![Page 1: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/1.jpg)
Tachydysrhythmias
TABAN MD.Internist & cardiologist
Tabriz medical faculty
![Page 2: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/2.jpg)
3 types of tachydysrhythmias
Re-entrant Respond well to electricity
Atrial fib and flutter PSVT Ventricular tachycardia
Monomorphic, Polymorphic (non-torsade) Some atrial tachycardias
Automatic Sinus, junctional, most atrial tach, MAT, AIVR
Triggered automaticity Some atrial tach, Torsades
![Page 3: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/3.jpg)
Re-entry Requires 2 functional pathways that differ in
their refractory periods. Triggered by early beat (e.g., PAC)
Atrium
Ventricle
AV nodeLA
LVSinus node
![Page 4: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/4.jpg)
Mechanism of Reentry
![Page 5: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/5.jpg)
Mechanism of Reentry
![Page 6: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/6.jpg)
Enhanced Automaticity--Pacemaker cell
Pacemaker has spontaneous depolarization Fires when reaches threshold
1) Enhanced Normal automaticity (normal pacer cells): Steepening of depolarization, usually by adrenergic stimulation Some Atrial and Junctional tachycardia
2) Abnormal automaticity Happening in tissues that are not normally pacemakers Myocardial ischemia or recent cardiac surgery
Accelerated idioventricular rhythm Atrial tachycardia, MAT
Diagnosis Accelerates and decelerates gradually Beat to beat variability
Treatment Do not respond well to standard interventions May respond to overdrive pacing
![Page 7: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/7.jpg)
Cardiac Action Potential
Automaticity depends on the slope of phase 4
![Page 8: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/8.jpg)
Triggered Automaticity/Dysrhythmias Afterdepolarizations
Early or Late afterdepolarizations
“R on T” phenomenon Long preceding R-R interval Conditions that prolong QT Occur in salvos More likely to occur when
sinus rate is slow Torsades de Pointes Digoxin toxicity
![Page 9: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/9.jpg)
Ventricular Tachycardia, wide (>120 ms) the origin of the arrhythmia is within the ventricles
Re-entrant Classic VT
Monomorphic Polymorphic
Triggered Torsade de pointe
Polymorphic long QT on baseline EKG
Automatic Accelerated Idioventricular
![Page 10: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/10.jpg)
WQRST تاکی تشخیص کاردی
![Page 11: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/11.jpg)
Wide Complex Tachycardia--Sinus tach with aberrancy vs.--SVT (PSVT, AF, flutter) with aberrancy vs. --Ventricular tachycardia
Pretest probability: Majority of wide complex tachycardia is
ventricular tachycardia
REMEMBER: VT does not invariably cause hemodynamic collapse; patients may be conscious and stable
![Page 12: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/12.jpg)
Clinical Clues to Basis for Regular Wide QRS Tachycardia
History of heart disease, especially prior myocardial infarction, suggests VT
Occurrence in a young patient with no known heart disease suggests SVT
12-lead EKG (if patient stable) should be obtained
![Page 13: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/13.jpg)
5 Questions in tachyarrhythmia 1- QRS:Wide or Narrow?Axis?Shap?
2- Regularity? Regular Regularly irregular Irregularly irregular
3- P-waves? 4- Rate?HR?
5- Rate change sudden or gradual?
