ventricular arrhythmias august 14, 2013 part i. mksap item #119 a 31-year old man is evaluated in...
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Ventricular Arrhythmias
August 14, 2013
Part I
MKSAP Item #119• A 31-year old man is evaluated in the ED after
experiencing a syncopal episode while playing basketball. A friend playing with him reported that he was unconscious for about 15 seconds with no evidence of seizure-like activity. Medical history is significant for arrhythmogenic RV cardiomyopathy/dysplasia. His only medication is atenolol.
• On PE, the patient is afebrile, BP is 128/76 mm Hg and pulse rate is 64/min.
MKSAP Item #119• ECG shows normal sinus rhythm with T
wave inversions in leads V1-V3 with an epsilon wave.
• Echo demonstrates moderate RV dysfunction and enlargement. Cardiovascular magnetic resonance (CMR) imaging of the heart shows dilatation and akinesia of the RV outflow tract.
Item 119 (con’t)
• Which of the following is the most appropriate management?
(A) Electrophysiology study
(B) 24-hour continuous ambulatory electrocardiographic monitoring
(C) Implantable cardioverter-defibrillator placement
(D)Looping event recorder implantation
(E) Sotalol administration
MKSAP Item #54
• A 52-year old woman is evaluated for a 1-year history of nonischemic cardiomyopathy. She reports feeling shortness of breath with exertion when walking up one flight of stairs or walking one city block. Medical and family histories are unremarkable. Medications are carvedilol, lisinopril, digoxin, spironolactone and furosemide.
• On PE, she is afebrile, BP is 112/74 mm Hg and pulse rate is 82/min. Cardiac evaluation reveals a regular rate and rhythm, positive S3, and a grade 2/6 holosystolic murmur heard best at the apex and radiating to the axilla.
MKSAP Item #54 (con’t)
• An ECG demonstrates sinus rhythm and left bundle branch block with QRS interval of 155 msec.
• Echocardiogram shows a moderately dilated LV and severely depressed left ventricular systolic function, with an ejection fraction of 25%.
Item 54 (con’t)• Which of the following is the most
appropriate treatment?
(A) Biventricular pacemaker with implantable cardioverter defibrillator (ICD)
(B) Dual chamber (right atrial and right ventricular leads) ICD
(C)Dual chamber (right atrial and right ventricular leads) pacemaker
(D)Single chamber (right ventricular lead) ICD
Classification of Ventricular Arrhythmias
ACC/AHA/ESC 2006 Guidelines
• Classification by Clinical Presentation
JACC 2006;48:e-247-346
• Classification by ECG
• Classification by Disease Entity
Ventricular Arrhythmias
• Classification by Clinical Presentation– Hemodynamically stable
• Asymptomatic (no symptoms)• Minimal symptoms (palpitations, skipped beats)
– Hemodynamically unstable• Presyncope (dizziness, lightheadedness, faint)• Syncope• Sudden cardiac death • Sudden cardiac arrest
JACC 2006:e247-346
Classification of Ventricular Arrhythmias
ACC/AHA/ESC 2006 Guidelines
• Classification by Clinical Presentation
JACC 2006;48:e-247-346
• Classification by ECG
• Classification by Disease Entity
Ventricular Arrhythmias
• Classification by Electrocardiography– Nonsustained VT– Sustained VT– Bundle branch block reentrant tachycardia– Bidirectional tachycardia
– Torsades de pointes– Ventricular flutter– Ventricular fibrillation
JACC 2006:e247-346
Classification of Ventricular Arrhythmias
ACC/AHA/ESC 2006 Guidelines
• Classification by Clinical Presentation
JACC 2006;48:e-247-346
• Classification by ECG
• Classification by Disease Entity
Ventricular Arrhythmias
• Classification by Disease Entity– Chronic coronary heart disease– Heart failure– Congenital heart disease– Neurological disorder
– Structurally normal hearts– Sudden infant death syndrome– Cardiomyopathies (Dilated, hypertrophic,
arrhythmogenic RV cardiomyopathy)
JACC 2006:e247-346
Ventricular Arrhythmias
• Classification by Electrocardiography– Single PVCs and nonsustained VT– Sustained VT– Bundle branch block reentrant tachycardia– Bidirectional tachycardia
– Torsades de pointes– Ventricular flutter– Ventricular fibrillation
JACC 2006:e247-346
Premature Ventricular Complex
Full Compensatory Pause
Premature Ventricular Complexes
Multifocal PVCs
PVCs in bigeminy
Premature Ventricular Complexes
Compensatory pause is not full
Retrograde P waves due to V-A conduction
Ventriculo-Atrial Conduction
Ventriculo-Atrial Conduction
Interpolated PVC
PVCs in Bigeminy
Premature Ventricular Complexes
Paired PVCs or Couplets
Trigeminy
Non-sustained monomorphic VT
• Non-sustained Ventricular Tachycardia– 3 or more PVC’s, rate >100 bpm– Less than 30 seconds duration– No hemodynamic symptoms
Therapy: PVC’s and Non-Sustained VT
• PVC’s including frequent PVCs and non-sustained VT are not targets for anti-arrhythmic therapy.
• In patients with structurally normal hearts, PVC’s including runs of non-sustained VT are not prognostically significant.
PVC’s and Non-Sustained VT
• If the PVCs are frequent (>10,000 PVCs over a 24 hour period or >20% of total heart beats counted), LV function should be reassessed annually because it can result in tachycardia mediated CMP.
JACC 2012;59:1733-1744
Atria
Ventricles
Bifurcation of the bundle of His
Ventricular Arrhythmias
Atria
Ventricles
Bifurcation of the bundle of His
Supraventricular Arrhythmias
Not all beats with a wide QRS complex are ventricular
Wide complex beats may also be supraventricular in origin.
• Supraventricular– Pre-existent bundle branch block
– Accessory pathway
– Aberrancy also called functional or rate related bundle branch block
• Ventricular
Wide Complex Beats
Wide Complex Tachycardia
Ventricular
Supraventricular Beats With Wide QRS Complexes
Preexistent BBB
Bypass Tract
Rate related BBB
Aberrantly Conducted PAC
Aberrantly Conducted PACs
Wide Complex Tachycardia
Ventricular
Supraventricular Arrhythmias With Wide QRS Complexes
Preexistent BBB
Bypass Tract
Rate related BBB
Pre-Excitation
V1 Rhythm Strip is Continuous
Wide Complex Tachycardia
Ventricular
Supraventricular Arrhythmias With Wide QRS Complexes
Preexistent BBB
Bypass Tract
Rate related BBB
Pre-Existent Right Bundle Branch Block
Diagnosis?
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