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90: :
Arrhythmias
2009

Arrhythmias palpitation
palpitation arrhythmias
Palpitation volume load
cardic neurosis
volume load cardic neurosis
palpitation
palpitation arrhythmia
heart rate 60 90
90 100 High normal
100 tachycardia
60 bradycardia
S.A.Node peace maker of the heart
A.V.Node .... A.V.block
atrial arrhythmias
atrial tachycardia ..... atrial fibrillation
.....atrial flutter
digitalis A.V. block to
1


..............................................................
protect the ventricles
basic
No retrograde conduction
focus
focus in atrium atrium focus
focus atrium ventricle focus
focus S.A. node atrium
atrium ventricle
focus in ventricle ventricle
atrium focus in ventricle
focus ventricle Impulses

arrhythmias ventricular
tachycardia
focus ventricle
ventricle atrium focus .....
S.A. node
atrium S.A. node ventricle focus

atrio-ventricular dissociation
no retrograde conduction

Respiratory sinus arrhythmia

Normal persons S.A. node
peace maker
Inspiration reflex tachycardia
S.A. node Peace maker of the heart
Normal carotid massage vagal
stimulation
vagus Inhibitory atrium ventricles


..............................................................
focus atrium
carotid sinus massage suppression
focus ventricles
carotid sinus massage suppression
tachycardia focus
atrium ventricles
carotid massage
carotid massage abortion arrhythmia
focus atrium
Canon wave
atrio-ventricular dissociation
example
complete heart block
complete heart block atrium S.A. node
ventricle idio ventricular rhythm

harmony
contraction at the same time
right side
right ventricle right atrium

ventricle valve
right ventricle contraction closure
tricuspid valve
tricuspid valve closed right atrium
right atrium pressure sudden rise

neck vein
canon wave
sterno mastoid muscle


atrio ventricular dissociation
ventricular tachycardia complete heart block
3


..............................................................
tachycardia bradycardia atrio
ventricular dissociation

A.V. node
block atrial tachycardia
focus atrium heart
focus ventricle ventricle atrium

carotid sinus massage Inhibitory focus
atrium focus ventricle
canon wave atrio ventricular
dissociation complete heart block
ventricular tachycardia


arrhythmia
.......... written

Pathophysiology etiology
etiology ....functional, pathological and drugs
functional heart rate
exertion Pregnancy thyrotoxicosis
functional Organic lesion Heart
Physiological thyrotoxicosis
Physiology
thyrotoxicosis Pathology
heart .........functional disturbance
functional bradycardia

Hypo thyrodism Obstructive jaundice
Obstructive jaundice .... bile salts
4


..............................................................
bradycardia
.....
Heart ......heart Heart rate
jaundice
drugs heart rate Beta blocker Ca
channel blocker Verapamil Beta blocker
diltazem
Nefidipine tachycardia
hydralazine tachycardia
Nefidipine
Ischaemic heart ... small dose
Beta blocker tachycardia
Nefidipine
Nefidipine

Beta blocker
tachycardia....
ischaemic
symptoms palpitation
...... low cardic output Heart rate
Heart rate filling
cardic output

palpitation
Palpitation

palpitation

syncope
hypotension syncope cardiovascular
system
5


..............................................................
arrhythmia at rest
cause rheumatic
heart Pulse
regular blood pressure
hypotensive

carotid sinus massage
carotid massage abort arrhythmia
focus focus atrium
respiratory sinus arrhythmia
Peace maker of the heart S.A. node
monitor respiratory sinus
arrhythmia
canon wave
occasional
occasional neck vein
atrio ventricular dissociation
complete heart block ventricular tachycardia
Local examination Heart
first sound tachycardia
Murmur gallop

Canon wave
contraction atrium ventricle right side
contraction atrium ventricle
canon sound
rd
th
canon sound 3 or 4 canon sound
wave sounds
exception
investigations
Investigations arrhythmia
6


..............................................................
arrhythmia
Organic
epilepsy brain

....

