ARRHYTHMIAS

BY
ZARISH FAZIL
 Cardiac Arrhythmias

An abnormality of the cardiac rhythm is called a

cardiac arrhythmia.
● Arrhythmias may cause sudden death, syncope,
heart failure, dizziness, palpitations or no symptoms
at all.
● There are two main types of arrhythmia:
bradycardia: the heart rate is slow (< 60 bpm).
tachycardia: the heart rate is fast (> 100 bpm).
 TYPES OF ARHYTHMIAS
3

1. ATRIAL ARRHYTHMIAS
2. ATRIAL FLUTTER
3. ATRIAL FIBRILLATION

4. JUNCTIONAL RHYTHM
5. AV NODAL REENTRY
6. SUPRA VENTRICULAR TACHYCARDIA

7. PREMATURE VENTRICULAR COMPLEX

8. VENTRICULAR TACHYCARDIAS
9. VENTRICULAR FIBRILLATION
10. IDIOVENTRICULAR RHYTHM
11. VENTRICULAR ASYSTOLE
12. FIRST DEGREE ATRIOVENTRICULAR BLOCK TYPE 1
13. SECOND DEGREE ATRIOVENTRICULAR BLOCK TYPE 2
14. THIRD DEGREE ATRIOVENTRICULAR BLOCK TYPE
4
 1-ATRIAL ARRHYTHMIAS
5

Premature atrial complex.

A signal ECG complex that occurs when an electrical
impulse starts in the atrium before the next normal
impulse of the sinus node.
 ATRIAL ARRHYTHMIAS
6
Ventricula Ventricular QRS P wave PR P:QRS
r and and atrial interval ratio
Atrial rate rhythm

Depends on Irregular due Usually Early and Early P Usually

underlying to early P normal, different, wave has 1:1
rhythm (eg, wave, shorter May be shorter shorter PR
sinus PP interval abnormal, May be interval,
tachycardia) called non aberrantly hidden in between
compensatory conduct the T wave 0.12 and
pause PAC. while other 0.20
May be p waves in seconds
absent strip remain
(blocked consistent
PAC)
 ATRIAL ARRHYTHMIAS
causes and factors
7

Caffeine
Alcohol
Nicotine
Stretched atrial myocardium. (as in hypervolemia)
Anxiety
Hypokalemia( potassium)
Hyper metabolic states( eg pregnancy)
Atrial ischemia
Injury
Infarction
PAC’s are common in normal hearts.
ATRIAL ARRHYTHMIAS
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ATRIAL ARRHYTHMIAS
SIGN AND SYMPTOMES

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 ATRIAL ARRHYTHMIAS

10

PAC’s are often seen with sinus tachycardia.

PAC’s common in normal hearts.
 TREATMENT FOR ATRIAL ARHYTHMIAS
Direct towards the causes.(Catheter ablation)
11
 2-ATRIAL FLUTTER
12

Atrial flutter (AFL) is a common abnormal heart

rhythm that starts in the atrial chambers of the
heart. When it first occurs, it is usually associated
with a fast heart rate and is classified as a type of
supraventricular tachycardia
Occurs in atrium and creates impulses at regular rate
between 250 and 400 times per minute.
Because the atrial rate is faster than the AV node can
conduct, all atrial impulses are not conducted into
the ventricle, causing a therapeutic block at AV node.
 ATRIAL FLUTTER
13

Automaticity foci (60-80bpm)

In atrial flutter has an irritable Automaticity foci (250-300bpm)
Faster than rest of foci
Electrical signals travels around in a circular patron which
causes the atria to contract at a rate of 250-300bpm.
Every time it hits the AV node.
Ventricles usually contract 150 bpm because there is a built in
mechanism called refractory period.
AV nod conducts the signals to lower heart, there is a window of
time where the AV node cant fire again .back up mechanism to
prevent overtiring in AV node.
 Atrial flutter
14

