Basic ECG & Arrhythmias
Damrong Sukitpunyaroj, MDg p y j,
ECGECG
âĒ 12 lead ECG âĒ ECG strip (Rhythm strip)(Rhythm strip)
ECGECG12 l d ECG ECG t iâĒ 12 lead ECGâ Complete
âĒ ECG stripâ Limited information
R t h th +informationâĒ Rate, rhythm, axis,
h t h
âĒ Rate, rhythm, + Ischemia
â Easy to gethypertrophy, ischemia, miscellaneous
Easy to getâĒ Monitor : Telemetry,
Defibrillator
â Takes more timeâ May not obtained
â Longer strip give more information about rhythm =May not obtained
from telemetry monitor
about rhythm = rhythm strip
Cardiac CycleR
SP TST
PR Q SQT interval
S
P wave: Atrial contraction (<2.5 small box)
PR interval: AV conduction time (< 1 large box)
QRS complex: Ventricular depolarization(< 3 small box )
Twave: Ventricular repolarization
Five Aspects for ECG ReadingFive Aspects for ECG Reading
âĒRateâĒ Rhythm
A iâĒ AxisâĒ HypertrophyHypertrophyâĒ Infarction
ECG PaperECG Paper5 big box = 1 sec
0.1 mV
âĒ ECG paper runs by a machine with the rate of 25 mm/sec
âĒStandardization 10 mm = 1 mVolt
Rate = 300/N 1500/nRate = 300/N = 1500/n
R 0 R1
300 150 100 75 60 50 43
āļāļĢāļ°āļāļēāļĐāļ§āļāļāļ§āļĒāļāļ§āļēāļĄāđāļĢāļ§ 25 mm āđāļ 1 āļ§āļāļēāļâ â 1 â 1/ 25 = 0.04 ââ â 5 â 0.04 x 5 = 0.2 â5 0.0 5 0.
āļāļēāļ R0 āļāļ R1 : 0.2 sec āđāļ = 1 cardiac cycle0 1 60 sec = 60/ 0.2 = 300/ 1
Quick rate determinationQuick rate determination
Rate = ????Rate ????
Marked Bradycardia or Total Irregular Rhythm y g y
3 second marks
6 second strip
Rate = Cardiac cycle in 6 second strip x 10
Rate = ???
Rate = ???
Five Aspects for ECG ReadingReading
R tâĒ Rate
Rh thâĒRhythmâĒ AxisâĒ HypertrophyâĒ HypertrophyâĒ Infarction
Rhythm(Arrhythmia)y ( y )â Al M P R I t l d QRS C l ââ Always Measure P-R Interval and QRS Complex â
Varying Rhythm : sinus arrhythmia, Wandering pacemaker AFpacemaker, AFExtra Beats and Skips : premature beats, escape beats, sinus arrestRapid Rhythm : PSVT, AFl, AF, VT, VFl, VFHeart Blocks : SA blockk, AV block, BBB
āļāļēāļĢāļāļēāļāļāļāļŦāļ§āļ°āļāļēāļĢāđāļāļāļŦāļ§āđāļāļāļēāļĢāļāļēāļāļāļāļŦāļ§āļ°āļāļēāļĢāđāļāļāļŦāļ§āđāļ
âĒ āļāļāļāļĄāļāļāļŦāļē P waves āđāļĨāļ° QRS complexesRateâ Rate
â Regular or IrregularM h lâ Morphology
