..............................................................

Arrhythmias
2009

palpitation

Arrhythmias

arrhythmias
cardic neurosis

volume load

palpitation

palpitation
Palpitation

cardic neurosis

volume load

arrhythmia
90

palpitation
60

heart rate

High normal

100

tachycardia
bradycardia
peace maker of the heart
atrial

90

100
60

S.A.Node

A.V.block

A.V.Node
arrhythmias

atrial fibrillation

atrial tachycardia
atrial flutter

to protect the ventricles

A.V. block

digitalis
basic
No retrograde conduction

 ..............................................................
focus
focus

atrium

focus

focus in atrium

ventricle
atrium

atrium

S.A. node

focus

focus

ventricle
ventricle

atrium

focus in ventricle

focus in ventricle
Impulses

ventricle

ventricular tachycardia

focus

arrhythmias
ventricle

S.A. node

atrium

focus

focus

atrium

focus

ventricle

ventricle

S.A. node

atrium

atrio-ventricular dissociation
no retrograde conduction

Respiratory sinus arrhythmia

peace maker

S.A. node

Normal persons

reflex tachycardia
Peace maker of the heart
vagal stimulation

Inspiration
S.A. node

carotid massage

ventricles

Normal

atrium

Inhibitory

atrium

focus

suppression

carotid sinus massage

ventricles

suppression
focus

vagus

focus

carotid sinus massage

tachycardia
ventricles

atrium

carotid massage
atrium

focus

arrhythmia

abortion

carotid massage
Canon wave

atrio-ventricular dissociation
example

 ..............................................................
complete heart block
idio ventricular

ventricle

S.A. node

atrium

complete heart block

rhythm

harmony
contraction at the same time
right side
right atrium

right ventricle

valve
tricuspid valve

closure

ventricle

contraction
right atrium

sudden rise

right ventricle
tricuspid valve closed

right atrium pressure

neck vein
canon wave
sterno mastoid muscle

atrio ventricular dissociation

complete heart block
atrio ventricular dissociation

atrial

bradycardia

block

ventricular tachycardia
tachycardia

A.V. node
tachycardia
heart
atrium

focus

atrium

focus

ventricle
Inhibitory

atrium

focus

ventricle

focus

carotid sinus massage

ventricle

complete

atrio ventricular dissociation

canon wave

ventricular tachycardia

heart block

arrhythmia
written
etiology

etiology

Pathophysiology
functional, pathological and drugs

 ..............................................................

heart rate

functional

thyrotoxicosis
Heart
Physiology
functional disturbance

Pregnancy

Organic lesion

functional

thyrotoxicosis

heart

Physiological

Pathology

thyrotoxicosis

bradycardia
Obstructive jaundice

functional

Obstructive jaundice
bradycardia

jaundice

Verapamil

Heart rate

Ca channel blocker

exertion

bile salts

heart

Beta blocker

Hypo thyrodism

Heart

heart rate
diltazem

drugs

Beta blocker

tachycardia

Nefidipine

tachycardia

hydralazine
Nefidipine

small dose Beta blocker

Ischaemic heart
tachycardia
Nefidipine
Nefidipine

Beta blocker
tachycardia
ischaemic

palpitation

symptoms

Heart rate

low cardic output

filling

Heart rate
cardic output

palpitation

Palpitation
palpitation

 ..............................................................

hypotension

syncope
cardiovascular system
at rest

syncope

arrhythmia
rheumatic

blood

regular

Pulse

cause

heart
pressure

hypotensive
carotid sinus massage
focus

focus

arrhythmia

abort

carotid massage
atrium

respiratory sinus arrhythmia

S.A. node

Peace maker of the heart

respiratory sinus arrhythmia

monitor
canon wave
occasional
neck vein

complete heart block

occasional

atrio ventricular dissociation

ventricular tachycardia
Heart
tachycardia

Local examination
first sound

gallop

Murmur

Canon wave
right side

ventricle

canon sound

ventricle
wave

canon sound

atrium
atrium

3rd or 4th

contraction

contraction

canon sound

exception

sounds
investigations
arrhythmia

Organic

arrhythmia
brain

epilepsy

Investigations

 ..............................................................

