Summary of arrhythmias

Rhythm or Rate Disorder Features Treatment

Sinus arrhythmia -the sinus rate increases during inspiration and slows no need for treatment
during expiration
-its absence is due to autonomic neuropathy (like DM)
Sinus tachycardia -sinus rate of more than 100/min (not exceed 150 bpm) -Treat the underlying cause
-due to anxiety, fever, anemia, HF, thyrotoxicosis, -if not, use B-blockers or CCB
pheochromocytoma, drugs like B-agonist, ...
Atrial ectopic -Abnormal P-wave with normal QRS complex
-No need for Rx
beats -these are of no consequence / just sensation of missed
-B-blockers if the symptoms are
(extrasystoles, or strong beats
intrusive
premature beats) -if frequent (more than 1% of all the beats of 24 hrs by
holter—> may herald AF
-may be couplet or triplet, if more than 3 —> atrial
tachycardia

Atrial tachycardia -abnormal P-wave with narrow QRS complex + rate -β-blockers, class I or III anti-
more than 100 bpm arrhythmic drugs.
-due to atrial automaticity, sinoatrial disease or digoxin -catheter ablation for ectopic site
toxicity

Atrial flutter -due to macro re-entry (usually within the RA) B-blocker, digoxin, verapamil,
-atrial rate 300/min, and ventricular rate 75-150/min (if no response) --> DC or IV
(due to AV block) amiodarone (if no response)
-The ECG shows -Atrial flutter should always be suspected when there is —> catheter ablation
sawtoothed flutter a narrow-complex tachycardia of 150/min.
waves. -carotid sinus pressure or adenosine —> establish diagnosis
Atrial Fibrillation -abnormal automatic firing and the presence of multiple early treatment of AF will
(AF) interacting re-entry circuits looping around the atria. prevent re-initiation of the
-usually initiated by rapid bursts of ectopic beats arising arrhythmia.
from conducting tissue in the pulmonary veins or from
diseased atrial tissue -Assessment of patients with
-Re-entry is more likely to occur in atria that are enlarged newly diagnosed AF includes
-uncoordinated and ineffective contraction a full history, physical
-The ventricles are activated irregularly at a rate examination, 12-lead ECG,
determined by conduction through the AV node. echocardiogram and thyroid
-This produces the characteristic ‘irregularly irregular’ function tests.
pulse.
AF can be classified as: Rx of Paroxysmal
-paroxysmal (intermittent episodes which self-terminate atrial fibrillation
within 7 days),
-persistent (prolonged episodes that can be terminated
by electrical or chemical cardioversion) or Rx of persistent &
-permanent. permanent AF
-causes of AF : CAD, valvular heart disease (especially
rheumatic mitral disease) , HTN, sinoatrial disease,
hyperthyroidism, alcohol, CMP, CHD, pericardial disease Prevention of
disease, PE, chest infection, idiopathic (lone AF) thromboembolism
-AF can cause palpitation, breathlessness and fatigue, it
may precipitate or aggravate cardiac failure
-A fall in BP may cause lightheadedness, and chest pain
may occur with underlying coronary artery disease.
-it may be asymptomatic in elderly.
-the most disabling consequence is its association with
stroke and systemic embolism.
SVT/AVNRT -re-entry circuit or automatic focus involving -Treatment is not always necessary.
the atria -an episode may be terminated by
-regular tachycardia with a rate of 120–240/ carotid sinus pressure or by the Valsalva
min with narrow QRS manœuvre.
-The patient is usually aware of a rapid, very -IV adenosine, verapamil, B-blockers,
flecainide
forceful, regular heart beat and may
-in rare cases (hemodynamically
experience chest discomfort, lightheadedness
unstable) —> DC
or breathlessness.
-Polyuria, mainly due to the release of atrial For recurrent cases : catheter ablation
natriuretic peptide, is sometimes a feature. or prophylaxis with oral B-blocker,
varapamil or flecainide
-catheter ablation (first-line treatment)
WPW & AVNRT -flecainide or amiodarone can also be
used

*digoxin & verapamil shorten the

refractory period and should be
avoided.