âĒ āļŠāļāđāļāļāļāļ§āļēāļĄāļŠāļĄāļāļāļāļĢāļ°āļŦāļ§āļēāļ P waves āđāļĨāļ° QRS complexes -> PR interval
1 āļĄāļāļāļŦāļē QRS complex1. āļĄāļāļāļŦāļē QRS complex
āđ QRS l âĒ QRS complexâĒ āđāļĄāđāļŦāļ QRS complexâ Asystole
âĒ āđāļŦāļ QRS complexâ Rate
âĒ < 60 Bradycardia
â Ventricular fibrillation (VF)
âĒ 60-100 normalâĒ >100 tachycardia
â Regularityâ Connector problem âĒ Totally irregular likely
AFâ Narrow or Wide
âĒ Wide QRSâĒ Wide QRSâ Ventricular rhythm e.g
VTâ Pacemaker rhythmâ Pre-existing BBBâ Aberrant conductionâ WPW
Quick Approach to RhythmQuick Approach to Rhythm
L k f QRSâĒ Look for QRSâ No QRS identified : Asystole, VF, connector problems
QRS id tifi d Id tif h t tâ QRS identified Identify heart rateâĒ Normal resting heart rate: 60 â 100 bpmâĒ Tachycardia: >100 bpmTachycardia: 100 bpmâĒ Bradycardia: <60 bpm
â Regular or irregularâĒ Totally irregular likely AF
â Wide or narrow QRS complexâĒ Wide QRS complex : Ventricular rhythm e g VT; pre existingâĒ Wide QRS complex : Ventricular rhythm e.g. VT; pre-existing
BBB or aberrant conduction; pre-excitation (WPW), pacemaker rhythm
Quick Approach to Rhythm
Look for P wave and association of P wave to QRS (PR
Quick Approach to Rhythm
âĒ Look for P wave and association of P wave to QRS (PR interval)â P wave : not identified
âĒ P wave hidden in T wave, QRS complex, small P waveâĒ No P wave with flat line : sinus arrest, sinus blockâĒ No P wave with fibrillation/flutter wave: AF, A flutter
P id tifi dâ P wave: identifiedâĒ Is it sinus P wave? â P wave + in II, III, aVF
â Not sinus P wave : ectopic atrial rhythm (bradycadia or normal HR), atrial tachycardia (tachycardia)atrial tachycardia (tachycardia)
âĒ Retrograde P wave?â Junctional rhythm, SVT, VT
âĒ Association of P wave to QRS -- > PR interval is consistent?â No association : AV Block Vs AV dissocitationâ Some associtation but not consistent : 2nd degree AVBâ Consistent association but long PR: 1st degree AVB
Mechanism of Cardiac ArrhythmiasArrhythmias
âĒ Abnormal Impulse Formationâ Increase Automaticityâ Triggered ActivityTriggered Activityâ ReentryâĒ Abnormal Impulse Conductionp
âĒ Combination
Classification of Cardiac arrhythmiay
Supraventricular
in Origin
SA node, Atrium,
AV node, etc.
