Cardiac rhythm disorders-Dr.(Mrs.) Deepa S. Gunawardena
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Cardiac rhythm disorders-Dr.(Mrs.) Deepa S. Gunawardena

Cardiac rhythm disorders-Dr.(Mrs.) Deepa S. Gunawardena

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Cardiac rhythm disorders-Dr.(Mrs.) Deepa S. Gunawardena Presentation Transcript

  • 1. Cardiac Rhythm Disorders Dr. (Mrs.) Deepa S. Gunawardena, MBBS, M.D. Consultant Cardiac Electrophysiologist 1
  • 2. Rhythm Disorders Tachyarrhythmias >100 bpm Narrow Complex T.C. QRS < 0.12 s Regular Iregular Bradyarrhythmias <60 bpm Broad Complex T.C. QRS > 0.12 s Regular Iregular 2
  • 3. • Narrow Complex T.C. • Broad Complex T.C. – Regular – Regular • Sinus T.C. • Atrial flutter with regular AV block • Re-entry T.C. – Irregular • Atrial fibrillation • Atrial flutter with variable block. • Ventricular T.C. • SVT with preexisting BBB • Aberrant conduction • Ante-grade conduction over accessory path way (a.p.). – Irregular • Ante-grade conduction over a.p. during A.F. 3
  • 4. Narrow- complex Tachycardias. • Compromised or not (BP,acute heart failure,check airway, breathing). • IV access,ECG monitoring. • Pattern of arrhythmia, prodromal symptoms, associated symptoms, • cardiac history,H/O arrhythmia,recent illness, acute triggers. 4
  • 5. • Investigations: – – – – – – 12 lead ECG with rhythm strip BU/SE CXR Thyroid function 2DEcho ECG during sinus rhythm (atrial ectopics, short PR and Delta waves). 5
  • 6. Management • Compromised patient – Immediate Synchronized DC shock with 50J,100J, 200J, 360J (IV Diazepam 10 mg, under general anesthesia) – If arrhythmia recurs consider anti- arrhythmic agents (IV Amiodarone). 6
  • 7. • If the patient is not compromised – 1. Try Vagal manoeuvres • • • • Carotid Sinus Pressure, Valsalva manoevours, Diving reflex, DO NOT use eye ball pressure. – 2. I.V. Adenosine test • contraindications Bronchial Asthma, • Side effects-chest pain flushing,headache How to give 7
  • 8. – Run continuous rhythm strip – Insert 18 G venous cannula – Keep ready a 20 ml syringe filled with normal saline. – Give IV Adenosine through the cannula followed by normal saline flush. – Dose: 3mg, 6 mg, 9mg, 12 mg , 15 mg,18mg – Can be given using 3 way tap as well. – Action:AV block. 8
  • 9. – 3. I.V. Verapamil 5-10 mg over 10 min. • DO NOT use in patients on Beta blockers or in broad complex TC. – – – – 4. AV node blockers( oral or IV Digoxin) 5.Anti-Arrhythmic(IV Amiodarone) 6. Over drive pacing 7.Cardioversion 9
  • 10. Long term Prophylaxis • Indicated for patients with spontaneous recurrent symptomatic episodes. • No prophylaxis if identifiable trigger is found and correctable. • .Electro-physiological testing and ablation. • Drugs:AV node blockers, Anti arrhythmics ( Amiodarone). 10
  • 11. Atrial Fibrillation (A.F.) • Two types – 1.Chronic A.F. – 2. Intermittent AF. • Management Objectives – Prevention of thrombo-embolic complications – Rate control or Restoration of sinus rhythm. 11
  • 12. Chronic AF • Restoration of sinus rhythm(at least one attempt) by elective Cardioversion . • Using: – Electrical Cardioversion (D.C. shock) – Chemical Cardioversion. • Preparation: – 4 weeks of prior anti- coagulation with Warfarin (INR-2-3.5) 12
  • 13. – Check Serum K,Fasting >6 hours,IV access,With hold Digoxin • Electrical cardioversion – Synchronized D.C. shock at 100J, 200J, 360J. Under GA. – Continue Warfarin for 4 more weeks. – If D.C. shock unsuccessful give antiarrhythmics (Amiodaron,Sotalol),second attempt of D.C. shock later. 13
  • 14. • Chemical Cardioversion. – If AF is more than 48 hours,consider anticoagulation for 4 weeks before and after CCV.Drug:IV Flecanide 2 mg /KG iv – Advantages of CV:No long term anticoagulation,preserve atrial contribution to Ventricular filling. – Failed CV: consider anticoagulation with rate or rhythm control drugs. 14
  • 15. Intermittent A.F. • Long term anticoagulation – for high risk patients (patients with a high risk of stroke: hypertension, DM, IHD, TIA, h/o. stroke, thromboembolism, >65 years, cardiac failure, significant valvular heart disease). • Warfarin (INR-2-3.5) – For low risk patients (lone A.F.) • low dose Aspirin 15
