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Cardiac Rhythm Disorders

Dr. (Mrs.) Deepa S. Gunawardena, MBBS, M.D. Consultant Cardiac Electrophysiologist


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Rhythm Disorders

Tachyarrhythmias >100 bpm

Bradyarrhythmias <60 bpm

Narrow Complex T.C. QRS < 0.12 s

Broad Complex T.C. QRS > 0.12 s

Regular

Iregular

Regular

Iregular
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Narrow Complex T.C.


Regular
Sinus T.C. Atrial flutter with regular AV block Re-entry T.C.

Broad Complex T.C.


Regular
Ventricular T.C. SVT with preexisting BBB Aberrant conduction Ante-grade conduction over accessory path way (a.p.).

Irregular
Atrial fibrillation Atrial flutter with variable block.

Irregular Ante-grade conduction over a.p. during A.F.


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Narrow- complex Tachycardias.


Compromised or not (BP,acute heart failure,check airway, breathing). IV access,ECG monitoring. Pattern of arrhythmia, prodromal symptoms, associated symptoms, cardiac history,H/O arrhythmia,recent illness, acute triggers.
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Investigations:
12 lead ECG with rhythm strip BU/SE CXR Thyroid function 2DEcho ECG during sinus rhythm (atrial ectopics, short PR and Delta waves).
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Management
Compromised patient
Immediate Synchronized DC shock with 50J,100J, 200J, 360J (IV Diazepam 10 mg, under general anesthesia) If arrhythmia recurs consider anti- arrhythmic agents (IV Amiodarone).

If the patient is not compromised


1. Try Vagal manoeuvres
Carotid Sinus Pressure, Valsalva manoevours, Diving reflex, DO NOT use eye ball pressure.

2. I.V. Adenosine test


contraindications Bronchial Asthma, Side effects-chest pain flushing,headache How to give
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Run continuous rhythm strip Insert 18 G venous cannula Keep ready a 20 ml syringe filled with normal saline. Give IV Adenosine through the cannula followed by normal saline flush. Dose: 3mg, 6 mg, 9mg, 12 mg , 15 mg,18mg Can be given using 3 way tap as well. Action:AV block.
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3. I.V. Verapamil 5-10 mg over 10 min.


DO NOT use in patients on Beta blockers or in broad complex TC.

4. AV node blockers( oral or IV Digoxin) 5.Anti-Arrhythmic(IV Amiodarone) 6. Over drive pacing 7.Cardioversion

Long term Prophylaxis


Indicated for patients with spontaneous recurrent symptomatic episodes. No prophylaxis if identifiable trigger is found and correctable. .Electro-physiological testing and ablation. Drugs:AV node blockers, Anti arrhythmics ( Amiodarone).
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Atrial Fibrillation (A.F.)


Two types
1.Chronic A.F. 2. Intermittent AF.

Management Objectives
Prevention of thrombo-embolic complications Rate control or Restoration of sinus rhythm.
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Chronic AF
Restoration of sinus rhythm(at least one attempt) by elective Cardioversion . Using:
Electrical Cardioversion (D.C. shock) Chemical Cardioversion.

Preparation:
4 weeks of prior anti- coagulation with Warfarin (INR-2-3.5)
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Check Serum K,Fasting >6 hours,IV access,With hold Digoxin

Electrical cardioversion
Synchronized D.C. shock at 100J, 200J, 360J. Under GA. Continue Warfarin for 4 more weeks. If D.C. shock unsuccessful give antiarrhythmics (Amiodaron,Sotalol),second attempt of D.C. shock later.
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Chemical Cardioversion.
If AF is more than 48 hours,consider anticoagulation for 4 weeks before and after CCV.Drug:IV Flecanide 2 mg /KG iv Advantages of CV:No long term anticoagulation,preserve atrial contribution to Ventricular filling. Failed CV: consider anticoagulation with rate or rhythm control drugs.
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Intermittent A.F.
Long term anticoagulation
for high risk patients (patients with a high risk of stroke: hypertension, DM, IHD, TIA, h/o. stroke, thromboembolism, >65 years, cardiac failure, significant valvular heart disease).
Warfarin (INR-2-3.5)

For low risk patients (lone A.F.)


low dose Aspirin
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Ventricular rate control


AV node blocking drugs Anti arrhythmics ( Class1a,1c,111)

Electrophysiological testing and ablation (lone AF). Intra-cardiac devices

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Tachycardias due to Accessory Pathways


Types of tachycardias
regular narrow complex tachycardias due to reentry. regular broad complex tachycardias due to reentry. irregular broad complex tachycardia due to conduction of atrial fibrillation through the accessory pathway.
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Management
if compromised, D.C. shock indicated if not compromised: regular narrow/broad T.C.
I.V. Adenosine to block AV node I.V. Amiodarone to block AP.

if not compromised: irregular broad T.C.