![Page 14: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/14.jpg)
![Page 15: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/15.jpg)
![Page 16: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/16.jpg)
![Page 17: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/17.jpg)
1- QRS: Wide or Narrow
Narrow Sinus, PSVT, A flutter, A fib
(All without aberrancy)
Wide SVT with aberrancy
Ventricular tachycardia
![Page 18: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/18.jpg)
Aberrancy - SVT with wide complex
Abnormal ventricular conduction RBBB LBBB Nonspecific intraventricular conduction defect Rate-related BBB Antidromic Reciprocating
Goes down through bypass tract
![Page 19: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/19.jpg)
Suggest VT
In RBBB pattern > 140 ms
In LBBB pattern > 160 ms
![Page 20: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/20.jpg)
1- QRS: Shape? Typical or atypical LBBB/RBBB
Look for a true bundle branch block pattern Right or left (sinus or SVT with aberrancy)
absence of RS complex in all leads V1-V6 (negative Concordance)
![Page 21: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/21.jpg)
![Page 22: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/22.jpg)
Morphology criteria for VTRBBB
LBBB
V1 V6
V1V6
![Page 23: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/23.jpg)
![Page 24: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/24.jpg)
1-QRS: Axis
>45 degree
R in aVR
![Page 25: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/25.jpg)
1- QRS : Fusion beats / capture beats
Fusion beats (occasional narrow complex fused with wide one)
Capture beats
![Page 26: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/26.jpg)
![Page 27: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/27.jpg)
![Page 28: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/28.jpg)
Ectopic ventricular activation
Normal ventricular activation
Fusionbeat
Accelerated Idioventricular Rhythm ( Ventricular Escape Rate, but 100 bpm)
Sinus acceleration
![Page 29: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/29.jpg)
Ventricular tachycardia in the arrhythmogenic right ventricular dysplasia
![Page 30: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/30.jpg)
2- P waves If p waves, and associated with QRS, then
sinus (or, rarely, atrial tachycardia) PSVT: generally no p wave visible
PR short P wave hidden in QRS, inverted
A fib and flutter: No p waves, but flutter may fool you
V tach May rarely see P waves, but with no association(AV dissociation) or retrograde
![Page 31: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/31.jpg)
More R-Waves Than P-Waves Implies VT!
II
![Page 32: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/32.jpg)
P-waves in front of QRS?
![Page 33: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/33.jpg)
![Page 34: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/34.jpg)
SANode
Ventricular Focus
ATRIA AND VENTRICLESACT INDEPENDENTLY
AV Dissociation
![Page 35: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/35.jpg)
V1
Ventricular Tachycardia (VT)
• Rates range from 100-250 beats/min• Non-sustained or sustained • P waves often dissociated (as seen here)
![Page 36: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/36.jpg)
3- Regularity in tachycardia
Regular VT, Sinus, PSVT, flutter,
Regularly irregular Atrial flutter
Irregularly irregular AF, MAT
![Page 37: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/37.jpg)
![Page 38: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/38.jpg)
4- rate
Rate: the faster, the less likely it is sinus
(260 beats/min)
![Page 39: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/39.jpg)
5- Sudden vs. Gradual change(Re-entry vs. automaticity)
Sinus: gradual PSVT: sudden Atrial flutter: sudden AF: always changing, but sudden onset Ventricular tachycardia: Sudden
![Page 40: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/40.jpg)
Rate gradually changes or always the same? Gradual: sinus Unchanging: flutter vs. PSVT vs. v tach
![Page 41: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/41.jpg)
Very Fast and Irregular think :WPW and AF Never give AV nodal blocker
Never give Dig or Calcium channel blocker (IV).
Even adenosine associated with VF
Electrical or chemical conversion procainamide, amiodarone, ibutilide
WPW with regular rhythm (orthodromic/antidromic), not atrial fib:
•AV nodal blockers are OK
![Page 42: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/42.jpg)
Atrial Fibrillation with Rapid Conduction
Via Accessory Pathway: Degeneration to VF
![Page 43: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/43.jpg)
![Page 44: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/44.jpg)
تمرین :چند
Regular Wide QRS Tachycardia: VT or SVT with Aberrant Conduction?
![Page 45: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/45.jpg)
V1
![Page 46: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/46.jpg)
Identify ventricular tachycardia
Step 1: Is there absence of RS complex in all leads V1-V6? (Concordance) If yes, then rhythm is VT
Step 2: Is interval from onset of R wave to nadir of the S > 100 msec (0.10 sec) in any precordial leads? If yes, then rhythm is VT.
Step 3: Is there AV dissociation? If yes, then rhythm is VT.
Step 4: Are morphology criteria for VT present (not typical BBB)? If yes, then VT
> 0.10 sec?
