Министерство здравоохранения Российской Федерации

Государственное бюджетное образовательное учреждение высшего

профессионального образования
Волгоградский государственный медицинский университет

Кафедра факультетской терапии

ARRHYTHMIAS
 ANATOMY OF THE CARDIAC CONDUCTION SYSTEM.

AV, atrioventricular;
SA, sinoatrial.
 CLASSIFICATION
I. Automatism disturbances
1. Sinus arrhythmia
2. Sinus tachycardia
3. Sinus bradycardia
4. Sinoatrial exit block/sinoatrial arrest
• impulse is not spent from sinus node neither on
auricles, nor on ventricles – the whole PQRST
complex together with P-wave drops out
5. “Sick” sinus node syndrome (SSSN) or sinus node
dysfunction (DSN)
 CLASSIFICATION
II. Conduction disturbances
1. Atrioventricular block (AV-block)
a) I degree
b) II degree
- Mobitz type I
- Mobitz type II
c) III degree (complite AV-block)
2. Disturbances of intra-ventricular conductivity (bundle
branch block - nonspecific ).
 CLASSIFICATION
III. Excitability disturbances
1. Ectopic complexes or beats (extrasystols)
A) Supraventricular
- atrial
- nodal
B) Ventricular
2. Paroxysmal Tachycardia
A) Supraventricular
a) With regular rhythm:
- sinus tachycardia
- paroxysmal atrial tachycardia (WPW-syndrome)
- atrial flutter (“regular” form)
b) With irregular rhythm:
- atrial fibrillation
- atrial flutter (“irregular” form)
B) Ventricular
- ventricular tachycardia
- ventricular fibrillation
 SINUS NODE DYSFUNCTION
Is usually idiopathic and associated with fibrosis and
fatty infiltration of the SA node as patients age.
Other causes of sinus node dysfunction include:
• endocrine disturbances,
• medications,
• electrolyte abnormalities,
• autonomic disturbances,
• intrinsic heart disease.
 PATIENTS WITH SUSPECTED
ARRHYTHMIAS CAN PRESENT IN A
VARIETY OF WAYS.
Typical symptoms include:
• palpitations,
• syncope,
• presyncope (dizziness).
On occasion, arrhythmias can manifest more subtly as
exercise intolerance, lethargy, and vague complaints of
malaise or without any symptoms at all. Conversely,
arrhythmias occasionally manifest as aborted sudden
cardiac death (cardiac arrest).
• Palpitations
 APPROACHES IN ARRHYTHMIAS
DEPEND ON SEVERITY AND CAUSE
• The specific differential diagnosis, prognosis, and
treatment of these symptoms are determined by:
• the severity of the symptom (i.e., whether it results in
syncope) and
• whether the patient has underlying structural heart
disease.
• In general, the likelihood of a life-threatening arrhythmia, such as
ventricular tachycardia or ventricular fibrillation, in a patient with
symptoms of palpitations or syncope is significantly greater in a patient
who has structural heart disease. Therefore, determination of whether a
patient has structural heart disease is a key step in the diagnosis and
prognosis of patients with suspected arrhythmias.
 PALPITATIONS

• Palpitations, defined as an awareness of an irregular or rapid

heartbeat, are most commonly due to ectopic beats, namely,
premature atrial contractions (PACs) and premature
ventricular contractions (PVCs), or to tachyarrhythmias.
• An irregularly irregular pattern suggests atrial fibrillation,
whereas a more regular, rapid pattern suggests a sustained
tachycardia.
• Conversely, most patients who complain of symptoms from
PACs or PVCs are often more aware of the post-extrasystolic
pause or the accentuated output of the post-extrasystolic beat
than of the actual premature beat itself
 PALPITATIONS

• . The majority of patients who have symptoms suggestive

of premature beats but not of sustained tachycardia do not
require further evaluation if they have no other symptoms
and no evidence of structural heart disease, that is, an
otherwise normal cardiac history, physical examination,
and electrocardiogram (ECG). If, however, the symptoms
are not due to a single occasional extrasystole or are
accompanied by presyncope or syncope, further evaluation
is required ).
 PALPITATIONS

