1. Arrhythmias Dr. Ahmad Hersi Med 441 6/1/2009

2. Conduction System Septal Branch

3. Depolarization Sequence

4. CatechismCatechism Identification Quality Rate Rhythm Axis Waves and intervals Specifics Identification Quality Rate Rhythm Axis Waves and intervals Specifics

5. Frontal (limb lead) axis I I aVF II

6. Limb-lead Misplacement I I aVF II

7. Precordial Leads V 4 : 5th ICS mid-clavicular line V 6 : lateral to V 4 mid-axillary line V 1 : V 1 : Right 4th ICS parasternal V 2 : Left 4th ICS parasternal

8. RateRate 300 100 60 40 150 75 50 Start if possible on a beat whose QRS (usually R wave) is on the border of a large square Start if possible on a beat whose QRS (usually R wave) is on the border of a large square Count Large squares (0.2 seconds each) Count Large squares (0.2 seconds each) This tracing example shows a rate of 100 bpm

9. Rate determination for irregular rhythm 30 8 times 10 = 80 bpm For irregular rhythm (such as atrial fibrillation), the method shown on the last slide may be inaccurate. Use this alternate method. Start as before by finding a QRS that lands on the border of a large square (*). Then count 30 large squares (= 0.2 X 30 = 6 seconds). Add up all beats (QRSs) that land within the interval (not counting that first beat (*) and multiple by 10. This equals the number of beats per minute. *

10. RhythmRhythm “Cherchez la P” To be convinced of sinus rhythm, you should see a P wave in front of every QRS, and the PR interval should not alter, and be of a plausible length. To be convinced of sinus rhythm, you should see a P wave in front of every QRS, and the PR interval should not alter, and be of a plausible length. Lead II is usually the best lead for seeing P waves, and is often used for rhythm strips. Lead II is usually the best lead for seeing P waves, and is often used for rhythm strips. “Cherchez la P” To be convinced of sinus rhythm, you should see a P wave in front of every QRS, and the PR interval should not alter, and be of a plausible length. To be convinced of sinus rhythm, you should see a P wave in front of every QRS, and the PR interval should not alter, and be of a plausible length. Lead II is usually the best lead for seeing P waves, and is often used for rhythm strips. Lead II is usually the best lead for seeing P waves, and is often used for rhythm strips.

11. QRS Axis QRS Axis Left RightNormal I (-) aVF (-) II (-) I (-) aVF (+) II (+) I (+) aVF (-) II (-) I (+) aVF (+) II (+)

12. Quick Method for QRS Axis I aVF II

13. The P Wave Normally from sinus node Upright in I, II, aVF, V4-V6 Monophasic (except V1) Normal ranges: o < 0.12 sec wide o < 2.5 mm tall

14. The PR Interval Measure from beginning of P wave to onset of QRS. Usually measure in Lead II Measure from beginning of P wave to onset of QRS. Usually measure in Lead II Measure the longest PR interval in the limb leads Measure the longest PR interval in the limb leads Normal range 0.12- 0.20 seconds Normal range 0.12- 0.20 seconds < 0.12 = Accelerated conduction < 0.12 = Accelerated conduction > 0.2 = Heart block > 0.2 = Heart block Measure from beginning of P wave to onset of QRS. Usually measure in Lead II Measure from beginning of P wave to onset of QRS. Usually measure in Lead II Measure the longest PR interval in the limb leads Measure the longest PR interval in the limb leads Normal range 0.12- 0.20 seconds Normal range 0.12- 0.20 seconds < 0.12 = Accelerated conduction < 0.12 = Accelerated conduction > 0.2 = Heart block > 0.2 = Heart block

15. Right Atrial Enlargement

16. Left Atrial Enlargement

17. The QRS Complex

18. The Q Wave

19. The J - Point

20. QRS Waveforms

21. The ST Segment

22. The T Wave T waves may be normally inverted in aVR (almost always), III (frequently), and V1 (sometimes). T waves may be normally inverted in aVR (almost always), III (frequently), and V1 (sometimes). T waves are “tall” if their height is: T waves are “tall” if their height is: –> 50% QRS height –> 5mm in limb lead –> 10 mm in precordial lead T waves may be normally inverted in aVR (almost always), III (frequently), and V1 (sometimes). T waves may be normally inverted in aVR (almost always), III (frequently), and V1 (sometimes). T waves are “tall” if their height is: T waves are “tall” if their height is: –> 50% QRS height –> 5mm in limb lead –> 10 mm in precordial lead