for example epilepsy neurological
renal

normal
ECHO
ECG .... ECG attack
Holter Holter

ECHO
48

arrhythmia

lab investigations
T3 and T4 TSH
Free T4 , free T3 and free TSH
hemoglobin serum K, Mg
investigations
7


..............................................................
Mg extra systole
Extra systole
Hypo magnesemia
Lasix lasix hypo
magenesmia
Lasix hypo
hypo magenesemia

frusamide
..... Mg

side effect lasix

every other day




aldactone ..... K sparing Urine
K


trace elements

arrhythmia
arrhythmia Paroxysmal DC shock
Intravenous Heart sinus
In between attack
arrhythmia non paroxysmal maintenance
therapy from the start


..............................................................
sinus Tachycardia
sinus tachycardia
focus normal S.A. node
discharge 100
etiology

functional stress , anemia, thyrotoxicosis
fever sinus tachycardia
pathological reflex tachycardia
Heart failure
Heart failure digitalis small
dose Beta blocker heart rate normal

heart rate digitalized

sinus tachycardia
vasodilator Nefidipine Hydralzine Beta
blocker
thyroxin
thyroxin .... thyroxin
replacement
replacement therapy






serotonin reuptake inhibitor thyroxin


9


..............................................................

B2 agonist
COPD bronchial asthma
tachycardia
sympathomimetics
symptoms
palpitation
rapid regular , exertional onset gradual
tachycardia
tachycardia
100 160 150
tachycardia 150 sinus

tachycardia sinus tachycardia
syncope low cardic output


sinus tachycardia itself chest pain
tachycardia chest pain sometimes
tachycardia coronary filling

sinus tachycardia
tachycardia
heart rate coronary filling
Palpitation chest pain

palpitation
decline coronary filling
Heart rate regular
150 160

carotid sinus massage effective

10


..............................................................
respiratory sinus arrhythmia
Canon wave
first sound
first sound tachycardia

gallop S3 gallop
left side apex failure
heart failure reflex tachycardia
manifestations


ECG sinus tachycardia
T3 and T4 .... ........... anemic
thyrotoxic
ECHO ECHO heart
organic
ejection fraction
reflex tachycardia Heart


anxiety







120

Beta blocker
contraindication

11


..............................................................
2.5



heart rate 100
2.5
stable





dose
.......

Heart rate


anti depressant thyroxin

paroxysmal atrial tachycardia

written
suddenly focus atrium
up to 200

focus S.A. node focus
S.A. node .... focus
atrium .... Heart focus
focus

focus .... Heart S.A. node
net result
paroxysmal attack of tachycardia
12


..............................................................
rapid regular

Heart rate
160 170 200 hypotension

low cardic output focus atrium

ventricle ....
atrium ventricle
Canon wave
carotid sinus massage effective

etiology

Pathological Heart sympathomimetics

symptoms
sudden onset sudden offset
sudden onset exertion
sudden onset , sudden offset.... In between
Normal attack filling of the
heart Low cardic output

Poly urea attack
Poly urea excessive excretion atrial
natriuretic peptide
tachycardia
tachycardia cardic output
filling
cardic output
tachycardic cardic output
13


..............................................................
kidney perfusion
diuresis
diuresis
atrial nat riuretic peptide
anginal pain
palpitation
attack of paroxysmal atrial tachycardia
Palpitation anginal pain decline
coronary filling

chest pain palpitation
palpitation chest pain
chest pain Palpitation ..... chest
pain coronary insufficiency
signs
Pulse
pulse
focus
focus atrium
respiratory sinus arrhythmia peace
maker of the heart S.A. node
carotid sinus massage

.....
first sound
..... cause Mitral

Investigations
Investigations ECG
in between attack Holter
Organic ECHO
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..............................................................
T3 and T4 TSH


during the attack vagal stimulation carotid
sinus massage
successful %50
massage successful
drug of choice Verapamil
Verapamil intravenous
verapamil saline infusion
very slowly monitoring
verapamil intravenous Hypotension

antidote calcium gloconate

verapamil Ca channel
Verapamil anti arrhythmic contractility
ejection fraction
Heart verapamil