• Antiarrhythmic therapy is usually not necessary for

treatment of PACs or PVCs unless the symptoms are
frequent or severe.
• β-Blockers (metoprolol, 25 mg/day, or atenolol, 25 mg/day)
are first-line therapy in those highly symptomatic patients
with documented PACs or PVCs
 PALPITATIONS ARE THE MOST
COMMON PRESENTATION OF
TACHYARRHYTHMIAS.
• The majority of tachyarrhythmias in patients without structural
heart disease are due to supraventricular tachycardias that
resolve spontaneously within several seconds.
• When the tachyarrhythmia is more prolonged, however, it
often will resolve with simple interventions.
• Patients themselves can cough several times, perform the
Valsalva maneuver, exhale forcefully against a closed glottis
for several seconds, or even rub gently on their eyeballs
 PALPITATIONS IN
TACHYARRHYTHMIAS.
• A physician can use carotid sinus massage, performed by
pressing and rubbing the carotid pulse just below the angle
of the mandible for 5 to 15 seconds. This maneuver should
be avoided in elderly patients and in patients who have a
history of a previous cerebrovascular accident, known
carotid artery stenosis, or a carotid bruit on auscultation.
• In patients with structural heart disease, palpitations may
signify ventricular tachycardia, particularly if they occur
with syncope or presyncope.
• Rarely do bradyarrhythmias manifest as palpitations
 SYNCOPE AND PRESYNCOPE

• Syncope and presyncope, defined as a sudden loss of

consciousness (syncope) or lightheadedness (presyncope),
can be a manifestation of tachyarrhythmias,
bradyarrhythmias, or neurocardiogenic syncope or can be
unrelated to any arrhythmia .
• A careful history and physical examination are necessary
to exclude other cardiac causes (such as acute ischemia,
aortic stenosis) or neurologic causes. Important historical
features that suggest an arrhythmic cause are association
with palpitations and lack of any neurologic deficits
preceding or following the event
 IMPORTANT DIFFERENTIAL
DIAGNOSES INCLUDE:
Conditions other than lightheadedness that may be termed
dizziness by the patient.
• Vertigo , a sense of imbalance or of the “room spinning,”
and ataxia can usually be distinguished by the history and
physical examination.
• The possibility of seizures must also be evaluated because
syncope from an arrhythmia or neurocardiogenic syncope
occasionally results in seizure-like activity and because
seizures can sometimes be confused with syncope.
 DIAGNOSIS

• Arrhythmias are generally categorized as 1.bradyarrhythmias

(slow heart rates), 2.tachyarrhythmias (fast heart rates), or
3.premature beats (single extrasystoles from the atria or the
ventricle, PACs or PVCs, respectively.
• Although not a primary arrhythmia, neurocardiogenic syncope,
also known as vasovagal syncope, is a related diagnostic and
management issue because its symptoms are frequently similar to
those of arrhythmias and because neurocardiogenic syncope
secondarily results in bradycardia.
•
 BRADYARRHYTHMIAS

• Bradyarrhythmias can be due to dysfunction in the

sinoatrial node, atrioventricular (AV) node, or His-
Purkinje system (below the AV node).
• Sinus bradycardia is manifested as a slow atrial (sinus)
rate and can occur at rest or as an inappropriately slow
rate during exercise (chronotropic incompetence).
• Sinus arrest can be intermittent when transient loss of
sinus activity (loss of the P wave on the ECG) causes brief
sinus pauses or persistent with prolonged loss of atrial
activation.
 BRADYARRHYTHMIAS

• Sinus bradycardia, especially if it is intermittent, can also

signify coronary disease of the right coronary artery.
• Bradyarrhythmias from AV nodal disease are a result of
failure of impulse conduction from the atrium to the
ventricle.
• Like the sinus node, the AV node is also dramatically affected by
autonomic tone. Mobitz type I second-degree AV block (Wenckebach
type ) can be seen during periods of high vagal tone and is not
necessarily pathologic; for example, it does not progress to complete
heart block and is not associated with a widened QRS
 BRADYARRHYTHMIAS

