Arrhythmias Bradyarrhythmias 1. Sinus Bradyarrhythmias a. Sinus Bradyarrhythmia i. Normal in highly trained athletes ii.

Times of high vagal tone b. Sick Sinus Syndrome i. Can predispose to tachycardias, then called Bradycardia-tachycardia syndrome ii. If symptomatic, treat medically (atropine/ isoproteranol) or with a pacer 2. Escape Rhythms a. Junctional (40-60 BPM) i. AVN or proximal Bundle of His, therefore narrow rhythms b. Ventricular (30-40 BPM) i. Bundle branches rhythm: Conducts normally ipsilaterally, but gives contralateral bundle branch block ii. Distal BB rhythm: Very wide complex 3. AV Blocks a. First degree PR > 0.2s i. Reversible: Vagal tone, AVN ischemia, AVN-affecting drugs (BB, CCB, dig) ii. Structural: Infarction, degeneration of conducting system (e.g. age) iii. Patient susceptible to higher degrees of block iv. No treatment b. Mobitz I (Wenckeback) - AVN i. Impaired AVN conduction ii. Benign children, trained athletes, high vagal tone iii. Less benign infarction/ischemia (usually temporary) iv. If symptomatic IV atropine/ isoproteranol (transiently) v. Persistant can use pacemaker c. Mobitz II (High Grade if >2 missed QRS) Distal to AVN i. Infarction/ conducting system degeneration ii. Can progress to 3rd degree iii. Pacemaker even if asymptomatic d. Third degree i. Infarction/ conducting system degeneration ii. Rate determined by location of escape rhythm iii. Requires pacemaker Tachyarrhythmias 1. Supraventricular a. Sinus Tachycardia

b. Atrial Flutter (180-350 atrial BPM) i. Re-entry usually around tricuspid valve ii. **Do not use antiarrhythmics that slow atrial conduction a small change may allow faster ventricular conduction if its just perfect iii. Treatment 1. Symptomatic or recent onset: Electrical cardioversion or rapid atrial stimulation (burst pacing) 2. If not pressing need to convert first control ventricular rate (BB, CCB, dig), then chemically cardiovert by slowing conduction/ increasing refractory (e.g. 1A/1C/III) may require chronic therapy 3. If chronic therapy ablation therapy possible c. Atrial Fibrillation (350-600 atrial BPM) i. Large re-entry circuits or paroxysmal by pulmonary vein atrial myocyte firing ii. Ventricular rate typically 140-150 BPM iii. Caused atrial pressure/ volume increase (CHF, HTN, CAD, pulmonary disease) iv. Also metabolic thyrotoxicosis/ alcohol v. Problems by compromising CO but also with thrombosis vi. Treatment 1. Control AVN BB, CCB (Dig less useful unless need increased contractility) 2. If still symptomatic, cardiovert (MS, HOCM) a. Chemically by 1A,1C,III b. Electrically c. If >48 hours, do TEE or anticoagulate for 3 weeks FIRST d. Dont convert if not necessary 3. If need to be maintained in sinus: a. Maze procedure b. Percutaneous ablation of pulmonary vein c. Ablation of AVN with pacemaker d. Paroxysmal SVT i. AVN re-entry tachycardia most common 2 pathways in AVN 1. Usually have no P waves but if anterograde down FAST pathway then can have retrograde P waves after (uncommon AVNRT) 2. Usually young adults/ teens 3. Vagal manoeuvres or Adenosine usually terminate 4. Frequent events give AVN drugs 5. Can also give chronic 1A/1C or ablation if need to ii. AV re-entry tachycardias 1. Ventricular Pre-excitation Syndrome (WPW) a. Narrow if orthodromic, but rarely antidromic wide

