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Phase 2
Michelle Mair
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Aims
Arrhythmias:
-
Atrial fibrillation
Atrial flutter
Heart block
Sinus tachycardia
SVTs
Ventricular ectopics
Prolonged QT syndrome
Aberrant pathways
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ECGs
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1) Heart Rate
2) Heart Rhythm
3) Cardiac axis
4) P waves
5)P-R interval
6) QRS complex
7) ST segment
8) T waves
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Cardiac axis
Normal Axis
Positive
AVR
AVL
I
Positive
Positive
III
II
AVF
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Cardiac axis
Right Axis Deviation
Negative
AVR
AVL
I
Positive
Positive
III
II
AVF
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Cardiac axis
Left Axis Deviation
Positive
AVR
AVL
I
Negative
Negative
III
II
AVF
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Atrial Fibrillation
• Irregularly irregular rhythm
• Varying rate
• Absent p waves
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Atrial Fibrillation
Types:
1. Paroxysmal= spontaneous termination within 7 days, most commonly
in 48 hours
2. Persistent= not self-limiting, lasting longer than 7 days or prior to
cardioversion
3. Permanent= long standing (over 1 year) not terminated by
cardioversion
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Atrial Fibrillation
Causes:
• Hypertension
• Coronary artery disease
• Valve disease (especially mitral valve)
• Hyperthyroidism
• Infection
• Idiopathic
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Atrial Fibrillation
Presentation:
• Asymptomatic
• Palpitations
• Breathlessness/dyspnoea
• Dizziness/syncope
• Chest discomfort
• Stroke/TIA
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Atrial Fibrillation
Investigations:
• ECG
• Bloods: FBC, TFTs, LFTs, U&Es (coagulation screen)
• CXR
• Echo
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Atrial Fibrillation
Complications:
• Stroke/ TIA – increased six-fold
• Heart failure
• Cardiomyopathy
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Atrial Fibrillation
Management:
1) Rate control- beta-blockers or rate-limiting sodium channel blocker e.g.
Verapamil
2) Rhythm control- pharmacological or electrical cardioversion
- left atrial ablation
- pace and ablate strategy
3) Thromboprophylaxis- use CHA2DS2-VASc score
- warfarin therapy
- apixiban, dibigitran, rivaroxiban
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Atrial Flutter
• ‘saw tooth’ pattern
• Atrial rates of 240-340
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Atrial Flutter
Causes:
• Coronary heart disease
• Atrial dilatation
• Open heart surgery
• Hypertension
• COPD
• Obesity
• Thyrotoxicosis
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Atrial Flutter
Presentation:
• Asymptomatic
• Palpitations
• Fatigue
• Dyspnoea
• Syncope
• Heart failure
• TIA
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Atrial Flutter
Investigations:
• ECG
• CXR
• TFTs, FBC, ESR, U&Es, LFTs, clotting
• Echo
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Atrial Flutter
Management:
• Catheter radiofrequency ablation
• Electrical/Pharmacological cardioversion
• Anti-coagulants
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Heart Block
Types:
1) First degree = prolonged P-R interval [>200ms]
Mobitz I (Wenckebach) = gradual
progressive P-R prolongation before a QRS
complex is dropped
2) Second degree
Mobitz II = same P-R interval followed
by absent QRS complex
3) Third degree = both present but no association between P wave and
QRS complex
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Heart Block
First degree
a)
c)
Mobitz I
Mobitz II
b)
d)
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Third degree
Heart Block
a)
b)
Third degree
Mobitz II
d)
c)
Mobitz I
First degree
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Heart Block
Causes:
First degree:
-
Athletes
Myocarditis
Hypokalaemia
Hypomagnesaemia
Medications
Second degree:
- Athletes
- Post MI
- Lyme disease
- Medications
Third degree:
- Complication of heart
surgery
- Coronary heart
disease
- Radiotherapy
- Infection
- Hypertension
- Medications
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Heart Block
Symptoms
First degree:
- asymptomatic
Mobitz I:
- light-headedness
- dizziness
- syncope
Mobitz II:
- chest pain
- shortness of breath
- tiring on exertion
- postural hypotension
Third degree:
- light-headedness
- dizziness
- fainting
- fatigue (extreme tiredness)
- chest pain
- slow heart beat (bradycardia)
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Heart Block
Management:
• Transcutaneous pacing
• Pacemaker
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Supraventricular Tachycardia
Supraventricular = above the ventricle
• SA node overridden and another part of the heart triggers faster
impulses
The heart rate must be FAST and REGULAR
Types:
• Atrio-ventricular nodal re-entry tachycardia
• Atrial tachycardia
• Wolff-Parkinson White syndrome
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SVT
Atrio-ventricular nodal re-entry tachycardia
• Most common
• Seen in people aged 20-30
• Electrical short circuit in centre of the heart
• Usually no underlying cause
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SVT
Atrial tachycardia
• Arises from anywhere in the atria
• Usually no underlying cause
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SVT
Wolff-Parkinson White syndrome
• Accessory pathway between atria and ventricles
• Congenital abnormality
• May get palpitations, severe dizziness or syncope
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SVT
Presentation:
• Tachycardia
• Palpitations
• Dizziness
• Breathlessness
• Chest discomfort
• Asymptomatic
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SVT
Management:
• Self-resolving
• Adenosine
• Long term digoxin, beta-blocker, verapamil
• Catheter ablation
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Sinus Tachycardia
Normal heart rate: 60-100bpm
Causes:
•
•
•
•
•
•
•
•
•
•
•
•
Pain
Exercise
Fever
Anxiety
Dehydration
Anaemia
Sepsis
Heart failure
Hyperthyroidism
MI
PE
Stimulant use
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Sinus Tachycardia
Treatment:
• Treat underlying cause
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Questions
A 51 year old gentleman is complaining of palpitations. He is a smoker
and you find his blood pressure is 145/92. He has an underactive thyroid
for which he take Levothyroxine. His ECG shows an irregularly irregular
rhythm.
Name this condition
………………………………………
What his main risk factor for developing this?
………………………………………….
What is the first line treatment of this condition?
………………………………………….
Give the class of drug suitable for this
…………………………………………
Give a complication of this condition?
..........................................................
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Questions
A man comes into hospital looking very unwell. His vital signs are:
-Temp :39.5
- SpO2 : 95% on air
- BP: 110/65
- HR: 135bpm
He is found to have a pneumonia causing sepsis
List 4 other cause of sinus tachycardia
………………………………………………..
………………………………………………...
………………………………………………..
……………………………………………….
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Questions
You are asked to review a ECG of a lady admitted to your ward. You
notice that the P-R interval is irregular and that after every now and then
there is an absent QRS complex
You diagnose heart block
Which type of heart block does she have?
…………………………………………………………
Give 2 symptoms that she might be experiencing
………………………………………………………….
What treatment does she require?
………………………………………………………….
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