V t i l
AV node, etc.
Ventricular
in Originin Origin
Normal Sinus RhythmNormal Sinus Rhythm
1. Rate 60-100 beats / min2 Rh th l2. Rhythm regular 3. P waves upright in I, II and aVF and uniform4 PR interval 0 12-0 20 sec and constant from beat to
ECG
Criteria 4. PR interval 0.12-0.20 sec and constant from beat to beat
5. QRS duration 0.10 sec or less
Criteria
Normal Sinus RhythmNormal Sinus Rhythm
1. āļāļ P waves1. āļāļ P waves āļĄ QRS complexes āļāļēāļĄāļĄāļē
2. QRS āđāļāļāđāļāļāļāļāļāļāļāđāļĄāđāļāļ 0.12 āļ§āļāļēāļ
3 āļĢāļ°āļĒāļ°āļĢāļ°āļŦāļ§āļēāļāđāļāļĨāļ° complexes āļŠāļĄāļēāđāļŠāļĄāļ3. āļĢāļ°āļĒāļ°āļĢāļ°āļŦāļ§āļēāļāđāļāļĨāļ° complexes āļŠāļĄāļēāđāļŠāļĄāļ
4. P wave āļŦāļ§āļāļāđāļ lead 2,3, aVF4. P wave āļŦāļ§āļāļāđāļ lead 2,3, aVF5. āļāļāļĢāļēāļāļēāļĢāđāļāļ 60-100 āļāļĢāļ/āļāļēāļ
Sinus Bradycardia
ECG criteria
1. Same NSR
2 R t 60 BPMcriteria 2. Rate < 60 BPM
Sinus BradycardiaSinus BradycardiaâĒ āđ āļ āđ āđ āđ āđ āđâĒ āļāļēāļāļāļāđāļāļāļāļāļāļāđāļ āđāļāļĒāđāļāļāļēāļ°āļāļēāđāļāļāđāļĄāļāļēāļĄāļēāļ āđāļĨāļ°āđāļĄāļĄāļāļēāļāļēāļĢāđāļāđ
â High vagal tone āđāļāļ āļāļāļāļŽāļē
â Nocturnal bradycardiaâ Nocturnal bradycardiaâĒ āļāļĢāļāļāļāļāļāļĢāļāļēāļĄāļēāļ āđāļāļ āļāļāļĒāļāļ§āļē 40 āļāļĢāļāļāļāļāļēāļ āđāļĨāļ°āļĄāļāļēāļāļēāļĢāļāļēāđāļāļāļāļāļāđāļāļĢāļ
āļāļēāļĢāļāđāļĨāļĢāļāļĐāļēāđāļāļĒāđāļāļāļēāļ°āļŦāļēāļāđāļāļ unstable bradycardia yâ Vagovagal reflex cardioinhibitoryâ Sinus node diseaseâ Drug effects
âĒ B-blocker, Ca blocker, antiarrhythmic ( Amiodarone, digoxin, etc)
â Electrolyte imbalance, acid-base abnomalityâ Acute coronary syndrome
Etcâ Etc.
Sinus Tachycardia
1. Same NSR
2 Rate: greater than 100 bpm
ECG
Criteria 2. Rate: greater than 100 bpmCriteria
Sinus tachycardiaSinus tachycardiaâĒ āļ āļŠ āļŠ āļ āđ āļ âĒ āļĄāļāđāļāļāļāļēāļĢāļŠāļāļāļāļāļāļāļāļēāļāļŠāļĢāļĢāļ°āļāļāļāļĢāļēāļāļāļēāļĒāļāļēāļĄāļāļāļ āđāļĄāļāļēāđāļāļāļāļāļāļĢāļāļĐāļēāļāļēāđāļāļēāļ°
āđāļāļāļ§āļĢāđāļāđāļāļŠāļēāđāļŦāļāļāļāļĢāļ°āļāļ āļŦāļ§āđāļāļāļāļāļ°āđāļāļāļāļēāļĨāļāļāļāđāļāļāļāļāļāđāļāļ āđāļ§āļāđāļŠāļĒāđāļāļ āļēāļ§āļ° Sinus tachycardia āđāļāļāļāļāļĄāļēāļāđāļāļāđāļāđāļāļĒāđāļĄāđāļŦāļĄāļēāļ°āļŠāļĄāđāļyāļŠāļēāđāļŦāļ āļāļēāļāļĢāļāļĐāļēāđāļāļĒāđāļāļĒāļē Beta blocker āđāļ
