Cardiac Arrhythmias:

Concise Clinical Notes

Definition
An arrhythmia is any deviation from the normal sinus rhythm. The normal heart
rate is 60–100 bpm with regular conduction through SA node → AV node →
Bundle of His → Bundle branches → Purkinje fibers.

Classification by Heart Rate

Category Rate Definition
Normal Sinus 60–100 bpm Regular cardiac rhythm
Rhythm
Bradyarrhythmia <60 bpm Abnormally slow heart
rate
Tachyarrhythmia >100 bpm Abnormally fast heart
rate

Classification by Origin
1. Supraventricular Arrhythmias (SVT)
Atrial Arrhythmias:

 Atrial Fibrillation (AF): Irregular, rapid atrial activation (>300 bpm);

irregular ventricular response

o ECG: Absent P waves, irregularly irregular QRS complexes,

baseline fibrillation waves
o Complications: Stroke risk (CHA₂DS₂-VASc scoring), heart failure
o Management: Anticoagulation (ABC pathway), rate/rhythm control
 Atrial Flutter: Regular atrial contractions (250–350 bpm); 2:1 or 4:1 AV
conduction typical

o ECG: Saw-tooth P waves (flutter waves), regular QRS intervals

 o Management: Similar to AF; often more responsive to
cardioversion
 Atrial Tachycardia (AT): Focal rapid discharge from atrial tissue

o ECG: Distinct P wave morphology different from sinus P waves

Nodal Arrhythmias:

 AVNRT (Atrioventricular Nodal Reentrant Tachycardia): Most

common SVT; reentry within or around AV node

o HR: 140–250 bpm; narrow complex

o ECG: P waves buried in/after QRS; adenosine-responsive
o Management: Vagal maneuvers → Adenosine → Ablation
 AVRT (Atrioventricular Reentrant Tachycardia): Reentry via
accessory pathway

o Often associated with Wolff-Parkinson-White (WPW) syndrome

o ECG during sinus rhythm: Short PR interval, delta wave (slurred
QRS upstroke)
o Management: Avoid AV nodal blockers in WPW with AF (risk of
rapid conduction via bypass tract)

2. Ventricular Arrhythmias
Premature Ventricular Contractions (PVCs):

 Single ectopic beats from ventricular myocardium

 ECG: Wide QRS (>120 ms), no preceding P wave, compensatory pause
 Benign if isolated; concerning if frequent or multifocal
Ventricular Tachycardia (VT):

 3 consecutive PVCs at rate >100 bpm

 Monomorphic VT: Single QRS morphology (usually reentrant);

associated with structural disease
 Polymorphic VT: Varying QRS morphology; often reflects severe
electrolyte abnormalities
 Torsades de Pointes: Polymorphic VT with twisting axis; associated with
prolonged QT interval
 Management: Antiarrhythmics (amiodarone preferred), ICD placement for
secondary prevention
Ventricular Fibrillation (VF):

 Chaotic, unorganized ventricular activity; no mechanical output

 ECG: Irregular, undulating baseline; no discrete QRS, P, or T waves
  Medical emergency: Immediate CPR and defibrillation

3. Bradyarrhythmias
Sinus Bradycardia: HR <60 bpm; normal P-QRS-T morphology

 Causes: Athletic training, hypothyroidism, increased ICP, drug effects

(beta-blockers, digoxin, Ca²⁺ channel blockers)
 Management: Treat underlying cause; pacing if symptomatic
Sinoatrial (SA) Block: Intermittent failure of SA node impulse conduction

 ECG: Abrupt P wave drop-out; pause lasting multiple P-P intervals

AV Block:

 First-Degree: Prolonged PR interval (>200 ms); all impulses conduct

 Second-Degree (Mobitz I/Wenckebach): Progressive PR prolongation
until P wave blocked; then cycle repeats
 Second-Degree (Mobitz II): Fixed PR intervals with sudden P wave
dropout
 Third-Degree (Complete AV Block): No atrial impulses conduct;
independent atrial and ventricular rhythms
 Management: Pacing if symptomatic or Mobitz II/3rd-degree block

Pathophysiologic Mechanisms
1. Enhanced Automaticity
 Increased spontaneous depolarization in pacemaker cells
 Occurs in SA node, atrium, AV node, or ventricle
 Causes: Sympathetic stimulation, catecholamines, ischemia, fever

2. Abnormal Automaticity
 Spontaneous depolarization in non-pacemaker tissue
 Usually seen in ischemia or acidosis

3. Reentry (Most Common Mechanism)

 Impulse travels along two conduction pathways with different conduction
velocities/refractory periods
 Impulse blocks one pathway but conducts the other
 Loop-back conduction reexcites the rested tissue
 Examples: AVNRT, AVRT, VT in old MI
4. Triggered Activity
 Early Afterdepolarizations (EADs): Repolarization interrupted; seen in
prolonged QT (drugs, electrolyte abnormalities)
 Delayed Afterdepolarizations (DADs): Spontaneous depolarization
during phase 4; from Ca²⁺ overload
 Associated: Digoxin toxicity, catecholaminergic polymorphic VT (CPVT)

