Arrhythmias and EKGs

Part 2
 Outline
1. Sinus Arrhythmia and Sick Sinus
Syndrome
2. Multifocal Atrial Tachycardia
3. Bigeminal Rhythms
4. Preexcitation and AVRT
Mechanisms of Arrhythmogenesis
 Sinus Arrhythmia

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

EKG Characteristics: Presence of sinus P waves

Variation of the PP interval which cannot be q
attributed to either SA nodal block or PACs

When the variations in PP interval occur in phase with respiration, this is

considered to be a normal variant. When they are unrelated to respiration,
they may be caused by the same etiologies leading to sinus bradycardia.
 Sick Sinus Syndrome
Characterized by a collection of symptoms and ECG
findings due to chronic dysfunction of the sinoatrial (SA)
node:
– Chronic and severe sinus bradycardia
– Sinus pauses
– Sinus arrhythmia
– Complete sinus arrest
– Progressive development of atrial arrhythmias (a-
flutter, a-fib, atrial tachycardia)

Patients are usually elderly and present with

lightheadedness and/or syncope, but it can also manifest
as angina, dyspnea, and palpitations.

About 50% of people with SSS also display some degree

of dysfunction of the AV node
 Sick Sinus Syndrome

Sinus bradycardia (rate of ~43 bpm) with a sinus pause

 Etiologies of Sick Sinus Syndrome
More Common Less Common

Sinus node firbosis Familial SSS (due to

Atherosclerosis of the mutations in SCN5A)
SA artery Infiltrative diseases
Congenital heart Pericarditis
disease Lyme disease
Excessive vagal tone Hypothyroidism
Drugs Rheumatic fever
 Tachycardia-Bradycardia
Syndrome
Common variant of sick sinus syndrome
severe bradycardia alternates with
paroxysmal tachycardias, most often atrial
fibrillation.

There is usually a prolonged pause in the

cardiac rhythm following cessation of the
tachyarrhythmia.
 Tachycardia-Bradycardia
Syndrome

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Abrupt termination of atrial flutter with variable AV block,

followed by sinus arrest with a junctional escape beat.
 Multifocal Atrial Tachycardia

EKG Characteristics: Discrete P waves with at least 3 different

morphologies.

Atrial rate > 100 bpm.

The PP, PR, and RR intervals all vary.

 Bigeminal Rhythms
Arrhythmias in which each normal sinus
beat is followed by a premature
contraction (PAC, PJC, or PVC).

Results in a couplet rhythm which can be

detected by pulse or auscultation.

Generally benign
Atrial Bigeminy
Ventricular Bigeminy
 Preexcitation
Preexcitation is a condition characterized by an accessory pathway of
conduction, which allows the heart to depolarize in an atypical
sequence.
The most common form of preexcitation is called Wolfe-Parkinson-
White (WPW) syndrome, in which a direct atrioventricular connection
allows the ventricles to begin depolarization while the standard action
potential is still traveling through the AV node.

ECG Characteristics of WPW:

1. Short PR interval
2. QRS prolongation
3. Delta wave
 AV Reentrant Tachycardia (AVRT)

In patients with WPW, a reentrant rhythm can be

generated where the AV node serves as one arm
of the reentrant circuit, and the accessory pathway
as the other.
 Types of AVRT
Orthodromic AVRT (More common) – Narrow
complex tachycardia in which the wave of
depolarization travels down the AV node and
retrograde up the accessory pathway.

Antidromic AVRT (Less common) – Wide

complex tachycardia in which the wave of
depolarization travels down the accessory
pathway and retrograde up the AV node.
Mechanism of orthodromic AVRT
Mechanism of antidromic AVRT
What is this arrhythmia?

Antidromic AVRT
 Classification Scheme for Arrhythmias
Abnormalities in Abnormalities in
Conduction Automaticity
Conduction Block Decreased Automaticity
Bradyarrhythmias SA node – SA block SA node – Sinus bradycardia
Atria - NA Atria – NA
AV node – AV block AV node – NA
Ventricles – NA Ventricles - NA
Reentry Increased/Abnormal
Tachyarrhythmias Automaticity
SA node – SA nodal reentry SA node – Sinus tachycardia
Atria – Intraatrial reentrant Atria – Ectopic atrial
tachycardia, a-flutter, a-fib tachycardia
AV node – AVNRT AV – Junctional tachycardia
Ventricles – Ventricular Ventricles – Ventricular
tachycardia (common) tachycardia (rare)
Accessory pathways – AVRT
Additional important arrhythmias: Multifocal atrial tachycardia, torsade de pointes