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Cardiac Dysrhythmias Sinus Dysrhythmias Bradycardia - A Sinus Rhythm That Is <60 BPM Tachycardia - A Sinus Rhythm That Is > 100 BPM Respiratory Arrhythmia • During Inspiration & Expiration, The R-R Interval Expands & Contracts • R-R Interval Widens During Expiration • R-R Interval Shortens During Inspiration Sinus Arrest Sinus Arrest Occurs Because The Sinoatrial Node Ceases To Fire Sinus Arrest Escape Or Rescue Beats Secondary Pacemakers Rescue The Heart & Create Escape Or Rescue Beats Rescue Beats May Have Their Origin High Up In The Atria Or Down Low Close To The AV Node Or Even In The Ventricles. If The Ectopic Pacemaker Is Close To The SA Node, It Will Be An Atrial Escape Beat. It Will Have These Features : The Escape Beat Is Delayed P Wave Is Irregularly Shaped A Normal QRS Complex Atrial Escape Or Rescue Beat If The Rescue Beat Is Close To The AV Node, Then It Will Likely Be A Junctional Escape Beat Characteristics Of A Junctional Escape Beat : A Rescue Beat Is Delayed No P Wave The QRS Is Normal Rate Will Be Slower Junctional Rescue Or Escape Beat If The Rescue Beat Is Located In The Ventricles, Then It Is A Ventricular Pacemaker That Is Activated To Rescue The Heart Characteristics Of A Ventricular Rescue Beat Are : No P Wave A Rescue Beat Is A Delayed Beat Wide Bizarre QRS Complex Rate Will Be Very Slow Ectopic Pacemakers Have Their Own Firing Rates A Maxim : The Lower Your Go Into The Heart To Find A Pacemaker, The Slower The Rate Ectopic Pacemaker Rates Atrial Pacemakers ~ 60-80 BPM Junctional Pacemakers ~ 40-60 BPM Ventricular Pacemakers ~ 30-45 BPM What Can Cause The SA Node To Go Into Sinus Arrest ? Cardiovascular Disease Increased Vagal Tone Infection Drugs - Digitalis, Quinidine Wandering Pacemaker A Wandering Pacemaker Is A Condition In Which You Have Two Or More Pacemakers Competing For Control Over The Heart’s Rhythm Characteristics Of A Wandering Pacemaker : P Waves Have Different Shapes PR Intervals Are Grossly Within Normal Limits But Are Slightly Variant From Each Other QRS Complexes Are Normal Wandering Pacemaker Wandering Atrial Pacemaker Sick Sinus Syndrome Patient Hx. Of Supraventricular Tachdysrhythmias Like Atrial Fibrillation Or Atrial Flutter Significant Ischemic Heart Disease Sick Sinus Syndrome Characterized By : Irregular Heart Rate Deteriorating Into Extreme Bradycardia Episodes Of Syncope Leads To Pacemaker Implant Sick Sinus Syndrome Ectopic Supraventricular Dysrhythmias Unsustained SVTD’s: PAC’s PJB’s Or APB’s Premature Atrial Contractions (PAC’s Or APB’s) Characteristics Of PAC’s : It Is A Premature Beat P Wave Is Irregularly Shaped Normal QRS Causes Of PAC’s : Stress Caffeine Tobacco Use Digitalis Toxicity Old MI’s Low Blood Potassium Levels Low Blood Magnesium Levels Premature Atrial Contraction Premature Atrial Contraction PAC’s Can Deteriorate Into : Atrial Flutter Atrial Fibrillation Supraventricular Tachycardia Premature Junctional Beats (PJB’s) PJB’s Occur from An Ectopic Focus Close To The AV Node Characteristics Of PJB’s : The Beat Is Premature There is No P Wave QRS Complex Is Normal Premature Junctional Beat Sustained Supraventricular Dysrhythmias Sustained SVTD’s Are : PSVT or PAT Atrial Flutter Atrial Fibrillation PSVT Or PAT’s Common Dysrhythmia Instigated Often By A Premature Atrial Beat Or A Premature Junctional Beat Causes Are : Ischemic Heart Disease Re-Entry Phenomenon Stress Drugs Characteristics Of PSVT Are : P Waves Are Absent - P Waves Are Hidden If They Are Present Repeating Pattern Of QRS-T Very High Heart Rates Of 150 250 BPM Paroxysmal Atrial Tachycardia Carotid Massage Can Bring A Person Out Of PSVT PSVT Can Be Stopped With Cardioversion, Valsalva & Coughing Exercise Can I Exercise A Patient With PSVT Or SVT ? No !! This Patient Has An Uncontrolled Atrial Dysrhythmia Atrial Flutter Atrial Flutter Is Also Known As The Sawtooth Pattern Characteristics Of Atrial Flutter : High Rate Of P Wave Appearance Of 250-350 QRS Complex Is Followed By A Regular Pattern Of P Waves - 2:1, 3:1 or 4:1 Block QRS Complexes