Atrial Fib and WPW incl- branch block
  8. 8. Sinus tachycardia Cardiac impulses arise in the sinus node at a rate more than 100/min. 4 Etiology: A- Physiological: Infancy, childhood, exercise and excitement. B- Pharmacological: Sympathomimetic drugs such as epinephrine and isoproterenol. Parasympatholytic drugs such as atropine. Thyroid hormones, nicotine, caffeine, alcohol. C- Pathological: Fever, hypotension, heart failure, pulmonary embolism, hyperkinetic circulatory states as anemia, hyperthyroidism.
  9. 9. A 34 year old woman with asthma
  10. 10. Sinus Bradycardia Cardiac impulses arise in the sinus node at a rate less than 60/min. Etiology: A- Physiologic: Athletes, sleep, and carotid sinus compression. B- Pharmacologic: Digitalis, propranolol, verapamil and diltiazem. C- Pathologic: Convalescence from infections, hypothyroidism, obstructive jaundice, rapid rise of the intracranial tension, hypothermia and myocardial infarction (particularly inferior wall infarction)
  11. 11. Benign Arrhythmias PVC in normal Heart
  12. 12. SUPRAVENTRICULAR TACHYARRHYTHMIAS SVTs may be separated into three groups based on duration: brief paroxysms, persistent, and chronic (permanent). Arrhythmias that are paroxysmal in onset and offset (e.g. paroxysmal SVT due to AV nodal reentry or WPW syndrome, paroxysmal atrial fibrillation, paroxysmal atrial flutter) tend to be recurrent and of short duration
  13. 13. Supraventricular tachyarrhythmias include: atrial tachycardia, atrial flutter, atrial fibrillation and AV tachycardias.
  14. 14. Mechanism of Reentry Mechanisms of AVNRT
  15. 15. PSVT
  16. 16. Management of PSVT Due to AV Nodal Reentry The acute attack: Vagal maneuvers serve as the first line of therapy. Simple procedures to terminate paroxysmal SVT - Carotid sinus massage: If effective the rhythm is abruptly stopped; occasionally only moderate slowing occurs - Cold water splash on face. - Performance of Valsalva's maneuver (often effective).
  17. 17. Management of PSVT Due to AV Nodal Reentry Intravenous adenosine, Ca channel blockers (verapamil), digoxin or B-blockers are the choices for managing the acute episodes. Adenosine, 6 mg given intravenously, followed by one or two 6-mg boluses if necessary, is effective and safe for acute treatment. A 5-mg bolus of verapamil (isoptin) , followed by one or two additional 5-mg boluses 10 min apart if the initial dose does not convert the arrhythmia
  18. 18. SVT
  19. 19. AVNRT
  20. 20. short PR interval, less than 3 small squares (120 ms) slurred upstroke to the QRS indicating pre-excitation (delta wave) broad QRS secondary ST and T wave changes Localising the accessory pathway An accessory pathway, bundle of Kent, exists between atria and ventricles and causes early depolarisation of the ventricle. The location of the pathway may be deduced as follows:- LOCATION V1 V2 QRS axis left posteroseptal (type A) +ve +ve left right lateral (type B) -ve -ve left left lateral (type C) +ve +ve inferior (90 degrees) right posteroseptal -ve -ve left anteroseptal -ve -ve normal Wolf-Parkinson-White syndrome
  21. 21. PSVT Due to Accessory Pathways (The Wolff-Parkinson-White Syndrome)
  22. 22. atrial fibrillation: Duration - Paroxysmal Minutes/hours - Short-lasting Seconds --<1 hour - Long-lasting >1 hour; -- < 48 hours - Persistent Two days -- weeks - Permanent (Chronic) Months / years
  23. 23. A 53 year old man with Ischaemic Heart Disease.
  24. 24. Causes of atrial fibrillation With structural heart disease - Rheumatic mitral valve disease - Ischemic heart disease - Hypertension - Cardiomyopathy: Dilated, Hypertrophic - Atrial septal defect, - Constrictive pericarditis, Myocarditis Without structural heart disease - Alcohol. Thyrotoxicosis - Acute pericarditis. Pulmonary embolism - Sick sinus syndrome, Lone atrial fibrillation
  25. 25. A woman with loud first heart sound and mid-diastolic murmur.