âĒ āļŠāļēāđāļŦāļāļāļāļāļāļāļĒ āļĄāļāļ§āļāļĢāļ°āļāļāļāļ sinus nodeāđ â āđāļ
â āļ āļēāļ§āļ°āļāļāđāļāļ
â āļŪāļēāļāļēāļĢāđāļŦāļāļāļĒāļāļēāļāđāļĢāļāļāļāļ āļāļēāļāļ§āļĄāļāļāļ etcâ āļ āļēāļ§āļ°āđāļāļĢāļĒāļâ āļ āļēāļ§āļ°āđāļāļĢāļĒāļ
â āļāļĒāļĢāļāļĒāļāđāļāļāļāļĐ
â āļĒāļēāļŦāļĢāļāļŠāļēāļĢāļāļĐ
â āļāļ§āļēāļĄāļāļāļāļāļāļāļēāļāđāļĄāļāļēāđāļāļĨāļ āđāļāļ āļāļēāļāļēāļĨāļāļē āļŊāļĨāļŊāļāļ§āļēāļĄāļāļāļāļāļāļāļēāļāđāļĄāļāļēāđāļāļĨāļ āđāļāļ āļāļēāļāļēāļĨāļāļē āļŊāļĨāļŊ
âĒ Sinus node reentry, Inappropriate sinus tachycardia āļāļāđāļāđāļĄāļāļāļĒ
Sinus Arrhythmia
1 Rate usually 60-100ECG
Criteria
1. Rate usually 60 100
2. Rhythm irregular, phasic with respiration (increaseCriteria respiration (increase during inspiration)
3 Other same NSR 3. Other same NSR
Sinus arrhythmiaSinus arrhythmia
āđ l i âĒ āļ āļēāļ§āļ°āļāļāļĨāļāļŦāļ§āđāļāđāļŦāļĄāļāļ normal sinus āđāļāļĄāļāļāļĢāļēāļāļēāļĢāđāļāļāđāļĄāļŠāļĄāļēāđāļŠāļĄāļ āļāļāđāļĢāļ§āđāļĨāļ°āļāļēāđāļāļĒāļŠāļĄāļāļāļāļāļāļāļēāļĢāļŦāļēāļĒāđāļ
P âĒ āđāļĄāļāļāļĢāļ§āļāļ P wave āđāļĨāļ§āļāļ°āļĄāļĨāļāļĐāļāļ°āđāļŦāļĄāļāļāđāļāļĄāļāļĨāļāļ āđāļŦāļĄāļāļāđāļāļĄāļāļĨāļāļ
âĒ āļāļāđāļāđāļāļāļāļāļāļāļāļāļēāļĒāļāļāļĒ
âĒ āđāļĄāļāļēāđāļāļāļāļāļāđāļŦāļāļēāļĢāļĢāļāļĐāļē
PrematurePremature
ContractionContraction
A. PAC
B. PJC
C. PVCC. PVC
Supraventricular Tachycardia
(SVT)âĒ From SA node (sinus node)âĒ From SA node (sinus node)
â Sinoatrial node reentry tachycardia (SNRT)â Inappropriate sinus tachycardia
âĒ Atrial sourceâĒ Atrial sourceâ Ectopic atrial tachycardia (EAT)â Multifocal atrial tachycardia (MAT)
Atrial fibrillation with rapid ventricular responseâ Atrial fibrillation with rapid ventricular responseâ Atrial flutter with rapid ventricular response
(Without rapid ventricular response, fibrillation and flutter are usually not classified as SVT)
âĒ Atrioventricular source (AV node)âĒ AV nodal reentry tachycardia (AVNRT)âĒ AV reciprogating tachycardia (AVRT)p g g y ( )âĒ Junctional ectopic tachycardia (JET)
Supraventricular Tachycardia
Nonsinus Atrial Rhythm (CS)
1 QRS Normal-looking1. QRS Normal-looking2. Rhythm regular 3 P waves negative in I II aVF
ECG
C i i 3. P waves negative in I, II, aVF4. Rate normal, tachycardia
Criteria
Nonsinus Atrial Rhythm(Atrial ectopic rhythm)
