9/24/2018. September 26, 2018 Vermont Cardiac Network Stowe, Vermont. Common Arrhythmias. none

Transcription

1 September 26, 2018 Vermont Cardiac Network Stowe, Vermont Common Arrhythmias Disclosures/Conflicts: none 1

2 OUTLINE A Bit of History Cardiac Electrical Anatomy Tachycardia Fast problems Bradycardia Slow problems Miscellaneous Interesting Rhythms Potential Triggers of Arrthythmias Simple Method of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 2

3 A Bit of History Invented by Augustus Waller in London 1887 but useful tracings first obtained by Willem Einthoven ( ) at the University of Leiden in the Netherlands, first publication years ago Oral History from Dr. Arthur Kunin How to do an EKG at the Peter Bent Brigham Hospital in Boston circa

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9 CASE #1 24 Year old medical student Referred by NP at Hardwick Health Center for Palpitations He came with an EKG, labs, echo and a normal holter Pt. brought in lots of strips showing rapid heart rate obtained while studying Hx significant for borrowed ritalin 9

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11 Simple Method of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 11

12 CASE #2 32 Year Old female referred by PCP in Morrisville ill for presynope and sinus bradycardia Elite Rower, Olympic development team Craftsbury Outdoor Center Review of Hx suggests presyncope is related to dehydration after workouts 12

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14 Simple Methods of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus Regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 14

15 CASE #3 77 year old French Canadian female who presented dto N. Country with rapid AF, reports allergy to all b blockers and calcium channel blockers. Started on.25 mg daily of digoxin daily, but inadvertently taking BID. 2 weeks later, seen by PCP, rhythm is regular in MD office, no ECG performed but That weekend c/o nausea, vomiting. 15

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18 CASE #4 60 year old male retired tennis coach seen by VNA post discharge after a pneumonia admission with HR of 30. No sx of bradycardia, but does feel crummy In the ER he did appear to have a palpable bradycardic pulse. 18

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20 CASE #5 68 year old diabetic female I had been following with rate controlled daf, anticoagulated and not requiring any rate control agents. 20

21 Case #5 continued. Presents to the ER complaining of palpitations and abdominal pain 21

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23 Case #5 continued 1 day after Thanksgiving Dinner with a lot of stress and overindulgence, about a bottle of wine Takes Apixaban (Eliquis), last dose that AM, Metoprolol, Metformin, Losartan Vitals show temp of 38.8, 8 HR 150, BP 130/70 Labs show leukocyitosis with a L shift, nl renal function, elevated LFTs Case #5 continued Treated with fluids, Ceftriaxone, IV Metoprolol RUQ showed evidency of cholecystitis Cholecystectomy by Dr. Dupuis Required fluids and IV BB in the OR No further BB after surgery Discharged on POD 1 23

24 Simple Methods of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 24

25 CASE #6 55 year old Irish American male presents to the Peter Bent Brigham Hospital in September of 1952 with several hours of chest discomfort Noted to have profuse diaphoresis EKG is obtained showing evidence of Inferior MI 25

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27 CASE #6 continued States I am really nervous and I know what I need dto calm me down Asks for a cigarette After some discussion, among the staff he is given one After several minutes patient noted to have repeat brief dizzy episodes repeat of EKG 27

28 Treatment Simple Method of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 28

29 CASE #7 77 year old WF farmer with recurrent, seemingly random spells of dizziness, sometimes postural, assoc. with blurry vision, fell once going up stairs. Seen in ER after a bad spell and kept overnight nocturnal bradycardia and an AM EKG showing Wenckebach (Mobitz I), but no events Hospitalist orders 30 day monitor refers pt. to Cardiology clinc 29

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31 CASE #7 continued Patient is on no cardiac meds Feels fine in between events Echo shows aortic and mitral valve calcification, otherwise normal Implantable cardiac LINQ monitor ordered Pt. has a spell within a week 31

32 Simple Methods of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 32

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35 CASE #8 Pacemaker Malfunction case CASE #9 76 year old white female, retired worker at Cabot Creamery with no complaints Underwent TAVR 2 years ago Preop for Total Hip Replacement Referred to Cardiology for abnormal EKG Other than her hip she is asymptomatic 35

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37 CASE # year old female retired school principal Hx of Mitral Valve Prolapse/Mitral Regurgition with distant mechanical Aortic Valve Replacement at age 50, on Warfarinn Felt different after her 50 th college reunion which did inolve overindulgence in alcohol. On Exam her heart rate was regular at normal rate 37

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40 Mechanism of Atrial Flutter In Type I Flutter, The reentrant loop circles the right atrium, passing through h the cavotricuspid isthmus More organized than Atrial Flutter. Can change from 1 to another, similar risk of stroke due to embolism from Left Atrial Appendage CASE # year old male disabled due to Chronic Obstructive Pulmonary Disease Presented to the ER with dyspnea and tachycardia Afib was diagnosed, started on subcutaneous heparin overnight Echocardiogram was obtained Case reviewed with Dr. Jennifer Peters, Hospitalist 40

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42 Simple Method of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy 42

43 Case #12 43 year old Dentist I saw in clinic at my previous practice, CVCA in 2011 She complaints of sudden, almost violent skips in heart beat often during delicate portions of her work, such as injecting lidocaine for gum surgery, to the point where she felt unsafe holding the syringe 48 hour holter ensued.. 43

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45 CASE #13 55 year old diabetic female c/o generalized fti fatigue and some doe, no angina No Hx of CAD or arrhythmia Seen by PCP with a normal baseline EKG Meds including Glipizide, Atenolol, Simvastatin 45

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48 Simple Method of Analysis Relationship between P waves and QRS Complex Fast versus Slow Irregular versus regular Narrow versus wide QRS Pattern Recognition (afib) Refer back to cardiac anatomy Summarize A Bit of History Cardiac Electrical Anatomy Tachycardia Fast problems Bradycardia Slow problems Miscellaneous Interesting Rhythms Potential Triggers of Arrthythmias 48

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