This document provides an overview of tachyarrhythmias, including their causes, clinical manifestations, and treatment approaches. It discusses various types of arrhythmias such as sinus tachycardia, atrial fibrillation, atrial flutter, premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation. For each type, it outlines the etiology, characteristics, management strategies including medication and procedures. The document is an educational guide for healthcare providers on understanding and managing different cardiac arrhythmias.

1. TACHYARRYTHMIAS
DR.JAKEER HUSSAIN
MD, DNB, IDCCM

2. BASICS
• NORMAL SINUS RYTHM: when
every heart beat originates with
depolarisation of sinus node.
• ARRYTHMIA/ DYSRYTHMIA Any
disturbance in rate, regularity, site
of origin, or conduction of the
cardiac electrical impulse

4. PRECIPITATING FACTORS FOR ARRYTHMIAS
• HYPOXIA : myocardium deprived of O2 – irritable myocardium. Pulm disorders, copd,
• embolus.
• ISCHEMIA & IRRITABILITY: ANGINA, MYOCARDIAL INFARCTIONS, MYOCARDITIS( Viral
SYMPATHETIC STIMULATION : enhanced sympathetic tone ( hyperthyroid, nervousness, exercise)
• DRUGS : Many drugs cause arrhythmias…
• ELECTROLYTE IMBALANCE: K, Ca , Mg.
• STRECTH : Hypertrophy & enlargement of ATRIA & VENTRICLES
• ( VALVULAR HEART Ds, CARDIOMYOPATHY, CHF)

5. CLINICAL MANIFESTATIONS
• ASYMPTOMATIC
• PALPITATIONS awareness of ones own heart beat
• SYNCOPE : symptoms of decreased cardiac output. ( light headedness.)
• CHEST PAIN: rapid heartbeat can inc O2 demand of myocardium, cause ANGINA.
• CHF sudden onset of arrhythmias in underlying heart ds precipitate CHF
• DEATH: sudden death… ( post MI Pt increase risk of sudden death 2* arrhythmias)
monitoring continuous rhythm imp,,
IN OP SETTINGS,,, RHYTHM STRIPS, HOLTER 24- 48, EVENT MONITORS.

9. SINUS TACHYCARDIA

10. CAUSES
• FeverPain
• ● Anxiety
• ● Pheochromocytoma
• ● Hyperthyroidism
• ● Decompensated heart failure
• ● Chronic pulmonary disease
• Exposure to stimulants (nicotine, caffeine,
amphetamines), anticholinergic drugs, beta
blocker
• withdrawal, or illicit drugs
• ● Abrupt withdrawal of medications such as
beta blockers
• ● Volume depletion
• ● Hypotension and shock
• ● Sepsis
• ● Anemia
• ● Hypoxia
• ● Pulmonary embolism
• ● Acute coronary ischemia and myocardial
infarction

11. • BETA BLOCKERS — For patients with symptomatic inappropriate sinus tachycardia, we
suggest a trial of beta blockade, rather than non-dihydropyridine CCB, as the initial medical
therapy. start long-acting metoprolol 25 to 50 mg daily.
• IVABRADINE — For patients with persistently symptomatic inappropriate sinus tachycardia,
ivabradine (5 mg to 7.5 mg twice daily) with or without a beta adrenergic receptor blocker
• 2015 ACC/AHA/HRS guideline for the treatment of supraventricular tachycardia both support
the use of ivabradine for inappropriate sinus tachycardia

12. ATRIAL TACHYCARDIA

14. ATRIAL FLUTTER

15. TYPICAL VS REVERSE TYPICAL

16. RX
• radiofrequency ablation (RFA). In all available studies, catheter ablation is
superior to rate-control and rhythm-control strategies with antiarrhythmic
drugs.

