ARRHYTHMIA Edited by Yingmin Chen

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ARRHYTHMIAEdited by Yingmin Chen
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• Definition of Arrhythmia
• The Origin, Rate, Rhythm, Conduct velocity and
  sequence of heart activation are abnormally.

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Anatomy of the conducting system
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Pathogenesis and Inducement of Arrhythmia

• Some physical condition
• Pathological heart disease
• Other system disease
• Electrolyte disturbance and acid-base imbalance
• Physical and chemical factors or toxicosis

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Mechanism of Arrhythmia

• Abnormal heart pulse formation
• Sinus pulse
• Ectopic pulse
• Triggered activity
• Abnormal heart pulse conduction
• Reentry
• Conduct block

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Classification of Arrhythmia

• Abnormal heart pulse formation
• Sinus arrhythmia
• Atrial arrhythmia
• Atrioventricular junctional arrhythmia
• Ventricular arrhythmia
• Abnormal heart pulse conduction
• Sinus-atrial block
• Intra-atrial block
• Atrio-ventricular block
• Intra-ventricular block
• Abnormal heart pulse formation and conduction

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Diagnosis of Arrhythmia

• Medical history
• Physical examination
• Laboratory test

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Therapy Principal

• Pathogenesis therapy
• Stop the arrhythmia immediately if the
  hemodynamic was unstable
• Individual therapy

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Anti-arrhythmia Agents

• Anti-tachycardia agents
• Anti-bradycardia agents

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Anti-tachycardia agents

• Modified Vaugham Williams classification
• I class Natrium channel blocker
• II class ß-receptor blocker
• III class Potassium channel blocker
• IV class Calcium channel blocker
• Others Adenosine, Digital

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Anti-bradycardia agents

• ß-adrenic receptor activator
• M-cholinergic receptor blocker
• Non-specific activator

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Clinical usage

• Anti-tachycardia agents
• Ia class Less use in clinic
• Guinidine
• Procainamide
• Disopyramide Side effect like M-cholinergic
  receptor blocker

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• Anti-tachycardia agents
• Ib class Perfect to ventricular tachyarrhythmia
• 1. Lidocaine
• 2. Mexiletine

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• Anti-tachycardia agents
• Ic class Can be used in ventricular and/or
  supra-ventricular tachycardia and extrasystole.
• 1. Moricizine
• 2. Propafenone

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Anti-tachycardia agents

• II class ß-receptor blocker
• Propranolol Non-selective
• Metoprolol Selective ß1-receptor blocker,
  Perfect to hypertension and coronary artery
  disease patients associated with tachyarrhythmia.
  

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Anti-tachycardia agents

• III class Potassium channel blocker,
  extend-spectrum anti-arrhythmia agent.
• Amioarone Perfect to coronary artery disease and
  heart failure patients
• Sotalol Has ß-blocker effect
• Bretylium

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Anti-tachycardia agents

• IV class be used in supraventricular tachycardia
• Verapamil
• Diltiazem
• Others
• Adenosine be used in supraventricular
  tachycardia

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Anti-bradycardia agents

• Isoprenaline
• Epinephrine
• Atropine
• Aminophylline

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Proarrhythmia effect of antiarrhythmia agents

• Ia, Ic class Prolong QT interval, will cause VT
  or VF in coronary artery disease and heart
  failure patients
• III class Like Ia, Ic class agents
• II, IV class Bradycardia

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Non-drug therapy

• Cardioversion For tachycardia especially
  hemodynamic unstable patient
• Radiofrequency catheter ablation (RFCA) For
  those tachycardia patients (SVT, VT, AF, AFL)
• Artificial cardiac pacing For bradycardia, heart
  failure and malignant ventricular arrhythmia
  patients.