• Many drugs, such as β-blockers and calcium-channel blockers,

commonly cause first-degree AV block and should be considered a
potential cause for any degree of AV block.
• Mobitz type II block signifies that the level of AV block is below the AV
node in the His-Purkinje system, which is not sensitive to autonomic
tone; the resulting QRS is widened, and there is a high likelihood of
progression to complete heart block (third-degree AV block).
• Intermittent complete heart block, which can result in drop attacks or
Stokes-Adams attacks, is usually preceded by abnormal baseline findings
on the ECG, such as a bundle branch block or second-degree AV block.
• The treatment of choice for symptomatic bradyarrhythmias or those
likely to progress to complete heart block is implantation of a permanent
pacemaker .
 TACHYARRHYTHMIAS

• Tachyarrhythmias can arise from the atrium or AV node

(supraventricular tachycardia) or from the ventricle (ventricular
tachycardia).
• Supraventricular tachyarrhythmias that may be associated with
palpitations, presyncope, or syncope include atrial tachycardia , AV
nodal re-entrant tachycardia, AV junctional tachycardia, atrial
flutter, and atrial fibrillation, sometimes in association with accessory
conduction pathways that facilitate the re-entry needed to sustain the
arrhythmia.
• Ventricular tachyarrhythmias include the various forms of ventricular
tachycardia.
• Treatments are guided by the specific tachyarrhythmia and its
underlying cause.
 ELECTROCARDIOGRAPHY
• The baseline ECG is critical in the evaluation of the patient with palpitations
or syncope. The presence of ventricular pre-excitation, as manifested by a
short PR interval and a delta wave , not only establishes the diagnosis of
Wolff-Parkinson-White syndrome in a patient with palpitations and AV
reciprocating tachycardia as the likely cause of the symptoms but also can be
used to determine the location of the responsible accessory pathway.
• The baseline ECG also provides useful predictive information about the
likelihood of conduction system abnormalities as a possible explanation for
bradyarrhythmias (e.g., sinus bradycardia suggests sinus node dysfunction, a
prolonged PR interval suggests the possibility of AV nodal disease, and a
widened QRS suggests disease below the AV node) and in diagnosis of prior
myocardial infarction (i.e., pathologic Q waves), which raises the likelihood
of ventricular tachycardia as a potential cause of syncope or palpitations.
•
 ELECTROCARDIOGRAPHY

• An ECG during an episode of palpitations is extremely useful in making a

definitive diagnosis.
• For narrow–QRS complex tachycardias, the specific supraventricular
tachycardia can often be surmised from the 12-lead ECG obtained during
symptoms.
• Moreover, for wide–QRS complex tachycardias, the 12-lead ECG is useful in
distinguishing a supraventricular tachycardia (with aberrancy) from a
ventricular tachycardia .
• The presence of fusion beats or AV dissociation during a wide–QRS complex
tachycardia makes the diagnosis of ventricular tachycardia. For ventricular
tachycardias, the morphology of the QRS complex is useful in determining the
location of the ventricular tachycardia focus and in identifying idiopathic
ventricular tachycardia (right ventricular outflow tract or fascicular), which
has a much more benign course than ventricular tachycardia in the setting of
coronary disease.
 ELECTROCARDIOGRAPHY

• During bradycardias, the ECG is useful in determining the

level of the conduction system (sinus node, AV node, or His
bundle) responsible for the bradycardia.
• Sinus bradycardia is diagnosed when a slow (<50 per
minute at rest) atrial rate (P wave) conducts to the
ventricle.
• Sinus arrest or sinus pauses are diagnosed by absent or
dropped P waves.
 ELECTROCARDIOGRAPHY

• 1. First-degree AV block is defined as a prolonged PR interval (>200 msec)

