ECG: Ventricular Premature Beats

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ECG: Ventricular Premature Beats

  1. 1. Prof .Dr.K.H.NOORUL AMEEN’S unit M6 Dr.G ARUN KUMAR ECG OF THE WEEK
  2. 2. <ul><li>45 YEAR OLD DIABETIC PRESENTED TO OPD WITH EPISODES OF PALPITATION ON AND OFF FOR 6 MONTHS </li></ul><ul><li>NO H/O CHEST PAIN , SYNCOPE </li></ul><ul><li>NO H/O ANY DRUG INTAKE(BUT FOR OHA) </li></ul>
  3. 5. <ul><li>Lead 2 rhythm strip </li></ul>
  4. 6. <ul><li>Whats the diagnosis ? </li></ul><ul><li>Whats the next investigation you would do ? </li></ul><ul><li>Drugs causing this pattern? </li></ul>
  5. 7. <ul><li>RATE – 88/MIN </li></ul><ul><li>RHYTHM – REGULARLY IRREGULAR </li></ul><ul><li>P WAVE - NORMAL MORPHOLOGY </li></ul><ul><li>PR INTERVAL – 180 ms </li></ul><ul><li>QRS NORMAL IN SINUS BEAT BUT WIDE AND BIZZARE AFTER EVERY 2 NORMAL SINUS BEAT(VENTRICULAR ECTOPIC) </li></ul><ul><li>RBBB PATTERN </li></ul>
  6. 8. IMP: VENTRICULAR PREMATURE BEAT WITH COMPLETE COMPENSATORY PAUSE (VENTRICULAR TRIGEMINY) PROBABLY OF LEFT VENTRICULAR ORIGIN NORMAL RR INTERVAL 720 ms 2 TIMES RR INTERVAL ( pre ectopic + post ectopic interval = 2 sinus interval ) 1440ms COMPENSATORY PAUSE
  7. 9. VENTRICULAR PREMATURE BEAT <ul><li>THEY ARE PREMATURE AND OCCUR BEFORE NEXT NORMAL BEAT IS EXPECTED </li></ul><ul><li>THEY ARE USUALLY WIDE , BIZZARE IN APPEARANCE DUE TO THEIR ECTOPIC FOCUS AND THE COURSE OF DEPOLARISATION IS ALSO ABNORMAL </li></ul><ul><li>THE T WAVE AND QRS COMPLEX POINT IN OPPOSITE DIRECTION </li></ul>
  8. 10. RELATION TO SINUS P WAVE <ul><li>VENTRICULAR EXTRASYSTOLE MAY MANIFEST </li></ul><ul><li>1 . BEFORE THE FOLLOWING SINUS DISCHARGE </li></ul><ul><li>2. AT THE TIME OF SINUS DISCHARGE </li></ul><ul><li>3. RELATIVELY LATE ie AFTER SINUS P WAVE BUT BEFORE THE NORMAL QRS ( END DIASTOLIC VENTRICULAR ES). SOMETIMES THIS TYPE OF IMPULSES INVADE THE VENTRICLES AT THE SAME TIME AS SINUS IMPULSE THEREBY RESULTING IN A VENTRICULAR FUSION BEAT </li></ul><ul><li>4.RETROGRADE CONDUCTION OF VENTRICULAR EXTRASYSTOLE PRODUCE A PREMATURE INVERTED P WAVE FOLLOWING A WIDE QRS </li></ul>
  9. 11. FREQUENCY <ul><li>WHEN ISOLATED VPBs ARISE AFTER EVERY SINUS BEAT- VENTRICULAR BIGEMINY </li></ul><ul><li>WHEN ISOLATED VPBs ARISE AFTER EVERY 2 SINUS BEATS- VENTRICULAR TRIGEMINY </li></ul><ul><li>VPBs OCCURING 2 IN A ROW – PAIR OR COUPLET </li></ul><ul><li>VPBs OCCURING 3 OR MORE IN A ROW - VT </li></ul>
