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Cardiac Arrhythmias and Conduction Abnormalities Andrew P. Wilper, MD Goals and Objectives • Diagnose common cardiac arrhythmias Discuss importance of, and indications for anticoagulation in atrial fibrillation • Diagnose common cardiac conduction abnormalities PART 1 We Are a Part of the Rhythm Nation You are seeing a 61-year-old man in urgent care. He complains of light headedness. He denies chest pain and dyspnea. ATRIAL FIBRILLATION Irregularly irregular & undulating baseline ATRIAL FIBRILLATION Rule #1 Narrow and irregularly irregular is atrial fibrillation until proven otherwise. Why did it occur? MI? PE? Hyperthyroidism? ETOH? Valvular Disease? Treatment Rate control: diltiazem, beta blocker, digoxin, ablation Rhythm control? Generally no unless very poor output Anticoagulation Embolic risk ~ 5%/year CHADS2 points score NNT CHF 1 0 417 Review VASc RF HTN 1 1 125 Anticoagulation Age > 75 1 2 81 Anticoagulation DM 1 3 33 Anticoagulation Secondary (TIA, CVA) 2 4 27 Anticoagulation 5/6 44 Anticoagulation What about CHADS2=0? • Consider use of additional risks in form of CHA2DS2-VASc – Gives two points for age 75 years and older – An additional point for age 65-74 – An additional point for females – An additional point for vascular dz (CAD, PVD) – Better identifies risk among CHADS2=0 patients Skanes. Can Jour Cardiol. 2012. 28, 125-136 RE-LY. NEJM. 2009 You are seeing a 44 yo female with a complaint of palpitations. Rate 180 QRS Morphology when in sinus rhythm What was the rhythm? Supraventricular tachycardia What was the treatment? Adenosine IV What is the problem? Wolff-Parkinson-White SUPRAVENTRICULAR TACHYCARDIA (SVT) RATE 150-250 (typically ~ 180) Why did it occur? Accessory pathway? ETOH? Stimulants? Treatment Vagal Maneuvers Adenosine (temporary A-V blockade) Cardiovert if unstable EPS w/ablation for WPW Caffeine? Common SVT Characteristics MAT Afib Aflutter WPW Rate Sinus EAT tachycardia >100 100-180 >100 Vent rate: 125-175 140+ Regularity Regular Regular Usually regular Sawtoothed Irregular or regular Buried 1:1 Ectopic focus different 1:1 Irregularly irregular At least 3 different morphologies 1:1 Variable (can be fast or slow) Irregularly irregular None None Most commonly 2:1, others are 3:1 and 4:1 Variable 1:1 if you can see it P wave P:QRS ratio PR interval Normal to slightly shortened Ectopic focus with different interval Variable None Very shortened; QRS is also typically wide You are seeing a patient in the ED with a complaint of palpitations. Recent history of pericarditis. Rate 150 ATRIAL FLUTTER Flutter waves ATRIAL FLUTTER Rule #2 Narrow, regular, and 150 is atrial flutter until proven otherwise. Why did it occur? CHF? Recent Cardiac Surgery? COPD? Treatment -Usually goes away or converts to A-fib -Anticoagulation-similar approach to atrial fibrillation -Radiofrequency ablation of reentrant circuit Pericartidis? FAST, NARROW RHYTHMS Irregularly irregular (Rule #1) A-FIB Rate > Rhythm Control (Remember MAT) CHADS2 Regular at ~ 150 (Rule #2) A-FLUTTER Adenosine for diagnosis Regular > 150 SVT Accessory pathway (ablation) Adenosine for treatment Stimulants You are seeing a 61-year-old man in urgent care. He complains of light headedness. He denies chest pain and dyspnea. 1. Abnormal and wide qrs (>120 ms) with secondary st and t wave changes, qrs concordance in V1-V6 2. Rate 140-200 3. Regular or slightly irregular 4. Abrupt onset and termination 5. AV dissociation 6. Capture beats-regular qrs from atrial p wave 7. Fusion Beats-partial depolarization by atrial and ventricular impulse V – TACH You are called to the bedside of a patient with a history of drug-induced long QT syndrome. Diagnosis? Polymorphic Ventricular Tachycardia Polymorphic VT 1) Paroxysms of VT with irregular RR interval 2) Ventricular rate 200-250 3) Two or more cycles of qrs complexes with alternating polarity 4) Changing amplitude of qrs complexes in sinusoidal fashion 5) If prolonged QTc=Torsades de pointes FAST, WIDE RHYTHMS Ventricular Tachycardia • QRS > 0.14 ms • QRS concordance in V1-6 • Notching in V1 down stroke SVT with LBBB • deep S in V1, V2 • wide R in I, V6 • T-wave opposite terminal QRS SVT with RBBB • some R wave in V1 • prominent S in V6 • T-wave opposite in III, V1-3 WiLLiaM MaRRoW=W in V1 and for M in V6 for LBBB, RBBB opposite V tach-fusion beat You are seeing a 61-year-old man in urgent care. He complains of light headedness. He denies chest pain and dyspnea. 