Recognizing Cardiac arrhythmias Normal anatomy Normal ECG Normal

Recognizing Cardiac arrhythmias

Normal anatomy

Normal ECG

Normal ECG

Classification - tachys Atrial • AF • Atrial Flutter • PAC Junctional • • Paroxysmal SVT (PSVT) Junctional Tachycardia Ventricular • VT • VF • PVC Broad Complex Mark Henderson

Classification - bradys Atrial • Sinus brady • Sick sinus syndrome Junctional • Junctional Escape Ventricular • Ventricular Escape Mark Henderson

Atrial Fibrillation • Atrial dilation & decreased CO • RAAS activation • Protease stimulation • Progressive atrial fibrosis • Fragmented, asynchronous depolarizations Mark Henderson

Atrial Fibrillation Mark Henderson

AF - Classification AF Type Definition New-onset No previous episodes Paroxysmal Recurrent episodes of < 7 days duration Persistent Recurrent episodes of > 7 days duration • Valvular Permanent. AF? • Lone AF? • Secondary AF? • Symptomatic AF? Long-term episode Mark Henderson

AF - Causes Primary Cardiac Causes Other Cause Coronary artery disease Hypertension Valvular disease Lung disease Hypertrophic cardiomyopathy Hyperthyroidism Congenital heart disease Medications, alcohol Pericardial disease Mark Henderson

symptoms • Palpitations • Breathlessnes s • • DDX • Tachyarrhythmias • Flutter Lightheaded • Panic attack/anxiety Fatigue • Drugs Chest pain • Caffeine/alcohol Exercise intolerance • Symp. Agents • Stimulants Mark Henderson

Diagnosis • Heart failure • Echo evidence of stroke risk • Alcohol • Regurg/stenosis • Thyroid Mark Henderson

Atrial flutter Ectopic loop (reentrant pathway) of atrial electrical activity, usually precipitated by a PAC Mark Henderson

Differences to AF • P waves clearly visible in characteristic ‘sawtooth’ pattern • Comment on degree of block 2: 1, 3: 1, 4: 1 etc • More sensitive to electrical CV • Less sensitive to chemical CV. • RFA useful because of the reentrant nature.

PAC • Premature Atrial Contractions • Common, not necessarily pathological • P wave is abnormal due to ectopic focus • P wave may be isolated or may have resulting QRS.

Junctional tachys PSVT • Paroxysmal Supra-Ventricular Tachycardia • AVNRT and AVRT (nodal or accessory pathway) AVNRT FP SP

AVRT • Atrioventricular Reentrant Tachycardia • (Wolf Parkinson White (WPW) Syndrome) • Narrow complex • P wave may be inverted and straight after T wave.

• Monomorphic • • VT Usually due to MI scarring causing an aberrant focal automaticity or a reentrant pathway like flutter Polymorphic • Usually abnormality of repolarization - prolonged QT eg. • Needs electrical cardioversion if pulseless, or progresses to VF • If < 30 seconds = non-sustained VT

VF • Causes: Trauma (physical or electrical), CAD, MI, cardiomyopathies, sudden cardiac death, congenital heart disease etc. . . • Most have no hx of heart disease • Though often have many risk factors - smoking, hyperlipidaemia, DM. • Episodes outwith hospital have 2 -25% long term survival • many survivors are comatose/permanently brain damaged. Seemingly random pattern No identifiable P or QRS rhythm Wandering baseline

Heart block • 1 st degree AV block (prolonged PR) • 2 nd degree AV block • Mobitz I (lengthening PR til dropped QRS) • Mobitz II (intermittently dropped P waves) • 3 rd degree AV block (complete) • Infranodal block • • Left BBB • Left Anterior Fascicular Block • Left Posterior Fascicular Block Right BBB

mobitz ii

l. BBB

AF

PSVT - AVRT

Atrial flutter

1 st degree AV Block

RBBB

Polymorphic vt - ecg TORSADES

mobitz 1

Premature Atrial Complexes

3 rd degree

Monomorphic vt

PSVT - AVNRT

VF

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