17. ATRIAL FIBRILLATION

18. ETIOLOGY
• CARDIAC
➢1.HYPERTENSION
➢2.VALVULAR HEART DISEASE
➢3.CORONARY HEART DISEASE
➢4.CARDIOMYOPATHY
➢5.CONGENITAL HEART DISEASE
➢6. CARDIAC SURGERY
➢7.ELECTRICAL DISEASE—SINUS NODE
DYSFUNCTION,TACHY INDUCED,FAMILIAL
➢8.PERICARDIAL DISEASES
• NON CARDIAC
➢ENDOCRINE--THYROID DISEASE
➢TOXIC SUBSTANCE—ALCOHOL
➢AUTONOMICALLY MEDIATED
➢PULMONARY DISEASE
➢NEUROLOGICAL
➢IDIOPATHIC

19. MANAGEMENT OF ACUTE AF (<48 HRS)
• Haemodynamically unstable : hypotension/heart failure/chest pain/syncope
Use DC Cardioversion
Haemodynamically stable :
Rate control : If significant tachycardia
Rhythm control : Flecainide, Propafenone (cl-I) Amiodarone, Sotalol (cl-III)
Anticoagulant : LMWH

21. RATE CONTROL VS RHYTHM CONTROL
• RHYTHM CONTROL AS PREFERRED THERAPY
• ? First episode afib
• Reversible cause (alcohol)
• Symptomatic patient despite rate control
• Patient unable to take anticoagulant (falls, bleeding, noncompliance)
• CHF precipitated or worsened by afib
• ? Young afib patient (to avoid chronic electrical and anatomic remodeling that
occurs with afib
• RATE CONTROL AS PREFERRED THERAPY
• Age > 65, less symptomatic, hypertension
• Recurrent afib
• Previous antiarrhythmic drug failure
• Unlikely to maintain sinus rhythm (enlarged LA)

22. AMIODARONE
•Large volume of distribution
& long half life
•Contraindications
•Sinus bradycardia
•Heart block
•Adverse effects
•Short term : Skin
reactions,Brady, hypotension,
•Long term :
• Pulmonary fibrosis, alveolitis,
pneumonitis
• Liver dysfunction..monitor LFT
• Hypo or Hyperthyroidism (check
TFT before starting)
• Peripheral neuropathy, myopathy,
Cerebellar dysfunction.

23. TEE LA THROMBUS
• 2DECHO ADVISED
• TEE better TTE for LA

24. 0 points – low risk (1.2-3.0 strokes per 100 patient years)
1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)
> 3 points – high risk (5.9-18.2 strokes per 100 patient years)

25. NEWER
ANTICOAGULANTS
•DABIGATRAN,
RIVAROXABAN,
APIXABAN
•Non-inferior to warfarin
re thromboembolism
(afib)
•Caution when CrCl <
30ml/min
•No reversal,,, DIALYSIS if
bleeding severe.

26. MULTI FOCAL ATRIAL TACHYCARDIA

27. WPW

28. SUPRA VENTRICULAR TACHYCARDIA

29. CAROTID MASSAGE
• Check for carotid bruit before massage.
• At the level of cricoid cartilage,at the angle of mandible the carotid sinus is situated.
• Gentle pressure is applied over the carotid sinus for 10-15 seconds.
• ECG recording to be present.
• In case of no response – try on the other side.
• Simultaneous pressure not to be applied both sides.
• Alternative manuevres are valsalva,gag reflex,ice water pouring over the face.
• IF EVIDENCE OF CAROTID @ Ds do not perform carotid massage.

30. • If SVT is suspected to be AVNode dependent – drug of choice is adenosine and CCBs verapamil
and diltiazem.
• But digoxin,BBs,CCBs better control of ventricular response in atrial tachycardias
• Class I agents to be combined with AV nodal blocking drugs – to eliminate 1:1 conduction of
atrial to ventricles.