renal

neurological

epilepsy

for example

normal
ECHO
attack

ECG

Holter

ECG

Holter
ECHO

48
arrhythmia

lab investigations
TSH

T3 and T4

Free T4 , free T3 and free TSH

serum K, Mg

hemoglobin

investigations
Extra systole

extra systole

Mg

Hypo magnesemia
hypo magenesmia

lasix

Lasix

hypo

Lasix
hypo magenesemia

frusamide

Mg

 ..............................................................

lasix

side effect
every other day

Urine

K sparing

aldactone

trace elements

arrhythmia
DC shock

Paroxysmal

Heart sinus

arrhythmia
Intravenous
In between attack

maintenance therapy from the start

non paroxysmal

arrhythmia

sinus Tachycardia
sinus tachycardia
S.A. node
100

normal

focus

discharge
etiology

fever

stress , anemia, thyrotoxicosis

functional
sinus tachycardia

Heart failure

reflex tachycardia

small dose Beta blocker

pathological

digitalis

Heart failure
normal

digitalized

heart rate
heart rate

 ..............................................................
Nefidipine

vasodilator

sinus tachycardia
Beta blocker

Hydralzine
thyroxin

thyroxin replacement

thyroxin
replacement therapy

thyroxin

serotonin reuptake inhibitor

B2 agonist
tachycardia

bronchial asthma

COPD

sympathomimetics

symptoms
palpitation
gradual

onset

rapid regular , exertional

tachycardia
tachycardia

150

160

sinus

100
150

tachycardia

sinus tachycardia
low cardic output
chest pain
tachycardia

sometimes

tachycardia
syncope

sinus tachycardia itself

chest pain

tachycardia

coronary filling
sinus tachycardia
tachycardia

 ..............................................................
coronary filling

heart rate
chest pain

Palpitation

palpitation
coronary filling
regular

decline

Heart rate
160
effective

150

carotid sinus massage

respiratory sinus arrhythmia
Canon wave

first sound
tachycardia

first sound

apex

left side

S3 gallop

gallop
failure

manifestations

reflex tachycardia

heart failure

sinus tachycardia
thyrotoxic

anemic

ECG
T3 and T4

heart organic

ECHO
ejection fraction
Heart

anxiety

reflex tachycardia

ECHO

 ..............................................................

120
Beta blocker
contraindication
2.5

100
stable

heart rate

2.5

dose

Heart rate

thyroxin

anti depressant

paroxysmal atrial tachycardia

written
atrium

focus

suddenly
up to 200

focus
atrium

S.A. node

focus

focus
S.A. node

focus

Heart
focus

S.A. node

Heart

focus
net result

 ..............................................................
paroxysmal attack of tachycardia
regular

rapid
Heart rate

hypotension

200 170

atrium

focus

160
low cardic output
ventricle

ventricle

atrium
Canon wave

effective

carotid sinus massage

etiology

sympathomimetics

Heart

Pathological
symptoms

sudden offset

sudden onset

exertion
attack

Normal

In between

Low cardic output

sudden onset
sudden onset , sudden offset

filling of the heart

attack
atrial natriuretic peptide

excessive excretion

Poly urea
Poly urea

tachycardia
cardic output

tachycardia
filling
cardic output

kidney

cardic output

tachycardic

diuresis

perfusion
diuresis
atrial nat riuretic peptide
anginal pain

 ..............................................................
palpitation
Palpitation

attack of paroxysmal atrial tachycardia

coronary filling

decline

palpitation
chest pain
chest pain

anginal pain

chest pain
palpitation

Palpitation

chest pain
coronary insufficiency
signs
Pulse
pulse
focus
atrium

peace maker of the heart

focus

respiratory sinus arrhythmia

S.A. node
carotid sinus massage

first sound
Mitral

cause
Investigations
ECG
Holter

in between attack

ECHO

Organic
TSH

carotid sinus massage

successful

Investigations

T3 and T4

vagal stimulation

massage

during the attack

50%

successful

Verapamil

drug of choice

Verapamil intravenous
very slowly

saline infusion

verapamil
monitoring

Hypotension

intravenous

verapamil

 ..............................................................

