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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 • • • • 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?