  10. 12. VENTRICULAR BIGEMINY
  11. 13. COUPLET
  12. 14. MORPHOLOGY <ul><li>LV ORIGIN - RBBB PATTERN </li></ul><ul><li>RV ORIGIN - LBBB PATTERN </li></ul><ul><li>IVS ORIGIN - LBBB PATTERN </li></ul>COUPLING INTERVAL <ul><li>INTERVAL BETWEEEN ECTOPIC BEAT AND PRECEEDING SINUS BEAT(IS SAME FOR VPBs ARISING FROM SAME FOCUS) </li></ul>
  13. 15. INTERPOLATED VENTRICULAR EXTRASYSTOLE <ul><li>THIS TYPE OCCURS </li></ul><ul><li>1. WITHOUT A COMPENSATORY PAUSE </li></ul><ul><li>2.DURING SLOW SINUS RHYTHM </li></ul><ul><li>3.SINUS BEAT FOLLOWING THE ES HAS A </li></ul><ul><li>LONGER PR INTERVAL </li></ul>
  14. 16. UNIFORM AND MULTIFORM VPB <ul><li>MULTIFOCAL VENTRICULAR EXTRASYSTOLES AND EXTRASYSTOLES IN PAIRS ARE ALWAYS ABNORMAL </li></ul><ul><li>UNIFOCAL VENTRICULAR EXTRAYSTOLES ARE USUALLY INDICATIVE OF CARDIAC DISEASE </li></ul><ul><li>IF OCCURS IN CROPS </li></ul><ul><li>IF THEY OCCUR IN BIGEMINAL RHYTHM </li></ul><ul><li>IF THEY OCCUR IN ASSO. CARDIAC DISEASE </li></ul><ul><li>IF AGE >40 </li></ul><ul><li>IF THEY ARE PRECIPITATED BY EXERCISE </li></ul>
  15. 17. R ON T PHENOMENON <ul><li>VPBs THAT FALL ON THE PEAK OF T WAVE OF SINUS BEAT MAY PRECIPITATE VT OR VF. </li></ul><ul><li>THIS USUALLY OCCUR WITH VPBs WITH SHORT COUPLING INTERVAL WHICH ALMOST OCCUR IN THE SETTING OF ANY ACUTE INSULT TO HEART (eg ACUTE MI) </li></ul>
  16. 18. CAUSES OF VPB <ul><li>ANXIETY </li></ul><ul><li>EXCESS CAFFEINE INTAKE </li></ul><ul><li>AMINOPHYLLINE </li></ul><ul><li>EPINEPHRINE </li></ul><ul><li>ISOPROTERENOL </li></ul><ul><li>DIGITALIS(V.BIGEMINY) </li></ul><ul><li>VALVULAR,HYPERTENSIVE,ISCHEMIC HEART DISEASE </li></ul><ul><li>ACUTE MI </li></ul><ul><li>HYPOKALEMIA,HYPOMAGNESIMIA, HYPOXEMIA OF ANY CAUSE </li></ul>
  17. 19. GRADING
  18. 20. CLINICAL FEATURES <ul><li>ASYMPTOMATIC </li></ul><ul><li>PALPITATIONS,MISSED OR EXTRA BEAT </li></ul>TREATMENT USE OF ANTIARRHYTHMICS IN ISOLATED VPBs AND SHORT RUN VT HAVE NOT SHOWN ANY IMPROVED SURVIVAL USE OF BETA BLOCKERS HAS BEEN HELPFUL IN ABOLISHING VPBs IN PATIENT WITH STEMI AND IN PREVENTION OF VF AT PRESENT PHARMACOTHERAPY IS RESERVED ONLY FOR PATIENT WITH SUSTAINED VENTRICULAR ARRHYTHMIAS USE OF PROPHYLACTIC ANTI ARRHYTHMICS IS CONTRAINDICATED IN THE ABSENCE OF CLINICALLY IMPORTANT VT
  19. 21. THANK YOU REF : SHAMROTH GOLDBERGER HARRISON

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