• 2. Second-degree AV block is defined by P waves that occasionally do not
conduct to the ventricle (P wave without an ensuing QRS);
• Mobitz type I second-degree AV block (also known as Wenckebach block) is
characterized by progressive lengthening of the PR interval until one P wave
does not conduct to the ventricle. This form of AV block is often seen in younger
patients, is usually benign, and rarely progresses to complete AV block (third-
degree AV block).
• Mobitz type II second-degree AV block, which is characterized by sudden
unexpected loss of conduction of a P wave to the ventricle (dropped QRS),
signifies disease of the His-Purkinje system and often progresses to complete
heart block.
• 3. Complete heart block or third-degree AV block is diagnosed by dissociation
of P waves from QRS complexes, with an atrial rate faster than the ventricular
rate.
 AMBULATORY MONITORING

• For intermittent symptoms such as palpitations, dizziness, or syncope,

it is often difficult to obtain a 12-lead ECG during the symptoms.
Therefore, ambulatory monitoring, which allows ECG monitoring
during long periods, is a vital tool in the diagnosis of these symptoms.
• There are currently three types of ambulatory monitors:
• 1. Holter monitors, which continuously record the ECG for 24 to 48 hours;
• 2. Event recorders, which are wearable loop recorders that record only
during specific events (at times when the patient activates the recorder because
of symptoms or the recorder detects a heart rate above or below a specified
threshold) but can be worn for 1 month or more;
• 3. Implantable loop recorders, which function similarly to event recorders but
can be used for up to 14 months.[2]
 HOLTER MONITORS

• Holter monitors use a tape or digital media to record either a three- or

five-lead surface ECG continuously for 24 to 48 hours. Processing,
printing, and analysis of the recordings are performed offline with
commercial systems.
• In addition to recording of the rhythm, analyses such as heart rate
variability, ST segment changes, and accurate counts of PACs and
PVCs can be automated.
• Holter monitoring is useful for detection of symptoms that are
frequent (multiple times daily) and for diagnosis of sinus node
dysfunction (sinus node arrest, sick sinus syndrome) or intermittent
AV block.
• It can also be useful to assess the adequacy of the control of the
ventricular rate in a patient with atrial fibrillation.
 EVENT MONITORS

• Event monitors, also known as loop recorders, are designed to record

intermittent episodes during long periods (weeks to months) and are thus
useful for patients with less frequent symptoms.
• The system records the ECG into a loop buffer that is continuously updated
and overwritten. The duration of memory varies from a few seconds to a few
minutes and is usually programmable.
• When activated, the information is “locked” into memory and continues to
record forward for a preprogrammed amount of time.
• Newer systems allow both patient-activated (when symptoms occur) and event-
triggered (when the heart rate is above or below a preset threshold) recording.
• Some recorders have algorithms to detect and record atrial fibrillation
automatically, regardless of the heart rate.
 IMPLANTABLE LOOP RECORDERS

• Implantable loop recorders are small devices with integrated leads that are
implanted in a small subcutaneous pocket during a simple surgery, usually in
the electrophysiology laboratory.
• They function similarly to the event recorders in terms of recording ECGs.
• Patients can activate the device with a small transmitter, or the device can
autotrigger on the basis of preprogrammed heart rates. The device can be
interrogated by a computer, similar to the way pacemakers are interrogated,
to program the device's parameters and to retrieve ECGs that have been
recorded.
• Implantable loop recorders are useful in patients with infrequent episodes,
elderly patients who have difficulty using wearable recorders, or patients who
cannot otherwise wear an event recorder (e.g., someone who is symptomatic
during swimming).
 OTHER TESTS
ECHOCARDIOGRAPHY

• Echocardiography can be useful to ensure that a patient

does not have underlying structural heart disease, which
can be an important prognostic factor in patients with
ventricular tachycardia or syncope. Echocardiography
should be performed in patients who present with syncope
that is not obviously neurocardiogenic to ensure that there
is no valvular or myocardial cause.
 TILT TABLE TESTING

• Tilt table testing is used to confirm the diagnosis of

neurocardiogenic syncope.