âĒ āļāļāļāļēāđāļāļāđāļāļāļēāđāļāļāļāļēāļāļāļēāđāļŦāļāļāļāļāđāļ atrium āļāļāļ
SA nodeSA nodeâĒ ECG â P wave āđāļĄāđāļāļāļāļ§āļāđāļ II,III,aVFECG P wave āđāļĄāđāļāļāļāļ§āļāđāļ II,III,aVF âĒ āļāļāđāļāđāļāļāļāļāļēāļĒāļāļāļĒ
âĒ āđāļāļĒāļāļ§āđāļāđāļĄāļāļāļāļĢāļēāļĒāđāļĨāļ°āđāļĄāļāļēāđāļāļāļāļāļāļĢāļāļĐāļē
Wandering PacemakerWandering Pacemaker
1. Normal-looking QRS ECG2. Rhythm:irregular
3 P th 3 t
ECG
Criteria 3. P waves:more than 3 contours
Wandering pacemakerWandering pacemakerâĒ Atrial arrhythmia āđāļāļ āđ āđāļ âĒ Atrial arrhythmia āļāđāļāļāļāļēāļāļāļāļāļēāđāļāļāļāļāļāđāļāļāļēāļŦāļ§āđāļāļŠāļāļāđāļāļĄāļēāļĢāļ°āļŦāļ§āļēāļ
sinoatrial node (SA node), atrium, and/or the atrioventricular node (AV node)
âĒ ECG â āđāļŦāļāļāļēāļĢāđāļāļĨāļĒāļāđāļāļĨāļāļĢāļāļĢāļēāļāļāļāļ P wave (upright, flattened, notched, biphasic)
āļĄāļāđāļŦāļāļāļāđāļ lead IIâ Ventricular conduction āļāļāļ QRS āļĢāļāļĢāļēāļāļāļāļ
âĒ āđāļāļāļāļēāļāļāļēāļĢāđāļāļĨāļĒāļāđāļāļĨāļāļāļāļĨāļāļāļāļ vagal tone ( varying vagal tone)â āđāļĄāļ vagal tone āļŠāļ SA node āļāļ°āļāļĨāļāļĒāđāļāļāļēāļāļēāļĨāļ āļāļēāđāļŦāļĄāļāļēāļĢāļāļĨāļāļĒāđāļāļāļēāļāļēāļāļāļāļāļēāđāļāļāđāļāļāļēâ āđāļĄāļ vagal tone āļŠāļ SA node āļāļ°āļāļĨāļāļĒāđāļāļāļēāļāļēāļĨāļ āļāļēāđāļŦāļĄāļāļēāļĢāļāļĨāļāļĒāđāļāļāļēāļāļēāļāļāļāļāļēāđāļāļāđāļāļāļē
āļŠāļēāļĢāļāļāļāļēāļāļāļēāđāļŦāļāļāļāļāđāļāļŦāļ§āđāļāļŦāļāļāļāļ
â āđāļĄāļ vagal tone āļĨāļāļĨāļ SA node āļāļ°āļāļĨāļāļĄāļēāļāļēāļāļēāļāļāļâĒ āļāļāđāļāđāļāđāļāļ āļāļāļāļĢāļē āļāļāļāļŽāļēâĒ āļāļāđāļāđāļāđāļāļ āļāļāļāļĢāļē āļāļāļāļŽāļē
âĒ āļĄāļāđāļĄāļāļēāđāļŦāđāļāļāļāļēāļāļēāļĢāđāļĨāļ°āđāļĄāļāļēāđāļāļāļāļāļāļĢāļāļĐāļē
Multifocal Atrial Tachycardia (MAT)Multifocal Atrial Tachycardia (MAT)
Common in
COPD
ECG C it i ECG Criteria 1. Same wandering pacemaker 2. Rate >100 bpm
Multifocal atrial tachycardiaMultifocal atrial tachycardia
ECGâĒ ECGâ P wave āļĄāļĨāļāļĐāļāļāđāļāļāļāļēāļāļāļāļāļāđāļ 3 āđāļāļāļāļāđāļ
â PR intervals āđāļāļāļāļēāļāļāļPR intervals āđāļāļāļāļēāļāļāļâ āļāļāļāļĢāđāļĢāļ§āļĄāļēāļāļāļ§āļē 100 āļāļĢāļ/okmu
âĒ āļŠāļēāđāļŦāļâ āļāļāļāļāļĒāđāļāļāļāļ§āļĒāļŠāļāļāļēāļĒāļāļĄāđāļĢāļāļāļāļ āđāļāļ COPD āļ āļēāļ§āļ° hypoxemiaâ āļāļēāļāļāļāđāļāļ āļēāļ§āļ° digitalis toxicity, AMI, hypokalemia,
h ihypomagnesemiaâĒ āļāļēāļĢāļĢāļāļĐāļē