Ca

verapamil

calcium gloconate

antidote
channel

contractility

anti arrhythmic

Verapamil
ejection fraction

verapamil

Heart

DC shock
direct current
contraction

atrium

focus

DC shock
abort
blood pressure

verapamil

In failure

shocked

during attack
digitalis intravenous

abort

DC shock

focus

digitalis intravenous
A.V. block
Verapamil

drug of choice

Hypotension
negative

Verapamil

DC shock

Intravenous
adenosine

inotropic

Verapamil
DC

Adenosine

Heart failure

Hypotension
shock

Adenosine
DC shock

DC shock

Verapamil

verapamil
In between attack

Beta blocker

stress

digitalis

sympathetic
attack
Beta blocker
beta blocker

in between
thyrotoxicosis

 ..............................................................
verapamil

tachycardia

stress

situation

Beta blocker

Beta blocker

catecholamine mediators

contraindicated

Beta blocker

junctional or A.V. nodal tachycardia

peace maker

A.V. node

Paroxysmal atrial tachycardia

the same

peace maker
ventricle
ventricle

A.V. node

atrium

atrium

A.V. node

stimulate

impulse

atrium and ventricular contraction at the same time

paroxysmal

attack
paroxysmal

ventricle

atrium

attack

regular Canon

Canon wave
Canon

paroxysmal atrial tachycardia

in attacks

paroxysmal atrial tachycardia

in attacks

focus

ventricle

Canon wave

Paroxysmal ventricular tachycardia

Paroxysmal ventricular tachycardia

occasionally

S.A. node

atrium

occasionally
occasionally

ventricles

atrium

Canon wave

stimulate

Impulse

peace maker

A.V. node

Regular canon wave

nodal rhythm

character

regular canon
nodal tachycardia

ECG

ECG finding

 ..............................................................
paroxysmal ventricular tachycardia
Organic heart disease
functional

ventricular tachycardia
Organic

ventricular tachycardia
Ventricle
200

focus

focus
focus

attack

ventricle

focus

ventricle

focus
No retrograde conduction

ventricle
focus

atrium

focus

ventricle

attack

S.A. node
attack

atrium

atrio ventricular dissociation

Occasional
focus

Ventricle

Canon

Canon wave

S.A. node

atrium
etiology

ischaemic heart disease

rheumatic heart
Organic heart disease

structure heart disease

Myocardial infraction

arrhythmia
ventricular fibrillation

digitalis toxicity
digitalis toxicity
tricyclic

anti cholinergic drugs

abuse
abuse of anti cholinergic drugs

ventricular tachycardia

abuse

antidepressant
symptoms

sudden onset , sudden offset , rapid , regular

palpitation
Heart rate

Low cardic out put

cause
ventricular tachycardia

 ..............................................................
ventricular fibrillation

cardic out put

180-200
Hypotensive
carotid massage
atrium

focus

respiratory sinus arrhythmia

occasional Canon wave
occasional Canon sound

Neck veins

occasional Canon wave

ECG
arrhythmia

electrolyte

thyroid function

DC shock

ECHO

ECG

during the attack

Lignocaine
In between attack

dangerous

ventricular tachycardia
ventricular fibrillation
Amiodarone

defibrillator

Defibrillator
heart

cardioverter
Peace maker

peace maker

ventricular tachycardia

attack of arrhythmia

defibrillator
DC shock

Peace maker

arrhythmia

sensor

Atrial flutter
flutter

flutter

atiral flutter
atrium

contraction

atrium

fibrillation

 ..............................................................
In between
focus
200
atrium

focus
400

350

flutter

Paroxysmal atrial tachycardia

300

focus

atrium
A.V.

flutter

300

atrial flutter

focus
atrium

focus
block

chronic
200-180

arrhythmia

pulse

200

well developed
focus

A.V. block

Paroxysmal atrial tachycardia

A.V.node
A.V. block

heart

paroxysmal A.F

A.F.