• The test involves continuous heart rate and blood pressure

monitoring during head-up tilting. After baseline
measurements in the supine position, the patient is tilted
(head-up to 60 to 80 degrees) for 60 minutes.
 ELECTROPHYSIOLOGIC STUDIES

• Electrophysiologic studies involve placement of several

transvenous catheters in the heart to perform temporary
measurements of intracardiac electrograms and to
perform pacing.
• Electrophysiologic studies are useful to identify the precise
mechanism of tachyarrhythmias and are a necessary
prelude to a curative ablation
 ELECTROPHYSIOLOGIC STUDIES

• Most arrhythmias, especially those with re-entrant mechanisms, can

be readily induced during electrophysiologic studies. In addition, the
existence and characteristics of accessory AV pathways (i.e., those
responsible for the Wolff-Parkinson-White syndrome or other re-
entrant tachyarrhythmia) can be readily assessed by an
electrophysiologic study.
• In patients with a previous myocardial infarction, electrophysiologic
studies are useful in determining the existence of the substrate for
ventricular arrhythmias, which may be treated with ablation or
implantable defibrillators. Electrophysiologic studies are also useful to
determine the integrity of the conduction system and the precise
mechanism of bradyarrhythmias that may be causing syncope.
 ELECTROPHYSIOLOGIC STUDIES

• Therefore, electrophysiologic studies are indicated in

patients with documented or suspected tachyarrhythmias
as a prelude to curative ablation; in patients with a
previous myocardial infarction and syncope, presyncope,
or palpitations to exclude ventricular tachycardia; and in
patients with severe or prolonged symptoms and no
apparent diagnosis by history or ambulatory monitoring,
especially in the setting of an abnormal ECG.
 EXERCISE TESTING

• Exercise testing can be useful to assess arrhythmias,

particularly in patients in whom symptoms are exercise
related.
• Exercise testing can also be useful in the evaluation of
patients with bradyarrhythmias to diagnose chronotropic
incompetence and can be useful in differentiating AV
block due to autonomic tone (improves with exercise) from
intrinsic conduction disease (generally worsens with
increasing rate).
 CLASSIFICATION OF ANTIARRHYTMIC DRUGS
I class – Na-channel blockers:
I A:
- Quinidine - supraventr.
- Disopyramide – supraventr.
- Novocainamide – universal
I B:
- Lidocaine – ventr.
- Diphenine (Phenytoin ) – ventr.
I C:
- Propafenone – ventr.
- Etmozine (Moracizine) – ventr.
- Ethacyzin – ventr.
II class – β- blockers - universal
- Propranolol
- Atenolol
III class – K-channel blockers – universal
- Cordarone ( Amiodaron )
- SotaHEXAL ( Sotalol )
IV class – Ca – channel blockers - supraventr.
- Verapamil
- Diltiazem
V class – glycosides
- Digoxin - supraventr.
 ESC GUIDELINES 2010
ON THE
MANAGEMENT OF
ATRIAL FIBRILLATION

EUROPEAN HEART
JOURNAL 2010

European Heart Rhythm Association (EHRA);

Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)

European Heart Journal (2010) 31, 2369-2429

CLINICAL EVENTS (OUTCOMES)
AFFECTED BY AF
CONDITIONS PREDISPOSING TO, OR
ENCOURAGING PROGRESSION OF AF
TYPES OF ATRIAL
FIBRILLATION
 EHRA SCORE OF AF- RELATED
SYMPTOMS

AF = atrial fibrillation; EHRA = European Heart Rhythm Association

 DIAGNOSIS AND INITIAL
MANAGEMENT OF AF

Class of recommendation.
a

Level of evidence.
b

AF = atrial fibrillation; ECG = electrocardiogram; EHRA = European Heart Rhythm Association.