āļĢāļāļĐāļēāļŠāļēāđāļŦāļ āļāļēāļĢāđāļŦ Oxygen āļāļēāļāļāļ§āļĒāđāļāļāļēāļāļĢāļēāļĒâ āļĢāļāļĐāļēāļŠāļēāđāļŦāļ āļāļēāļĢāđāļŦ Oxygen āļāļēāļāļāļ§āļĒāđāļāļāļēāļāļĢāļēāļĒâ āļāļēāļŦāļ§āđāļāđāļāļāđāļĢāļ§āļĄāļēāļāļāļēāļāļāļāļēāļĢāļāļēāđāļŦāļĒāļēāļāļĨāļĄ Ca blocker āđāļāļ Verapamil,
etc
Atrial Flutter
Rate atrium 250-400, ventricular vary usually 150
Rhythm atrial regular , vent may reg or irreg ECG y g y g gdepending on AV conduction
P wave saw-toothed or âflutterâ waves PR interval not measurable
CriteriaQRS normal or BBB
Atrial flutterAtrial flutterâĒ ECG : āļĨāļāļĐāļ P wave āļāļĨāļēāļĒāļāļāđāļĨāļāļĒâĒ ECG : āļĨāļāļĐāļāļ° P wave āļāļĨāļēāļĒāļāļāđāļĨāļāļĒâĒ āļŦāļ§āđāļāļŦāļāļāļāļāđāļāļāļāļāļāļāļŦāļ§āļ° āđāļāļāļāļēāļ
macroreentry āđāļāļŦāļ§āđāļāļŦāļāļāļāļāļāļ§āļēāļŦāļĢāļāļāļēāļĒâĒ āļĄāļāļāļāđāļāļāļāļ§āļĒāđāļĢāļāļŦāļ§āđāļ āđāļāļāļēāļāļāļĢāļāļāļāđāļāļāļāļāļĄāļŦāļ§āđāļ
āļāļāļāđāļ
âĒ āļāļāļĒāļāļĢāļāļāļāļ° degenerate āđāļāļĢ atrial fibrillation
āđ âĒ āļāļēāļāļēāļĢāļĄāļāļāļāļāļāļāļāļĢāļēāļāļēāļĢāđāļāļāļāļāļāļŦāļ§āđāļāļŦāļāļāļĨāļēāļ (ventricular response)
â Flutter rate 300 msâĒ 2:1 AVB V rate 150 bpmpâĒ 3:1 AVB V rate 100 bpm
âĒ āļāļēāļĢāļĢāļāļĐāļē
â Rate controlRhythm control : cardio versionâ Rhythm control : cardio version, drug, RF ablation
â Embolic prevention āđāļŦāļĄāļāļ AF
Atrial Fibrillation
Atrial FibrillationAtrial FibrillationâĒ āļ arrhythmia āđ āļŠ sick sinus syndrom (SSS)âĒ āđāļāļ arrhythmia āļāļāļāļāļāļĒāđāļāļĒāđāļāļāļēāļ°āļāļāļŠāļāļāļēāļĒ āļāļēāļāļāļāļĢāļ§āļĄāļāļ sick sinus syndrom (SSS)âĒ āļĄāļŠāļ§āļāļāļāļĒāļ āļāļāđāļāļāļāļāļāļ (lone AF)âĒ ECG : āđāļĄāđāļŦāļ P wave (āļāļēāļāđāļŦāļāļāļ fibrillatory activity) ; QRS āđāļĄāļŠāļĄāļēāđāļŠāļĄāļ
V t i l t t i l d tiâ Ventricular rate āļāļēāļāđāļĢāļ§āļŦāļĢāļāļāļē āļāļāļāļ ventricular conductionAF āļĢāļ§āļĄāļāļ WPW syndrome atrial activation āļāļēāļāļŠ ventricle āļāļēāļāļāļēāļ
bypass tract āđāļāļ AVN āļāļēāļāļĄ ventricular rate āđāļĢāļ§āļĄāļēāļ āļāļāđāļāļ VF āđāļAF āđ āđāļāđ āđ āļ AF ith WPW āđ t i l t âĒ AF āđāļāļĒāļāļ§āđāļāđāļĄāļāļēāđāļŦāļāļāļ§āļĒāđāļŠāļĒāļāļ§āļ āļĒāļāđāļ§āļ AF with WPW āđāļāđāļāļāļĢāļāļ ventricular rate āđāļĢāļ§āļĄāļēāļāđ āļāļēāļāļāļēāđāļŦāļāļĢāļāļŦāļ§āđāļāļŦāļĢāļāđāļĢāļāļāļāļāđāļāļāļāļĢāļāļĨāļāļāļāđāļāļāļ āļēāļ§āļ°āļŦāļ§āđāļāļĨāļĄāđāļŦāļĨāļ§ āļāļ§āļēāļĄāļāļāļāļē āļāļĢāļ°āļāļāđāļŦāđāļāļ acute coronary syndrome āđāļāļāļāļ