A.V. block
rate

building up

A.V. block

Paroxysmal tachycardia

flutter

paroxysmal atrial tachycardia

heart rate

paroxysmal atrial tachycardia

rules
carotid massage

atrial fibrillation

sinus
ECG
A.V. block

A.V. block

A.V. block
focus

atrial fibrillation

atrial fibrillation

sinus

very cautious

atrial fibrillation must be anti coagulated

 ..............................................................
arrhythmia
arrhythmia
anti coagulant

A.F.

signs
focus
effective

carotid massage

Low cardic out put

heart rate
canon

paroxysmal atrial tachy cardia

300

flutter

200

focus

DC shock
verapamil
heart

rule

DC shock

verapamil
DC shock
atrial fibrillation
written

impulses
atrium

foci

400

Impulses
A.F.

ventricles

400

paroxysmal

200
A.F.

atrium

Mitral valve disease

mitral stenosis

atrial fibrillation

trigger

dilation

stretch

chronic
heart dilation

chronic
organic

ventricular response
180

200

400

A.F.

 ..............................................................
A.V. block
digitalis

A.F.

tachycardia

A.V. block

slow A.F.

A.F.

A.V. block

digitalis
60
fibrillation

60

radial pulse

apical pulse

atrial fibrillation
digitalis toxicity
slow A.F.

A.F.

A.F.
A.F.

congenital heart , rheumatic heart and ischaemic heart

A.F.
tachycardia
Heart
cardic out put

Load

filling of the heart

A.F.
tachycardia
tachycardia

Loss of atrial contraction

ventricles

filling

Low cardic out put

atrial contraction

filling

tachycardia

25

A.F.

atrial contraction
A.F.

low cardic out put

ventricles

filling

A.F.
Low cardic out put

A.F.
A.F.
atrium

stagnation of blood
Mitral stenosis

A.F.

 ..............................................................
left atrial pressure
Pulmonary venous congestion
right atrium

left atrium

contraction
pulmonary venous congestion

elevate

A.F.
habituation

A.F.

atrial pressure
Mitral stenosis

pulmonary venous congestion

atrial dilated

Low cardic out put

intra cardic thrombosis

atrium

fibrillation

Mitral valve disease

thrombo embolism

systemic embolisation

A.F.

Pulmonary embolism
right atrium dilated
Pulmonary hyper

dilated

A.F.

left atrium

left atrium

mitral stenosis
tension

dilated
right atrium

right sided of the heart

left atrium

A.F. on top
pulmonary embolism

right atrium

systemic embolisation

left atrium

anti coagulated
anti coagulant

fibrillation
A.F.

Personality
A.F.
anti coagulant
concept

 ..............................................................

serotonin reuptake inhibitor

very aggressive

Personality

C.T. scan
A.F.
Neurological

changes in neurotransmitter
organic
dementia

dementia

Organic
behavior
aggressive

multiple brain infraction

brain

MRI
source of embolism

anti depressant

hemiplegia

embolism
emboli
brain

recurrent stroke

dementia

dementia

dementia

stroke
weakness

anti coagulant

fibrillation

etiology

 ..............................................................
congenital

mitral valve disease

atrium

rheumatic heart disease

dilatation
systemic hypertension

high

Left ventricle

hypertrophy

dilated

systemic hypertension

left atrium

Left ventricle

pressure

constrictive pericarditis
constrictive preicarditis
ventricle

catching effect

constrictive percarditis

dilatation

dilate

diastole

ventricle

ventricle
pressure

dilatation

atrium

thyrotoxicosis

Infective endocarditis
thyrocardia

thyrocardia

thyrotoxicosis

thryotoxicosis

Manifestations
thyrotoxicosis

thyrocardia

Palpitation
irregular at rest
radial pulse

apical pulse

comment

radial pulse

apical
pulse deficit

Pulse deficit
Pulse deficit

digitalized

Multiple foci

carotid sinus massage

foci
respiratory sinus arrhythmia
canon wave
neck vein
Loss of A wave

apex
cause

local examination

mitral valve disease

Investigations

 ..............................................................
TSH

T3 and T4

ECHO

ECG

A.F.
paroxysmal
paroxysmal
terminated

Persistent
DC
permanent

chronic

i.e. sinus rhythm can not be restored

chronic A.F.
ischaemic

hypertensive
A.F.

paroxysmal
paroxysmal A.F.
A.F.
paroxysmal
normal person
normal

Normal heart

Paroxysmal A.F.
Normal

No need for treatment

in between attack

Beta blocker

stress
stress

very common mistake

A.F.
TSH

T3 and T4

Persistent A.F.
Persistent

A.F.
Persistent
Paroxysmal
DC shock

 ..............................................................

persistent
A.F.
atrium
Atrium

A.F.

atrium

atrium

atrium

sinus rhythm

shower

thrombus

DC shock
palpitation

embolisation
3

A.F.

sinus rhythm
anti coagulated

12

dose

A.F.
DC shock

say

adjustment
Oral anti coagulant

cardiology

atrium

Palpitation

shift

PPT

A.F.
A.F.
centre
A.F.