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial rate atrial
rhythm
Atrial rate Atrial Usually Saw- Multiple F 2:1
range rhythm is normal, toothed waves make 3:1or may
between regular may be shape; it difficult be
250- ventricle abnormal These to 4:1
400bpm rhythm is or may be waves are determine
Ventricular usually absent referred to PR
rate ranges regular but as F waves intervals.
between 75- may change
150bpm in AV
conduction
 ATRIAL FLUTTER CAUSES
15

Ischemia : Lower blood flow to the heart due to

coronary heart disease, hardening of the arteries, or
a blood clot.
Hypertension : High blood pressure.
Cardiomyopathy : Disease of the heart muscle.
Abnormal heart valves: Especially the mitral valve
ATRIAL FLUTTER CAUSES
SIGN AND SYMPTOMES
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TREATMENT FOR ATRIAL FLUTTER
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 3-ATRIAL FIBRILATION
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Atrial fibrillation causes a rapid, disorganized , and

uncoordinated twitching of atrial musculature.
Can increase your risk of strokes, heart failure and
other heart-related complications.
Can be transient, starting and stopping suddenly and
occurring for short time.
 3-ATRIAL FIBRILATION
19

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial rate atrial
rhythm
Atrial rate Highly Usually No Can not be Many:1
300 to irregular normal, discernible measured
600bpm may be P wave.
Ventricular abnormal Irregular
rate ranges undulating
between waves are
120- seen and
200bpm are referred
to as
fibrillatory
or F waves
 3-ATRIAL FIBRILATION
CAUSES AND FACTORS
20

Usually associated with advanced age

 Valvular heart disease,
 Coronary artery disease,
 Hypertension,
 Diabetes,
 Hyperthyroidism
 Pulmonary disease
 Alcohol(holiday heart syndrome)
 After open heart surgery, coronary artery bypass (11%
to 64%),valvular replacement, heart transplant.
3-ATRIAL FIBRILATION
SIGNS AND SYMPTOMES
21
3-ATRIAL FIBRILATION
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 23
4-JUNCTIONAL RHYTHM

Junctional rhythm or idioventricular rhythm occur

when the AV node, instead of the sinus node
becomes the pacemaker of the heart.
 4-JUNCTIONAL RHYTHM
24

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial rate atrial
rhythm

Atrial and Regular Usually May be If the P 1:1 or 0:1

ventricular normal, absent, wave is in
rate 40-60 may be after the front of
bpm if P abnormal QRS QRS, the
waves are complex, or PR interval
discernible before QRS; is less than
may be 0.12
inverted seconds
specially in
lead 2
 4-JUNCTIONAL RHYTHM
CAUSES
25

Sick sinus syndrome (including drug-induced)

Digoxin toxicity.
Ischemia of the AVN, especially with acute inferior
infarction involving the posterior descending artery,
the origin of the AV nodal artery branch.
 4-JUNCTIONAL RHYTHM
SIGN AND SYMPTOMES
26

Abnormal heart sounds (S3, S4)

Angina
restlessness
Change in level of consciousness
Crackles, dyspnea, orthopnea, tachypnea
Decreased activity tolerance
Decreased cardiac output
Decreased peripheral pulses; cold, clammy skin/poor capillary refill
Decreased venous and arterial oxygen saturation
Dysrhythmias
Ejection fraction less than 40
Hypertension
Increased central venous pressure (CVP)
Tachycardia
Weight gain, edema, decreased urine output
 4-JUNCTIONAL RHYTHM
27

No pharmacologic therapy is needed for

asymptomatic, otherwise healthy individuals
with junctional rhythms that result from
increased vagal tone. In patients with complete AV
block, high-grade AV block, or symptomatic sick
sinus syndrome (ie, sinus node dysfunction), a
permanent pacemaker may be needed.
 5-AV NODAL REENTRY

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Occur when an impulse is conducted to an area in

the AV node that causes the impulse to be rerouted
back into the same area over and over again at a very
fast rate.
Each time its also conducted in ventricles causing a
fast ventricular rate.
Also occur when the duration of the QRS complex is
0.12 seconds or greater. And a block in the bundle
branch is known to be present.
 5-AV NODAL REENTRY
29