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Sinus Arrhythmia
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Sinus tachycardia

• Sinus rate gt 100 beats/min (100-180)
• Causes
• Some physical condition exercise, anxiety,
  exciting, alcohol, coffee
• Some disease fever, hyperthyroidism, anemia,
  myocarditis
• Some drugs Atropine, Isoprenaline
• Neednt therapy

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Sinus Bradycardia

• Sinus rate lt 60 beats/min
• Normal variant in many normal and older people
• Causes Trained athletes, during sleep, drugs
  (ß-blocker) , Hypothyriodism, CAD or SSS
• Symptoms
• Most patients have no symptoms.
• Severe bradycardia may cause dizziness, fatigue,
  palpitation, even syncope.
• Neednt specific therapy, If the patient has
  severe symptoms, planted an pacemaker may be
  needed.

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Sinus Arrest or Sinus Standstill

• Sinus arrest or standstill is recognized by a
  pause in the sinus rhythm.
• Causes myocardial ischemia, hypoxia,
  hyperkalemia, higher intracranial pressure, sinus
  node degeneration and some drugs (digitalis,
  ß-blocks).
• Symptoms dizziness, amaurosis, syncope
• Therapy is same to SSS

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Sinoatrial exit block (SAB)

• SAB Sinus pulse was blocked so it couldnt
  active the atrium.
• Causes CAD, Myopathy, Myocarditis, digitalis
  toxicity, et al.
• Symptoms dizziness, fatigue, syncope
• Therapy is same to SSS

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Sinoatrial exit block (SAB)

• Divided into three types Type I, II, III
• Only type II SAB can be recognized by EKG.

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Sick Sinus Syndrome (SSS)

• SSS The function of sinus node was degenerated.
  SSS encompasses both disordered SA node
  automaticity and SA conduction.
• Causes CAD, SAN degeneration, myopathy,
  connective tissue disease, metabolic disease,
  tumor, trauma and congenital disease.
• With marked sinus bradycardia, sinus arrest,
  sinus exit block or junctional escape rhythms
• Bradycardia-tachycardia syndrome

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Sick Sinus Syndrome (SSS)

• EKG Recognition
• Sinus bradycardia, 40 bpm
• Sinus arrest gt 3s
• Type II SAB
• Nonsinus tachyarrhythmia ( SVT, AF or Af).
• SNRT gt 1530ms, SNRTc gt 525ms
• Instinct heart rate lt 80bmp
  
  

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Sick Sinus Syndrome (SSS)

• Therapy
• Treat the etiology
• Treat with drugs anti-bradycardia agents, the
  effect of drug therapy is not good.
• Artificial cardiac pacing.

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Atrial arrhythmia
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Premature contractions

• The term premature contractions are used to
  describe non sinus beats.
• Common arrhythmia
• The morbidity rate is 3-5

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Atrial premature contractions (APCs)

• APCs arising from somewhere in either the left or
  the right atrium.
• Causes rheumatic heart disease, CAD,
  hypertension, hyperthyroidism, hypokalemia
• Symptoms many patients have no symptom, some
  have palpitation, chest incomfortable.
• Therapy Neednt therapy in the patients without
  heart disease. Can be treated with ß-blocker,
  propafenone, moricizine or verapamil.

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Atrial tachycardia

• Classify by automatic atrial tachycardia (AAT)
  intra-atrial reentrant atrial tachycardia (IART)
  chaotic atrial tachycardia (CAT).
• Etiology atrial enlargement, MI chronic
  obstructive pulmonary disease drinking
  metabolic disturbance digitalis toxicity
  electrolytic disturbance.

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Atrial tachycardia

• May occur transient intermittent or persistent.
  