DC shock
DC shock direct current
abort focus atrium
contraction blood pressure
shocked In failure
verapamil
during attack
DC shock abort digitalis
intravenous
digitalis intravenous focus

A.V. block

drug of choice Verapamil
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..............................................................
DC shock Hypotension
Intravenous Verapamil
negative inotropic adenosine
Verapamil
Hypotension Heart failure
Adenosine DC shock

DC shock Adenosine
.... verapamil Verapamil
DC shock In between
attack
digitalis Beta blocker


sympathetic stress
attack
in between Beta blocker
thyrotoxicosis beta blocker
stress tachycardia verapamil

Beta blocker situation
catecholamine mediators Beta blocker
Beta blocker ....contraindicated

junctional or A.V. nodal tachycardia
A.V. node peace maker
Paroxysmal atrial tachycardia

the same

A.V. node peace maker
A.V. node atrium ventricle
impulse stimulate atrium ventricle

16


..............................................................
atrium and ventricular contraction at the same
time
attack paroxysmal
paroxysmal
attack atrium ventricle

Canon wave regular Canon
Canon
paroxysmal atrial tachycardia
paroxysmal atrial tachycardia
in attacks
Paroxysmal ventricular tachycardia in attacks
Paroxysmal ventricular tachycardia
ventricle focus
atrium S.A. node occasionally...
Canon wave
occasionally

Canon wave
occasionally

A.V. node peace maker Impulse
stimulate atrium ventricles
Regular canon wave
regular canon character nodal rhythm

nodal tachycardia
ECG finding ECG
paroxysmal ventricular tachycardia
Organic heart disease
ventricular tachycardia functional
Organic

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ventricular tachycardia
Ventricle focus
focus focus ventricle
200
attack focus ventricle
focus atrium
No retrograde ventricle focus
conduction
focus ventricle attack
S.A. node atrium
atrio ventricular dissociation
attack
Occasional Canon Canon wave
focus Ventricle S.A. node atrium
etiology
ischaemic heart disease
rheumatic heart
Organic heart disease structure heart disease
Myocardial infraction arrhythmia

ventricular fibrillation

digitalis toxicity

digitalis toxicity abuse
anti abuse of anti cholinergic drugs
abuse tricyclic antidepressant cholinergic drugs
ventricular tachycardia
symptoms
sudden onset , sudden offset , rapid palpitation
Heart rate .... , regular
Low cardic out put
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cause
ventricular
tachycardia ventricular fibrillation

200-180 cardic out
put Hypotensive
carotid massage
focus atrium
respiratory sinus arrhythmia
Neck veins occasional Canon wave
occasional Canon wave occasional
Canon sound
ECG
arrhythmia
ECG ECHO thyroid function electrolyte


during the attack DC shock
Lignocaine
In between attack
ventricular tachycardia
dangerous ventricular fibrillation
Amiodarone

Defibrillator
defibrillator cardioverter heart

Peace maker
ventricular tachycardia
peace maker
Peace maker defibrillator
attack of arrhythmia sensor
arrhythmia DC shock
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Atrial flutter
atiral flutter flutter.... flutter

atrium
fibrillation atrium contraction
flutter In between
flutter focus
Paroxysmal atrial tachycardia focus 200
atrial flutter focus 300 400 atrium
focus atrium

focus atrium 300 350
A.V. block
A.V. block well developed arrhythmia
chronic

Paroxysmal atrial tachycardia focus 200
pulse 180-200
A.V.node
A.V. block
A.V. block .A.F
paroxysmal A.F heart rate
A.V. block building up

flutter Paroxysmal tachycardia

paroxysmal atrial tachycardia

rules paroxysmal atrial
20


..............................................................
tachycardia heart rate carotid massage

sinus atrial fibrillation
ECG
A.V. block
A.V. block A.V. block

focus

sinus atrial fibrillation

very cautious atrial fibrillation

atrial fibrillation must be anti coagulated
arrhythmia
arrhythmia
.A.F anti coagulant