âĒ Co morbidity āļŠāļēāļāļāļāļāļ AF āļāļ thromboembolism (Strokes; acuteâĒ Co-morbidity āļŠāļēāļāļāļāļāļ AF āļāļ thromboembolism (Strokes; acute embolism)
âĒ AF managementRhythm control : Cardioversion antiarrhythmic drugs RFâ Rhythm control : Cardioversion, antiarrhythmic drugs, RF ablation
â Rate controlEmbolic preventionâ Embolic prevention
Sick sinus syndrome (SSS)Sick sinus syndrome (SSS)
SiâĒ Sinus arrestâ +/- escape junctional rhythm (slow/ escape junctional rhythm (slow
junctional rhythm)âĒ Sinus pauseâĒ Sinus pauseâĒ Sinus exit blockâĒ Extreme sinus bradycardia
+/ chronotropic incompetenceâ +/- chronotropic incompetenceâĒ Tachy-bradyarrhythmiay y y
Sinus ArrestSinus Arrest
Sinus pause/Sinus arrestSinus pause/Sinus arrestECGâĒ ECG â P wave āļŦāļēāļĒāđāļ > 2 āļ§āļāļēāļ (10 āļāļāļāđāļŦāļ) āļāļēāđāļŦ QRS āļŦāļēāļĒāđāļ āļŦāļĢāļāļĄ QRS āļāđāļāļāļāļēāļāļāļ
āļāļēāđāļāļāđāļāļāļēāļŠāļēāļĢāļāļ (escape rhythm)At il t 60 80 BPMâĒ Atrail escape: rate 60-80 BPM
âĒ Junctional escape : rate 40-60 BPMâĒ Ventricular escape; rate 20-40âĒ No escape rhythm: asystoleâĒ No escape rhythm: asystole
âĒ āđāļāļāļāļēāļ Sinus node (Sinoatrial node) āļŦāļĒāļāļāļĨāļāļĒāļāļĢāļ°āđāļŠāđāļāļāļēāļāļ§āļāļĢāļēāļ§āļŦāļĢāļāļāļēāļ§āļĢ
âĒ āļŠāļēāđāļŦāļ
â Sick sinus syndromeâĒ Fibrosis, infiltrative disease, ischemia, ,
â Drugs, toxicityâ Electrolyte imbalancesâ High vagal tone â carotid massage vagal maneuver vagovagal/High vagal tone carotid massage, vagal maneuver, vagovagal/
vasovagal reflex (cardioinhibitory type)
Escape Beatp
Junctional RhythmJunctional Rhythm
Junctional BradycardiaJunctional Bradycardia
Sinus exit blockSinus exit block
Sinus Exit BlockSinus Exit Block
âĒ ECGP wave āđāļ QRS āđāļâP wave āļŦāļēāļĒāđāļ QRS āļŦāļēāļĒāđāļ
âāđāļĒāļāļāļēāļ sinus pause āđāļāļĒāļŠāļāđāļāļāļāļēāļ pause p pinterval āļāļ°āđāļāļāļāļēāļāļ§āļāđāļāļē (2x, 3x,4x,âĶ) āļāļāļ
PP interval PP interval āļāļāļāļŦāļāļēâĒ āļŠāļēāđāļŦāļāļŠāļēāđāļŦāļ
â āđāļŦāļĄāļāļ Sinus pause/arrestp
Tachy-bradycardia SyndromeTachy-bradycardia Syndrome
AV conduction abnormalityAV conduction abnormality