Regular and wide
![Page 47: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/47.jpg)
![Page 48: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/48.jpg)
Ventricular Tachycardia Concordance Step 1: Absence of RS in all precordial leads
![Page 49: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/49.jpg)
![Page 50: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/50.jpg)
Ventricular TachycardiaVentricular Tachycardia
Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)
Step 2: RS in V5 > 0.10 ms, therefore v tach
Step 3: No AV dissociation
Step 4: RBBB pattern (tall R in V1). Notching of this monophasic R indicates VT
![Page 51: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/51.jpg)
V tachRS > 0.10 sec
![Page 52: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/52.jpg)
What is it?
![Page 53: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/53.jpg)
What is it?
![Page 54: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/54.jpg)
Tracing from a young boy with congenital long-QT syndrome. The QTU interval in the sinus beats is at least 600 milliseconds. Note TU wave alternans in the first and second complexes. A late premature complex occurring in the downslope of the TU wave initiates an episode of ventricular tachycardia
![Page 55: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/55.jpg)
Ventricular tachycardia originating from the right ventricular outflow tract. This tachycardia is characterized by a left bundle branch block contour in lead V1 and an inferior axis.
![Page 56: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/56.jpg)
Left septal ventricular tachycardia. This tachycardia is characterized by a right bundle branch block contour. In this instance, the axis was rightward. The site of the ventricular tachycardia was established to be in the left posterior septum by electrophysiological mapping and ablation.
![Page 57: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/57.jpg)
Ventricular Flutter
• VT 250 beats/min, without clear isoelectric line• Note “sine wave”-like appearance
![Page 58: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/58.jpg)
Ventricular Fibrillation (VF)
• Totally chaotic rapid ventricular rhythm• Often precipitated by VT• Fatal unless promptly terminated (DC shock)
![Page 59: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/59.jpg)
Sustained VT Degeneration to VF
![Page 60: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/60.jpg)
Artifact Mimicking “Ventricular Tachycardia”
Artifact precedes“VT”
QRS complexes “march through”the pseudo-tachyarrhythmia
![Page 61: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/61.jpg)
Ventricular flutter and ventricular fibrillation. A, The sine wave appearance of the complexes occurring at a rate of 300 beats/min is characteristic of ventricular flutter. B, The irregular undulating baseline typifies ventricular fibrillation.
![Page 62: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/62.jpg)
![Page 63: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/63.jpg)
![Page 64: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/64.jpg)
کاردی تاکی مرور
![Page 65: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/65.jpg)
![Page 66: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/66.jpg)
polymorphic ventricular tachycardia
Polymorphic VT Long QT on baseline ECG--Torsade de pointes Normal QT on baseline ECG = not Torsade
treat ischemia, correct electrolytes, amiodarone
![Page 67: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/67.jpg)
Polymorphic VT and prolonged QT (Torsade) Usually self terminating, may progress to v fib Treatment: correct electrolytes (K, Mg)
At risk of torsade: Mg, 2g over 15 minActive v tach: Mg, 2g over 30-60 sec, max 6gSerum K > 4.5Overdrive pacing (100-140)
Lowest pacing rate that prevents PVB’s dilantin, lidocaine
![Page 68: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/68.jpg)
Isoproterenol or beta blocker?
Beta blockers: long term therapy for familial LQTSLimited role for acute beta blockade in congenital
LQTS
Isoproterenol (beta 1 and 2 agonist) Can terminate acquired LQTS
Isoproterenol only if all of the below: Torsade is definitely the result of acquired LQTS Underlying bradycardia Pause dependent Pacing cannot be started immediately
![Page 69: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/69.jpg)
Accelerated idioventricular rhythm
Ventricular (wide) Automatic Regular No p-waves 60-100 (ventricular escape is 20-40) Reperfusion dysrhythmia
![Page 70: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/70.jpg)
Accelerated idioventricular rhythm
![Page 71: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/71.jpg)
Fast, Narrow, and Irregular
Atrial Fibrillation Irregularly irregular
Atrial Flutter Regularly irregular
Diagnosis may be aided by adenosine
![Page 72: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/72.jpg)
Identify DysrhythmiaFeatures
P-waves, regular, gradual rate change—sinus No p-waves, regular, 130-250
Narrow PSVT or flutter—intranodal (AVNRT) or orthodromic bypass
Wide Ventricular tachycardia
Most common PSVT with aberrancy
[intranodal or bypass tract (orthodromic)] PSVT due to antidromic reciprocating tachycardia Atrial Flutter with aberrancy
Regularly irregular Atrial Flutter
Irregularly irregular Atrial fibrillation, (V tach can be only slightly irreg irreg)
![Page 73: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/73.jpg)
درمان
![Page 74: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/74.jpg)
Is patient stable or unstable?