signs
focus
heart rate Low cardic out put
carotid massage effective canon

flutter paroxysmal atrial tachy cardia

focus 200 300


DC shock
verapamil
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..............................................................
verapamil DC shock rule
heart DC shock
atrial fibrillation
written
foci impulses
Impulses 400 atrium
.A.F
400 ventricles
200 paroxysmal....
.A.F


mitral stenosis Mitral valve
disease atrium stretch dilation trigger
atrial fibrillation
chronic
chronic heart dilation
organic
.A.F ventricular response
400 200 180
tachycardia A.V. block
.A.F A.V. block
.A.F digitalis
digitalis A.V. block slow
.A.F .... 60
fibrillation


apical pulse
atrial fibrillation
radial pulse 60 digitalis toxicity
.slow A.F

.A.F .A.F
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.A.F
congenital heart , rheumatic heart and
ischaemic heart

.A.F

.A.F tachycardia
tachycardia Load Heart

tachycardia filling of the heart cardic out
put

.A.F Loss of atrial contraction

atrial contraction % 25 filling ventricles

.A.F Low cardic out put

low cardic out put tachycardia filling
atrial contraction filling ventricles
.A.F

Low cardic out put

.A.F
.A.F
.A.F stagnation of blood atrium
Mitral stenosis
left atrial pressure
Pulmonary venous congestion
.A.F left atrium right atrium
habituation contraction
atrial pressure .... .A.F elevate
pulmonary venous congestion
Mitral stenosis
Low cardic out put pulmonary
venous congestion
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intra cardic thrombosis
atrial dilated Mitral valve disease
fibrillation atrium
thrombo embolism
.A.F systemic embolisation
.A.F Pulmonary embolism
left atrium right atrium dilated
mitral stenosis left atrium dilated
Pulmonary hyper tension
right sided of the heart dilated
A.F. on top left atrium
right atrium
right atrium pulmonary embolism
left atrium systemic embolisation
anti coagulated

fibrillation
anti coagulant
.A.F



Personality

.A.F

anti coagulant

concept



...

serotonin reuptake inhibitor..
24


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Personality very aggressive

C.T. scan
.A.F
Neurological


changes in
neurotransmitter
organic
Organic dementia dementia
behavior
aggressive
MRI brain multiple brain infraction

source of embolism
anti depressant


embolism hemiplegia

emboli
brain
dementia dementia
recurrent stroke
stroke dementia
weakness
fibrillation anti coagulant

25


..............................................................
etiology
mitral valve disease rheumatic heart disease
congenital
atrium dilatation
systemic hypertension
Left hypertrophy systemic hypertension
Left ventricle high pressure ventricle
dilated left atrium
constrictive pericarditis
constrictive preicarditis
catching effect constrictive percarditis
ventricle
dilatation
dilate ventricle
diastole ventricle pressure
dilatation atrium
Infective endocarditis
thryotoxicosis thyrotoxicosis
thyrocardia
thyrotoxicosis Manifestations
thyrocardia
thyrotoxicosis thyrocardia

Palpitation
irregular at rest

apical comment radial pulse apical
pulse deficit radial pulse pulse
Pulse deficit
Pulse deficit digitalized

Multiple carotid sinus massage
foci foci
26


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respiratory sinus arrhythmia
canon wave
neck vein
Loss of A wave

local examination apex

mitral valve disease

cause
Investigations
ECG ECHO T3 and T4 TSH

.A.F
paroxysmal
paroxysmal
Persistent terminated
DC
chronic permanent
i.e. sinus rhythm can not be restored
.chronic A.F
hypertensive ischaemic
.A.F



paroxysmal
.paroxysmal A.F
.A.F

paroxysmal
Normal heart ...normal person
.Paroxysmal A.F
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normal
.... Normal

No need for treatment

stress Beta blocker in between

attack
stress
.A.F very common mistake
T3 and T4 TSH
.Persistent A.F
.A.F Persistent
Persistent
Paroxysmal