• Symptoms palpitation chest uncomfortable,
  tachycardia may induce myopathy.
• Auscultation the first heart sound is variable

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Intra-atrial reentry tachycardia (IART)

• ECG characters
• Atrial rate is around 130-150bpm
• P wave is different from sinus P wave
• P-R interval 0.12
• Often appear type I or type II, 21 AV block
• EP study atrial program pacing can induce and
  terminate tachycardia

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Automatic atrial tachycardia (AAT)

• ECG characters
• Atrial rate is around 100-200bpm
• Warmup phenomena
• P wave is different from sinus P wave
• P-R interval 0.12
• Often appear type I or type II, 21 AV block
• EP study Atrial program pacing cant induce or
  terminate the tachycardia

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Chaotic atrial tachycardia (CAT)

• Also termed Multifocal atrial tachycardia.
• Always occurs in COPD or CHF,
• Have a high in-hospital mortality ( 25-56).
  Death is caused by the severity of the underlying
  disease.
• ECG characters
• Atrial rate is around 100-130bpm
• The morphologies P wave are more than 3 types.
• P-P, P-R and R-R interval are different.
• Will progress to af in half the cases
• EP study Atrial program pacing cant induce or
  terminate the tachycardia

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Therapy

• IRAT Esophageal Pulsation Modulation, RFCA, Ic
  and IV class anti-tachycardia agents
• AAT Digoxin, IV, II, Ia and III class
  anti-tachycardia agents RFCA
• CAT treat the underlying disease, verapamil or
  amiodarone.
• Associated with SSS Implant pace-maker.

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Atrial flutter

• Etiology
• It can occur in patients with normal atrial or
  with abnormal atrial.
• It is seen in rheumatic heart disease (mitral or
  tricuspid valve disease), CAD, hypertension,
  hyperthyroidism, congenital heart disease, COPD.
• Related to enlargement of the atria
• Most AF have a reentry loop in right atrial

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Atrial flutter

• Symptoms depend on underlying disease,
  ventricular rate, the patient is at rest or is
  exerting
• With rapid ventricular rate palpitation,
  dizziness, shortness of breath, weakness,
  faintness, syncope, may develop angina and CHF.

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Atrial flutter

• Therapy
• Treat the underlying disease
• To restore sinus rhythm Cardioversion,
  Esophageal Pulsation Modulation, RFCA, Drug (III,
  Ia, Ic class).
• Control the ventricular rate digitalis. CCB,
  ß-block
• Anticoagulation

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Atrial fibrillation

• Subdivided into three types paroxysmal,
  persistent, permanent.
• Etiology
• Morbidity rate increase in older patients
• Etiology just like atrial flutter
• Idiopathic
• Mechanism
• Multiple wavelet re-entry
• Rapid firing focus in pulmonary vein, vena cava
  or coronary sinus.

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Atrial fibrillation

• Manifestation
• Affected by underlying diseases, ventricular rate
  and heart function.
• May develop embolism in left atrial. Have high
  incidence of stroke.
• The heart rate, S1 and rhythm is irregularly
  irregular
• If the heart rhythm is regular, should consider
  about (1) restore sinus rhythm (2) AF with
  constant the ratio of AV conduction (3)
  junctional or ventricular tachycardia (4) slower
  ventricular rate may have complete AV block.

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Atrial fibrillation

• Therapy
• Treat the underlying disease
• Restore sinus rhythm Drug, Cardioversion, RFCA,
  Maze surgery
• Rate control digitalis. CCB, ß-block
• Antithrombotic therapy Aspirine, Warfarin

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Atrioventricular Junctional arrhythmia
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Atrioventricular junctional premature contractions

• Etiology and manifestation is like APCs
• Therapy the underlying disease
• Neednt anti-arrhythmia therapy.

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Nonparoxysmal AV junctional tachycardia

• Mechanism relate to hyper-automaticity or
  trigger activity of AV junctional tissue
• Etiology digitalis toxicity inferior MI
  myocarditis acute rheumatic fever and
  postoperation of valve disease
• ECG the heart rate ranges 70-150 bpm or more,
  regular, normal QRS complex, may occur AV
  dissociation and wenckebach AV block

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Nonparoxysmal AV junctional tachycardia

• Therapy
• Treat underlying disease stopping digoxin,
  administer potassium, lidocaine, phenytoin or
  propranolol.
• Not for DC shock
• It can disappear spontaneously. If had good
  tolerance, not require therapy.

