Arrhythmias

introduction
Domina Petric, MD
Arrhythmias are
 common
 often benign
 often intermittent causing
diagnostic difficulty
 occasionally severe causing
cardiac compromise
Causes
Cardiac Non cardiac
 myocardial infarction  caffeine
 coronary artery disease  smoking
 left ventricle aneurysm  alcohol
 mitral valve disease  pneumonia
 cardiomyopathy  drugs
 pericarditis  metabolic imbalance
 myocarditis
 phaeochromocytoma
 abberant conduction
pathways
Non cardiac causes
 Drugs that can cause arrhythmias
are β2-agonists, digoxin, L-dopa,
tricyclics, doxorubicin.
 Metabolic imbalance: K+, Ca2+ , Mg2+
, hypoxia, hypercapnia, metabolic
acidosis and thyroid disease.
Symptoms
 palpitation
 chest pain
 presyncope, syncope
 hypotension
 pulmonary oedema
 asymptomatic
History


Past medical history and family history!
Precipitating factors!
O
 Associated symptoms: chest pain, dyspnoea, collapse.
 Nature: fast or slow, regular or irregular.
 Duration!
 Drug history!
 Onset/offset!
Tests
 Fullblood count!
 Urea, electrolytes and
creatinine!
 Glucose!
 Calcium and magnesium ions!
 TSH!
Tests
 ECG
 24 hours ECG monitoring
 Echocardiography
 Excercise ECG
 Cardiac catheterization
 Electrophysiological studies
Part two

TREATMENT OVERVIEW OF
MOST COMMON
ARRHYTHMIAS
Bradycardia

If asymptomatic and rate >40 bpm,

treatment is not necessary.

If heart rate is less than 40 bpm or patient

is symptomatic, treatment is ATROPINE
0,6-1,2 mg iv. (up to maximum 3 mg).
 Bradycardia

 Temporary pacing wire

 Isoprenaline infusion
 External cardiac pacing

Image source: Wikipaedia.org

Sick sinus syndrome
Sinus node dysfunction can cause:
 bradycardia
 arrest
 sinoatrial block
 supraventricular tachycardia alternating
with bradycardia/asystole (tachy-brady
syndrome)
Sick sinus syndrome
Atrial fibrillation and
thromboembolism may also
occur.

If the patient is symptomatic,

pacing may be necessary.
Sick sinus syndrome

Image source: lifeinthefastlane.com

Supraventricular tachycardia
Narrow complex tachycardia (rate >100
bpm, QRS width <120 ms):
 vagotonic manoeuvres
 adenosine or verapamil iv.
 DC (direct current) shock if patient is
compromised
Maintenance therapy: beta-blockers,
verapamil.
Atrial fibrillation/flutter

May be incidental finding.

Beta-blockers for controling

ventricular rate, digoxine is
usefull in heart failure with AF.
Conversion of atrial fibrillation
Within 48 hours from acute onset,
propafenone 600 mg per os in
patients without structural heart
disease.
Within 48 hours, amiodarone
300 mg per os in patients with
structural heart disease.
Conversion of atrial fibrillation
Immediate electrocardioversion:
 transesophageal
echocardiography + 5000 IJ LMWH
OR
 Electrocardioversion after 3 weeks
of warfarin therapy.
Ekg.academy.com
Atrial fibrillation

Atrial flutter
Atrial flutter
Ventricular tachycardia (VT)
Broad complex tachycardia (rate >100 bpm, QRS
duration >120 ms)

Acute management: amiodarone or lidocaine iv.

Oral therapy: loading dose of amiodarone 200 mg

every 8 hours for 7 days, 200 mg every 12 hours for
next 7 days and maintenance therapy 200 mg a day.
Image source: Healio.com
Literature
 Oxford Handbook of Clinical Medicine.
Longmore M. Wilkinson I. B. Baldwin A.
Elizabeth W. Ninth edition.
 Wikipaedia.org
 Lifeinthefastlane.com
 Healio.com
 Ekg.academy.com