Are Normal & Regular No Visible T Waves No Visible S-T Segment No Visible PR Interval Causes Of Atrial Flutter : Ischemic Heart Disease PAC’s Re-Entry Phenomenon Pulmonary Emboli Stress MI’s Cor Pulmonale Valvular Heart Disease Atrial Flutter Exercise Can I Exercise A Patient With Atrial Flutter ? No !! This Patient Has An Uncontrolled Atrial Dysrhythmia Atrial Fibrillation Some Causes Are : MI’s Pulmonary Embolism Hypertension CAD Heart Valve Disease Characteristics Are : High Rates Of Atrial Discharge Of Between 350-500 BPM Flat Or Undulating Baseline Absent P Waves Irregularly Timed Normal QRS Complexes Atrial Fibrillation Atrial Fibrillation Exercise Can I Exercise A Patient In Atrial Fibrillation ? NO !! - The Patient Has An Uncontrolled Atrial Dysrhythmia Symptoms What Will The Patient Feel With A Supraventricular Tachydysrhythmia ? Lightheadedness Dizziness Or Syncope Shortness Of Breath Palpitations Angina Can A Patient Chronically Live With These Dysrhythmias ? Yes, But There Are Some Inherent Dangers ! Inherent Dangers Supraventricular Tachydysrhythmias Can Cause The Formation Of Blood Clots In The Atria. Patients Can Auto-Embolize Organ Systems If The Heart Spontaneously Converts Out Of The Dysrhythmia Patients Must First Be AntiCoagulated & Then Converted Out Of The Dysrhythmia Ectopic Ventricular Dysrhythmias Premature Ventricular Contractions (PVC’s) Ventricular Tachycardia Ventricular Fibrillation Premature Ventricular Contractions PVC’s Occur In Normal Hearts As Well As Those With Pathology People With Thousands Of PVC’s Per Day Can Be Normal PVC’s Can Also Be An Ominous Sign Of Disease Characteristics Of PVC’s Are : PVC’s Are Premature Beats The P Wave Is Absent QRS Complex Is Wide & Bizarre A Compensatory Pause Follows The PVC Premature Ventricular Contractions Premature Ventricular Contractions PVC’s May Appear Randomly PVC’s May Appear In Patterns Bigeminy Trigeminy Bigeminy Bigeminy Trigeminy Quadrigeminy Couplets Triplets Couplets Triplets Couplets Are Scary But Triplets Are Really Frightening Triplets Are A Hair’s Breath Away From Ventricular Tachycardia Multiform PVC’s Rules Of Malignancy An Ordering System For Grading The Severity Of Ventricular Ectopies From Least Severe To Most Severe Frequent Single Focus PVC’s Runs Of PVC’s Quadrigeminy Trigeminy Bigeminy Appearance Of Multifocal PVC’s RT On T Phenomenon Ventricular Tachycardia Ventricular Fibrillation RT On T Phenomenon Thought To Be Very Dangerous A PVC Occurs During Ventricular Depolarization RT On T Phenomenon Why Is It Dangerous ? • The Cardiac Cells Are Various Stages Of Depolarization - Some Have Repolarized While Others Are In Various Stages Of Repolarization • A Stimulus That Occurs Before Repolarization Is Finished Will Set Off A Disorganized Electrical Response To The Stimulus & May Set The Heart Up For A Malignant Ventricular Ectopy Like V-Tach Or V-Fib. Exercise Can I Exercise A Patient Who Is Having PVC’s ? Yes, You Can Exercise A Patient Having PVC’s. However, They Should Only Be Occasional Single Focus Single PVC’s. If The Exercise Regimen Makes The Incidence Of PVC’s Occur More Often Or If The PVC’s Become More Malignant, Exercise Should Be Terminated. A Person Should Not be Exercised When They Are Displaying Multiforme PVC’s Or Any PVC Rhythm (Bigeminy, etc.) Until Cleared By Their Cardiologist The ACSM Guidelines The ACSM Guidelines State : If There Is A “Noticeable Change In Heart Rhythm”…. ...or “Signs Of Poor Perfusion: Light Headedness, Confusion, Ataxia, Pallor, Cyanosis, Nausea, Or Cold & Clammy Skin” Then STOP THE EXERCISE !!! Table 3-10, pp 42, 5th edition Ventricular Tachycardia Ventricular Tachycardia Is Defined As A Run Of Three Or More Consecutive PVC’s The Rate Is Usually Between 100-200 BPM Short Runs Of V-Tach Will Make The Patient Feel : Dizzy Have Palpitations Feel Faint Be Short Of Breath Sustained Runs OF V-Tach Will Render The Patient Unconscious Because The Cardiac Output Is So Negatively Effected As To Decrease Perfusion To The Brain & The Heart. Ventricular Tachycardia Ventricular Tachycardia Will