Dysrrhythmia Dr. Ahmed Taha HusseinAssistant lecturer cardiology and electrophysiology Faculty of medicine Zagazig university 2
Mechanisms of Arrhythmogenesis
BRADYARRYTHMIAThe heart runs down !!!!
Classification• Sinus Bradycardia• Junctional Rhythm• Sino Atrial Block• Atrioventricular block
Impulse Conduction & the ECG Sinoatrial node AV node Bundle of His Bundle Branches
SA Block• Sinus impulses is blocked within the SA junction• Between SA node and surrounding myocardium• Abscent of complete Cardiac cycle• Occures irregularly and unpredictably• Present :Young athletes, Digitalis, Hypokalemia, Sick Sinus Syndrome
AV Block• First Degree AV Block• Second Degree AV Block• Third Degree AV Block
First Degree AV Block• Delay in the conduction through the conducting system• Prolong P-R interval• All P waves are followed by QRS• Associated with : AC Rheumati Carditis, Digitalis, Beta Blocker, excessive vagal tone, ischemia, intrinsic disease in the AV junction or bundle branch system.
Second Degree AV Block• Intermittent failure of AV conduction• Impulse blocked by AV node• Types:• Mobitz type 1 (Wenckebach Phenomenon)• Mobitz type 2
Mobitz type 1 (Wenckebach Phenomenon) The 3 rules of "classic AV Wenckebach"2. Decreasing RR intervals until pause;2. Pause is less than preceding 2 RR intervals3. RR interval after the pause is greater than RR prior to pause.
Mobitz type 1 (Wenckebach Phenomenon)
•Mobitz type 2•Usually a sign of bilateral bundle branch disease.•One of the branches should be completely blocked;•most likely blocked in the right bundle•P waves may blocked somewhere in the AV junction, the Hisbundle.
Third Degree Heart Block•CHB evidenced by the AV dissociation•A junctional escape rhythm at 45 bpm.•The PP intervals vary because of ventriculophasic sinus arrhythmia;
Third Degree Heart Block3rd degree AV block with a left ventricular escape rhythm,B the right ventricular pacemaker rhythm is shown.
Tachyarrythmiaalso known as things that go crump in the night!)
Ventricular Tachycardia• Deviation from NSR – Impulse is originating in the ventricles (no P waves, wide QRS).
Rhythm #9• Rate? none• Regularity? irregularly irreg.• P waves? none• PR interval? none• QRS duration? wide, if recognizableInterpretation? Ventricular Fibrillation
Ventricular Fibrillation• Deviation from NSR – Completely abnormal.
Narrow Complex Tachycardia• Differential diagnoses – Sinus tachycardia – Atrial tachycardia – AV nodal reentrant tachycardia – Orthodromic AV reciprocating tachycardia (CMT) – Atrial fibrillation/flutter – Unusual VTs• Look for P-waves• Let the PR-RP relationship help you
Looking at the PR-RP intervals• Long RP tachycardia – Sinus tachycardia – Atrial tachycardia – Some AVRTs – Junctional tachycardia PR RP – Aytypical AVNRT RP PR• Short RP tachycardia – Typical AVNRT RP<PR RP>PR (Short RP) (Long RP) – Most AVRTs – Atach with long PR interval
AV Nodal Reentrant Tachycardia (AVNRT)• Most common reentrant SVT• May achieve rates >200 bpm• Look for the psuedo-R’ in V1 or NO P wave AT ALL!• AV node dependent!• Most common type (>90%) is the slow-fast variety (typical)
Atrial tachycardia• Can be an incessant rhythm• Rate: usually <220 bpm• Does not need the AV node for perpetuation• Adenosine response: – Transient AV block WITHOUT termination – Transient AV block WITH termination (40%)• Use your knowledge of the AV node to make the diagnosis
Atrioventricular Reciprocating Tachycardia (AVRT)• Can be orthodromic (most common) or antidromic (very uncommon)• Needs AV node to perpetuate rhythm• Always associated with an AV bypass tract• May mimic AVNRT and atrial tachycardia• Can be short or long RP