Arrhythmias in Real LifeNarrow Complex Tachycardias Salah Abusin, MBBS, MRCP (UK), ABIM Cardiology Fellow ...
Outline• Types• Mechanism of Tachyarrhythmias• ECG Interpretation & Acute Management• Algorithm for Management of ...
Types Atrial Tissue AV Junction (Supraventricular)• Sinus Tachycardia • AV nodal Reentr...
Mechanisms of tachyarrhythmias1. Automaticity2. Triggered Activity3. Reentry
Automaticity • Normal – SA Node – AV Node • Abnormal – Idioventricular rhythm
Reentry • Requires the presence of two pathways – One slow, the other fast – Unidirectional block in ...
Triggered Activity Delayed After Depolarization• Early – Prolonged QT – Torsades de Pointes• Late – Digoxin Toxicity
Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAtr...
Atrial Fibrillation
Atrial Fibrillation• Irregular Narrow Complex Tachycardia• The commonest sustained arrhythmia• Absence of P waves• Atrial ...
Types• Paroxysmal – self-terminating episodes that generally last <7 days (most <24 hours)• Persistent – generally la...
Causes• Ischemic Heart Disease• Hypertensive Heart Disease• Other organic heart disease/cardiomyopathy• Mitral Val...
II aVL V2 III aVF ...
Multifocal Atrial Tachycardia (MAT)• Irregular Narrow Complex Tachycardia• >= 3 P wave morphologies• ...
Causes• COPD• Cor pulmonale• Hypoxia• Heart Failure• Postoperative State• Sepsis• Pulmonary Edema
Management• Treatment of the underlying cause• Correction of electrolytes (K, Mg)• AV nodal blocking agents• Antic...
Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAV nodal Reentry Iden...
AV nodal Reentry Tachycardia
AVNRT• Regular Narrow Complex Tachycardia• Usual rate 150-250• Abrupt onset and offset• Variable relation to P wav...
Mechanism of AVNRT
Management• Acute Episode – Vagal Maneuvers • Valsalva, carotid sinus massage, – IV adenosine – IV/PO Betablockers,...
Narrow Complex TachycardiaIrregular Regular No P Waves P Waves present Identify P wave ...
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...
Long RP IntervalRP interval > ½ RR interval RR RP
Short RP intervalRP interval < ½ RR interval RR RP
Regular Narrow Complex Tachycardia P wave morphology ...
Definition of normal P• Duration 0.08 to 0.11 (2-3 small squares)• Axis (0-75)• Upright in II, III, aVF• Upright/biphasic ...
RR P P P P RPAV node reentry tachycardia, AVNRT
F F F F F Atrial Flutter
Atrial Flutter• Regular Narrow Complex Tachycardia• Flutter waves conducting ~ 300/min• Usually 2:1 block with a ventricul...
Mechanism of Atrial Flutter • Typical F waves inverted F waves in II, III, aVF
Management• Similar to atrial fibrillation – Requires anticoagulation• More Difficult to control rate with medical trea...
RR RPP P P P Atrial Tachycardia
Atrial tachycardia• Atrial rate is 100-240 i.e. slower than atrial flutter• Usually 1:1 conduction without medical treatm...
Management• AV nodal blocking agents• Some are amenable to Radiofrequency ablation
ECG PROBLEMS
Problem 1• 68 year old Nigerian male with PMH of HTN, DM comes to Cardiology clinic for a routine check up• He takes met...
• Regularity of rhythm• P wave present or absent Atrial Fibrillation
Problem 2• 62 year old female with known ESRD on HD via left AV fistula developed sudden onset of palpitations during di...
• Regularity of rhythm• P wave present or absent•• RP interval P wave morphology/rate AVNRT• Relatio...
Problem 3• 59 year old African American Male, with DM, HTN, Obesity presents to his internist with two weeks history of ...
• Regularity of rhythm• P wave present or absent Atrial• RP interval• P wave morphology/rate Flu...
Problem 4• 74 year old African American Female with remote history of ASD repair and Pulmonary Hypertension comes for fo...
• Regularity of rhythm• P wave present or absent Atrial• RP interval Tachycardia• P w...
Problem 5• 52 year old Middle Eastern Female with known non ischemic cardiomyopathy is admitted with heart failure exace...
• Regularity of rhythm•• P wave present or absent RP interval Atrial• P wave...
Problem 6• 54 year old White Male with PMH of a known arrhythmia comes for routine follow up• He takes metoprolol XL 200m...
• Regularity of rhythm• P wave present or absent Atrial Flutter• RP interval with varia...
Problem 7• 49 year old male with no PMH, presents to the Emergency Room with sudden onset of palpitations, headache• HR ...
• Regularity of rhythm• P wave present or absent• RP interval•• P wave morphology/rate Relationship between P ...
Problem 8• 36 year old African American Male with no PMH comes for a routine outpatient visit to his primary care doctor...
• Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate ...
Problem 9• 61 year old Hispanic female with no PMH, presents to the Emergency Room with fatigue, loss of weight, palpita...
• Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate ...
Problem 10• 48 year old male with severe obesity, a chronic skin disorder, and chronic LE edema is sent to hospital from...
• Regularity of rhythm• P wave present or absent• RP interval Atrial• P wave morphology/rate ...
• Diagnosed with probable ectopic atrial tachycardia• No response to IV adenosine• No response to IV esmolol• NO response...
• Performed DC Cardioversion 50J Biphasic, then 200 with no response• At second attempt at DC Cardioversion 200J reverted...
THANK YOU
Narrow complex tachycardias
of 60

