1. Practical Electrocardiography - Rate and Rhythm
Scott Ewing, D.O.
Cardiology Fellow
August 16, 2006

2. Syllabus Introduction Axis Determination
Atrial Arrhythmias, Bradycardias, and AV Conduction Block
Junctional and Broad Complex Tachycardias
Myocardial Ischemia and Acute Myocardial Infarction
Conditions Affecting the Left Side of the Heart
Conditions Affecting the Right Side of the Heart
Conditions Not Primarily Affecting the Heart
Exercise Tolerance Testing

3. Waveform Review

4. Axis Review

5. Axis Review

6. Axis Review

7. Axis Review

8. Axis Review

9. Rate Determination

11. Rate

12. Rate?

13. Rate?

14. Rate?

15. Rate?

16. Rate?

17. Normal Sinus Rhythm

18. Normal Sinus Rhythm

19. Sinus Bradycardia

20. Sinus Bradycardia Pathophysiology Increased vagal tone in athletes
Inferior wall myocardial infarction
Digitalis glycosides, beta-blockers, calcium channel-blocking agents, class I antiarrhythmic agents, amiodarone
Other drugs, toxins, environmental exposure (lithium, paclitaxel, toluene, dimethyl sulfoxide, topical ophthalmic acetylcholine, fentanyl, alfentanil, sufentanil, reserpine, clonidine)
Electrolyte disorders
Infection (diphtheria, rheumatic fever,viral myocarditis)
Sleep apnea
Hypoglycemia
Hypothyroidism
Hypothermia
Increased intracranial pressure.

21. Sinus Bradycardia

22. Sinus Tachycardia

23. Sinus Tachycardia Pathophysiology Hypoxia Hypovolemia / Sepsis Pain
Fever
Anxiety
Hyperthyroidism PE
Exercise
Drugs (nicotine, caffeine, atropine, salbutamol, cocaine, amphetamines, methamphetamines, ecstasy)

24. Sinus Tachycardia

25. 1st Degree AV Block

26. 1st Degree AV Block Pathophysiology
PR interval represents time needed for electrical impulse from sinoatrial node to conduct through the atria, AV node, bundle of His, bundle branches, and Purkinje fibers
PR interval prolongation due to conduction delay within the right atrium, the AV node, or the His-Purkinje system
AV nodal dysfunction accounts for the majority of cases
First-degree AV block caused by conduction delay in the His-Purkinje system often is associated with bundle-branch block

27. 1st Degree AV Block

28. 2nd Degree Mobitz Type I AV Block Wenckebach phenomenon

29. Karel Frederik Wenckebach
Attended the University of Utrecht, Netherlands and received his doctorate in 1888
Spent his assistant period at the institutes of zoology, and for pathological and normal anatomy in Utrecht
1901 was appointed professor of internal medicine at Groningen, Netherlands
Held the same tenure at Strasbourg , France
Followed a call to Vienna, Austria, where he retired from his chair in 1929
Early work concerned embryology, later concentrated his efforts in the study of the pathology and clinics of heart and circulatory diseases
Apart from his well known phenomenon, he wrote one of the first descriptions of the beneficial effects of the quinine alkaloids on arrhythmias and that its successful use was mainly in patients with auricular fibrillation or recent onset ( )
Wrote an important monograph on beriberi in 1934

30. 2nd Degree Mobitz Type I AV Block
Pathophysiology
Conduction disturbance in the AV node
Rarely secondary to AV nodal structural abnormalities when the QRS complex is narrow in width and no underlying cardiac disease is present
May be vagally mediated (well-trained athletes, digoxin excess, neurally mediated syncopal syndromes)
Vagally mediated AV block improves with exercise and may occur more commonly during sleep when parasympathetic tone dominates
Cardioactive drugs (digoxin, beta-blockers, calcium channel blockers, and certain antiarrhythmic drugs)
Various inflammatory, infiltrative, metabolic, endocrine, and collagen vascular disorders

31. 2nd Degree Mobitz Type I AV Block

32. 2nd Degree Mobitz Type I AV Block

33. 2nd Degree Mobitz Type II AV Block
Intermittent failure of conduction of P waves
PR interval is constant (may be normal or prolonged)
May include wide QRS
May progress to complete third degree AV block

34. 2nd Degree Mobitz Type II AV Block

35. Woldemar Mobitz
Studied in Freiburg im Breisgau and in Munich, where he obtained his doctorate in 1914
Hospital service and assistant years in the surgical clinics in Berlin and Halle, as well as the medical clinics in Munich and Freiburg
1924 he was habilitated for internal medicine in Munich, and in 1928 he became professor extraordinary at Freiburg im Breisgau
Became head physician at the university medical clinic, then director of the medical clinic of the city hospital in Magdeburg
Remained in Magdeburg until it was occupied by the Russian army in 1945
His main work concerns heart and circulation

36. 3rd Degree Heart Block

37. 3rd Degree Heart Block Pathophysiology
Class Ia antiarrhythmics (eg, quinidine, procainamide, disopyramide)
Class Ic antiarrhythmics (eg, flecainide, encainide, propafenone)
Class II antiarrhythmics (beta-blockers)
Class III antiarrhythmics (eg, amiodarone, sotalol, dofetilide, ibutilide)
Class IV antiarrhythmics (calcium channel blockers)
Digoxin or other cardiac glycosides
Infection
Profound hypervagotonicity
Anterior wall MI
Cardiomyopathy, eg, Lyme carditis and acute rheumatic fever
Metabolic disturbances, eg, severe hyperkalemia

38. 3rd Degree Heart Block

39. 3rd Degree Heart Block

40. Atrial Fibrillation

41. Atrial Fibrillation Pathophysiology Long-standing hypertension
Valvular heart disease (rheumatic)
Left ventricular hypertrophy
Coronary artery disease
Diabetes mellitus
AMI
CHF
Pulmonary embolism
Cardiomyopathy
Pericarditis
Hyperthyroidism
Ethanol use (holiday heart)
Cardiothoracic surgery (postoperative)
Use of illegal drugs, such as cocaine or amphetamine derivatives
Over-the-counter herbs (eg, ephedra, ginseng)
Idiopathic or “Lone” AF

42. Atrial Fibrillation

43. Atrial Fibrillation

44. Atrial Fibrillation

45. Atrial Fibrillation

46. Atrial fibrillation with Wolff-Parkinson-White Syndrome

47. Atrial Flutter

48. Atrial Flutter Pathophysiology Long-standing hypertension
Valvular heart disease (rheumatic)
Left ventricular hypertrophy
Coronary artery disease with or without depressed left ventricular function
CHF
Pericarditis
Pulmonary embolism
Hyperthyroidism
Diabetes Mellitus
Postoperative revascularization
Digitalis toxicity

49. Atrial Flutter

50. Atrial Flutter

51. Atrial Flutter