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Paroxysmal tachycardia

• Most PSVT (paroxysmal supraventricular
  tachycardia) is due to reentrant mechanism.
• The incidence of PSVT is higher in AVNRT
  (atrioventricular node reentry tachycardia) and
  AVRT (atioventricular reentry tachycardia), the
  most common is AVNRT (90)
• Occur in any age individuals, usually no
  structure heart disease.

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Paroxysmal tachycardia

• Manifestation
• Occur and terminal abruptly.
• Palpitation, dizziness, syncope, angina, heart
  failure and shock.
• The sever degree of the symptom is related to
  ventricular rate, persistent duration and
  underlying disease

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Paroxysmal tachycardia

• ECG characteristic of AVNRT
• Heart rate is 150-250 bpm, regular
• QRS complex is often normal, wide QRS complex is
  with aberrant conduction
• Negative P wave in II III aVF, buried into or
  following by the QRS complex.
• AVN jump phenomena

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Paroxysmal tachycardia

• ECG characteristic of AVRT
• Heart rate is 150-250 bpm, regular
• In orthodromic AVRT, the QRS complex is often
  normal, wide QRS complex is with antidromic AVRT
• Retrograde P wave, R-Pgt110ms.

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Paroxysmal tachycardia

• Therapy
• AVNRT orthodromic AVRT
• Increase vagal tone carotid sinus massage,
  Valsalva maneuver.if no successful,
• Drug verapamil, adrenosine, propafenone
• DC shock
• Antidromic AVRT
• Should not use verapamil, digitalis, and
  stimulate the vagal nerve.
• Drug propafenone, sotalol, amiodarone
• RFCA

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Pre-excitation syndrome(W-P-W syndrome)

• There are several type of accessory pathway
• Kent adjacent atrial and ventricular
• James adjacent atrial and his bundle
• Mahaim adjacent lower part of the AVN and
  ventricular
• Usually no structure heart disease, occur in any
  age individual

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WPW syndrome

• Manifestation
• Palpitation, syncope, dizziness
• Arrhythmia 80 tachycardia is AVRT, 15-30 is
  AFi, 5 is AF,
• May induce ventricular fibrillation

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WPW syndrome

• Therapy
• Pharmacologic therapy orthodrome AVRT or
  associated AF, AFi, may use Ic and III class
  agents.
• Antidromic AVRT cant use digoxin and verapamil.
• DC shock WPW with SVT, AF or Afi produce agina,
  syncope and hypotension
• RFCA

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Ventricular arrhythmia
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Ventricular Premature Contractions (VPCs)

• Etiology
• Occur in normal person
• Myocarditis, CAD, valve heart disease,
  hyperthyroidism, Drug toxicity (digoxin,
  quinidine and anti-anxiety drug)
• electrolyte disturbance, anxiety, drinking, coffee

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VPCs

• Manifestation
• palpitation
• dizziness
• syncope
• loss of the second heart sound

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PVCs

• Therapy treat underlying disease, antiarrhythmia
• No structure heart disease
• Asymptom no therapy
• Symptom caused by PVCs antianxiety agents,
  ß-blocker and mexiletine to relief the symptom.
• With structure heart disease (CAD, HBP)
• Treat the underlying diseas
• ß-blocker, amiodarone
• Class I especially class Ic agents should be
  avoided because of proarrhytmia and lack of
  benefit of prophylaxis

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Ventricular tachycardia

• Etiology often in organic heart disease
• CAD, MI, DCM, HCM, HF,
• long QT syndrome
• Brugada syndrome
• Sustained VT (gt30s), Nonsustained VT
• Monomorphic VT, Polymorphic VT

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Ventricular tachycardia

• Torsades de points (Tdp) A special type of
  polymorphic VT,
• Etiology
• congenital (Long QT),
• electrolyte disturbance,
• antiarrhythmia drug proarrhythmia (IA or IC),
• antianxiety drug,
• brain disease,
• bradycardia

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Ventricular tachycardia

• Accelerated idioventricular rhythm
• Related to increase automatic tone
• Etiology Often occur in organic heart disease,
  especially AMI reperfusion periods, heart
  operation, myocarditis, digitalis toxicity

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VT

• Manifestation
• Nonsustained VT with no symptom
• Sustained VT with symptom and unstable
  hemodynamic, patient may feel palpitation, short
  of breathness, presyncope, syncope, angina,
  hypotension and shock.

