This document discusses diagnosis and management of supraventricular tachycardia (SVT). It provides an overview of different types of SVT such as atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial fibrillation (AF), and atrial flutter (AFL). It describes approaches to differentiate between these types based on electrocardiogram (ECG) patterns such as P wave morphology, PR and RP intervals. The document emphasizes using a physiological approach and considering the beginning and termination of the arrhythmia. It provides tips on localizing accessory pathways and discusses appropriate management strategies for different SVT types
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Tachycardias are broadly categorized based upon the width of the QRS complex on the electrocardiogram (ECG). A narrow QRS complex (<120 milliseconds) reflects rapid activation of the ventricles via the normal His-Purkinje system, which in turn suggests that the arrhythmia originates above or within the His bundle (ie, a supraventricular tachycardia). The site of origin may be in the sinus node, the atria, the atrioventricular (AV) node, the His bundle, or some combination of these sites. A widened QRS (≥120 milliseconds) occurs when ventricular activation is abnormally slow. The most common reason that a QRS is widened is because the arrhythmia originates below the His bundle in the bundle branches, Purkinje fibers, or ventricular myocardium (eg, ventricular tachycardia). Alternatively, a supraventricular arrhythmia can produce a widened QRS if there are either pre-existing or rate-related abnormalities within the His-Purkinje system (eg, supraventricular tachycardia with aberrancy), or if conduction occurs over an accessory pathway. Thus, wide QRS complex tachycardias may be either supraventricular or ventricular in origin.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Tachycardias are broadly categorized based upon the width of the QRS complex on the electrocardiogram (ECG). A narrow QRS complex (<120 milliseconds) reflects rapid activation of the ventricles via the normal His-Purkinje system, which in turn suggests that the arrhythmia originates above or within the His bundle (ie, a supraventricular tachycardia). The site of origin may be in the sinus node, the atria, the atrioventricular (AV) node, the His bundle, or some combination of these sites. A widened QRS (≥120 milliseconds) occurs when ventricular activation is abnormally slow. The most common reason that a QRS is widened is because the arrhythmia originates below the His bundle in the bundle branches, Purkinje fibers, or ventricular myocardium (eg, ventricular tachycardia). Alternatively, a supraventricular arrhythmia can produce a widened QRS if there are either pre-existing or rate-related abnormalities within the His-Purkinje system (eg, supraventricular tachycardia with aberrancy), or if conduction occurs over an accessory pathway. Thus, wide QRS complex tachycardias may be either supraventricular or ventricular in origin.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Supraventricular tachycardia: ECG recognition and diagnosis
1. Diagnosis and Management of
Supra-ventricular Tachycardia
Dr. D. Khanra
SR3
LPS Institute of Cardiovascular Sciences
GSVM Medical College, Kanpur
1
2. SVT in a nut-shell
Onset
Termination
2
AVNRT AVRT AT
AFLAVNRT
3. Regular Narrow QRS Tachycardia
Visible P Waves AF / AT /AFL
A >V
AFL /AT ? RP Interval
Short Long
< 70 ms > 70 ms
AVNRT
AVRT / AVNRT /
AT
AT / PJRT /
Atypical AVNRT
Yes No
Yes No
Yes
No
Pattern recognition vs Physiological approach
Wide freeways but narrow viewpoints
3
4. Breaking complexity with complexity
Differentials
• AT
• AFL
• Afib
• AVNRT
• AVRT
• JT
• VT
‘’Game Plan’’
• What’s the ‘drill’? eg. NCT vs WCT
• Eyeballing morphology? eg. VT criteria
• ‘Smoking gun’? eg. PR prolongation
• Pre test prob? eg. Patient profile, age, MI
• Absolute vs probable? eg. Termination with P
• Having a ‘tool box’! eg. P, delta, PR/ RP, axis, BBB
• ‘Big picture’ working diagnoses Be Open-minded
Beginning + tachycardia + termination = SVT
4
5. Hunt for P
Look at the Ts
Seek for the
midpoint
High to low P
(anterograde)
Low to high P
(retrograde)
5
6. ST: high to low: warm up usually present
No P at al: AVNRT> JT
Low to high P: AT/ AFL (non sinus), PR short
if retrograde: very long RP: atypical AVNRT
Pseudo q pattern in 4% of AVNRT
Pseudo S: AVNRT
Rarely, JT with VA conduction
RP short: AVNRT
AVRT may be possible
RP longer: AVRT (<50% of RR)
Atypical AVNRT if RP >50% of RR
Variable P + PR+ RR = MAT
AV dissociation
JT > VT
Myriads of P
6
7. Think physiologically
VV dictates AA
Ventricular participation +ve
AT ruled out, can be VT/ AVRT
AA dictates VV
Atrial participation +ve
VT ruled out, can be AT/ AVNRT
No PR prolongation
So no AVN involvement
Can not be AVNRT/ o-AVRT
PR prolongation
So AVN involvement
AVNRT/ o-AVRT 7
8. Do not miss ‘The End’
Ends with P
Can not be AT
Can be AVNRT/ AVRT/ VT/JT
Ends with no P
Can be anything
VAV (not AT)
vs VAAV (AT)
AT
8
10. LBBB + Right axis (discordant): VT likely
North west axis: VT likely
Axis helps
Axis changes
With onset of tachy
Or after termination
VT is likely
10
11. No RS in precordial lead: VT
Absolute vs probable
Sudden transition is V3: AP/ VT 11
12. AV dissociation: VT (may be in JT also)
Capture/ fusion: VT (may be in a-AVRT also)
‘The smoking gun’