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial rate atrial
rhythm
Atrial rate Regular Usually Usually If the P 1:1 or 2:1
usually 150 sudden normal, very wave is in
to 250 onset and may be difficult to front of
ventricular termination abnormal discern QRS, the
rate 75-250 of PR interval
bpm techycardia is less than
0.12
seconds
 5-AV NODAL REENTRY
Causes
30

Conduction of impulse in an area in the AV node that

causes the impulse to be rerouted back into the same
area over and over again at a very fast rate.
 5-AV NODAL REENTRY
Sign and symptoms
31

Vary with the rate and duration of the tachycardia the patients underlying conditions
The tachycardia is usually of short duration resulting only in palpitations
Dizziness
 Syncope
Shortness of breath
pain/discomfort in the neck,
pain/discomfort in the chest,
anxiety, and polyuria secondary atrial natriuretic factor secreted mainly by the heart
atria in response to atrial stretch.
A fast rate may also reduce cardiac output resulting in significant signs and
symptoms such as
Restlessness
Pallor
Hypotension
Loss of consciousness
 5-AV NODAL REENTRY
Sign and symptoms------
32

Patients with AVNRT and known history of

coronary artery disease may present with a
myocardial infarction secondary to the stress on the
heart.
 Patients with AVNRT and known history of heart
failure may present with acute exacerbation and
possibly reduced ejection fraction secondary to
tachycardia-induced cardiomyopathy
5-AV NODAL REENTRY
TREATMENT
33
 6-SUPRA VENTRICULAR TACHYCARDIA

34

If P wave can not be identified, the rhythm may be

called supraventricular tachycardia SVT, or proximal
supraventricular tachycardia (PSVT), if it had an
abrupt onset, until the underlying rhythm and
resulting diagnosis is determined.
SVT and PSVT indicate only that the rhythm is not
ventricular tachycardia (VT) . SVT could be atrial
fibrillation, atrial flutter, or atrioventricular reentry
tachycardia among others.
 7-PREMATURE VENTRICULAR COMPLEX

35

A premature ventricular complex is an impulse that

starts in ventricle and is conducted through the
ventricles before the next normal sinus impulse.
PVS can occur in healthy people especially with
intake of caffeine, nicotine, or alcohol.
 7-PREMATURE VENTRICULAR COMPLEX

36

Ventric Ventricular QRS P wave PR interval P:QRS

ular and atrial ratio
and rhythm
Atrial
rate
Depends irregular Durati Visibility of P If the P wave 0:1 or 1:1
on the Due to early on is wave depends is in front of
underlyi QRS, creating 0.12 on the timing of QRS, the PR
ng one RR second the PVC; may be interval is
rhythm Interval that is s or absent (hidden less than 0.12
(eg sinus shorter than longer; in the QRS or T seconds
rhythm) the others. PP shape wave) or in front
interval may is of the QRS . If
be regular, bizarre the P wave
indicating that and follows the QRS,
the PVC did abnor the shape of the
not depolarize mal P wave may be
the sinus nod different.
 7-PREMATURE VENTRICULAR COMPLEX
37

using certain types of medications, such as

stimulants and asthma medications.
hormonal imbalances.
alcohol consumption.
using illegal drugs.
caffeine consumption.
increased anxiety.
high blood pressure.
heart disease
7-PREMATURE VENTRICULAR COMPLEX
SIGN AND SYMPTOMES
38
 7-PREMATURE VENTRICULAR COMPLEX
TREATMENT

39

Initial treatment is to correct the underlying cause.

