Cardiac arrhythmias

It occurs when normal rhythm is altered.

Types

1.Atrial-

• Atrial ectopic/May be normal
• Atrial flutter
• Atrial fibrillation/AF
• Supraventricular tachycardia

2.Ventricular-

• Ventricular ectopic/May be normal
• Ventricular fibrillation/VF
• Ventricular tachycardia/VT
• Ventricular asystole

Note

Commonest arrhythmia-Atrial ectopic ,ventricular ectopic

Commonest arrhythmia with sign-Atrial flutter ,atrial fibrillation ,ventricular tachycardia ,ventricular asystole

Dangerous arrhythmia-Ventricular asystole ,VF [বুকে বেথা and sudden death-Cardia arrest by these two cause]

Less dangerous arrhythmia-AF ,VT

Atrial fibrillation

Pulse: >350 beats/min

Causes(Cardiac and non cardiac)

1.Mitral valvular disease(Particularly MS)

2.IHD(Acute MI)

3.Thyrotoxicosis

4.Hypertensive heart disease

5.Dyselectrolytaemia(Hyperkalemia)
6.Lone AF(Idiopathic)

7.Chest infection

8.Cardiomyopathy

9.Electrocution

10.Cardiac catherisation

11.Cardia surgery

12.Drugs-Adrenaline ,NA ,methylxanthine ,sulbutamol ,digoxin(Cardia stimulants)

Clinical features

Asymptomatic(Incidental diagnosis)

Palpitation

If complication-

Pulmonary edema-(Cough ,distress ,bilateral fine basal Crepitation)

Stroke-(By thromboembolism ,source is left atrial appendages in MS with AF)

Question.20 years old girl stroke in morning/young stroke-

Ans. by thromboembolism ,source is MS with AF

Examination

1.Pulse-Irregularly irregular

2.Precordium(Depends on cause)

3.Visible apex beat

4.Apex beat is tapping and in normal site

5.Left parasternal heave[Due to RVH due to pulmonary  HTN due to MS]

6.Diastolic thrill in mitral area

7.Auscultation-

         Loud 1st heart sound(Also loud 2nd if present )

             Loud P2 if pulmonary  HTN

              May be opening snap(After 2nd sound)-Low pitch ,rumbling ,mid diastolic murmur

                No presystolic accentuation(It is found if sinus rhythm present)

        

Note:

Arrhythmia in thyrotoxicosis-Graves disease

Eye sign-Exophthalmas

Arrhythmia in Dyselectrolytaemia-

• Diarrhoea
• Addison's disease

Diagnosis

ECG-Irregular R-R interval ,absence of P wave being replace by f wave

Chest x ray

Echocardiogram-MS/MR/thrombus

Thyroid function test

Serum electrolyte

[If no abnormality is found ,it is called lone AF]

Treatment

1.If hemodynamically stable-

           If tachycardia-Digoxin

           If normal pulse-Find etiology and treat the cause

           If untreated-Digoxin

           If still persists-Flecainide ,DC shock

2.If hemodynamically unstable(Due to pulmonaryedema)-DC shock

Question.60 years old patient with chest pain ,death by cardiac arrest in front of you.What will you do?-

Examination-Whether dead/not(Unconscious ,dilated pupil ,no light reflex ,no pulse ,no BP)

Immediate CPR

Checkup in monitor(Must in VF/ventricular asystole)

If no monitor(Take it as VF and treat accordingly by DC shock)

If later found ventricular asystole-Give Pace maker

[As a whole: CPR-->DC-->Pace maker]

Supraventricular tachycardia/SVT

• Pulse: 150 to 200beats/min
• Diagnosis-By ECG and pulse rate[In SVT- RR interval is absolutely regular ,but in AF- RR interval is irregular ; use paper dots for this]

Treatment

• Reassurance
• Rest and sedation
• Carotid sinus message
• Vulsalva maneuver(Close nose and mouth and give pressure for expiration)
• Drugs-I/V verapamil/diltiazem

Note:

R on T phenomenon: R start on downslope of next T wave indicates the patient may develope VF anytime

Ventricular tachycardia

• Causes-All causes except MS
• Diagnosis-ECG(3/more consequetive wide QRS)
• Treatment-Cardioversion

Note:

Torsades de pointes-Sudden death with form of polymorphic VT with prolonged QT interval

Brugada syndrome-Genetic disorder that present with polymorphic VT

Both cases Implantable defibrillator is required]