Cardiac Arrhythmias in Sleep

Transcription

1 Cardiac Arrhythmias in Sleep Only 53 Slides! Gauresh H Kashyap, MD, FACP, FCCP, FAASM 1

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3 Cardiac Arrhythmias in Sleep Out of 400 Patients with OSA, 48% had some Arrhythmias 20% - 2 PVCs/min 7% - Bradycardia 3% - NSVT (Non Sustained Ventricular Bradycardia) 5% - Mobitz I Type of Second Degree Heart Block 3% - Mobitz II Type of Second Degree Heart Block 11% - Sinus Arrest Secs long (AASM recommends reporting > 3 secs long) 14% - Atrial Fibrillation; Its Cause And Association With OSA Remains Uncertain (Guilleminault et al 1983 (AJC) 3

4 Cardiac Arrhythmias in Sleep Another Study: Harbison et al 2000 (Chest) 45 patients of recent Dx of OSA underwent Holter Monitor Immediately and 2-3 after been treated with CPAP found : Only 8/45 had significant cardiac arrhythmias including:- Non Sustained V.Tach (>30 seconds is a medical emergency) A. Fib (More with Central Apneas, Obesity and degree of Oxygen Desaturation rather than AHI) SVT 2 nd and 3 rd degree of Heart Block PVCs, no relation with Hypoxemia (unless <SaO2 60%), sleep stage, More with obstructive Apneas CPAP resolved arrhythmias in 7/8 individuals! CPAP improves Arrhythmias, Decreases Sympathetic Tone & Decreases Urinary Nor-Epinephrine Levels, Reduces of Chances Of Recurrence of A. Fib after Treatment of A. Fib (meds, ablation, cardioversion) 4

5 Cardiac Arrhythmias in Sleep Heart Rhythm slows during Expiration, Faster During Inspiration Tachycardia: >90/min Wide or Narrow Complex Tachycardia: > 100/min Bradycardia: <40/min Asystole: >3seconds 1 small box = 0.04 secs QRS : N = <0.12 secs (3 small Boxes) PR Interval: N = < 0.12 sec (3 small boxes) During NREM: Parasympathetic (Vagal) Predominance During REM: Sympathetic Predominance 5

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7 Cardiac Arrhythmias in Sleep Steps In Interpretation of Cardiac Rhythm: First: Change to 10 seconds window Second: Identify P Waves Third: Observe Relation Of P wave with QRS Complex Fourth : Measure Duration of QRS (N < 0.12 sec, 3 small Boxes) Fifth: Calculate Rate by switching back to 30 seconds window And Measure Distance between R waves By # of Large Boxes, including its fractions) Sixth: Divide 300 by Number of Large Boxes. For Example: Large Box = Rate 300/min Large Boxes = Rate 150/min Large Boxes = Rate 75/min Large Boxes = Rate 60/min Seventh:? Regular or Irregular (Both P waves & QRS complex) Normal Sinus Rhythm RR INTERVAL PR INTERVAL Rate = 150/min P WAVE QRS Complex ONE LARGE BOX, 0.4x5=0.2 Seconds 7

8 Cyclic variation in QRS Amplitude due to Respiratory related Cardiac Position Atlas of Sleep Medicine, Chokroverty.S. et al,2005:177

9 PVC Atlas of Clinical Polysomnography, Butkov 1996:308

10 Ventricular Couplets (PVCs) Atlas of Clinical Polysomnography, Butkov 1996:309 10

11 Ventricular Couplets & Triplets 11

12 Multiform (Multifocal) PVCs Atlas of Clinical Polysomnography, Butkov 1996:309 12

13 Interpolated PVCs, truly extra contractions, note: No Compensatory Pause 13

14 Normal Sinus Beat PVC Ventricular Bigeminy Atlas of Clinical Polysomnography, Butkov 1996:308 14

15 Ventricular Bigeminy & Trigeminy, REM sleep Atlas of Sleep Medicine, Chokroverty.S. et al,2005:173 15

16 Spontaneous Ventricular Beats Sinus Beats Ventricular Parasystole A Rhythm of Ventricular Beats Compete with a Normal Sinus Rhythm at Approximately the Same Rate 16

17 Compensatory Pause Normal RR Interval PAC Premature Atrial Contraction (PAC), with Compensatory Pause (Usually with a partial compensatory Pause) 17

18 Normal P Waves Followed By QRS Extra Interpolated PAC followed By Normal Appearing QRS Normal RR Interval Interpolated PAC (Premature Atrial Contraction, Truly An Extra Beat), In between Normally Occurring QRS Complexes) 18

