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Introduction To Cardiac Arrhythmias - ECG assessment and ECG interpretation made easy
Junctional and Ventricular Arrhythmias
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Junctional rhythm is an arrhythmia that arises from the AV node, leading to palpitations, fatigue, poor exercise tolerance, dyspnea, or presyncope. ECG findings include bradycardia with a heart rate of 40-60/min with narrow QRS complexes.
Most patients who experience junctional rhythm do not require specific treatment.
Ventricular tachycardia originates downstream of the bundle of His. Symptoms of VT include chest pain, palpitations, shortness of breath, and syncope.
VT appears as wide QRS complexes on ECG due to asynchronous contraction of the ventricles.
Treatments for VT include cardioversion and antiarrhythmic drugs.
Ventricular fibrillation presents as cardiac arrest and causes the ventricles to quiver, greatly diminishing cardiac output. Symptoms include syncope and sudden cardiac death if not treated immediately.
On ECG for VF, there are no p-waves or QRS complexes; in fact, there is no discernable ECG pattern for VF.
Defibrillation is required for treatment of ventricular fibrillation.
Accelerated Idioventricular rhythm arises from the ventricular cardiomyocytes after the SA and AV nodes have been damaged. On ECG, idioventricular rhythm shows wide QRS complexes with a rate greater than 40/min.
Brugada syndrome is an autosomal dominant genetic disorder that leads to bouts of VT/VF. It is defined by right bundle branch block and ST segment elevation in the anterior precordial leads.
Symptoms of Brugada syndrome can include syncope, palpitations, and nocturnal agonal respiration. However, most patients with Brugada syndrome are typically asymptomatic until they present in sudden cardiac arrest from VT or VF.
Premature atrial contractions (PACs) and premature ventricular contractions (PVCs) are common, minimally symptomatic arrhythmias that cause an extra heartbeat.
On ECG, PACs appear as atypical p-waves with PR intervals greater than120 ms, and PVCs appear as QRS complexes with a duration of greater than120 ms.
Treatment of premature contractions, which are not life threatening, involves avoiding precipitants like nicotine, alcohol, or caffeine.
Supraventricular Arrhythmias
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Arrhythmias are deviations from normal sinus rhythm.
Supraventricular arrhythmias occur above the ventricles.
Atrial flutter (AFL) is a supraventricular tachycardia where the atria beat faster than the ventricles.
AFL can be asymptomatic or present with palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, and development of mural thrombus.
The ECG baseline with AFL is described as a saw-tooth pattern.
Atrial fibrillation (AF) is a supraventricular tachycardia where the atria fibrillate or quiver.
AF can be asymptomatic or present with palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, and development of mural thrombus. There is a risk of stroke that mandates anticoagulation.
On ECG, AF is described as an irregularly irregular pattern.
Multifocal atrial tachycardia is seen in patients with chronic lung disease, especially COPD. There are multiple foci of p-waves on ECG.
Atrioventricular nodal re-entrant tachycardia (AVNRT) occurs because of the presence of slow and fast pathways in the AV node that conduct and repolarize at different rates, allowing a re-entry circuit to be set up inside the AV node.
ECG findings in AVNRT include narrow QRS complex (less than120 ms) with retrograde p-waves and a heart rate greater than100/min.
Wolff-Parkinson-White (WPW) syndrome is a congenital disorder leading to abnormal AV pathways.
WPW is characterized by an accessory AV pathway that produces ventricular pre-excitation and manifests with symptoms of palpitations, syncope, presyncope, or sudden cardiac death.
ECG findings in WPW can include a delta wave at the initiation of each QRS complex. Treatment involves radio-ablation of the abnormal pathways during electrophysiological studies.
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