  26. 26. AF with AP degenerating to VF
  27. 27. Treatment of Atrial Fibrillation Pharmacologic Management of Patients with Recurrent Persistent or Permanent AF: - Recurrent Persistent AF: A) Minimal or no symptoms: Anticoagulation and rate control as needed. B) Disabling symptoms in AF: 1- Anticoagulation and rate control 2- Antiarrhythmic drug therapy 3- Electrical cardioversion as needed, continue anticoagulation as needed and therapy to maintain sinus rhythm - Permanent AF: Anticoagulation and rate control as needed.
  28. 28. 35
  29. 29. AF management
  30. 30. Drugs for Pharmacologic Cardioversion of AF (Rhythm control) Drug Route of Admin. And Dosage Amiodarone Oral: 1.2 to 1.8 g /day then 200 to 400 mg /d maintenance. IV: 1.2 g /d IV continuous or in divided doses, then 200 to 400 mg /d maintenance Dofetilide Oral: Creatinine clearance > 60 ml/min: 500 mcg BID Flecainide Oral 200 to 300 mg IV: 1.5 to 3 mg /kg over 10 to 20 min Propafenone Oral: 450 to 600 mg IV: 1.5 to 2 mg per kg over 10 to 20 min
  31. 31. Orally Administered Pharmacological Agents for Heart Rate Control in Patients with AF Drug Maintenance dose Digoxin 0.125 to 0.375 mg daily Metoprolol* 25 to 100 BID Propranolol 80 to 360 mg daily in divided doses Verapamil 120 to 360 mg daily in divided doses Diltiazem 120 to 360 mg daily in divided doses
  32. 32. Anticoagulation of Patients with Atrial Fibrillation: Indications Rheumatic mitral valve disease with recurrent or chronic atrial fibrillation. Dilated cardiomyopathy with recurrent persistent or chronic atrial fibrillation. Prosthetic valves. Prior to (>3 weeks) elective cardioversion of persistent or chronic atrial fibrillation, and also for 3 weeks after cardioversion (because of atrial stunning). Coronary heart disease or hypertensive heart disease with recurrent persistent or chronic atrial fibrillation
  33. 33. Atrial Flutter
  34. 34. Treatment of Cardiac Arrhythmias with Catheter Ablative Techniques Radiofrequency ablation destroys tissue by controlled heat production. Catheter ablation is used to treat patients with four major tachyarrhythmias: atrial flutter/fibrillation, AV nodal reentry, accessory pathways and ventricular tachycardia.
  35. 35. A 76 year old man with SOB
  36. 36. A 60 year old woman with HTN
  37. 37. A 68 year old women on Digoxin complaining of fatigue
  38. 38. A 57 year old woman with palpitations
  39. 39. A woman with Romano-Ward Syndrome
  40. 40. QTc Normal QTc • Men < 0.43 – borderline o.43-0.45 – prolonged >0.45 • Women < 0.43 – borderline o.43-0.47 – prolonged >0.47
  41. 41. A 50 year old man with chest pain for 2-4 hours
  43. 43. 6
  44. 44. A 45 year old women with palpitation and a history of CRF (Chronic Renal Failure)
  45. 45. A 69 year old man 2 weeks post IW MI
  46. 46. A 60 year old man with IHD
  47. 47. A 25 year old man with bouts of tachycardia
  48. 48. A 23 year old male with palpitations
  49. 49. AV HEART BLOCK
  50. 50. Mobitz type I (Wenckebach) block Mobitz Type II second degree heart block
  51. 51. 10
  52. 52. 18 10 year old girl who is asymptomatic and found to have this ECG. Q: What are the ECG findings?
  53. 53. A 73 year old woman with dizziness.
  54. 54. A 70 year old man with exercise intolerance.
  55. 55. An 82 year old lady with dizzy spells
  56. 56. Sudden Cardiac Death Definition: unexpected natural death due to cardiac cause within one hour from the onset of symptoms .
  57. 57. Your diagnosis please? 20