DC shock

persistent

.A.F
atrium

atrium atrium .A.F
Atrium
atrium sinus rhythm atrium

thrombus shower
embolisation DC shock
.A.F .A.F 3 palpitation

DC shock sinus rhythm

say 12 anti
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coagulated

adjustment dose
PPT shift Oral anti coagulant

.A.F Palpitation
cardiology

.... .A.F
centre
.A.F


oral anti coagulant Prothrombin time
INR
anti coagulant
INR
Prothrombin time Oral anti coagulant

mortality
Permanent chronic

A.V. block ventricle
anti coagulant


anti coagulant
shift oral
warfarin


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Extra systole

very common
etiology functional extra systole
drugs digitalis toxicity
extra systole
Palpitation palpitation occasional
palpitation occasional irregularity


.A.F pulse
deficit atrial fibrillation
carotid massage canon
ECG

No need for treatment
extra systole

no need extra systole beta
blocker
Beta blocker Irritable

extra systole dangerous

dangerous extra systole ventricular , multifocal
frequent
ventricular tachycardia
extra systole
Amiodarone
Amiodarone
ventricular tachycardia in between attacks
extra systole dangerous multifocal
focus
Amiodarone
.
30


..............................................................

sinus bradycardia

sinus bradycadia
.. hypo thyroidism... heart block...


bile salts
Increase tension
Increase tension problem
solving

... ....

... ...
...
....






subarachonid haemorrhage ..... brain tumor

increase tension
Increase tension 60

60

Parkinsonism
.... extrasystole extra systole

... Increase tension
31


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Under graduates straight
Increased tension brain tumor
sub arachonoid haemorrhage reflex bradycardia
reflex reflex systolic hypertension
cushing reflex
sub arachonoid
sub arachonoid haemorrhage
) ( diffuse T wave
inversion ECG
ECG T wave Inverted
heart
sub arachonoid
sub arachonoid ....sudden sever headache
T wave sub arachonoid

60 regular
bradycardia carotid sinus
massage
investigations


effective safe
....

100/70 females
sympathetic


Heart lesion stenosis
ECHO
renal insfficiency
32


..............................................................
CBC Blood sugar
hyper nateremia Hypo glycemia
cortisone level


hypo tension idiopathic

) ( ) ( ...

females
females
un human

)
as you like (






test test




....

sickness




................

33


..............................................................



females


Fludrocortisone

aldosterone analongue

salt retention

sympathomimetics
midoprine









very easy syncope fainting
Hypo tension occasional

sinus bradycardia
safe
sympathomimetics
B2 agonist
safe Peace
maker
34


..............................................................
heart block
) arrhythmia
(
heart block A.V. block
A.V. block
first degree heart block
Prolonged PR interval
PR interval prolonged fixed
PR interval P complex
PR interval P complex
PR interval ...PR interval

Maximum
first degree heart block asymptomatic

first degree heart block
beta blocker digitalis

second degree heart block

PR

... Heart block 80 atrium
ventricle 60
Impulses

Clinical pictures
asymptomatic
atrium 80
60

..... ....

!!!
35


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Adam's stock attack
Adam's stock attack

impulse .... imuplses
ECG

Impulses atrium Impusles

Impulses atrium
ventricles impulses atrium
ventricle
Impulse atrium
impulse
Impulse

impulses atrium

asysotle
atrium




cardio vascular
system ECG

focus impulses
atrium impulse

syncope complete heart block
idio ventricular rhythm
Adam's stock attack
Adam stock attack
36


..............................................................

