Download Arrhythmia During STEMI: Recognition and What to Do

Arrhythmia During STEMI:
Recognition and What to Do
J. P. Erwin, III, MD, FACC, FAHA
PVC’s
• Frequency: Common
• Usually requires no treatment
• Check for metabolic and electrolyte
disturbance
• Is your patient on a B-blocker?
Accelerated Idioventricular Rhythm
• Frequency: 15-20%
• Observation—no treatment usually
needed
• AIVR is often a clue to certain underlying
conditions, like myocardial ischemia--reperfusion, digoxin toxicity, and
cardiomyopathies
32 y/o male found down
Idioventricular Rhythm, ST and/or T wave abnormalities suggesting
electrolyte disturbances consider
V-Tach
• Frequency: Up to 60%
• If non-sustained: intense observation
• If sustained: ACLS protocol (drug/DCCV)
Ventricular
Tachyarrhythmias
ECG Distinction of VT from SVT with
Aberrancy
Favors VT
Favors SVT
with Aberrancy
Duration
RBBB: QRS > 0.14 sec.
LBBB: QRS > 0.16 sec.
< 0.14 sec.
< 0.16 sec.
Axis
QRS axis -90° to ±180°
Normal
VT artifact
V-Fib
• Frequency:5%**
• V-Fib= Defib!!
**Of MI’s that survive to the hospital!!
Sinus Tachycardia
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Frequency: COMMON
Rule out hypoxemia and hypovolemia
Provide adequate analgesia
If no acute CHF or hypotension, more Bblocker
82 y/o female with chest pressure
Sinus Tachycardia, LVH, ST and T changes consider repolarization or
ischemia
Atrial Fibrillation
• Frequency:10-15%
• If adequate blood pressure, slow rate with
beta blocker (>Ca Channel blocker)
• If shocky = SHOCK!
Atrial Fibrillation
58 y/o male with chest pain
Atrial fibrillation with rapid ventricular response, Nonspecific ST
and/or T wave abnormalities . . .
Paroxysmal Supraventricular
Tachycardia
• Frequency: <10%
• Treat with adenosine (6-12mg IV push)
• Alternatives: beta-blockers >calcium
channel blockers
SVT- AV Nodal Reentry Tachycardia
Sinus Bradycardia
• Frequency: Up to 40% in acute Inferior MI
– Associated with higher mortality in association
with anterior MI
• 0.5-1mg atropine
• Pacing if hypotensive
• Positive chronotropes: Dobutamine,
Dopamine, or Epinephrine if remains
hypotensive
First Degree AV-Block
• Frequency: 15% in acute Inferior MI
• Observation
• If symptoms, atropine
1st Degree AV Block
• PR interval > 200ms
• Usually, conduction block occurs within
the AV node, especially when QRS is
normal
• Causes include aging, AV nodal blocking
agents, increased vagal tone
• Rarely requires any intervention
54 y/o female seen in clinic
Sinus rhythm, first degree AV block,, Low voltage,
Mobitz Type I Second Degree AVBlock
• Frequency: Up to 10%
• Observation
• If symptoms, give atropine
Sinus Rhythm, AV Block, second degree, Mobitz I (Wenckebach),
Demand pacing
Mobitz Type II Second Degree AVBlock
• Frequency: <1%
• Temporary external or transvenous
pacemaker
Sinus rhythm, AV Block, second degree, Mobitz II, LAE, Right axis deviation,
Nonspecific ST and/or T wave abnormalities . . .
Complete AV Block
• Frequency: 5-15%
• May be transient (especially in inferior MI)
or may require temporary pacing
Sinus rhythm, AV Block, third degree (complete heart block),
Idioventricular rhythm
Questions?