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وقل ربى زدنى علما. CardioMonday Oct.2005 Approach to narrow QRS tachycardias. EL-SAYED M.FARAG (Msc.Cardiology). Definiton. - PowerPoint PPT PresentationTRANSCRIPT
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CardioMonday Oct.2005
Approach to narrow QRS tachycardias
EL-SAYED M.FARAG (Msc.Cardiology)
Definiton
Narrow QRS complex tachycardias(NCT) are defined as tachyarrhythmias with a rate faster than 100 beats/minute and a QRS duration of 120 msec (0.12 sec) or less, as demonstrated on the electrocardiogram (ECG) or cardiac
monitor .
The normal QRS duration reflects normally synchronous activation of both ventricles through the His bundle, bundle branches, and terminal Purkinje conduction system.
SA node
AV node
Bundleof His
Bundle Branches
Purkinje Fibres
Internodal Pathways
Beat Originates from SA ,atrial tissue or AV Node
QRS Complex: normal, narrow
Sinus tachycardia (ST) Inappropriate sinus tachycardia (IST) Sinoatrial nodal reentrant tachycardia (SNRT) Atrial tachycardia (AT) Multifocal atrial tachycardia (MAT) Atrial fibrillation (AF) Atrial flutter (AFl) Junctional ectopic tachycardia (JET) Nonparoxysmal junctional tachycardia (NPJT) Atrioventricular nodal reentrant tachycardia (AVNRT) Atrioventricular reentrant tachycardia (AVRT)
The narrow QRS complex tachycardias include:
Altered automaticity
Triggered activity
Reentry
Mechanisms
Hypothermia decrease, hyperthermia increase phase 4 slope
Hypoxia & hypercapnia both increase phase 4 slope
Cardiac dilation increases phase 4 slope
Local areas of ischemia or necrosis increases automaticity of neighboring cells
Hypokalemia increases phase 4 slope, increases ectopics, prolongs repolarization
Hyperkalemia decreases phase 4 slope; slow conduction, blocks
1. Altered Automaticity
2. Triggered Activity
Afterdepolarization reaches threshold
Early: interrupt repolarization
Delayed: after completion of AP.
3. Reentry
Requires: available circuit, unidirectional block, and different conduction speed in limbs of circuit
Exp: WPW reciprocating tachycardia, AV-nodal reentry, …..
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
Electrical Impulse
Cardiac Conduction
Tissue
Tissues with these type of circuits may exist:• in microscopic size in the SA node, AV node, or any type of heart tissue• in a “macroscopic” structure such as an accessory pathway in WPW
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Premature Beat Impulse
Cardiac Conduction
Tissue
1. An arrhythmia is triggered by a premature beat
2. The beat cannot gain entry into the fast conducting pathway because of its long refractory period and therefore travels down the slow conducting pathway only
Repolarizing Tissue (long refractory period)
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
3. The wave of excitation from the premature beat arrives at the distal end of the fast conducting pathway, which has now recovered and therefore travels retrogradely (backwards) up the fast pathway
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Cardiac Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
4. On arriving at the top of the fast pathway it finds the slow pathway has recovered and therefore the wave of excitation ‘re-enters’ the pathway and continues in a ‘circular’ movement. This creates the re-entry circuit
Fast Conduction PathSlow Recovery
Slow Conduction PathFast Recovery
Cardiac Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms.
NCT WORKUPECGLab. Workup ( CBC,TFT,s.electrolyte,24 hour Holter monitorContinuous loop event recorderEchocardiogramTreadmill test ( with or after exercise)
ALL ARE NARROW BUT THE DIFFERENCE IS WIDE
!!
Tachycardias Arising From the Sinus Node Region
Sinus tachycardia and Inappropriate sinus tachycardia
Sinus node rentry tachycardia
Sinus node reentry tachycardia
Sinus node reentry tachycardia arises from a reentrant circuit involving the sinus node, producing P waves that are fairly similar if not identical to those during sinus rhythm .
sinus node reentry can be initiated and terminated abruptly by a premature atrial stimulus, which is consistent with its reentrant mechanism. It is usually nonsustained and associated with slower rates than inappropriate sinus tachycardia, making it clinically insignificant.
