Transcript Tachyarrhythmia

Tachyarrhythmia
Gaurav Panchal
Arrhythmogenesis
• Impulse formation
– Automaticity – inappropriate Tachy / brady;
accelerated Ventricular rate after MI.
– Triggered activity i.e. Long QT, CPVT
• Impulse conduction
– Block –
• Without re entry – SA/AV/ BBB
• With re entry – WPW, AVNRT,
– Reflection
• Both
– Interaction between automatic foci
– Interaction between automaticity and conduction
Presentations
• Mode of presentation – Clinic vs
Emergency
• Palpitations
– Mode of onset – rest vs exercise
– Mode of termination
– Severity of symptoms
• Syncope
• Dizziness / presyncope
• SOB
Evaluate
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Drug history
F/H
Assess – HR, BP, ECG
Effect of respiration, CSM
Case 1
• 24 year old female with palpitations –
– fast, regular,
– usually at rest,
– subsides after holding breath or pouring cold
water on face,
– usually lasts 25 min to 1 hour.
– No presyncope / syncope / SOB
• QRS
– >120ms = Broad Complex Tachycardia
– <120ms = Narrow Complex Tachycardia
• P-QRS relation
• Abnormal pattern of beats
– QRS morphology – normal / abnormal
– P wave morphology – normal / abnormal
• Origin or termination of arrhythmia
– P / QRS
SVT
• 90% reentrant, 10 % not reentrant
• 60% AV nodal reentrant tachycardia
(AVNRT)
• 30% orthodromic reciprocating tachycardia
(ORT)
• 10% Atrial tachycardia
• 2 to 5% involve WPW syndrome
Differential Dx of Regular SVT
• Short RP tachycardia
– AV nodal reentrant tachycardia
– AVRT
– atrial tachycardia when associated with slow
AV nodal conduction
AVNRT
• Responds to vagal maneuvers
in 1/3 cases
• Very responsive to AV nodal
blocking agents such as beta
blockers, CA channel blockers,
adenosine.
• Recurrences are the norm on
medical therapy
• Catheter ablation 95%
successful with 1% major
complication rate
• 2 pathways within or limited to
perinodal tissue
– anterograde conduction
down fast pathway blocks
with conduction down slow
pathway, with retrograde
conduction up fast
pathway.
• May have very short RP
interval with retrograde P wave
visible as an R’ in lead V1 or
psuedo-S wave in inferior
leads in 1/3 of cases . No p
wave seen in 2/3
Management
• Vagal manoeuvres
• Pharmacological
– Acute management – adenosine, flecainide,
amiodarone
– Prevention – flecainide, propranolol, sotalol,
amiodarone
• RFA
Case 2
• 64 year old male with palpitations – acute
onset for 12 hours – fast, regular,
associated with dizziness on standing up.
No syncope or SOB.
Management
• Cardioversion
– Pharmacological
– DCCV
• Ablation
• Rate control
– Beta blockers
– Amiodarone
• Anticoagulation
Narrow Complex Tachycardia
Regular
P before QRS:
Sinus tachy
Atach
Aflutter with 1:1 AV
P>QRS:
Aflutter
No p wave:
SVT
Atach
?very fast AFIB
Irregular
Irregularly Irregular: Regularly Irregular:
•Afib
•Aflutter with variable
•Multifocal Atach
response
•Atach with var
response
68 year old male collapse while on
coffee table.
Management
• Acute stabilisation
– Hemodynamically unstable
– Hemodynamically stable – amiodarone,
lidocaine
– Correct predisposing factors
• K+, hypotension, ischemia,
• Long term care
– Anti-arrhythmic – beta blocker, amiodarone
– ICD
• Cardiomyopathies
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Ischaemic
DCM
HCM
ARVC
• TOF
• Inherited arrhythmias
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CPVT
Brugada
Long QT
Short QT
• Idiopathic
– Outflow tract
– Annular
– Fascicular
• Questions