Degenerate Quickly Into Ventricular Fibrillation The Patient In V-Tach Must Be Supported With CPR Methods & Must Be Cardioverted Electrically Or Pharmacologically Out Of This Fatal Rhythm Both V-Tach & V-Fib Are Absolute Medical Emergencies Requiring High Level Medical Management Ventricular Fibrillation V-Fib Is Seen In Hearts That Are Dying Electrical Activity is Completely Chaotic No Meaningful Cardiac Output Is Occurring V-Fib Is Characterized By : No True QRS Complexes A Wandering Or Undulating Baseline No Recognizable Atrial Wave Forms No Recognizable T Waves The Patient Must Be Supported By CPR Methods & Must Be Electrically Cardioverted Out Of This Rhythm Or Death Ensues Ventricular Fibrillation Exercise Exercise Cannot be Sustained In Patients With V-Tach Or V-Fib Because 99.99 % Of The Time They Will Be Unconscious Exercise Is Never An Option Atrioventricular Blocks First Degree AV Blocks Second Degree AV Blocks • Mobitz Type I (Wenckebach Block) • Mobitz Type II Third Degree AV Blocks First Degree AV Blocks Characterized By : • Prolonged PR Interval > 5 mm • Every QRS Is Preceded By A P Wave • Every QRS Is Normal • No Dropped Beats First Degree AV Block First Degree AV Block Causes : Drug Toxicity Ischemic Heart Disease Of The Heart’s Conduction System Myocarditis First Degree AV Block Does Appear In Healthy Individuals As Well As In Those With Ischemic Heart Disease Exercise Can I Exercise A Patient In First Degree AV Block ? Yes, But The Rhythm Must Not Degenerate During Exercise To Second Degree AV Block. Also, The Rhythm Had To Have Been Present Before Exercise Started. If A Patient Is Normal On Their EKG Before Exercise & Degenerates Into First Degree AV Block, Exercise Must Stop !! First Degree AV Block Is Generally Not Considered To Be A Highly Malignant Dysrhythmia Second Degree AV Block Mobitz Type I Or A Wenckebach Block Second Degree AV Block Or A Mobitz Type I AV Block Is Characterized By : • • • • Progressively Lengthening PR Interval A Sudden Dropped QRS Complex Return Of A Normal Rhythm A Repeating Cycle Mobitz Type I Exercise Can I Exercise A Patient In A Mobitz Type I Second Degree AV Block ? Yes, Providing The Dysrhythmia Does Not Degenerate During Exercise. The Patient Must Also Have Been Cleared For Exercise A Problem Does Exist With A Mobitz Type I AV Block !! You Have To Be Concerned That It Will Degenerate Into A Mobitz Type II AV Block Second Degree AV Block Mobitz Type II Characteristics Are : A Series Of Normal Beats All PR Intervals Are Normal Duration Sudden Dropped Beat - No QRS Normal Rhythm Re-Established Cycle Begins Again Mobitz Type II Mobitz Type II Mobitz Type II AV Block Is A Dangerous Dysrhythmia Because Of The High Likelihood That It Will Convert To A Third Degree AV Block. Exercise Can I Exercise A Patient In A Mobitz Type II AV Block ? No. The Risk Is Too High That The Patient Will Convert To Third Degree AV Block. A Patient With A Mobitz Type II AV Block Is Going Eventually Convert To A Third Degree Block & Is A Candidate For A Surgically Implanted Pacemaker Third Degree AV Block This Is A Serious Condition In Which There Is No Communication Of The SA Node With The AV Node. It Is Also Called Complete Heart Block. The Atria Beat At Their Own Rate While The Ventricles Beat At Their Own Rate The P Waves Appear & Are Not Connected To Any QRS Complex The QRS Are Abherrantly Wide Ultimate Ventricular Rate Is Often Very Bradycardic 3rd Degree AV Block Most Patients In Third Degree AV Block Require The Implantation Of A Pacemaker. Bundle Branch Blocks Right Bundle Branch Block RSR’ (Bunny Ears) In V1-V4 Loss Of The R Wave Progression ST Segment Depression In V1 - V4 T Wave Inversion In V1 - V4 Wide QRS Complexes Can you exercise a patient in RBBB ? Yes as long as they have been cleared by their physician. Left Bundle Branch Block Loss of the R wave progression Huge S waves in V1 - V4 RSR’ in V4 - V6 Wide QRS complexes ST segment depression in V4 - V6 T Wave inversion in V4 - V6 Can you exercise a person in LBBB ? Yes, as long as the patient has been cleared by their physician.