Carotid sinus massage and other vagal maneuvers typically slow or terminate sinus node reentry.
Inappropriate sinus tachycardiaIt is a clinical syndrome characterized by sinus tachycardia without an identifiable physiologic stimulus. Secondary causes for resting sinus tachycardia must be ruled out, such as anemia, hyperthyroidism, pheochromocytoma, and diabetes mellitus with autonomic dysfunction.
At least two clinical variants have been described: (1) resting heart rate of 100 beats/min or greater and (2) increased heart rate response to minimal exertion .Sinus rates greater than 200 beats/min are not characteristic of inappropriate sinus tachycardia, and paroxysmal increases in heart rate are not seen.
The mechanism of inappropriate sinus tachycardia is still speculative but is thought to be a primary abnormality of the sinus node complex characterized by a high intrinsic heart rate, beta-adrenergic hypersensitivity,
and accentuation by a depressed cardiovagal reflex.
Atrioventricular Node Reentrant Tachycardia
(AVNRT)
The most common form of paroxysmal SVT is AV node reentrant tachycardia (AVNRT), which accounts for greater than 60% of cases referred to an electrophysiology laboratory. Patients typically present in their 30s or 40s, with greater than 70% being women .Although the mechanism for AVNRT is reentry involving the AV node, the precise location of the reentrant circuit is uncertain but includes atrial tissue surrounding the AV node. The reentrant circuit consists of an anterograde limb and a retrograde limb.
Types of AVNRTCommon (Slow – Fast).
Uncommon :
*Fast-Slow
*Slow-Slow
Common AVNRT
Uncommon AVNRT
Atrioventricular Reentrant Tachycardia Mediated by Accessory Pathways.
The second most common form of paroxysmal SVT is AV
reentrant tachycardia (AVRT) using an accessory pathway
Accessory pathways are discrete bundles of myocardial tissue
bridging the atrium and ventricle along the tricuspid or mitral
valve annulus. More than half of accessory pathways are
situated in the left free wall, 20% to 30% occur in the
posteroseptal location, 10% to 20% occur in the right free wall,
and 5% to 10% occur in the anteroseptal location near the AV
node.
Because the accessory pathway conducts more rapidly
than the normal conduction system, the ventricle is
producing a short P-R interval and a delta wave on the
surface ECG .
In contrast, about 25% of accessory pathways conduct
only retrogradely and are not manifest on the ECG
during sinus rhythm (Concealed accessory pathway).
Orthodromic atrioventricular reentrant tachycardia
involving an accessory pathway,the tachycardia is narrow
complex because of anterograde conduction down the AV
node and His-Purkinje system. Retrograde atrial
activation over the accessory pathway results in a P wave
within the early ST segment .
Ex.RT.Anteroseptal AP
Atrial tachycardia is less common than AVNRT or AVRT,
accounting for fewer than 15% of patients referred for
electrophysiology study. It can occur in the pediatric
population, especially in children with surgically corrected
congenital heart disease. Atrial tachycardia usually arises from
a single localized atrial focus .
Atrial Tachycardia
Atrial Tachycardia (3:2 & 2:1)
Paroxysmal junctional reciprocating Tachycardia ( PJRT)
Multifocal atrial tachycardia (MAT)
Multifocal atrial tachycardia is a rare SVT. It involves more than one atrial focus and requires at least three distinct P wave morphologies to be diagnosed on the surface ECG.
Because the foci fire independently of one another, the atrial rate is irregular and typically averages 100 beats/min. The P-R interval also may vary depending on the location of the foci relative to the AV node
The mechanism for multifocal atrial tachycardia has not been defined clearly but may be due to enhanced automaticity or triggered activity. Most patients with this arrhythmia have exacerbations of severe
underlying pulmonary disease with hypoxia.
MAT
Jnctional TachycardiaJunctional tachycardias arise from a discrete focus within the AV node or the His bundle. In the pediatric population, junctional tachycardia also is known as junctional ectopic tachycardia .