Peace maker peace
maker Option
peace maker
peace maker peace
maker

complete heart block

Impulse atrium ventricle
atrium S.A. node
ventricle idio ventricular rhythm

Idio ventricular rhythm
regular bradycardia regular
Heart rate

ventricle
brady cardia pulse rate slow

diastole
diastolic time stroke volume
systolic hypertension
systolic hyper tension
aortic regurge
thyrotoxicosis cardic out put ...
systolic pressure cardic out
put aortic regurge .... thyrotoxicosis
complete heart block
atherosclerosis

complete heart block ECG

peace maker

37


..............................................................
Wolff Parkinson white
MCQ
Wolff Parkinson white
atrium ventricle A.V. node
accessory pathway
accessory pathway A.V. node
impulses
Impulses atrium ventricle A.V. node



episode Impulses atrium
accessory pathway tachycardia
tachycardia atrial
fibrillation
atrial fibrillation
.A.F impulses atrium
accessory pathway
accessory pathway
digitalis Beta blocker A.V. node
impulses accessory pathway
impulses accessory pathway
Amiodarone
Amiodarone
arrhythmia
ventricular tachycardia in between attack
attack
dangerous extra systole ventricular
tachycardia
Wolff Parkinson white syndrome
Wolff ... ablation
ablation

pathway

38


..............................................................

Sick sinus syndrome
sick sinus syndrome under
graduates
I know

sick sinus syndrome disease S.A. node
S.A. node
sick sinus S.A. node sick
degenerative changes ischaemia
attack of sinus bradycardia
hint . paroxysmal tachycardia atrial tachy
cardia
Hint
.Paroxysmal A.F hint
sinus arrest S.A. node
cardic syncope syncope

clinical pictures

.A.F
S.A. node Peace maker
peace maker complete
heart block impulse
peace maker Impulses
conductive system ..... peace maker implanted
atrium ventricle
options Post
cardiology cardiology peace
maker Peace maker
atrium ventricle
Peace maker
Peace maker atrium peace maker
atrium wall atrium
ventricle wall system
39


..............................................................
atrium ventricle peace maker

heart peace maker impulses
Heart muslce fibers heart wall
A.V bundle A.V.node
anti arrhythmic
... sick sinus syndrome
tachycardia bradycardia syndrome

bradycardia tachycardia
sick sinus syndrome ...
... peace maker
sick sinus syndrome
anti arrhythmic Ca channel blocker
atrium arrhythmia atrium tachycardia

Paroxysmal atrial tachycardia drug of choice
lignocaine
attack ventricular tachycardia
convulsion
phenytoin
di phenyl anti epileptic
anti anti epileptic hydantoinate
digitalis ventricular tachycardia arrhythmia
induced
Beta blocker
stress arrhythmia anti arrhythmia
related
thyrotoxicosis related arrhythmia

40


..............................................................


Quinidine
.A.F

.A.F A.F. ....inhibitory
atrial foci
enhance A.V. conduction

atropine like action
suppression atrial foci
A.V. node enhance A.V. conduction
A.V. conduction Quinindine
You must digitalize
digitalis A.V. block Quinidine
.A.F
.... sinus rhythm
Quindine sinus rhythm
.A.F
Long duration Heart dilated atrium
dilated chronic

Amiodarone

Ca channel Na channel K channel

broad spectrum atni arrhythmic
dangerous extra systole
ventricular tachycardia In between attack
Indication
side effects
thyroid dysfunction
Mainly Hypo thyroidism
Amiodarone hyper thyroidism
41


..............................................................
commonly hypo thyroidism
corneal deposit Interstitial lung
disease
Adenosine
IV

drug of choice .... atrial tachycardia

atrial tachycardia ..... Verapamil
verapamil Heart DC shock
Adenosine .... adenosine
paroxysmal atrial tachycardia Heart
negative inotropic
adenosine A.V. Block
A.V. block Foci
Paroxysmal atrial tachycardia

suppression foci atrium A.V.
block
Verapamil
digitalis excitatory atrium excitatory
ventricle
ventricular extra systole digitalis
ventricular tachycardia
atrial extra systole atrial tachycardia
digitalis arrhythmogenic atrial arrhythmia
ventricular arrhythmia anti arrhythmic
A.V block

digitalis tachycardia atrium
foci A.V. block
adenosine
42


..............................................................
adenosine foci A.V. block
adenosine successful carotid sinus
massage
carotid massage Mainly
carotid massage inhibitory
foci

carotid massage suppression atrial foci
A.V. block
adenosine Mainly A.V. block
arrhythmia 2009

43