-absent P-wave, broad bizarre QRS complex + pause

Ventricular ectopic -may be there are couplet, triplet, or bigeminy, ... -if it is frequent post-MI —> no need for
beats (extrasystoles,
-Ectopic beats produce a low stroke volume —> give treatment
premature beats) irregular, with weak or missed beats
-Ventricular ectopic beats in otherwise healthy subjects -if it is persistent, frequent (10 beats/hr)
—> disappear with exercise, treatment is not necessary, —> B-blockers and treat the underlying
if symptomatic —> may need B-blocker or catheter cause
ablation
-Ventricular ectopic beats associated with heart disease
—> may a/w MI, HF , CMP, digoxin toxicity, mitral
valve prolapse, and may occur as 'escape beats' in the
presence of an underlying bradycardia.
 -It is caused by abnormal automaticity or triggered activity in Rx : When there is doubt, it is safer to
Ventricular manage the problem as VT.
ischaemic tissue, or by re-entry within scarred ventricular
tachycardia (VT) -DC cardioversion —> if the BP < 90 mmHg
tissue.
-a/w MI, CAD, CMP, LV dysfunction, LV aneurysm -if the arrhythmia is well tolerated —> IV
-may lead to hemodynamic compromise or degenerate to amiodarone
VF -any electrolyte disturbance should be
-Patients may complain of palpitation or symptoms of low corrected
cardiac output, e.g. dizziness, dyspnoea or syncope.
-VT may be difficult to distinguish from SVT with bundle For prevention :
branch block or pre-excitation (WPW syndrome) —> can be -B-blockers +/- amiodarone
differentiated if : A history of myocardial infarction, AV -patients at high risk of arrhythmic death
dissociation (pathognomonic), Capture/fusion beats (e.g. those with poor left ventricular
(pathognomonic,), Extreme left axis deviation, Very broad function, or where VT is associated with
QRS complexes (> 140 ms), No response to carotid sinus haemodynamic compromise) —> use ICD
massage or i.v. adenosine -surgery (e.g. aneurysm resection) or
-post-MI VT may be a good sign which indicates reperfusion catheter ablation can also be used
of the infarct territory (do not require treatment)
Ventricular -produce rapid, ineffective, unccordinated movement of the Rx: DC cardioversion is the only
fibrillation (VF) ventricles effective treatment (within 3
-produce no pulse minutes)
-ECH shows chaotic, bizarre, irregular ventricular complexes

Torsades de -form of polymorphic VT -treat the underlying cause like hypo Mg, hypo
K, hypo Ca, drugs like sotalol, amiodarone,
pointes -it is a Cx of prolonged V. depolarization (prolonged erythromycin, congenital syndrome like long QT
QT interval) -IV Mg should be given in all cases
-ECG : rapid irregular complexes that oscillate from an -atrial pacing or IV isoprenaline (avoided in
congenital long QT syndromes)
upright to an inverted position and seem to twist around -B-blockers —> prevent syncope in congenital
the baseline long QT syndromes
-may degenerate to VF -ICD : for extreme QT interval prolongation
-left stellate ganglion block : for resistant cases

Burgada syndrome -genetic disorder (Na channels defects) -RX : treat the symptoms
-presents with polymorphic VT or sudden death
-ECG : RBBB + ST elevation in V1 & V2
First degree -AV conduction is delayed and Rx : treat the underlying cause
heart block -constant PR interval prolongation (> 5 ss)
-may be related to increased age or drugs
-rarely symptomatic
Second degree -progressive prolongation which is followed by -no need for treatment
heart block dropped beat —> then the cycle is re-initiated
Mobitz type 1 -may be physiological and sometimes observed at
(Wenchebach’s rest or during sleep in athletic young adults with high
phenomenon) vagal tone and may also related to increased age or
drug, but not indicate ischemia
-rarely symptomatic
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Second degree -fixed PR interval —> then sudden dropped beat -Rx : permanent pacemaker
heart block -may indicate ischemia
Mobitz type 2

Third degree -there is AV dissociation (the atria and ventricles beat need permanent pacemaker if :
(complete) heart independently) 1-congenital cause with
block (CHB) -Cannon waves may be visible in the neck and the symptoms
intensity of the first heart sound varies due to the loss 2-chronic acquired cause with
of AV synchrony. symptoms
-causes : congenital or acquired (idiopathic fibrosis, 3-acute anteriolateral or
ischemia, acute inflammation like aortic root abscess extensive MI (either
in endocarditis, chronic inflammation like sarcoidosis, symptomatic or not)
trauma like in cardiac surgery, drugs like digoxin or 4-inferior MI which is not return
B-blockers) to the normal after one week
Stokes-Adams -episodes of ventricular asystole Rx : treat the underlying cause
attacks -may complicate CHB, Mobitz type 2 or occur in pt
woth sinoatrial disease
-lead to sudden LOC that occurs without warning
and results in collapse (pallor and death-like
appearnace) and a brief anoxic seizure may occur
if there is prolonged asystole
-unlike epilepsy, recovery is rapid
RBBB & LBBB

Sinoatrial disease (sick sinus syndrome)

Sinus bradycardia Rx :
-treat the underlying cause --> if
no response --> give atropin,
isoprenaline, salbutamol —> if no
response --> pacemaker
Sinus arrest -sudden disappearance of Q wave Rx : if the arrest is more than 2 sec
(10 LS) —> permanent pacemaker
Bradycardia- -when the atrial tachycardia such as AF is Rx : permanent pacemaker (even
tachycardia syndrome terminated, the underlying rhythm may reveal if the pt is asymptomatic)
bradycardia, SA exit block, or even complete atrial
standstill with escape rhythm