23. The QT Interval

24. The U Wave Causes: Causes: –Normal –Bradycardia –CAD –Hypertension –Hypokalemia –Hypercalcemia Causes: Causes: –Normal –Bradycardia –CAD –Hypertension –Hypokalemia –Hypercalcemia

25. Left Ventricular Hypertrophy * * * *

26. Right Ventricular Hypertrophy

27. LBBBLBBB

28. RBBBRBBB

29. Case 1 65 yr woman, presents to ER with Dizziness for 2hrs. 65 yr woman, presents to ER with Dizziness for 2hrs. In the past, a doctor told her that her heart rate is slow. In the past, a doctor told her that her heart rate is slow. Healthy otherwise, and is not on med’s. Healthy otherwise, and is not on med’s. O/E : Bp=170/100 O/E : Bp=170/100

32. Another dizzy lady

34. Had syncope

36. What is the appropriate therapy?

37. Management ABC ABC V/S V/S If serious symptoms or signs: If serious symptoms or signs: - Atropine 1 mg - Atropine 1 mg - TCP - TCP - Dopamine - Dopamine - Epinephrine - Epinephrine - Isoproterenol - Isoproterenol

38. Management If clinically stable: If clinically stable: - Prepare for TVP as a bridge device - Prepare for TVP as a bridge device

39. Case 2 25yr old woman 25yr old woman 1 hr h/o palpitation 1 hr h/o palpitation No other cardiac symptoms No other cardiac symptoms Intermittent palpitation in the last 3 months, this episode is long Intermittent palpitation in the last 3 months, this episode is long BP= 120/70 BP= 120/70

41. What is your management?

42. Management Serious signs and symptoms Narrow Complex tachycardia Immediate Cardioversion Stable clinically Vagal maneuvers Adenosine or Verapamil Consider BB, Diltiazem, or Digoxin

43. Case 3 60 yrs C/O sudden onset dyspnea for last 1/2hr 60 yrs C/O sudden onset dyspnea for last 1/2hr Past MI 1 yr ago, received thrombolytics. Past MI 1 yr ago, received thrombolytics. His ECHO at the time revealed impaired LV systolic function His ECHO at the time revealed impaired LV systolic function Med’s: ASA, Bisoprolol, Lisinopril, and Lasix Med’s: ASA, Bisoprolol, Lisinopril, and Lasix On exam, BP=80/50 On exam, BP=80/50

49. Bouts of palpitations

51.  Short PR interval, less than 3 small squares (120 ms)  Slurred upstroke to the QRS indicating pre-excitation (delta wave)  Broad QRS  Secondary ST and T wave changes An accessory pathway, bundle of Kent, exists between atria and ventricles and causes early depolarisation of the ventricle. WPW

53. Case 4 75 yrs woman 75 yrs woman Presents to ER with fever and productive cough Presents to ER with fever and productive cough PMH= HTN PMH= HTN BP=150/90 BP=150/90

55. How would you manage ?

56. Management If patient is hypoxemic  O2 If patient is hypoxemic  O2 Control BP ( may chose a BB or CCB for rate control and BP control) Control BP ( may chose a BB or CCB for rate control and BP control) Rate control the ventricular response if tachycardia. Rate control the ventricular response if tachycardia. Consider Long term anticoagulation if no contraindications Consider Long term anticoagulation if no contraindications

62. Normal ECG

63. A 63 year old woman with 10 hours of chest pain and sweating.

64. An 83 year old man with aortic stenosis.

65. A 75 year old woman with loud first heart sound and mid-diastolic murmur.

66. A 59 year old woman with chronic bronchitis.

67. An 84 year old woman with hypertension

68. A 73 year old woman with dizziness.

69. A 70 year old man with exercise intolerance.

70. A 90 year old lady with syncope.

71. A 76 year old man with SOB

72. A woman with Romano-Ward Syndrome

73. A 45 year old women with palpitation and a history of CRF

74. A 47 year old man with a long history of palpitations and blackouts.

75. A 58 year old man on hemodialysis presents with weakness

76. A 28 year old woman with prolonged vomiting