DO NOT GIVE Adenosine, Digoxin, Verapamil, beta blockers. Precipitates V.F due to accelerated conduction through the A.P. Treat with I.V. Amiodarone.

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Broad complex tachycardias


Ventricular TC
AV dissociation Fusion beats Capture beats Extreme axis deviation QRS duration > 0.14 s Concordance

SVT
Slowed by vagal maneuvers Slowed or terminated by Adenosine Initiated by AE. P>V

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During Sinus rhythm


Ventricular T.C.
VE Prolonged QT LVH, MI

SVT
LBBBor RBBB Wolf-Parkinson-White (WPW) Syndrome

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Management
If compromised and arrhythmia continues
Immediate precordial thump / synchronized DC cardioversion (100J,200J,360J). Resuscitation if patient has cardiac arrest If no response
Antiarrhythmic drugs, over drive pacing,IV Mg

If recurs
consider antiarrhythmics, treat the cause if any.
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Not compromised
Good LV function-IV Lignocaine 100mg(50 mg if <50 kg) followed by infusion of Lignocaine
4mg /min for 30 min 2 mg/min for 2 hours 1mg/min for upto24 hours

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Poor LV function cardiac failure.


IV Amiodarone 5 mg /KG over 30 min via central line.

If all above failed


IV Flecanide, Mexiletine, Procainamide, Bretylium, Beta Blockers ( ischemic VT) Can cause hypotension ,cardiac failure

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If episodes are brief and self terminated antiarrhythmic treatment is not indicated. Treat correctable factors if any (acute ischemia, electrolytes imbalance).

Long term prophylaxis


Indications:
recurrent episodes, no identifiable cause, uncorrectable cause.
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Antiarrhythmic drugs for prophylaxis


Oral Amiodaron 200mg tds for 5-7 days 200 mg bd for 5-7 days 100 -200 mg daily

Class-1a and 1b drugs

Ischemic VT
Consider prophylaxis if VT occurs after 48 hrs of MI. Beta blockers
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Investigations:
ECG after cardioversion, Cardiac enzymes, CXR, Holter monitoring, exercise testing, Echo, Serum K+, Mg++

Follow up

Treat correctable causes e.g For IHD revascularization. Long term prophylaxis if indicated EPS,Implantable Defibrillators Correct risk factors (DM,hypertension,Hyperlipidaemia)
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Ventricular Fibrillation
Leads to cardiac arrest
Immediate cardioversion and resuscitation Treat correctable causes Long term prophylaxis as in case of VT
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Torsades Pointes
Polymorphic VT, Axis twist around the base line, usually non- sustained and repetitive, can degenerate in to VF During SR- prolonged QT Causes:
Antiarrhythmic drugs(1a,1c,111) Elytes disturbances: K+, Mg++, Ca++ Antibiotics: Erythromycin Congenital long QT syndrome
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Management
Remove offending agent,

Temporary pacing,
Isopreneline IV (0.5-10 g/min) IV Mg
8 mmol over 15 min, 72 mg over 24 hours

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Accelerated Idio-Ventricular rhythm


Rate-60-110 bpm

Non sustained VT
minimum of 3 beats reverted back spontaneously within 30 s. If symptomatic: Beta blockers, Amiodarone

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Bradyarrhythmias
Ventricular rate < 60 bpm. Categories of Bradyarrhythmias:
Sinus bradycardia, Sinus arrest/block, AV block (2nd, 3rd degree)

Causes:
Drugs, IHD, hypothyroidism

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Investigations
ECG with long rhythm strip,CXR,Thyroid function,Digoxin level,Cardiac enzymes.

Management:
Withhold offending drug, if any Asystole/pulseless bradycardiaresuscitation Sinus bradycardia ,AV block:IV atropin,IV Isoprenelin,Salbutamol compromised:Temporary pacing ,plan for permanent pacing
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