ECG Interpretation: Key Features

Arrhythmia Rate QRS Width P Wave Management
Priority
AF Irregular 90– Narrow Absent/ Anticoagulat
180 buried ion, rate
control
SVT 140–250 Narrow Buried/ Adenosine,
(AVNRT) retrograde ablation
VT 100–250 Wide Dissociated Amiodarone,
ICD
VF Chaotic None None Immediate
CPR/defibrill
ation
Bradycardia <60 Normal Normal Pacing if
symptomatic

Clinical Presentation
Feature Description
Symptoms Palpitations, dyspnea, chest
discomfort, syncope, presyncope,
fatigue
Asymptomatic Many arrhythmias (AF, PVCs, SVT)
may be detected incidentally on ECG
or monitoring
Hemodynamic Effect Depends on rate and underlying
cardiac function; VF → immediate
collapse
Red Flags Syncope, VT/VF, rapid rates >150
bpm, acute decompensation
Diagnostic Approach
1. 12-lead ECG: First-line; captures morphology, rate, conduction intervals
2. Continuous Monitoring (Holter/Event Monitor): Captures paroxysmal
arrhythmias
3. Electrophysiology (EP) Study: Reserved for diagnostic uncertainty or
ablation planning
4. Echocardiography: Assess structural disease, ejection fraction,
thrombus (especially AF)
5. Labs: Electrolytes (K⁺, Mg²⁺, Ca²⁺), troponin, TSH, digoxin levels if
applicable

Management Overview (ABC

Pathway for AF as Example)
A: Anticoagulation
 Assess stroke risk via CHA₂DS₂-VASc score
 Anticoagulation with DOAC or warfarin if score ≥1

B: Better Symptom Control

 Rate Control: Target HR <110 bpm at rest; beta-blockers, Ca²⁺ channel
blockers, digoxin
 Rhythm Control: Antiarrhythmic drugs (amiodarone, sotalol, flecainide),
catheter ablation

C: Cardiovascular Risk Factor & Comorbidity

Management
 Treat hypertension, diabetes, heart failure, CKD
 Lifestyle modification: Weight loss, exercise, alcohol/caffeine reduction

Acute Management Summary

Arrhythmia First-Line Second-Line
SVT (AVNRT/AVRT) Vagal maneuver / Verapamil, diltiazem, or
Adenosine 6 mg IV beta-blockers
Atrial Flutter with Rate control (AV nodal Cardioversion if
RVR blocker) hemodynamic
compromise
AF with RVR Rate control (AV nodal Cardioversion;
blocker) anticoagulation
VT Amiodarone 150 mg IV Synchronized
(Hemodynamically over 10 min cardioversion if
Stable) worsens
VT/VF (Unstable) Immediate ICD placement for
unsynchronized secondary prevention
defibrillation + ACLS
Bradycardia Atropine 0.5–1 mg IV; Permanent pacing for
(Symptomatic) temporary pacing if chronic disease
refractory

Drug Interactions &

Contraindications
 Avoid AV nodal blockers (beta-blockers, Ca²⁺ channel blockers) in
WPW with AF → risk of rapid accessory pathway conduction
 QT-prolonging drugs (amiodarone, sotalol, antipsychotics, antiemetics)
+ electrolyte abnormalities → Torsades risk
 Digoxin toxicity → PVCs, AV block, SVT; narrow therapeutic window;
monitor levels

Key Clinical Pearls

1. Always obtain ECG during or immediately after arrhythmia symptoms
2. Hemodynamic stability guides management → unstable arrhythmia =
cardioversion first
3. Treat underlying cause (anemia, hyperthyroidism, pneumonia,
dehydration, electrolyte abnormalities)
4. AF stroke risk is not based on symptom severity; anticoagulation
decision independent of symptoms
5. Accessory pathways (WPW) require careful drug selection to avoid
sudden cardiac death if AF develops
 6. Prolonged QT = Torsades risk; avoid QT-prolonging drugs and correct
electrolytes
7. Asymptomatic arrhythmias often require monitoring/treatment based
on underlying disease and hemodynamic effects
8. Reentry mechanisms respond well to adenosine and catheter ablation;
automaticity-based arrhythmias may require antiarrhythmic drugs

Summary Table: Arrhythmia at a

Glance
Type Rate QRS P Wave Cause Treatment
Sinus 60–100 Normal Normal — —
Rhythm
AF Irregular Narrow Absent Structural Anticoagu
90–180 disease, lation,
HTN rate/rhyth
m control
SVT 140–250 Narrow Buried Reentry, Adenosine
dual , ablation
pathways
VT 100–250 Wide Dissociate MI, Amiodaro
d cardiomyo ne, ICD
pathy
VF Chaotic — — Acute MI, Defibrillat
severe ion, ACLS
ischemia
Bradycar <60 Normal Normal Sick Pacing if
dia sinus, AV symptoma
block tic

References
1. Steinbeck G, et al. NCBI StatPearls: Arrhythmias. 2023.
2. Hindricks G, et al. ESC Guidelines on Atrial Fibrillation. European Heart
Journal. 2020.
3. Mayo Clinic. Heart Arrhythmia: Diagnosis and Treatment. 2023.
4. Issa ZF, Miller JM, Zipes DP. Clinical Arrhythmology and
Electrophysiology: A Companion to Braunwald's Heart Disease. 3rd ed.
2019.