2o, Mobitz type I (Wenckeback ) Grouped beating Lengthening P-R interval Dropped beat APPROACH TO HEART BLOCK (P = QRS) Are there as many P waves as QRS complexes? NO YES 1o (P-R =) Is the P-R interval always equal? NO YES 2o, Mobitz II (QRS =) Is the QRS interval always equal? NO 2o, Mobitz I (Wenckebach) YES 3o Sinus Node Wenckebach (Sick Sinus) 0.10 0.10 0.86 0.10 0.82 Sinus Wenckebach AV Wenckebach SA SA A A AV AV V V 54 year old male with intermittent dizziness 54 year old male with intermittent dizziness Unchanging PR with unexpected dropped beats Diagnosis=Mobitz II Block When to get help! Name the Rhythm You review the chart…. And find this Name the Rhythm Paced Rhythm Motion Artifact Aberrantly Conducted Native Beats 42 year old, screening physical RBBB 1. QRS >0.12 sec (in ANY lead) – look for this first 2. Slurred S wave in I and V6 – look for this second 3. RSR’ pattern in V1 with R’ taller than R (“Rabbit ears”) 4. Should be predominately positive in V1 – look for this only AFTER looking for the previous 2 criteria Right Bundle Branch Block • Clinical Correlates-RVH, sudden increase in right ventricular pressure with stretch (as in pulmonary embolism), Cor Pulmonale, myocardial ischemia, infarction, or inflammation (myocarditis), hypertension. • Caveats: Sometimes you will see a qR’ wave indicating an anteroseptal MI in V1 (floppy eared rabbit). • You cannot diagnose RVH in RBBB 75 yo male presents to establish care, prior history of lymphoma LBBB 1. QRS duration >0.12 sec 2. Broad, monomorphic (meaning all positive or all negative) R waves in I and V6, with no Q waves 3. Broad, monomorphic S waves in V1; may have small r wave Left Bundle Branch Block • Clinical associations: HTN, CAD, valvular heart disease (rheumatic heart disease), endocarditis, cardiomyopathy, infiltrative diseases of the heart, prior XRT • Caveats: You cannot Dx LVH or RVH in patients with LBBB. Infarction is tricky to diagnose in LBBB, but possible Delays • Intraventricular Conduction Delay (IVCD) • Criteria: – QRS duration > 0.12 seconds – Doesn’t qualify for LBBB or RBBB **When this is seen, look for hyperkalemia Blocks • Hemiblocks (Left Anterior Fascicular Block, Left Posterior Fascicular block) • A few words: The Left bundle splits into the left anterior fascicle and the left posterior fascicle Blocks • Criteria: • Left Anterior Hemiblock/Fascicular Block (fairly common) – LAD with axis at –30 to –90 degrees – qR complex or an R wave in lead 1, AvL – An rS complex in lead III and usually in II and aVF – Easy shortcut: LAD?yes, then check lead II – if net vector is negative LAHB LAFB ECG Axis? Left QRS duration? <120ms Net Vector in II? Negative Causes of LAFB • • • • CAD Hypertension Valvular disease Degenerative disease of the conducting system • Sclerosis of the left cardiac skeleton • Myocardial fibrosis • Normal Variant (2-5%) Blocks • Left Posterior Hemiblock/ Fascicular Block (fairly rare) – RAD with axis 90-180 – S wave in lead I and a q in III – Exclusion of RAE and/or RVH Left Posterior Hemiblock Axis? Right QRS? <120 ms rS in I and aVL qR in III and aVF Causes of LPFB • • • • • • Similar to LAFB Cardiomyopathies Chagas disease Myocarditis Hyperkalemia Acute cor pulmonale Note • RBBB+LAFB or RBBB + LPFB commonly referred to as bifascicular blocks Practice! Normal Sinus Rhythm A fib w/BBB VT A Fib LBBB NSR with PAC Rate related LBBB LVH with strain Sinus Tachycardia, A-V dissociation RBBB LAFB NS ST/T abn Thank you