31. • Pre-excitation syndromes seen on ECG when patient in sinus rhythm (WPW changes). These are
lost when AVRT is established
• Short PR, delta wave, widened QRS
• Anatomical re-entrant pathway (Bundle of Kent). Circus movement between the AV node and
accessory pathway.
• May be triggered by PAC or PVC
• Circus movement may by orthodromic or antidromic

32. PREMATURE VENTRICULAR CONTRACTION

33. PREMATURE VENTRICULAR CONTRACTION (PVC)
• The ectopic beat is not preceded by a p-wave
• Irregular rhythm due to ectopic beat
• Rate will be determined by the underlying rhythm
• QRS is wide and may be bizarre in appearance
• Caused by a irritable focus within the ventricle which fires prematurely
• Must identify an underlying rhythm

34. PREMATURE VENTRICULAR CONTRACTION (PVC)
• Classify as UNIFOCAL, OR MULTIFOCAL PVC’S
• UNIFOCAL-originating from same area of the ventricle; distinguished by same
morphology
• MULTIFOCAL-originating from different areas of the ventricle; distinguished by
different morphology

35. MONOMORPHIC PVC

36. POLYMORPHIC PVC

37. VENTRICULAR BIGEMINY
Every second beat is PVC

38. VENTRICULAR TRIGEMINY
Every 3rd beat is PVC

39. VENTRICULAR QUADRIGEMINY
Every 4th beat is PVC

40. COUPLETS

41. MONOMORPHIC VT

42. POLYMORPHIC VT

45. IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD)
•ICD therapy compared with conventional AAD associated with mortality
reduction of 23-55% depending on risk group.
•Current ICD options:
• Single chamber
• Dual chamber
• Biventricular cardiac resynchronization
• Multilevel shock discharge for VT or VF
Complications:
Inappropriate shock discharge
Defibrillator storm
Infections
Exacerbation of HF

46. LONG QT SYNDROME
• Long QT syndrome (LQTS) is a rare congenital and inherited or acquired heart condition in
which delayed repolarization of the heart following a heartbeat increases the risk of episodes
of torsades de pointes (TdP, a form of irregular heartbeat that originates from the ventricles)
• QTc is prolonged if > 440ms in men or
• > 460ms in women.
• QTc > 500 is associated with increased risk of torsades de pointes.
• a normal QT is less than half the preceding RRinterval.

47. LONG QT SYNDROME

50. TREATMENT
• Beta-adrenergic blocking agents are the drugs of choice to treat long QT syndrome and include
the following medications:
• Propranolol, Nadolol, Metoprolol, Atenolol
• SURGICAL OPTION
• Surgical intervention in patients with long QT syndrome may include the following procedures:
• Implantation of cardioverter-defibrillators
• Placement of a pacemaker
• Left cervicothoracic stellectomy
• FAMILY HISTORY,, AVOID EXERCISES, AVOID DRUGS

51. TORSADES DE POINTES
• Torsades de pointes is a specific form of polymorphic VT in patients with a
long QT interval. It is characterized by rapid, irregular QRS complexes,
• which appear to be twisting around the ECG baseline.
• This arrhythmia may cease spontaneously or degenerate into ventricular
fibrillation.

52. TORSADES DE POINTES

53. RX
MAGNESIUM
decreasing the influx of calcium, thus lowering the amplitude of EADs.
Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be
repeated in 5-15 minutes.
• Because of the danger of hypermagnesemia (depression of neuromuscular function), the
patient requires close monitoring.
LONG-TERM TREATMENT
• Beta-adrenergic antagonists at maximally tolerated doses are used as a first-line long-
term therapy in congenital long QT syndrome. Propranolol is used most extensively
• Implantable cardioverter-defibrillators (ICDs) are useful in instances when torsade
recurs despite treatment with beta-blockers, pacing, and possibly left thoracic
sympathectomy.

54. VENTRICULAR FIBRILLATION

55. • VENTRICULAR FIBRILLATION
• No discernable p-waves
• No regularity
• Unable to determine rate
• Multiple irritable foci within the ventricles all firing simultaneously
• May be coarse or fine
• This is a deadly rhythm
• Patient will have no pulse
• begin CPR & resustication.

58. QUIZ…..

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60. ATRIAL FLUTTER,,, 4:1 BLOCK

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62. SINUS TACHY……

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64. AVNRT

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66. VT

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68. A FIB

70. WPW

72. THANK YOU….
Seminar is defined as process in which
one spoils his sleep for one night ,,,
in an effort to make others sleep …….