Junctional ectopic tachycardia presenting before 6 months of age usually is associated with underlying heart disease that carries a high mortality. In contrast, adult junctional tachycardia has a more benign prognosis and typically develops after the acute phase of myocardial infarction, digitalis intoxication, and acute myocarditis.
Although the precise mechanism for junctional tachycardia has not been defined, it is likely due to enhanced impulse initiation in the region of the AV node by automaticity or triggered activity rather than reentry
Nonparoxysmal atrioventricular junctional tachycardia in a healthy young adult. Top, This tachycardia occurs at a fairly regular interval (“W-shaped” complexes) and is interrupted intermittently with sinus captures that produce functional right and left bundle branch blocks. Middle, Two P waves are indicated by arrowheads. The junctional discharge rate is approximately 120 beats/min (cycle length = 500 milliseconds) and the rhythm irregular, sometimes shortened by sinus captures or delayed by concealed conduction that resets and displaces the junctional focus. Bottom, Carotid sinus massage slows the junctional as well as the sinus discharge rates.
Atrial Flutter
Atrial flutter is an atrial arrhythmia characterized by a regular rate, a uniform morphology, and a rate
greater than 240 beats/min. Atrial flutter is usually accompanied by a fixed 2:1 ventricular response,
and it is this rapid ventricular response that results in most symptoms. Atrial flutter may be observed
transiently after cardiac surgery or may persist for months to years. Many different forms of atrial
flutter exist, which has led to multiple classification schemes.
Classification of atrial Flutter
Common (Typical)
- Isthmus dependant
- Non Isthmus dependant
Uncommon (Atypical)
Type I atrial flutter
Type II atrial Flutter
Atrial Fibrillation Atrial Fibrillation
Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance occuring in approximately 0.4 to 1% of general population with increasing prevelance with age (10% over 80 years)AF may be:
Primary, no underlying disease Secondary to: HPT, IHD, MVD, …...
Increased MorbidityEmbolic complications (stroke)Reduced cardiac function; hemodynamic changesComplaints and symptomsIncreased mortality
Induction of atrial fibrillation by a premature atrial beat originating in the orifice of one of the pulmonary veins. These triggers can be caused by microreentrant circuits that occur in the transitional zone of cells as the pulmonary vein endothelium transitions into the left atrial endocardium
The trigger for the induction of intermittent atrial fibrillation is located in the pulmonary veins in 90% of patients and outside the pulmonary vein area in 10% of patients
IT IS TOO WIDE HOW TO NARROW??
Take home messege
Observe either the onest or the termination.
Note the P ,PR and RP.
Do vagal maneuver and adenosine.
STILL VAGUE?EPS
Electrophysiologic study
HRA
HIS ds
HIS px
CSp
CSds
RVa
CS
RV
HRA HIS
Abl
Ex. Concealed LLAP
Ex.SA reentry
Ex. PAF (RUPV)
EX.Atrial tachycardia by CARTO (electroantomic mapping)
HOW TO TREAT?
Priority order: •Ca2+ Channel blocker• B-Blocker• Digoxin• DC cardioversion• Consider procainamide, amiodarone, sotalolPriority order:
• No DC cardioversion• Amiodarone• Diltiazem
• No DC cardioversion• Amiodarone
• No DC Cardioversion• Amiodarone• B-Blocker• Ca2+ channel blocker
• No DC cardioversion• Ca2+ channel blocker• B-Blocker• Amiodarone
• No DC cardioversion• Amiodarone• Diltiazem
Preserved
Preserved
Preserved
EF<40%, CHF
EF<40%, CHF
EF<40%, CHF
Junctional tachycardia
Paroxysmal supraventricular tachycardia
Ectopic or multifocal atrial tachycardia
Attempt therapeutic diagnosis maneuver• Vagal stimulation• Adenosine
Narrow-Complex SupraventricularTachycardia, Stable
Non Pharmacologic AF therapy
Catheter ablation.
Atrial pacing (single or dual site pacing).
Intraatrial ICD.
AFFIRM TRIAL
RACE TRIAL
SPECIAL GROUP NEEDS SPECIAL TREATMENT
WHAT IS COLOUR OF THIS TISSUE!!???
Thank You Thank You