GENERAL MANAGEMENT OF THE
AF PATIENT
 THE MANAGEMENT CASCADE FOR
PATIENTS WITH AF

ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker;
PUFA = polyunsaturated fatty acid; TE = thrombo-embolism.
PREVENTION OF THROMBOEMBOLISM IN AF
 CHADS2 SCORE AND STROKE
RATE

*The adjusted stroke rate was derived from the multivariable analysis assuming no aspirin usage; these stroke rates are
based on data from a cohort of hospitalised AF patients, published in 2001, with low numbers in those with a CHADS2 score
of 5 and 6 to allow an accurate judgement of the risk in these patients. Given that stroke rates are declining overall, actual
stroke rates in contemporary non-hospitalised cohorts may also vary from these estimates. Adapted from Gage BF et al.
AF = atrial fibrillation; CHADS 2 = cardiac failure, hypertension, age, diabetes, stroke (doubled).
 RISK FACTOR-BASED POINT-BASED
SCORING
SYSTEM - CHA2DS2-VASC

*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary
cohorts may vary from these estimates.
 THE HAS-BLED BLEEDING RISK
SCORE

*Hypertension is defined as systolic blood pressure > 160 mmHg.

INR = international normalized ratio.
 DRUGS AND DOSES FOR
PHARMACOLOGICAL
CONVERSION OF (RECENT-ONSET) AF

ACS = acute coronary syndrome; AF = atrial fibrillation; DCC = direct current cardioversion; i.v. = intravenous;
N/A = not applicable; NYHA, New York Heart Association; p.o. = per os; QRS = QRS duration; QT = QT interval;
T-U = abnormal repolarization (T-U) waves.
CHOICE OF RATE AND RHYTHM
CONTROL STRATEGIES
 DCC AND PHARMACOLOGICAL CONVERSION
RECENT-ONSET AF

AF = atrial fibrillation; i.v. = intravenous.

 DC (DIRECT CURRENT)
CARDIOVERSION FOR
AF

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; DCC = direct current cardioversion.

 RATE AND RHYTHM
CONTROL OF AF

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; EHRA = European Heart Rhythm Association.

OPTIMAL LEVEL OF HEART
RATE CONTROL
 RATE CONTROL OF ATRIAL
FIBRILLATION
The choice of drugs depends on life style and underlying disease
 DRUGS FOR

RATE
CONTROL

ER = extended release formulations; N/A = not

applicable. ‡Only in patients with non-permanent
atrial fibrillation.
 ACUTE RATE
CONTROL IN AF

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; i.v. = intravenous.

 LONG-TERM RATE CONTROL
IN AF

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; bmp = beats per minute; LV = left ventricular; NYHA = New York Heart Association.
 LEFT ATRIAL CATHETER
ABLATION

Class of recommendation.
a

Level of evidence.
b

AF = atrial fibrillation; i.v. = intravenous; LMWH = low molecular weight heparin; OAC = oral anticoagulant;
UFH = unfractionated heparin.
 AV NODE ABLATION IN AF
PATIENTS

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronization therapy; LV = left ventricular;

LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
 PRINCIPLES OF ANTIARRHYTHMIC DRUG
THERAPY TO MAINTAIN SINUS RHYTHM

1. Treatment is motivated by attempts to reduce AF-related

symptoms.
2. Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest.
3. Clinically successful antiarrhythmic drug therapy may reduce rather
than eliminate recurrence of AF.
4. If one antiarrhythmic drug ‘fails’ a clinically acceptable response
may be achieved with another agent.
5. Drug-induced proarrhythmia or extra-cardiac side-effects are
frequent.
6. Safety rather than efficacy considerations should primarily guide
the choice of antiarrhythmic agent.
 SUGGESTED DOSES AND MAIN CAVEATS FOR
COMMONLY USED ANTIARRHYTHMIC DRUGS

AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
 SUGGESTED DOSES AND MAIN CAVEATS FOR
COMMONLY USED ANTIARRHYTHMIC DRUGS
(CONTD)

AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
 SUGGESTED DOSES AND MAIN CAVEATS FOR
COMMONLY USED ANTIARRHYTHMIC DRUGS
(CONTD)

AF = atrial fibrillation; AV = atrioventricular; bpm = beats per minute; CYP = cytochrome P; ECG = electrocardiogram;
LV = left ventricular; NYHA = New York Heart Association.
 CHOICE OF AN ANTIARRHYTHMIC DRUG
FOR AF CONTROL

Class of recommendation. bLevel of evidence.

a

AF = atrial fibrillation; AV = atrioventricular; LoE = level of evidence; NYHA = New York Heart Association.