ECG-Arrhythmias

Tiang Soon Wee

Bradyarrhythmia

1) Slow Atrial Rhythms

2) AtrioVentricular Block (AV Block)

Bradyarrhythmia –
Slow Atrial Rhythm

1. Sinus Bradycardia
2. Sinoatrial Block
3. Sinus Arrest
4. Sinus Arrhythmia
Sinus Bradycardia

HR less than 60bpm

PR interval normal
Normal sinus P wave
Sinus Arrhythmia

HR slows with expiration and accelerates

with inspiration.
PR interval normal
May occur in healthy
heart,myocarditis,MI,digitalis toxicity
Treatment depend on causes
Sinoatrial Block
Atrioventricular Block

1. First Degree AV Block

2. Second Degree AV Block
i) Mobitz Type I
ii) Mobitz Type II
iii) 2:1 AV block
3. Third Degree AV Block
First Degree AV block

PR interval >0.20 sec

PR interval does not change from beat to
beat.
Second Degree AV block
Mobitz Type I

Progressive increase in PR interval before the

block
The level of block almost always located in AV
node
Second Degree AV block
Mobitz Type II

Constant PR interval before the block

The level of block almost always located in
bundle branch.
Third Degree AV Block
(Complete Heart Block)
Junctional rhythm
Causes of AV block

Acute Myocardial Infarction

esp Inferior MI
Electrolytes Imbalance
Hypokalemia
Hypothyroidism
Drug Induced AV block
Beta blocker : Metoprolol, Atenolol etc
Amiodarone
Tachyarrhythmias

Supraventricular
Ventricular
Rateatrial 250-350/min; ventricular
conduction depends on the capability of the
AV junction (usually rate of 150-175 bpm).
P wavenot present; usually a "saw tooth"
pattern is present.
QRSnormal
Conduction2:1 atrial to ventricular most
common.
Rhythmusually regular, but can be
irregular if the AV block varies.
Atrial fibrillation
Rate:atrial rate usually between
400-650/bpm.
P wave:not present; wavy baseline is seen
instead.
QRS:normal
Conduction:variable AV conduction; if
untreated the ventricular response is
usually rapid.
Rhythm:irregularly irregular. (This is the
hallmark of this dysrhythmia).
Clinical presentation of AF

Palpitation.
Irregular heart beat.
Dyspnoea
Chest pain
Atrial Fibrillation
SVT
SVT
Response to I/V Adenosine
 Adenosine

Is the initial drug of choice

Should be given fast bolus
Literally injecting it as fast as possible
followed by saline flush
Use antecubital fossa venous access.
Dose from 6 to 12 mg
Resuscitation trolley on standby
 SVT
Supraventricular
tachycardia

haemodynamics

stable unstable

Carotid sinus DC cardioversion

massage

adenosine

verapamil

DC cardioversion
WPW
 Wide QRS tachyarrhythmia

What should I do?

What should I do?
What should I do?
Stay calm

Check Haemodynamic status

But Take it seriously

 Wide QRS tachycardia

Broad, bizarre looking QRS morphology

Rate 120-220 bpm
Regular
80% of the time, VT
Especially in the setting of previous MI!
Wide QRS tachyarrhythmia
Other Causes :

1. Supraventricular Tachycardia with

pre-existing BBB
2. Supraventricular Tachycardia with
conduction over an accessory pathway
ie : Atrial Fibrillation with conduction over an
accessory pathway
VT

classify ventricular arrhythmias:

sustained: > 30 sec duration or
requiring intervention for termination
non-sustained: 6 beats - 29 sec
Non-sustained VT
treat symptomatic patients only
innocuous forms: reassurance may be
all that is necessary
first line: beta blockade. Sotalol 0.5-1.5
mg/kg IV over 5-20 min or amiodarone
if these fail try other drugs known to be
effective against VT. No scientific way
to choose agent but selection should
take account of risk/benefit ratio
Ventricular Tachycardia

Rateusually between 100 to 220/bpm,

but can be as rapid as 250/bpm
P waveobscured if present and are
unrelated to the QRS complexes.
QRSwide and bizarre morphology
Conductionas with PVCs
Rhythmthree or more ventricular beats
in a row; may be regular or irregular.
ECG
Is a RS complex present in any precordial lead? If not then diagnosis is VT
If RS present measure duration of R to S nadir. If >100 ms in any V lead then
diagnosis is VT
If RS not > 100 ms look for AV dissociation (independent p waves, fusion beats or
capture beats)
If AV dissociation not present decide whether QRS complexes have a right or left
BBB pattern. If pattern is typical in both V1 and V6 the rhythm is SVT. If any
atypical features rhythm is VT
Pre-existing complete BBB. Very helpful in diagnosis. eg in patient with complete
RBBB during sinus rhythm, it is highly likely that wide complex tachycardia with
LBBB pattern is VT
Narrow complex tachycardia. Very rarely VT may be narrow complex. This may be
the case, for example, if, in patient with an anterior wall aneurysm the site of origin
of the VT is in the basal portion of the intraventricular septum. Arrhythmia may then
spread over both ventricles in a similar fashion to the spread of intraventricular
beats
If in doubt, in patients with structural heart
disease it is safer to diagnose VT and this
usually proves to be correct
 VT
Classification of Ventricular Arrhythmia
by Clinical Presentation
•Hemodynamically stable
♥ Asymptomatic
♥ Minimal symptoms, e.g., palpitations
•Hemodynamically unstable
♥ Presyncope
♥ Syncope
♥ Sudden cardiac death
♥ Sudden cardiac arrest

AHA/ACC/ESC Guidelines on Ventricular arrhythmias 2006

VT
Patient with previous MI with an EF=35%
Torsade De Pointes
Torsade de pointes

VT characterized by QRS complexes

of progressively changing amplitude
and contour that seem to revolve
about the isoelectric line
diagnosis based on characteristic VT
and prolonged ventricular
repolarisation time with QT intervals
usually > 500 msec
Question?
What is your diagnosis?
Presented with hypotension
What is the diagnosis?
What will you do?
Post MI with palpitation
What is the diagnosis?
What will you do?
 This patient was in the cath lab for coronary angiogram.
To our horror the cardiac monitor showed this ECG while doing angiogram
 What is the ECG?

VF?
VT?
Torsade de pointes?
SVT?
 What is the treatment?

Defibrillation?
Synchronised cardioversion?
Antiarrhythmics?
Do Nothing?
Conclusion

Remember:
Treat the patient, not the
monitor
Look at 12 leads ECG
Thank you
MEQ
List 3 main ECG features of atrial fibrillation.How
do they present clinically usually?
Answer;
1)P wave:not present; wavy baseline is seen
instead.
2)QRS:normal
3)Rhythm:irregularly irregular. (This is the
hallmark of this dysrhythmia).

Usually present with: palpitation, dyspnoea,

irregular heart beat, chest pain
MCQs

1)Hypokalemia showed a tall tented T

wave.
A)True
B)False

Answer:False
MCQs
2)This is the ECG
of Torsades de
pointes
A)True
B)False

Answer:True
MCQs

3)In LBBB ,ST-segment and T-wave

vectors is same to that of the QRS
vectors.
A)True
B)False

Answer:False
MCQs
4)This is an ECG
of ventricular
tachcardia.
A)True
B)False

Answer:True
MCQs

Patient with ECG rhythm of ventricular

fibrillation is usually conscious.

A)True
B)False

Answer:False
WPW with AF