  • 16. • Ventricular rate control – AV node blocking drugs – Anti arrhythmics ( Class1a,1c,111) • Electrophysiological testing and ablation (lone AF). • Intra-cardiac devices 16
  • 17. Tachycardias due to Accessory Pathways • Types of tachycardias – regular narrow complex tachycardias due to reentry. – regular broad complex tachycardias due to reentry. – irregular broad complex tachycardia due to conduction of atrial fibrillation through the accessory pathway. 17
  • 18. • Management – if compromised, D.C. shock indicated – if not compromised: regular narrow/broad T.C. • I.V. Adenosine to block AV node • I.V. Amiodarone to block AP. – if not compromised: irregular broad T.C. • DO NOT GIVE Adenosine, Digoxin, Verapamil, beta blockers. Precipitates V.F due to accelerated conduction through the A.P. • Treat with I.V. Amiodarone. 18
  • 19. Broad complex tachycardias • Ventricular TC – – – – – – AV dissociation Fusion beats Capture beats Extreme axis deviation QRS duration > 0.14 s Concordance • SVT – Slowed by vagal maneuvers – Slowed or terminated by Adenosine – Initiated by AE. – P>V 19
  • 20. During Sinus rhythm • Ventricular T.C. – VE – Prolonged QT – LVH, MI • SVT – LBBBor RBBB – Wolf-Parkinson-White (WPW) Syndrome 20
  • 21. Management • If compromised and arrhythmia continues – Immediate precordial thump / synchronized DC cardioversion (100J,200J,360J). – Resuscitation if patient has cardiac arrest – If no response • Antiarrhythmic drugs, over drive pacing,IV Mg – If recurs • consider antiarrhythmics, treat the cause if any. 21
  • 22. • Not compromised – Good LV function-IV Lignocaine 100mg(50 mg if <50 kg) followed by infusion of Lignocaine • 4mg /min for 30 min • 2 mg/min for 2 hours • 1mg/min for upto24 hours 22
  • 23. – Poor LV function cardiac failure. • IV Amiodarone 5 mg /KG over 30 min via central line. – If all above failed • IV Flecanide, Mexiletine, Procainamide, Bretylium, Beta Blockers ( ischemic VT) • Can cause hypotension ,cardiac failure 23
  • 24. – If episodes are brief and self terminated antiarrhythmic treatment is not indicated. – Treat correctable factors if any (acute ischemia, electrolytes imbalance). • Long term prophylaxis – Indications: • recurrent episodes, • no identifiable cause, • uncorrectable cause. 24
  • 25. • Antiarrhythmic drugs for prophylaxis – Oral Amiodaron• 200mg tds for 5-7 days • 200 mg bd for 5-7 days • 100 -200 mg daily – Class-1a and 1b drugs • Ischemic VT – Consider prophylaxis if VT occurs after 48 hrs of MI. – Beta blockers 25
  • 26. • Investigations: – ECG after cardioversion, Cardiac enzymes, CXR, Holter monitoring, exercise testing, Echo, Serum K+, Mg++ • Follow up K – Treat correctable causes e.g For IHD revascularization. – Long term prophylaxis if indicated – EPS,Implantable Defibrillators – Correct risk factors (DM,hypertension,Hyperlipidaemia) 26
  • 27. Ventricular Fibrillation • Leads to cardiac arrest • Immediate cardioversion and resuscitation • Treat correctable causes • Long term prophylaxis as in case of VT 27
  • 28. Torsades Pointes • Polymorphic VT, Axis twist around the base line, usually non- sustained and repetitive, can degenerate in to VF • During SR- prolonged QT • Causes: – – – – Antiarrhythmic drugs(1a,1c,111) E’lytes disturbances: K+, Mg++, Ca++ Antibiotics: Erythromycin Congenital long QT syndrome 28
  • 29. • Management – Remove offending agent, • Temporary pacing, – Isopreneline IV (0.5-10 µg/min) – IV Mg • 8 mmol over 15 min, • 72 mg over 24 hours 29
  • 30. • Accelerated Idio-Ventricular rhythm – Rate-60-110 bpm • Non sustained VT – minimum of 3 beats – reverted back spontaneously within 30 s. – If symptomatic: Beta blockers, Amiodarone 30
  • 31. Bradyarrhythmias • Ventricular rate < 60 bpm. • Categories of Bradyarrhythmias: – Sinus bradycardia, Sinus arrest/block, AV block (2nd, 3rd degree) • Causes: – Drugs, IHD, hypothyroidism 31
  • 32. • Investigations – ECG with long rhythm strip,CXR,Thyroid function,Digoxin level,Cardiac enzymes. • Management: – Withhold offending drug, if any – Asystole/pulseless bradycardiaresuscitation – Sinus bradycardia ,AV block:IV atropin,IV Isoprenelin,Salbutamol – compromised:Temporary pacing ,plan for permanent pacing 32