2. ARRHYTHMIA

3. Objectives At the end of this session students should be able to:  Distinguish the normal from abnormal rhythms.  Understand the pathophysiologic basis of arrhythmia.  Differentiate ventricular from supraventricular arrhythmias.  Recognize different types of supraventricular arrhythmias.  Recognize the different types of heart block.  Be familiar with strategies of arrhythmia management.

4. Conduction system hierarchy

5. Basic ECG elements ST interval TP segment T wave QT interval ST segment QRS PR interval PR segment P wave Duratio n Intervals Joining Segments Basic elements

6. 2 dimensions P Q R S T Time Axis

7. Electrical axis

8. Classification of arrhythmia

9. Mechanisms of arrhythmia Enhanced automaticity Triggered activity Reentry

10. Mechanisms of arrhythmia IMPULSE GENERATION IMPULSE CONDUCTION IMPAIRED CONDUCTION ENHANCED CONDUCTION IMPAIRED GENERATION ENHANCED GENERATION BRADYARRHYTHMIA TACHYARRHYTHMIA A. tachy Junct. Tachy Acc. J rhythm Acc. LV rhythm V. tachycardia Sinus pause Sick sinus syndrome High vagal tone Medication A. Fibrillation A. flutter PSVT VF & VT Pre-excitation SN exit block AV block Bundle branch & fascicular block

11. Reentry macro & micro reentry functional or structural

12. Rhythm analysis (P-QRS) Rhythm (P waves & QRS)Present Sinus / non sinus Absent Real / technical Rate (P waves & QRS)SlowAppropriate/inappropriate Fast Narrow/wide complex Regularity (P waves & QRS)Regular Irregular Group beating or haphazard P wave morphology & QRS morphologyAxis up/down P waves, extreme axis Duration & Axis Normal or wide (RBBB, LBBB), sup. axis P-QRS relationshipNormal 1:1, normal PR interval Abnormal Ratio, duration (fixed, variable, unrelated) Others PR & QT intervalsNormal Abnormal Long or short

13. Rhythm interpretation Pulse initiation P wave Present Deflection (Lead II & aVF) RateRegularity Consistency (Shape & rate) YNupdownFastNSlowReg.Irreg.YN QRS Present Morphology (duration) RateRegularityAxis YNNarrowWideFastNSlowReg.Irreg.NAbn Pulse propagation P-QRS Relation 1:1 <0.21:1 > 0.2Progressive 2:1Fixed 2:1Dissociation Conclusions: …………………………………………………………………………(diagnosis)

14. Normal sinus rhythm

15. Normal Sinus Rhythm

16. Sinus Tachycardia (Appropriate vs inappropriate)

17. Sinus Tachycardia

18. Sinus Bradycardia (Appropriate vs inappropriate)

19. Sinus Bradycardia

20. Sinus Arrhythmia (normal or abnormal?)

21. Sinus Arrhythmia

22. What is the abnormality ?

23. Premature atrial contractions (ectopic beats)

24. Premature Atrial Complexes

25. Atrial Tachycardia

26. Atrial Flutter

28. Atrial Fibrillation

31. Junctional Rhythm

33. Accelerated JR

35. Accelerated Junctional Rhythm

36. Junctional Tachycardia

38. Paroxysmal supra- ventricular tachycardia (AV nodal reentrant tachycardia)

39. Paroxysmal supra- ventricular tachycardia (AV nodal reentrant tachycardia)

40. Paroxismal SVT (AVNRT)

41. Clinical Signs of Tachyarrhythmia

43. 1 st degree AV block

45. Type I second degree AV block

46. 2 nd Degree Block Type 1

47. Type II second degree AV block

48. Second degree AV block (type- II)

49. Complete Heart Block (third degree AV block)

50. Complete heart block

52. Premature ventricular beats (RVOT type)

53. Isolated PVCS, couplets and tripplets

55. PVC with R on T phenomenon

56. What do you notice?

57. Non-sustained VT

59. Ventriculat tachycardia Why? PPPP

60. Monomorphic VT What is the mechanism?

61. Polymorphic VT What is the mechanism?

62. Ventricular fibrillation

65. What is this rhythm? Accelerated Idioventricular Rhythm

67. Idioventricular rhythm

69. Asystole

72. Case Study 5

73. QT (corrected) QTc= QT (msec) √R-R (sec) = 640/ 1.05 = 610 msec > 450 m sec is long Long QT syndrome (Jervell-Nielson-Lange)

75. WPW

77. Arrhythmia management Aim: Hemodynamic stability Prevent complications Symptomatic relief Strategies: Restoration of normal rhythm Slowing of tachyarrhythmia Augmenting the slow rhythm Options: Pharmacological agents Electrical cardioversion Transcatheter ablation Device implantation Emergency versus elective management Electrophysiology lab

79. Emergency cardioversion

81. وَفِي أَنفُسِكُمْ أَفَلَا تُبْصِرُونَ