INR
INR

Prothrombin time

oral anti coagulant

anti coagulant
Oral anti coagulant

Prothrombin time

mortality
chronic
ventricle

Permanent

A.V. block
anti coagulant

anti coagulant

 ..............................................................
oral warfarin

shift

Extra systole
very common
drugs

extra systole

functional

etiology

digitalis toxicity
extra systole
occasional

occasional palpitation

palpitation

Palpitation
irregularity

atrial

pulse deficit

A.F.
fibrillation
canon

carotid massage
ECG
No need for treatment
extra systole

beta blocker

extra systole
Irritable

Beta blocker
dangerous

frequent

no need

extra systole

ventricular , multifocal

dangerous extra systole

ventricular tachycardia
extra systole
Amiodarone
Amiodarone
in between attacks
focus

multifocal

ventricular tachycardia
dangerous

extra systole

Amiodarone

 ..............................................................

sinus bradycardia
sinus bradycadia
heart block

hypo thyroidism

bile salts
Increase tension
problem solving

Increase tension

brain tumor

subarachonid haemorrhage
increase tension

60

Increase tension
60

extrasystole

Parkinsonism
extra systole
Increase tension
straight

sub arachonoid

brain tumor

Under graduates
Increased tension
reflex bradycardia

cushing reflex

reflex systolic hypertension

haemorrhage
reflex

 ..............................................................
sub arachonoid
sub arachonoid haemorrhage
ECG

diffuse T wave inversion

Inverted

T wave

ECG

heart
sub arachonoid
sudden sever headache

sub arachonoid

sub arachonoid

T wave

regular

60

carotid sinus massage

bradycardia

investigations

safe
females

effective

100/70
sympathetic

stenosis

Heart lesion
ECHO

renal insfficiency
hyper nateremia

Blood sugar

CBC
Hypo glycemia
cortisone level

idiopathic

hypo tension

females
females

 ..............................................................
un human
as
you like

test

test

sickness

females

Fludrocortisone
aldosterone analongue
salt retention
midoprine

sympathomimetics

 ..............................................................

syncope fainting

very easy

occasional

Hypo tension

sinus bradycardia
sympathomimetics

safe
B2 agonist

Peace maker

safe
heart block
arrhythmia

A.V. block

heart block
A.V. block

first degree heart block

Prolonged PR interval
fixed
complex
complex

prolonged

PR interval

PR interval

PR interval

PR interval

PR interval
Maximum

asymptomatic
beta blocker

first degree heart block

first degree heart block

digitalis

second degree heart block

PR
60 ventricle

atrium

80

Heart block
Impulses

 ..............................................................

Clinical pictures
asymptomatic
80

atrium
60

!!!
Adam's stock attack
Adam's stock attack
imuplses

impulse

ECG
Impusles
impulses

ventricles

atrium
atrium

Impulses

Impulses
ventricle

atrium

atrium

Impulse
impulse
Impulse

atrium
atrium

ECG

impulses
asysotle

cardio vascular system

impulses
impulse

focus
atrium

 ..............................................................
complete heart block

syncope
idio ventricular rhythm

Adam's stock attack

Adam stock attack
Option

peace maker

Peace maker

peace maker

peace maker

peace maker

complete heart block

ventricle

atrium

Impulse

S.A. node

atrium

idio ventricular rhythm

ventricle

Idio ventricular rhythm

Heart rate

brady

regular

bradycardia

regular

ventricle
slow

pulse rate

cardia
diastole

stroke volume

diastolic time

systolic hypertension
systolic hyper tension
aortic regurge
systolic pressure
thyrotoxicosis

cardic out put

aortic regurge

thyrotoxicosis

cardic out put

complete heart block
atherosclerosis

ECG

complete heart block

peace maker

 ..............................................................