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VT

• ECG characteristics
• Monomorphic VT 100-250 bpm, occur and terminate
  abruptly,regular
• Accelerated idioventricular rhythm a runs of
  3-10 ventricular beats, rate of 60-110 bpm,
  tachycardia is a capable of warm up and close
  down, often seen AV dissociation, fusion or
  capture beats
• Tdp rotation of the QRS axis around the
  baseline, the rate from 160-280 bpm, QT interval
  prolonged gt 0.5s, marked U wave

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Treatment of VT

• Treat underlying disease
• Cardioversion Hemodynamic unstable VT
  (hypotension, shock, angina, CHF) or hemodynamic
  stable but drug was no effect
• Pharmacological therapy ß-blockers, lidocain or
  amiodarone
• RFCA, ICD or surgical therapy

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Therapy of Special type VT

• Accelerated idioventricular rhythm
• usually no symptom, neednt therapy.
• Atropine increased sinus rhythm
• Tdp
• Treat underlying disease,
• Magnesium iv, atropine or isoprenaline, ß-block
  or pacemaker for long QT patient
• temporary pacemaker

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Ventricular flutter and fibrillation

• Often occur in severe organic heart disease AMI,
  ischemia heart disease
• Proarrhythmia (especially produce long QT and
  Tdp), electrolyte disturbance
• Anaesthesia, lightning strike, electric shock,
  heart operation
• Its a fatal arrhythmia

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Ventricular flutter and fibrillation

• Manifestation
• Unconsciousness, twitch, no blood pressure
  and pulse, going to die
• Therapy
• Cardio-Pulmonary Resuscitate (CPR)
• ICD

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Cardiac conduction block

• Block position
• Sinoatrial intra-atrial atrioventricular
  intra-ventricular
• Block degree
• Type I prolong the conductive time
• Type II partial block
• Type III complete block

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Atrioventricular Block

• AV block is a delay or failure in transmission of
  the cardiac impulse from atrium to ventricle.
• Etiology
• Atherosclerotic heart disease myocarditis
  rheumatic fever cardiomyopathy drug toxicity
  electrolyte disturbance, collagen disease, levs
  disease.

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AV Block

• AV block is divided into three categories
• First-degree AV block
• Second-degree AV block further subdivided into
  type I and type II
• Third-degree AV block complete block

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AV Block

• Manifestations
• First-degree AV block almost no symptoms
• Second degree AV block palpitation, fatigue
• Third degree AV block Dizziness, agina, heart
  failure, lightheadedness, and syncope may cause
  by slow heart rate, Adams-Stokes Syndrome may
  occurs in sever case.
• First heart sound varies in intensity, will
  appear booming first sound

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AV Block

• Treatment
• I or II degree AV block neednt antibradycardia
  agent therapy
• II degree II type and III degree AV block need
  antibradycardia agent therapy
• Implant Pace Maker

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Intraventricular Block

• Intraventricular conduction system
• Right bundle branch
• Left bundle branch
• Left anterior fascicular
• Left posterior fascicular

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Intraventricular Block

• Etiology
• Myocarditis, valve disease, cardiomyopathy, CAD,
  hypertension, pulmonary heart disease, drug
  toxicity, Lenegre disease, Levs disease et al.
• Manifestation
• Single fascicular or bifascicular block is
  asymptom tri-fascicular block may have
  dizziness palpitation, syncope and Adams-stokes
  syndrome

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Intraventricular Block

• Therapy
• Treat underlying disease
• If the patient is asymptom no treat,
• bifascicular block and incomplete trifascicular
  block may progress to complete block, may need
  implant pace maker if the patient with syncope