19 Ventricular Tachycardia, Irregular & No P waves Atlas of Clinical Polysomnography, Butkov 1996:309 19

20 PVC V Tach PVCs & V Tach & Irregular Breathing in REM Atlas of Clinical Polysomnography, Butkov 1996: 20

21 P waves Bundle Branch Block (Not V Tach) Note P Waves Atlas of Clinical Polysomnography, Butkov 1996:309 21

22 R on T PVC Preceding Ventricular Tachycardia R on T Phenomenon, Early PVC falling on Previous T wave Ventricular Tachycardia 22

23 NSR Slow Fast Ventricular tachycardia Atlas of Clinical Polysomnography, Butkov 1996:315 23

24 Premature Junctional Contraction (PJC) Atlas of Clinical Polysomnography, Butkov 1996:308 24

25 INSPIRATION EXPIRATION Sinus Arrhythmia, Slower During Expiration, Faster During Inspiration Sleep Medicine Pearls,Berry R,Wagner M,2015:153 25

26 Sinus Arrhythmia : Sinus Rhythm with variable RR intervals 26

27 MWCSD

28 MWCSD

29 Tachycardia and Bradyarrhythmia during sleep, especially REM stage Atlas of Clinical Polysomnography, Butkov 1996: 29

30 Slow Fast Deceleration, often Bradycardia, May cause Blocks Too Tachycardia during Apnea Atlas of Clinical Polysomnography, Butkov 1996: 30

31 P Waves Wandering Pacemaker (Changing shape of P wave with normal PR interval) 31

32 Junctional Escape Beats, No P wave, Narrow QRS Sinus Rhythm NSR Apnea in REM, AV Block Vent Escape NSR with sinus arrhythmia in the last beat Atlas of Clinical Polysomnography, Butkov 1996:313 32

33 Atrial Fibrillation Atlas of Clinical Polysomnography, Butkov 1996:309 33

34 MWCSD

35 MWCSD

36 SVT Atlas of Clinical Polysomnography, Butkov 1996:309 36

37 MWCSD

38 SVT MWCSD

39 Junctional Escape, No P wave, Narrow QRS Blocked P Wave Normal Sinus Rhythm A V Block Junctional Escape Beat NSR Atlas of Clinical Polysomnography, Butkov 1996:309 39

40 Blocked P Wave AV Block MWCSD

41 PR Interval First degree AV Block, 0.24 secs-6 small lines, N < 0.08 sec (2 small lines) 41

42 Conducted P Waves Conducted P Waves Second Degree Heart Block - Mobitz Type II 42

43 DROPPED P WAVES 2 degree Mobitz type I block Wenckebach type Atlas of Sleep Medicine, Chokroverty.S. et al,2005:174 43

44 F Flutter Waves Atrial Flutter (F waves) with Variable A-V Block Sleep Medicine Pearls, Berry R,Wagner M,2015:157 44

45 Two Flutter Waves Three Flutter Waves QRS Complex Atrial Flutter, 2:3 Block Rapid Interpretation of EKG's,Dubin D,1984:117 45

46 P Waves 3 rd degree AV Block (complete Heart Block) 46

47 PP Interval Wide QRS Complex R Wave P RR Interval 3 rd Degree Complete Heart Block, No Relation Of P Waves With Wide QRS Complex Atrial Rate = 70/min, Ventricular Rate = 38/min 47

48 Atrial Spike Ventricular Spike P wave T Wave Ventricular Wave Normally Functioning Bi-Ventricular Pacemaker 48

49 Non-sensing Atrial Lead P wave QRS (wide) Non-sensing of Atrial Lead, with spontaneous Atrial & Ventricular Contraction 49

50 QRS (Wide) P wave T wave Ventricular Spike, Non-Sensing or Pacing 50

51 #1 #2(Captured) #5 (Spontaneous P) #6 #3 #4 Intermittent Non-Capture of Atrial Lead #1, 2 & 6: Captured Atrial Signal #3 & 4: Non-Captured Atrial Signal #5: Spontaneous Atrial Contraction 51

52 P Wave Absence Of Ventricular Spike & QRS Complex Ventricular Oversensing with Inhibition of Ventricular Pacing after 3 rd P wave 52 G.H. Kashyap

53 Ventricular Pacemaker Spikes Paced Rhythm By A Single Ventricular Lead, Rate 110/min (A. Fib, s/p AV Ablation, Pacemaker insertion) 53