1. Presented by: Kristi Metzger, CNP Sanford Cardiovascular Institute April 7 th, 2015

2. - Review of Atrial arrthymias

3.  The heart has a conduction system separate from any other system  The conduction system makes up to PQRST complex  An arrhythmia is a disruption in this system  Understanding how the heart conducts normally is essential to understanding arrhythmias

4.  SA Node  Inter-nodal and inter-arterial pathways  A-V node  Bunkle of His  Perkinje Fibers

5.  The primary pacemaker of the heart  Each normal beat is initialted by the sinus node  Rate is 60-100 bpm  Represents the P- wave in the QRS complex or atrial depolarization

6.  Located in the septum of the heart  Receives impulse from SA node. Holds the signal before sending on the Bundle of His  Represents the PR segment of the complex  Serves as a “filter” for the ventricules

7.  Rate is 40-60 bpm  Acts as a back up if the SA node fails  Where all junctional rhythms originate

8. First Degree AV Block (PR >.20 sec [1 big box]) II PPP.36 Site of delay most commonly the AV node, but may be localized to the His-Purkinje system

9. Second Degree AV Block - Type I (Wenkebach or Mobitz I Block) PPP P Block II Example of 3:2 conduction ratio; general pattern, n:n-1 Note PR  prior to block and  post-block Characteristic of AV nodal site of block

10. II Block P PP P P 4:3 conduction ratio Note first RR longer than second RR Second Degree AV Block - Type I (Wenkebach or Mobitz I Block)

11. II P PPPPP Second Degree AV Block - Type II (Mobitz II) Example of 3:2 conduction ratio; general pattern, n:n-1 Note fixed PR for all conducted beats Characteristic of His-Purkinje system site of block Block

12. Third Degree AV Block (Complete Heart Block) V1 PP PP P P waves at 50-60 beats/min QRS complexes (ventricular escape rhythm) at 35 beats/min Atrial and ventricular activity are completely unrelated Ventricular escape rhythm suggests His-Purkinje site of block

13.  Represents the ventricles depolarizing (firing) collectively.  Origin of all ventricular rhythm  Rate of about 20- 40 bpm

14.  1. is there a P-wave for every QRS?  P-waves are upright and uniform  One p-wave preceding each QRS  2. Is the rhythm regular or irregular?  Verify by assessing R-R interval  Confirm by assessing P-P interval  3. What is the rate?  Count the number of beats occuring in one minute  Counting the p-wave will give you the atrial rate  Counting the QRS will give you the ventricular rate

15.  Normal ◦ Heart Rate= 60-100 ◦ PR interval= 0.12-0.20 sec ◦ QRS <0.12 ◦ SA node discharge 60-100/min ◦ AV node discharge 40-60/min ◦ Ventricular discharge 20-40/min

16.  Normal sinus rhythm ◦ Sinus node is the primary pacemaker ◦ One upright uniform p-wave for every QRS ◦ Rhythm is regular ◦ Rate is between 60- 100bpm

17.  One upright p-wave for every QRS  P wave upright in leads I and II, just as in normal sinus rhythm  Rhythm is regular  Rate is less than 60 bpm  SA node is slower the normal  Normal for many individuals

18.  One upright uniform p-wave for every QRS  Rhythm is regular  Rate is greater than 100bpm  Usually 100-160bpm  Causes are stress, anxiety, fever, medications, or anything that increases oxygen consumption

19.  One upright uniform p-wave for every QRS  Rhythm is irregular  Rate increases are you breath in  Rate decreases as you breath out

20.  Sinus Arrest ◦ Stop of sinus rhythm  Sinus pause  One dropped beat is a sinus pause

21.  No discernible p-waves preceding the QRS  Rhythm is grossly irregular  If HR is > 100 it is considered controlled, if HR is greater than 100 it is considered RVR  AV node acts as a “filter” blocking most of the impulses sent by the atria in attempt to control heart rate

22.  Background  Most common cardiac arrhythmia in adults in USA  3.1 million patients in 2005; 7.6 million by 2050  Lifetime risk 26% for men, 24% women  10% of all patients over 80 have AF  > 50% of all AF patients are 80 years or older Lloyd-Jones DM, et. al, Circulation. 2004;110(9):1042 Naccarelli GV et. Al, Am J Cardiol. 2009;104(11):1534

23. Go AS, Hylek EM, Phillips K, et al. JAMA 2001; 285:2370

24.  Thyroid abnormalities  Hypertension  Obesity  Obstructive sleep apnea  Family history  Coronary artery disease  Valvular heart disease

25.  Rhythm Control  Options  A) cardioversion  B) anti-arrthymic medications  C) pulmonary vein isolation/atrial fibrillation ablation if patient fails AA.  Rate control ◦ AV nodal blocking agents such as beta blockers or calcium channel blockers ◦ Pacemaker/AV node ablation ◦ Anticoagulation ◦ Holter monitor to assess average ventricular rate

26.  Pulmonary Vein Isolation  Roughly 70%

27.  Typical vs atypical atrial flutter. Right sided vs left sided.  More than one p-wave for every QRS complex  Demonstrates a “sawtooth” appearance  Classified as ratio of p-waves per QRS. (ex: 3:1 flutter)

30.  3 Main types ◦ 1). AVNRT-AV nodal re-entry tachycardia ◦ 2). AVRT- accessory bypass tract ◦ 3). Atrial Tachycardia

32.  Roughly 10% of the population has dual AV nodal physiology  Most common type of SVT  Comes on “like a light switch”  Can attempt vagel maneuvers to terminate

33.  Look for retrograde p-waves

34.  Also known as WPW  Wolf-parkinson- white syndrome  Delta wave seen on baseline 12 lead EKG

35.  Delta wave

36.  Atrial tachycardia is a form of SVT.  Impulse originating within the atria but outside the sinus node  Can be multifocal or unifocal  Known to cause cardiomyopathy if untreated especially in asymptomatic patients

37. ◦ Described as “fire works” on the forth of July ◦ Many times it is MAT “multi-focal atrial tachycardia ◦ Generally associated with lung disease such as emphysema and COPD. Not always.

38.  RF vs cryo ablation  3D mapping systems such as CARTO

39.  48 year old male: chief complaint palpitations- couple times a week  Large anterior MI 8 months ago, LAD was stented  EF 38%, mild MR  NYHA 2  Meds- asa, plavix, lisinopril 20mg daily, Metoprolol succinate 75mg bid

41.  Add sotalol?  Add amiodarone?  ICD implant?  EP Study?

42.  67 year old female admitted for syncope  EP consult to evaluate rhythm

44.  A) SVT  VT  Torsades  ??

45.  24 year old female referred to cardiology for palpitations by her PCP  Previously healthy  Meds: BCP, levaquin for bronchitis, MVI  Smoke 1 ppd x 5 years

47.  33 year old female who was referred by her PCP.  Had a baseline EKG done for life insurance puposes

50.  Refused EP Study when offered. She was placed on BB and flecainide.  Was admitted on with palpitations.