Long term pharmaceutical treatment is not indicated
for only PVS
 8-VENTRICULAR TACHYCARDIAS

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VT is defined as three or more PVCs in a row,

occurring at a rate exceeding 100 bpm.
Usually associated with coronary artery disease, and
may precede ventricular fibrillations.
CAUSES
Are similar to those in PVC.
 8-VENTRICULAR TACHYCARDIAS
41

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial rate atrial
rhythm
Ventricular Usually Duration is Difficult to If the P Difficult to
rate is 100- regular 0.12 detect. wave are determine
200bpm seconds or seen If P waves
Atrial rate longer; interval is are
depends on shape is very apparent,
the more irregular there are
underlying bizarre and usually
rhythm. abnormal more QRS
than P wave
 8-VENTRICULAR TACHYCARDIAS
42

Lightheadedness or dizziness.
Palpitations (skipping, fluttering or pounding in the
chest)
Fatigue.
Chest pressure or pain.
Shortness of breath.
Fainting spells.
 8-VENTRICULAR TACHYCARDIAS
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Treatment for ventricular tachycardia involves underlying

causes.
 These treatments may improve or prevent the abnormal heart
rhythm from returning.
In emergency situations, CPR, electrical defibrillation and IV
medications may be needed to slow the heart rate.
These drugs can be effective but are associated with some
serious, potentially fatal side effects, and they are not used as
much as they were in the past.
 Nonemergency treatment usually includes radiofrequency
catheter ablation (RCA) or an
implantable cardioverter defibrillator (ICD)
 9-VENTRICULAR FIBRILLATION

44

Ventricular fibrillation is a rapid, disorganized

ventricular rhythm that causes ineffective quivering
of the ventricle.
No atrial activity is seen on ECG.
This arrhythmia is always characterized by the
absence of an audible heart beat, a palpable
pulse, and respiration, because of no
coordinated cardiac activity.
 9-VENTRICULAR FIBRILLATION
45

Ventricular and Atrial Ventricular and atrial QRS

rate rhythm

Ventricular rate is greater Extremely irregular Irregular waves, without

than 300bpm without any specific recognizable QRS complex
pattern
 9-VENTRICULAR FIBRILLATION
CAUSES
46

Causes are the same as for VT

May also result from untreated VT
Other causes include electric shock and Brugada
syndrome.
The cause of ventricular fibrillation isn't always
known. The most common cause is a problem in the
electrical impulses traveling through your heart after
a first heart attack or problems resulting from a scar
in your heart's muscle tissue from a previous heart
attack.
 9-VENTRICULAR FIBRILLATION
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Ventricular Fibrillation Signs and Symptoms

Lightheadedness or dizziness.
Palpitations (skipping, fluttering or pounding in the
chest)
Fatigue.
Chest pressure or pain.
Shortness of breath.
Fainting spells.
 9-VENTRICULAR FIBRILLATION
TREATMENT
48

Treatment for VF starts with early and effective

CPR. Keeping the brain, heart and other vital organs
perfused is very important in an arrest.
Once the rhythm is identified as ventricular
fibrillation, a shock should be delivered
immediately. After the shock is delivered, begin CPR
again for two minutes.
 10-IDIOVENTRICULAR RHYTHM

49

Also called ventricular escape rhythm.

Occur when impulse starts in the conduction system
below the AV node.
When the sinus node fails to create impulse(eg from
increased vagal tone).
Or impulse is created by sinus node but is not be
conducted through AV node.
 10-IDIOVENTRICULAR RHYTHM
50

Ventricular and Ventricular and QRS

Atrial rate atrial rhythm
Ventricular rate; Ventricular rhythm; Bizarre abnormal
between 20 to 40bpm, if regular shape,
rate exceeds 40 its Duration is 0.12 sec or
called accelerated more
idioventricular rhythm
(AIVR)
 10-IDIOVENTRICULAR RHYTHM
CAUSES AND FACTORES
51

This arrhythmia may occur for several reasons

including systemic diseases (e.g., anemia, splenic
hemangiosarcoma), drugs (e.g., digoxin, opiods) and
electrolyte abnormalities (e.g., hypokalemia).
 Generally, no clinical signs are associated
with idioventricular rhythms
 10-IDIOVENTRICULAR RHYTHM
SIGNS AND SYMPTOMES
52