b. ***Sometimes Kent bundle low refractory time, so beware of AFib and Aflutter, and dont give AVN drugs which can SPEED up conduction through Kent Give 1A/1C/III c. Treatment: i. Electrically cardiovert if unstable ii. Terminate arrhythmia with antiarrhythmics if stable iii. Should send for invasive electrophysiologic studies, with possible ablation or chronic antiarrhythmics 2. Concealed pathways (bundle with only retrograde transport) a. Different from WPW because pathway only allows retrograde b. So very similar to AVNRT, but you can also do ablation of accessory pathway iii. Focal Atrial Tachycardia 1. Can be focal firing or focal re-entry 2. Slightly different P-Waves 3. Commonly caused by dig toxicity or sympathetic tone 4. Treatment a. No effect with Vagal maneuvres on active focus b. BB, CCB, 1A/1C/III antiarrhythmics c. Possible ablation iv. Multifocal Atrial Tachycardia 1. 3 different p waves 2. Increased automaticity or triggered activity 3. Hypoxemia/ lung disease 4. High mortality rate treat underlying condition 5. Can use verapamil to slow rate temporarily 2. Ventricular a. Ventricular Tachycardia (series of 3+ PVC) i. Sustained: 30s+ ii. Common in any kind of structural/ electrical heart disease iii. Monomorphic usually re-entry but can be an ectopic focus 1. If in a healthy person idiopathic VT, rarely life-threatening (BB, CCB, ablation usually enough) iv. Polymorphic 1. When sustained usually degenerate to VFib 2. Multiple ectopic foci or re-entry 3. Usually Torsades or MI a. Torsades Caused by Long QT (drugs [especially potassium blockers], congenital, metabolic, persistent bradycardia) b. Correct problem, give magnesium, beta-agonists (isoproteranol), or artificial pacemaker

c. If Congenital Long QT might want to give Beta-blockers instead or ICD 4. Also rare, inherited conditions predispose to this v. Treatment 1. Usually electrical synchronized (so as not to land on T) cardioversion 2. If stable, can do electrical cardioversion 3. Find out cause if due to structural problem, needs an ICD because high risk of recurrence and death! b. V Fib i. Major cause of mortality in MI ii. VT that degenerates to VFib iii. Defibrillate, correct underlying abnormalities, and if no underlying problem (i.e. underlying heart disease) give ICD

Appendix General Approach to treating arrhythmias 1. Acutely a. Unstable break the rhythm electrically if possible b. SVT: AVN control (drugs, techniques) Unless WPW c. Use antiarrhythmics to break rhythm 2. Then a. Correct underlying abnormalities or investigate 3. Chronically a. Can use antiarrhythmics chronically b. Ablate for SVTs or give ICD for Ventricular arrhythmias

Genetic Causes of Arrhythmias 1. Inherited Structural Disease (HOCM, Familial Dilated Cardiomyopathies, etc) 2. Arrhythmogenic Right Ventricular Dysplasia (mutation in desmosome) a. Reentrant VT caused by fibrosis/ adipose tissue deposition b. Needs ICD c. Inverted T waves in V1-V3 with epsilon wave (upward notch right after QRS) 3. Brugada Syndrome (Sodium channel mutation) a. Cause of Idiopathic Ventricular Fibrillation b. Requires ICD c. Intermittent or persistent V1-V3 ST elevation with RBBB pattern 4. Congenital Long QT Syndrome (potassium or sodium channel mutations)

a. Very heterogeneous b. Prone to Torsades c. LQT1 and 2 more prone to VT/VF during exercise/exertion while LQT3 during rest/sleep d. Beta-blockers dont shorten QT but help. May need ICD 5. Familial Catecholaminergic Polymorphic VT (often Ryanodine Receptor) a. VT/ VF during physical or emotional arousal b. Delayed afterdepols c. Beta-blockers or ICD Approach to Wide QRS Rhythms 1. Causes of Wide QRS a. BBB b. BB Refractory at time of stimulation (e.g. PACs) c. Conduction initiating from ventricles 2. Clues to VT a. History of heart disease b. ECG QRS similar to usual pattern c. V1-V6 have similar appearance