Wolff Parkinson white

MCQ
ventricle

atrium

Wolff Parkinson white

A.V. node
accessory pathway
impulses

A.V. node

A.V. node

accessory pathway

ventricle

accessory pathway

atrium

atrium

Impulses

Impulses

episode
tachycardia

atrial fibrillation

tachycardia
atrial fibrillation

accessory pathway

atrium

impulses

A.F.

accessory pathway
impulses

A.V. node

Beta blocker

digitalis
accessory pathway

Amiodarone

accessory pathway

arrhythmia

impulses

Amiodarone

attack

ventricular tachycardia in between attack

ventricular tachycardia

dangerous extra systole

Wolff Parkinson white syndrome

ablation

ablation

Wolff

pathway

Sick sinus syndrome

under graduates

sick sinus syndrome

I know

S.A. node

disease

sick sinus syndrome

S.A. node

sick
ischaemia
paroxysmal . hint

S.A. node

sick sinus
degenerative changes

attack of sinus bradycardia

 ..............................................................
atrial tachy cardia

tachycardia
Hint

hint

Paroxysmal A.F.

S.A. node

sinus arrest

syncope

cardic syncope
clinical pictures
A.F.

Peace maker
impulse

complete heart block

S.A. node

peace maker

conductive system

Impulses
ventricle

cardiology

peace maker

atrium

implanted

Post

peace maker

options

peace maker
Peace

cardiology

ventricle

atrium

Peace maker
maker

wall

atrium

peace maker
system

wall

wall
A.V bundle

heart

Peace maker

ventricle

atrium
heart

atrium

atrium

ventricle

peace maker

peace maker

A.V.node

impulses

Heart

muslce fibers

anti arrhythmic
sick sinus syndrome
tachycardia bradycardia syndrome
bradycardia

tachycardia
sick sinus syndrome
peace maker
sick sinus syndrome
anti arrhythmic

atrium arrhythmia

Ca channel blocker

atrium tachycardia

Paroxysmal atrial tachycardia

drug of choice

 ..............................................................
lignocaine
attack

ventricular tachycardia
convulsion
phenytoin

di phenyl hydantoinate
digitalis

anti epileptic

ventricular tachycardia

anti arrhythmia

anti epileptic
induced
Beta blocker

stress related

arrhythmia

anti arrhythmia

thyrotoxicosis related

arrhythmia

Quinidine
A.F.
atrial foci

inhibitory

A.F.

A.V. conduction

A.F.

enhance
atropine like action
atrial foci

enhance A.V. conduction

You must

Quinindine

suppression
A.V. node

A.V. conduction
digitalize

A.F.
Quindine

Quinidine

A.V. block

digitalis

sinus rhythm
sinus rhythm
A.F.

chronic

atrium dilated

Heart dilated

Long duration

Amiodarone
K channel
dangerous extra
In between

Na channel

Ca channel

broad spectrum atni arrhythmic

ventricular tachycardia

systole

 ..............................................................
Indication
thyroid dysfunction

side effects
Hypo thyroidism

hypo

attack

commonly

Mainly

hyper thyroidism

Amiodarone
thyroidism

Interstitial lung disease

corneal deposit
Adenosine
IV

atrial tachycardia

atrial tachycardia

DC shock

Heart

paroxysmal atrial

drug of choice
verapamil

adenosine

Verapamil

Adenosine
Heart

tachycardia

negative inotropic
A.V. Block

adenosine

Foci

A.V. block

Paroxysmal atrial tachycardia

A.V. block

atrium

foci

suppression

Verapamil
ventricle
ventricular

excitatory
digitalis

atrium

excitatory

digitalis

ventricular extra systole

tachycardia

atrial tachycardia
ventricular arrhythmia

atrial arrhythmia

atrial extra systole

arrhythmogenic

A.V block
foci

atrium

digitalis

anti arrhythmic

tachycardia

digitalis
A.V. block
adenosine

A.V. block

foci

successful carotid sinus massage

adenosine

Mainly
foci

inhibitory
atrial foci

adenosine
carotid massage

carotid massage
suppression

carotid massage

 ..............................................................
A.V. block
Mainly A.V. block
2009

arrhythmia

adenosine