Fi d AV bl kâĒ First degree AV blockâĒ Second degree AV blockSecond degree AV block
â Mobitz Iâ Mobitz IIâ 2:1 AV block
âĒ (high grade AV block)Thi d d AV bl k (C l t AVâĒ Third degree AV block (Complete AV block, complete heart block)p )
Types of AV block
First Degree AV BlockFirst Degree AV Block
CriteriaCriteria âĒ Prolong PR interval > 0.20 sec
First degree AV blockFirst degree AV blockECG : PR interval > 0 2 sec (200 msec)âĒ ECG : PR interval > 0.2 sec (200 msec)
âĒ Common causesâ Normal variant (incidence 0.6 -1.1% in normal population)( p p )â Enhanced vagal tone Ie.g. atheletes)â Medicationâ Electrolyte imbalanceElectrolyte imbalanceâ AV conduction diseaseâ Myocarditis, AMI etc.
âĒ ManagementâĒ Managementâ Identifying and correcting electrolyte imbalandeâ Witholding the offending medication
âĒ Prognosisâ Isolated first degree AV block â no direct clinical consequences
Second Degree AV Block, Mobitz I
Second degree AV block, Mobitz I
(Wenckebach)
âĒ ECG : PR interval āļāļāļĒāđāļĒāļēāļ§āļāļāļāđāļāļ dropped QRS complex āļŦāļĨāļāļāļēāļāļāļāļāļāļ°āļĄāļāļēāļĢ reset āļāļāļ QRS complex āļŦāļĨāļāļāļēāļāļāļāļāļāļ°āļĄāļāļēāļĢ reset āļāļāļ PR interval āļāļĨāļāļĄāļēāļŠāļāļĨāļ§āļāļāļĒāđāļĒāļēāļ§āļāļāļāļāđāļāļāļ§āļāļāļĢ (Wenckebach cycle)(Wenckebach cycle)
âĒ āļŠāļ§āļāđāļŦāļāđāļāļāļāļāļāļŦāļĄāļāđāļāļ benign condition āđāļĨāļ°āđāļĄ ifi t t tāļāļāļāļāļēāļĢ specific treatment
Second Degree AV Block, Mobitz II
Second degree AV block Mobitz IISecond degree AV block, Mobitz II
ECG Dropped QRS (blocked P a e) āļâĒ ECG : Dropped QRS (blocked P wave) āđāļāļāļāļ§āļāđ āđāļāļĒāļ P wav āļĄāļēāļŠāļĄāļēāđāļĄāļāļ āđāļĨāļ°āđāļĄāļĄāļāļēāļĢāļĒāļēāļ§āļāļāļāļāļ PR intervals āļāļāļāļ QRS complexes āļŦāļēāļĒāđāļintervals āļāļāļāļ QRS complexes āļŦāļēāļĒāđāļ
âĒ āđāļāļāļāļāļāļŦāļĄāļāđāļāļāļāļēāļāļāļ§āļēāļĄāļāļāļāļāļāļāļāļ AV conduction āļŠāļ§āļāļāļĨāļēāļĒ (infrahisian block)āļāļĨāļēāļĒ (infrahisian block)
âĒ āļāļ§āļēāļĄāļŠāļēāļāļ:āđ āļ l t AV bl k āđ āđâ āļĄāđāļāļāļēāļŠ progress āđāļāļ complete AV block āđāļāđāļ
āļĢāļ°āļĒāļ°āđāļ§āļĨāļēāļāļāļŠāļ syncope, cardiac arrest āļŦāļĢāļ sudden cardiac deathsudden cardiac death
â āđāļāļāļāļāļāļāļāļāđāļāļāļēāļĢāđāļŠ Pacemaker