Patient has serious signs or symptoms? Look for Chest pain (ischemic? possible ACS?) Shortness of breath (lungs ‘wet’? possible CHF?) Hypotension Decreased level of consciousness
(poor cerebral perfusion?) Clinical shock
(cool and clammy -- peripheral vaso-constriction?)
Are the signs & symptoms due to the rapid heart rate?
Or are S/Sx’s & rapid HR due to something else?
I.e., is it sinus tach due to sepsis, hemorrhage, PE, tamponade, dehydration, etc.
![Page 75: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/75.jpg)
Treatment when in doubtStable or unstable-Electricity If possible, get 12-lead ECG first If electricity does not work
Automatic rhythm Sinus, accelerated junctional, accelerated idioventricular,
automatic atrial, MAT—treatment of underlying disorder Chronic atrial fib
Be sure it is not physiologic tachycardia Amiodarone for conversion Diltiazem or Digoxin to control rate
Refractory ventricular tachycardia Amiodarone
150 mg, may repeat several times Treat underlying ischemia
![Page 76: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/76.jpg)
Conclusion: When in doubt
Shock a fast rhythm Pace a slow rhythm In anterior STEMI
Be certain that transcutaneous pacing will capture if there is high grade block
But don’t shock sinus tachycardia!!
![Page 77: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/77.jpg)
Sinus Rhythm and PACsWith Aberrant Conduction
![Page 78: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/78.jpg)
Wide-Complex Tachycardia Followed by Second-Degree AV Block
![Page 79: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/79.jpg)
STEMI: “Warning Arrhythmias”STEMI: “Warning Arrhythmias”
Antman and Rutherford. Coronary Care Medicine. Boston, MA: Martinus Nijhoff Publishing;1986:81.
Treat resus v fib, and v tach in STEMI, with amiodarone or lidocaine bolus and drip.
![Page 80: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/80.jpg)
Class I for Transvenous Pacing
1. Left Bundle Branch Block or RBBB + LAFB (Bifascicular block
1. AND
2. 2nd deg Mobitz type 2 block
Alternating Left and Right BBB
OR
3rd Degree Block (complete AV dissociation)
OR
![Page 81: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/81.jpg)
Class IIa for transvenous
Anterior MI and New LBBB or new RBBB + ant or post FB And
1st degree AVB or 2nd degree AVB, Mobitz I (Wenckebach)
![Page 82: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/82.jpg)
Questions?
![Page 83: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/83.jpg)
Drug-induced ECG abnormalities
![Page 84: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/84.jpg)
Drug-induced ECG abnormalities
![Page 85: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/85.jpg)
![Page 86: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/86.jpg)
![Page 87: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/87.jpg)
Ventricular tachycardia
> 120 ms QRS Rate 140-200 Slow rates due to anti-arrhythmics, e.g. amio V1 positive (RBBB config-origin in LV) V1 negative (LBBB config-origin in RV) V1 indeterminate, Pos and Neg (RS) Rate >200 “Ventricular flutter”
Fusion beats
![Page 88: Tachydysrhythmias TABAN MD. Internist & cardiologist Tabriz medical faculty](https://reader037.vdocuments.us/reader037/viewer/2022102808/56649d225503460f949f8e94/html5/thumbnails/88.jpg)