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Narrow complex tachycardias

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by Salah Abusin, MD, Cardiology Fellow, Cook County Hospital, Chicago, IL

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Narrow complex tachycardias

  1. 1. Arrhythmias in Real LifeNarrow Complex Tachycardias Salah Abusin, MBBS, MRCP (UK), ABIM Cardiology Fellow Chicago, IL,USA
  2. 2. Outline• Types• Mechanism of Tachyarrhythmias• ECG Interpretation & Acute Management• Algorithm for Management of NCTs• Problems
  3. 3. Types Atrial Tissue AV Junction (Supraventricular)• Sinus Tachycardia • AV nodal Reentry Tachycardia• Atrial Tachycardia • AV Reentry Tachycardia• Multifocal Atrial Tachycardia Pre Excitation Syndromes• Atrial Flutter • WPW• Atrial Fibrillation • Permanent Junctional Reentry• Sinus Node Reentry Tachycardia tachycardia• Inappropriate Sinus Tachycardia • Mahaim tachycardia • Lown-Ganong- Levine Syn.
  4. 4. Mechanisms of tachyarrhythmias1. Automaticity2. Triggered Activity3. 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. Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAtrial Fibrillation Multifocal Atrial Tachycardia Atrial Flutter with variable block
  9. 9. 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. Hursts 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. II aVL V2 III aVF V3 V1 P P P P P P P II V525mm/s 10mm/mV 100Hz 005D 12SL 233 CID: 31 EID:34 EDT: 09:14 16-M Multifocal Atrial Tachycardia
  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. Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAV nodal Reentry Identify P wave morphology/ratetachycardia, AVNRT 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. Narrow Complex TachycardiaIrregular Regular No P Waves 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 IntervalRP interval > ½ RR interval RR RP
  25. 25. Short RP intervalRP interval < ½ RR interval RR RP
  26. 26. Regular Narrow Complex Tachycardia P wave morphology Atrial rate Relationship betweenNo P Waves P Waves present P and QRS RP interval Atrial rate >200 Short RP Long RP interval Flutter waves Abnormal P wave Abnormal P wave Atrial Flutter Atrial tachycardia Atrial tachycardia With AV delay Short RP Long RP interval Retrograde P wave Retrograde P wave AVNRT, AVRT 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. RR P P P P RPAV node reentry tachycardia, AVNRT
  29. 29. F F F F F Atrial Flutter
  30. 30. Atrial Flutter• Regular Narrow Complex Tachycardia• Flutter 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
  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. RR RPP P P P 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. • 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. • Regularity of rhythm• P wave present or absent•• RP interval P wave morphology/rate AVNRT• Relationship between P and QRS
  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 Atrial• RP interval• P wave morphology/rate Flutter• Relationship between P and QRS
  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. • Regularity of rhythm• P wave present or absent Atrial• RP interval Tachycardia• P wave morphology/rate• Relationship between P and QRS with 2:1 Block
  45. 45. Problem 5• 52 year old Middle Eastern Female with known non ischemic cardiomyopathy is admitted with heart failure exacerbation• HR 105/min, BP 100/60• JVP raised, bibasal crackles, and bilateral LE edema 2+
  46. 46. • Regularity of rhythm•• P wave present or absent RP interval Atrial• P wave morphology/rate Fibrillation• Relationship between P and QRS
  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. • Regularity of rhythm• P wave present or absent Atrial Flutter• RP interval with variable Block• P wave morphology/rate• Relationship between P and QRS
  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. • 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. • Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate Tachycardia• Relationship between P and QRS 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. • Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate Fibrillation• Relationship between P and QRS
  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 Atrial• P wave morphology/rate Tachycardia• Relationship between P and QRS
  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. THANK YOU

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