Narrow complex tachycardias

by Salah Abusin, MD, Cardiology Fellow, Cook County Hospital, Chicago, IL
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Narrow complex tachycardias

  • 1. Arrhythmias in Real LifeNarrow Complex Tachycardias Salah Abusin, MBBS, MRCP (UK), ABIM Cardiology Fellow Chicago, IL,USA
  • 2. Outline• Types• Mechanism of Tachyarrhythmias• ECG Interpretation & Acute Management• Algorithm for Management of NCTs• Problems
  • 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. Mechanisms of tachyarrhythmias1. Automaticity2. Triggered Activity3. Reentry
  • 5. Automaticity • Normal – SA Node – AV Node • Abnormal – Idioventricular rhythm
  • 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. Triggered Activity Delayed After Depolarization• Early – Prolonged QT – Torsades de Pointes• Late – Digoxin Toxicity
  • 8. Narrow Complex Tachycardia Irregular Regular No P Waves P Waves presentAtrial Fibrillation Multifocal Atrial Tachycardia Atrial Flutter with variable block
  • 9. Atrial Fibrillation
  • 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. 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. 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. 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. 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. Causes• COPD• Cor pulmonale• Hypoxia• Heart Failure• Postoperative State• Sepsis• Pulmonary Edema
  • 16. Management• Treatment of the underlying cause• Correction of electrolytes (K, Mg)• AV nodal blocking agents• Anticoagulation depending on stroke risk
  • 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. AV nodal Reentry Tachycardia
  • 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. Mechanism of AVNRT
  • 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. Narrow Complex TachycardiaIrregular Regular No P Waves P Waves present Identify P wave morphology/rate Relationship between P and QRS Identify RP interval
  • 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. Long RP IntervalRP interval > ½ RR interval RR RP
  • 25. Short RP intervalRP interval < ½ RR interval RR RP
  • 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. 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. RR P P P P RPAV node reentry tachycardia, AVNRT
  • 29. F F F F F Atrial Flutter
  • 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. Mechanism of Atrial Flutter • Typical F waves inverted F waves in II, III, aVF
  • 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. RR RPP P P P Atrial Tachycardia
  • 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. Management• AV nodal blocking agents• Some are amenable to Radiofrequency ablation
  • 36. ECG PROBLEMS
  • 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. • Regularity of rhythm• P wave present or absent Atrial Fibrillation
  • 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. • Regularity of rhythm• P wave present or absent•• RP interval P wave morphology/rate AVNRT• Relationship between P and QRS
  • 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. • Regularity of rhythm• P wave present or absent Atrial• RP interval• P wave morphology/rate Flutter• Relationship between P and QRS
  • 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. • 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. 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. • Regularity of rhythm•• P wave present or absent RP interval Atrial• P wave morphology/rate Fibrillation• Relationship between P and QRS
  • 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. • 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. 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. • Regularity of rhythm• P wave present or absent• RP interval•• P wave morphology/rate Relationship between P and QRS AVNRT
  • 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. • 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. 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. • Regularity of rhythm• P wave present or absent Atrial•• RP interval P wave morphology/rate Fibrillation• Relationship between P and QRS
  • 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. • Regularity of rhythm• P wave present or absent• RP interval Atrial• P wave morphology/rate Tachycardia• Relationship between P and QRS
  • 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. • Performed DC Cardioversion 50J Biphasic, then 200 with no response• At second attempt at DC Cardioversion 200J reverted to Sinus rhythm
  • 59. THANK YOU

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