Lose of consciousness
 Cardiac output
 10-IDIOVENTRICULAR RHYTHM
53

The treatment is the same as in asystole and pulseless

cardiac activity.
Under these situations, atropine can be used to increase
the underlying sinus rate to inhibit AIVR.
 Other treatments for AIVR, which include
isoproterenol, verapamil, antiarrhythmic drugs such as
lidocaine and amiodarone, and atrial overdriving pacing
are only occasionally used today.
In some cases IVR patients do not present with
decreased cardiac output but still bed rest is prescribed,
not to increase cardiac workload.
 11-VENTRICULAR ASYSTOLE

54

Commonly called flat line ventricular asystole is

characterized by ABSCENT QRS COMPLEX
confirmed in two different leads
Although P waves may be apparent for short
duration.
There is no heart beat, no palpable pulse, and no
respiration.
 11-VENTRICULAR ASYSTOLE
CAUSES AND
55 FACTORES

Hypoxia
Acidosis
Sever electrolyte imbalance
Drug overdose
Hypovolemia
Cardiac tamponade
Tension pneumothorax
Coronary or pulmonary thrombosis
Trauma
Hypothermia
 11-VENTRICULAR ASYSTOLE
SIGNS AND SYMPTOMES
56

Ventricular tachycardia may only last for a few

seconds or for much longer. It doesn't always
cause symptoms, but when symptoms do occur, they
may include
Lightheadedness
Dizziness
Fainting
The condition most commonly affects people who
have heart disorders, such as coronary artery disease
and cardiomyopathy
 11-VENTRICULAR ASYSTOLE
TREATMENT
57

Ventricular asystole is treated same as PEA focusing on high quality

CPR with minimum interruption
After the initiation of CPR, intubation and and establishment of IV
access are the next recommended actions with no or minimum
interruptions in chest compressions.
After 2 minuts or five cycles of CPR, a bolus of IV epinephrine is
administered and repeated at 3 to 5 minutes intervals.
One does of vasopressin may be administered for the first or second
does of epinephrine.
1 mg bolus of IV atropine
If patient still not respond resuscitation efforts are ended
The code is called
 12-FIRST DEGREE ATRIOVENTRICULAR BLOCK TYPE 1

58

First degree AV block occurs when all the atrial

impulses are conducted through the AV node into
the Ventricles at a rate slower than normal.
12-FIRST DEGREE ATRIOVENTRICULAR BLOCK TYPE 1
59

Ventricul Ventricul QRS P wave PR P:QRS

ar and ar and interval ratio
Atrial atrial
rate rhythm
Depends Depends Usually In front of Greater 1:1
on the on the normal, but the QRS than 0.20
underlying underlying may be complex; seconds;
rhythm. rhythm. abnormal shows PR interval
sinus measureme
rhythm, nt is
regular constant
shape
12-FIRST DEGREE ATRIOVENTRICULAR BLOCK TYPE
1
60

Causes. The most common causes of first-degree

heart block are 
AV nodal disease, enhanced vagal tone (for example
in athletes), myocarditis
acute myocardial infarction (especially acute inferior
MI)
electrolyte disturbances and medication
13- SECOND DEGREE ATRIOVENTRICULAR BLOCK TYPE
1
61

Second degree AV block occur when there is a

repeating pattern in which a series of atrial impulses
are conducted through the AV node into the
ventricles (eg every 4 of 5 impulses are conducted)
Each atrial impulse takes a longer time for the
conduction than before. Until one impulse is fully
blocked
13- SECOND DEGREE ATRIOVENTRICULAR BLOCK TYPE
1
62

Ventri Ventricular and QRS P wave PR interval P:QR

cular atrial rhythm S
and ratio
Atrial
rate
Depen PP interval in reguler Usually In front of Pr interval 3:2,
ds on if the patient has an normal, the QRS becomes 4:3,
the underlying normal but may complex; longer with 5:4,6:5
underl sinus rhythm be shape each and so
ying PR Interval reflects a abnormal depends on succeeding on
rhythm pattern of change underlying ECG
. RR interval gradualy rhythm complex until
shortens until there is there is a P
another long RR wave not
interval folowed by
QRS
SECOND DEGREE ATRIOVENTRICULAR BLOCK TYPE
2
63
14-THIRD DEGREE ATRIOVENTRICULAR BLOCK TYPE

64