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tachyarrhythmias (SVT)
Tachycardi
a
Narrow Wide
complex complex
to the atria
QRS morphology
based on origin and
conduction
On
time Late
Asynchronous Wide
scenario I:
On
Head start time
(or late) Wide
Asynchronous
scenario II:
A. Re- entry SVT types and
1. SN reentrant mechanisms 1
3 4
tachycardia
2. Atrial reentrant
tachycardia (atrial
flutter)
3. AV node reentrant
tachycardia- slow/fast
pathway
4. AV reentrant 2
tachycardia-accesory
pathway
B. Automatism
1. Atrial automatic
2. Jonctional automatic
Regular SVT
Sinus tachycardia
Atrial flutter
Atrial tachycardia
AV node reentrant
tachycardia
AV reentrant
tachycardia
Irregular SVT
Atrial Fibrillation
Multifocal atrial tachycardia (TAM)
Atrial Flutterul with variable
conduction block
Diagnostic protocol
Atrialactivity
QRS morphology
R-R interval
Abberant conduction
Response to vagal maneuvers
Atrial premature beats
Frequency>100 b/min
p wave of constant morphology
Causes:
Hyperthyroidism
Hypovolemia
Hypotension
Fever
Respiratory failure
Pain
Ischemic disease
Respiratory sinus
arrhythmia
Mechanism:abnormal automatism
Frequency: 100-140/min
Different p wave morphologies in the same lead
Narrow QRS
Irregular rhythm, variable PR interval
Can degenerate into atrial fibrillation
Treatment: beta blockers, amiodarone,
verapamil
Jonctional tachycardia
Etiology:
Digitalis intoxication
congenital
Inferior MI
S = slow pathway
(His
Bundle)
retrograde P
waves (AVN
atria) appear
within or at the
end of the QRS
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
Retrograde p wave
Negative in DII, DIII, aVF
Positive in V1
Pseudo S in DII
Pseudo R in V1
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
Treatment
Acute:
Adenozine 6-12 mg IV
Verapamil 5-10 mg IV
Metoprolol 5 mg iv
Chronic, prophilactic:
Paleative
Beta blockers
Curative
Electrophisiologic study and abblation of the slow pathway
Preexcitation syndrome
Accesory conduction pathway between atria and ventricles:
embrionic myocardial tissue
Not always manifest= doesnt always conduct
pathway
ECG:
delta wave
Negative T wave
syndrome
Preexcitation syndrome
Sinus impulse
Hybrid QRS
Delta wave
PR < .12 s
AP
Apparently absent
,,preexcitated AF
Preexcitation syndrome
Preexcitation syndrome
Variable duration delta wave,
accordion effect
Varying Degrees of Ventricular Preexcitation-
Variable duration delta wave, accordion effect
Preexcitation syndrome
intermitent Delta
wave
AV reentrant tachycardia (AVRT)
ortodromic
mechanism:
Frequency180-200 / min
Regular narrow QRS complex tachiarrhythmia
Second cause of sustained SVT
AV reentrant tachycardia (AVRT)
ortodromic
Anterograde
conduction on
normal pathways
Retrograde
conduction pn
accesory
pathway
AV reentrant tachycardia (AVRT)
ortodromic
APB
Initiation of AVRT
Atria
AP
AVN APB
Ventricles
AP
AVN
Ventricles
retrograde P on the ST
AV reentrant tachycardia (AVRT) ortodromic
AV reentrant tachycardia (AVRT)
antidromic
AV reentrant tachycardia (AVRT)
antidromic
mechanism:
Antegrade conduction on AP
Retrograde conduction through AVN
ortodromic,narrow QRS :
Adenozine iv
Alcoolism, pericarditis
Pulmonary embolism
Aritmie recurenta
Atrial Flutter
mechanism: macroreentry circuit
Regular narrow QRS tachycardia
Absent P waves, F waves 250-350 / min, izoelectric
line:
FlA -tipical (antiorar): negative in DII, DIII, aVF
Dupa CSC
Atrial Flutter
Treatment
Acute
cardioversion (low energy EES)
clasa I iv
CCB iv
B iv
Vagal maneuvers
Chronic
Rhythm control
curativ?
NB!: risk of embolism
Same anticoagulation guidelines as for AF
Atrial fibrillation
Atrial
Fibrillation
Multiple focal
depolarization
s
rapid atrial
frequency 400-600
b/min
Atrial Fibrillation
V5
V1
tachyarrhythmia
AF = atrial fibrillation
Management of AF patients
ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker;
PUFA = polyunsaturated fatty acid; TE = thrombo-embolism.
CHADS2 Score
CHADS2 score Risk
Criteria
C Congestive heart failure 1
H Hypertension high blood 1
pressure
A Age75 1
D Diabetes mellitus 1
S2 Stroke or TIA (transient 2
ischemic attack)
AF = atrial fibrillation; CHA2DS2-VASc = cardiac failure, hypertension, age 75 (doubled), diabetes, stroke
(doubled)-vascular disease, age 6574 and sex category (female); INR = international normalized ratio;
OAC = oral anticoagulation, such as a vitamin K antagonist (VKA) adjusted to an intensity range of INR
2.03.0 (target 2.5).
HAS-BLED bleeding score
AF
AF =
= atrial
atrial fibrillation;
fibrillation; DCC
DCC =
= direct
direct current
current cardioversion; LA = left atrium; LAA = left atrial appendage; OAC = oral anticoagulant;
SR=
SR= sinus rhythm; TOE= transoesophageal echocardiography.
sinus rhythm; TOE= transoesophageal echocardiography.
Pharmacological conversion of recent
onset AF
ACS = acute coronary syndrome; AF = atrial fibrillation; DCC = direct current cardioversion; i.v. = intravenous;
N/A = not applicable; NYHA, New York Heart Association; p.o. = per os; QRS = QRS duration; QT = QT interval;
T-U = abnormal repolarization (T-U) waves.
Pharmacological an electrical
conversion of recent onset AF