Arrhythmia
Vipul Brahmbhatt, MD
Cardiac Electrophysiologist
Cardiology Consultant of Johnson City
Outline
• We will discuss Tachyarrhythmia
• Understand SVT mechanism
• Analyse EKG with Tachycardia
• Differential Diagnosis of Wide complex Tachycardia
INTRINSIC RATE
SA NODE- 60-100
JUNCTION- 40-60
VENTRICULAR- 20-40
Insert Normal EKG.
DIAGNOSTIC APPROACH TO TACHYCARDIA
Wide Complex
QRS>140msec
Narrow Complex
QRS<120msec
Irregular
Regular
AVNRT
AVRT
A-Tach
VT
SVT with Aberrancy
Preexited tachycardia
Paced Rhythm
Atrial fibrillation
A- Flutter with Variable Conduction
MAT
AVNRT
PSVT is a result of
DUAL AV NODAL PATHWAYS
AVNRT ABLATION SITE
Accessory Pathway Mediated Tachycardia
ACCESSORY PATHWAY LOCATION
Short PR interval
Initial Slurring of QRS (delta wave)
Change in appearance of QRS complex.
A. VT
B. SVT with aberrancy
C. Antidromic tachycardia
Risk of SCD in Patient with WPW
•
•
•
•
Shortest Preexited R-R Interval of <250msec either during Spontaneous A FIB or
during Induced A FIB.
History of Tachycardia
Multiple Accessory Pathway
Ebstein Anomaly.
Management of Asymptomatic Patient with Preexitation
Diagnosis <40 Year- 1/3 patient will have Symptoms
Diagnosis after 40 Year unlikely to have symptoms
Pt should be advised to seek attention if symptoms occur or any syncope
Family H/O SCD or Prior Syncope
Catheter Ablation is a choice if pt desires and in High Risk Public Job
Catheter Ablation has Success rate of 95% with Complication rate 1-2%
35 YF with Asymptomatic Preexitation and LVEF of 10-15%
LVEF Improved to 70% Post RFA
Which of the following is true?
A.
Mechanism of
tachycardia is VT
B.
Intravenous verapamil
should help
C.
Immediate DCCV is
needed
D.
Catheter ablation
could be performed
Atrial Fibrillation
•
•
•
•
Paroxysmal
Persistent
Long standing Persistent
Permanent
CAUSE
Pulmonary disease
Infection, IHD
Rheumatic Heart disease
Alcohol intoxication (Holiday heart)
Thyrotoxicosis, Toxins
Electrolyte Imbalance
Surgery, Structural heart disease
Hypertension
Pulmonary Vain Isolation
About 70% Success Free of
Arrhythmia
Success Rate varies based
on many Pt related factor and
Duration of Atrial Fibrillation
Dissociated PV potential
•
Wide complex Tachycardia
Ventricular
Paced Rhythm
SVT with aberrancy
Tachycardia
Usually has
Concordant Positive
Precordial Lead
Complexes
Check Medication list
class IA and IC
Hyperkalemia Usually has
LBBB morphology
•
SVT with AV nodal or HP system
disease
•
SVT with Slow Ventricular conduction
•
AVART (Bypass tract tachycardia)
•
SVT with Drug and electrolyte effect
• History and Physical Examination
* Age >35 year
* Prior MI or Structural Heart disease
* Previous Palpitation favors SVT while
first time palpitation after MI favors VT.
* Do not let Symptoms Fool you
* AV dissociation-- Cannon A wave
Variable S1
Change in BP.
* Termination with AV nodal Blocking
agent favors SVT (remember rare case of VT)
• EKG
• QRS morphology
SVT with aberrancy will have Typical RBBB or LBBB pattern
Concordance R wave in precordial Leads either + or –(High specificity but low
sensitivity about 20%) ## Remember AVART (1-6% of WCT)
• QRS duration
RBBB >140msec and LBBB >160msec. (be aware of Drug effect)
occasionally VT can have relatively narrow (120-140mse)
• QRS axis
Northwest Axis favors VT. Axis change >40 degree compared to sinus Rhythm favors
VT.
LBBB with RAD Suggest VT and RBBB with normal Axis Suggests SVT
Brugada Criteria for Differential Diagnosis of WCT
• LBBB morphology during WCT
V1R >40msec, R-S duration >60msec, notch on down stroke of S wave and R
wave taller than that in Sinus Rhythm.
V6any q wave in V6.
• RBBB morphology During WCT
V1 or V2
Monophagic R wave, R>r’, qR pattern
V6
QR, QS, Monophagic R wave, rS.
55 YF with Recurrent palpitation and ICD Shock
21 YM presents with Palpitation and Presyncope
70 YM with Palpitation and persistent tachycardia
• You only see what you look for and you only look for what
you know!
• Systematic approach
• Understanding of common (and not-so-common)
arrhythmias
• Not all rhythm disorders produce symptoms
• View the rhythm in the context of the patient’s overall
condition: treat the patient, not the tracing