Arrythmia for 5th year medicine

1. Basics of Arrhythmias
Dr/ Waseem Omar, MD
Lecturer of cardiology

4. Arrhythmia - Definition
Abnormality of Heart
rate or rhythm

5. Normal heart
• Heart rate: () 60-100 b/min
• Regular
• ECG: regular RR interval,
each QRS preceded by 1 P wave
of sinus morphology.

6. Sinus P wave
• Smooth ascending and descending limb
• Fixed morphology in same lead.
• Fixed PR interval

7. Arrhythmia - Presentation
• Asymptomatic
• Palpitation
• Low COP
–Dizziness
–Syncope
–Heart failure
• Sudden death

8. Classification
• Tachyarrythmia.
• Brady arrhythmia.
• Irregular heart rhythm.

9. Classification of tachyarrhythmia

10. • SAN: appropriate, inapprropiate
• Atrium: AT, AFL, AF.
• AVN: ectopic junction, AVNRT, AVRT(SVT).
• Ventricle: VT

11. ECG identification
• Narrow QRS complex tachycardia
• Wide complex( more than 120 ms)
tachycardia

12. Wide complex tachycardia
• Regular: considered VT until prove
otherwise.
• Irregular: preexited AF( AF over
accessory pathway)

13. Narrow complex tachycardia
• Irrgeular: AF: no p wave.
AFL: multiple P wave.
MAT: P wave with 3 or more
morphology

14. Narrow complex tachycardia
• Regular:
no visible P wave: SVT
visible P wave:
• Multiple P waves: AFL, AT
• Single P wave: sinus tachycardia, AT

23. Acute management

25. Chronic management
• EP study and ablation
• Medical: BB, ND-CCB

26. Atrial Fibrillation
• Is the most common sustained
tachyarrhythmia
• Chaotic atrial rate: 400-700/min

27. Atrial Fibrillation - Definitions
• First detected AF:
–Patient with first diagnosed AF
• Recurrent AF
–Tow or more episodes of AF
• Paroxysmal AF
–Terminated within 1 week either
spontaneous or induced AF

28. Atrial Fibrillation - Aetiology
• Advanced Age
• HTN
• VHD
• CHF
• CAD
• Cardiac Surgery
• Others: Hyperthyroidism, Digitalis,
Sympathomimitics

29. Atrial Fibrillation – Clinical Picture
• Asymptomatic
• Symptoms
–Palpitation
–Low COP symptoms (dizziness, syncope)
• Complication
–Thrombo-embolic
–Precipitate HF
–Precipitate Angina

30. Atrial Fibrillation – Clinical Picture
• Signs:
• Pulse
–Pulsus Deficit >10 /min
–Response to vagal manuvers
• Gradual decrease
–Response to Exercise
• Increase

31. Atrial Fibrillation – Clinical Picture
• Signs:
• Neck Veins
–Absent (a) wave
• Auscultation
–Variable intensity of heart sounds

32. Management
• Recent or chronic (48 Hr).
• Hemodynamic stable or not.

33. Recent AF
• Cardioversion: electrical.
medical: amiodaron
propaphenon.
• Anticoagulation
• investigation.
• Maintain sinus rhythm

34. Chronic AF
• Control HR: b blocker
CCB
Digoxin
• Anticoagulation
• investigation.
• Cardioversion after TEE

35. Anticoagulation
• Vitamin K antagonist: warfarin (regular
INR follow up, INR=2-3).
• DOACs: no need for INR follow up
High cost
no antidote
CI in pregnancy and valvular AF

36. WPW
• Wolf-Parkinson-white

37. • WPW pattern
• WPW syndrome: ECG pattern+
tachycardia.
• Tachycardia: narrow (orthodromic)
wide (antidromic).

39. Management
• No AVN blockers: BB, CCB, digitalis IF
WCT.
• Preexited AF=DC
• EP study and ablation.

40. Bradyarrhythmia

41. Mechanism
• Defect in impulse generation: SND
• Defect in impulse conduction: HB

42. Escape rhythm
• Junctional(supra Hisian): narrow complex
HR:45-60 b/m.
• Ventricular(infra Hisian): wide complex
HR: 25-40 b/m.

43. AV Heart Block
–First degree: prolonged PR interval.
–Second degree: non conducted
beat
•Mobitz I
•Mobitz II
–Third degree (complete): complete
AV dissociation

44. Heart block ECG
• HR less than 60 b/m
• Regular: fixed PR interval sinus bradycardia
1 st degree HB
variable PR CHB.
• Irregular: fixed PR Mobitiz II ( multiple Ps).
variable PR Mobitiz I (gradual
prolongation of PR interval).

50. Management

52. Permanent Pacemaker
• Advance degree of HB:(mobitiz II, complete).
• Prolonged pauses(more than 6 sec during
sleep or symptomatic more than 3 sec)
• Symptomatic other bardyarrhythmia.

53. Thank you