12
13. Localising AP
-ve Delta
1. In I: left lat AP (most common)
2. In II: CS AP (adenosine sensitive)
3. In V1: Septal AP (DD AVNRT)
4. Rest: right lat AP
13
QRS transition AP localisation
At or before V1 Left sided pathways
b/w V1 – V2 or at V2 Mostly Right sided pathway
Lead 1: R>S Right sided pathway
Lead 1: R<S left sided pathway
b/w v2-v3 Right septal pathway
After v4 Right lateral pathway
Onset of LBBB prolong TCL: left sided AP
Onset of RBBB prolong TCL: Right sided AP
ECG mimicking IWMI: CS or post-septal AP
Fitzpatrick’s algorithm
14. AP: benign or malignant?
14Late coupled PAC renders AP to refractory Even prolonged PR did not start AVRT
Different level of fusion depending on prematurityBenign
15. His-refractory VPC
Long RP
BUT >50% of RR
BUT NOT atypical AVNRT
A advanced by his refractory VPC
SA – VA < 85 ms suggests AP
PPI – TCL <115 ms suggests AP
TCL PPI
NO Reset
AVNRT 15
Capture & Reset
= AVRT
16. Identifying Focus of AT
16
Focus of AT P in Limb leads P in Precordial leads
High Crista Terminalis (MC) Inf leads –ve
AVR +ve
-ve to +ve
Coronary sinus (Adenosine) Inf leads +ve
AVR -ve
+ve to -ve
Pulm veins (RSPV MC) I, AVL -ve All +ve
(large to small)
LA (LAA Mostly) least of all I, AVL -ve
Or flat
All –ve
Or flat
Zhi Young’s algorithm
Clin EP 2011
17. Short PR is not synonymous to AP
Anterograde AP PR (<50ms)
AT near to AVN PR (>50 ms) (low to high P)
AFL near to CS (low to high P) (baseline undulating)
JT with non conducted P (high to low P) (structural heart dis)
17
18. RP and PR
PR RP Diagnosis
const const ST
varies varies AVNRT
Varies const AVRT
const varies AT
RP is religiously fixed: AVRT
PR is religiously fixed: AT
Typical AVNRT: PR>RP
Atypical AVNRT: RP>PR
AVNRT:
Pseudo R in v1
Pseudo S in inf leads
Also pseudo q in 4% 18
AVRT:
Long RP
Distorts ST/ T
Mostly Left lat AP
19. Ugly BBB
LBBB
Rapid & steady descent
SVT
Slow & stuttered descent
VT
RBBB
later peak taller
SVT
First peak taller
VT
Bizarre BBB also in a-AVRT, ischemia
19
22. 22
Mechanism of arrhythmia?
Warm up and cool down
Rate <200
TCL variation >30ms
P anterograde
VAAV
Abrupt onset & offset
Rate >200
TCL variation <30ms
P retrograde
VAV
Rare
Precipitating factors
Eg QT long
Slow
velocity
Cut
Propagation
No overdrive
Suppression
Overdrive
Modify
Physical
milieu
23. How to manage?
23
Scenario Management
AVN involved in tachycardia
O-AVRT AVNRT JT
AVN blocker
(Adenosine, Diltiazem)
Long term: Diltiazem/ Verapamil in AVNRT
Sotalor for AVRT (blocks AVN and AP)
AVN not involved in tachycardia
A-AVRT with AF AFL
AVN blockers contraindicated
Amiodarone increases ERP of AP
May be terminated with Adenosine if near CS
Long term: Amiodarone
AT AFL Diltiazem blocks AVN
Reduces FVR
May be terminated with adenosine If near CS
Long term: beta blockers/ CCB
If hemo-dynamically unstable DC shock
(Heparin)
If recurrent AVNRT: RFA of slow pathway
AVNRT: RFA of AP
24. What we have learned?
24
Be careful with the Ps
Do not miss the beginning and the end
Old ECG records are valuable for any axis change or BBB
Ectopic activity during tachycardia is a gift
Short PR doe not always mean WPW
Long RP does not always mean AVRT
Bizarre BBB does not always mean VT
AV dissociation/ capture does not always mean VT
Looks can be deceptive. Spinal reflexes are not wise
So, think physiologically. And be logical & open-minded
26. QUIZ ECG # 1
26
If o-AVRT (LL AP), why no early transition in V1-V2?
How come varying degree of capture at same rate?
ANS: recurrent VPCs (‘’R on P’’)
27. 27
QUIZ ECG # 2
APC (within T) prolongs PR and starts o-AVRT
With the resolution of LBBB TCL shortens
ANS: o-AVRT (Left lateral pathway)
28. 28
QUIZ ECG # 3A
Regular WCT with LBBB morphology
Low to high P (retrograde), RP short
Axis normal, transition at V5
In V1, descent of QRS is little staggered
What would you do next?
29. 29
QUIZ ECG # 3B
Post Diltiazem
ANS: AFL 1:1 converted to 2:1
30. 30
QUIZ ECG # 4
A C C
F F F
A A A
NCT retrograde P long RP normal axis
Atypical LBBB, sudden transition in V3
Capture/ Fusion/ AV dissociation (so NOT AVRT)
ANS: VT
31. 31
QUIZ ECG # 5
Long RP, RP less than 50% of RR, BUT PP dictates RR (so no AVRT)
Terminates with P (not AT), RP<PR and RP,PR both variable
ANS: AVNRT (? Atypical)