Arrhythmia Management Joshua M. Cooper, MD, FHRS, FACC Professor of Medicine Director of Cardiac Electrophysiology Temple University Health System
Plumbing
Electrical System
Bradyarrhythmias Sinus Node AV Conduction Medications Vagus Nerve Catechols AV Node His bundle or Purkinje system Discontinue Med or Implant Pacemaker
Tachyarrhythmias Atrial Conduction System Ventricular Focal Reentry Focal Reentry Focal Reentry Medication or Catheter Ablation
Palpitations Fast heart rate Slow heart rate Strong heart beat Extra beat(s) Skipped beat(s) Irregular heart beat Fluttering Butterflies Flip Flop Pounding Racing Start & Stop Once Seconds Minutes Hours Days Daily Weekly Monthly Yearly
Arrhythmia Mimics Symptoms History GI symptoms Reflux, eso spasm Muscle symptoms Pectoral, intercostal Panic attack Anxiety disorder Tripped and fell Seizures Car accident Drowning Heart attack
Ways To Record Arrhythmias ECG Non-Loop Monitor Holter Looping Monitor Smart Phone App Implantable Monitor
Slow Heart Rhythms
Sinus Node Setting the Pace!
Example #1 Sinus Node Dysfunction 3:00pm - HR 39 bpm Example #2 3:00am - 3.4 second pause
Tachy Brady Syndrome 5.5 second pause Atrial Fibrillation Sinus Node Resumes Firing after Being Suppressed
Chronotropic Incompetence Slow, Unchanging Heart Rate Normal Heart Rate Distribution
AV Conduction Delivering the Message!
Mobitz I (Wenckebach) Block occurring in AV node Typically narrow QRS (Purkinje tree is OK) Grouped beating Prolonging PR interval until blocked beat PR after pause shorter than PR before
Mobitz II Block occurring in His-Purkinje System Usually wide QRS (Purkinje tree missing branches) Often not in a pattern PR intervals constant all or none
Mobitz II Can progress to asystole at any time! (few minutes later)
Side-by-Side Comparison - ECG From Med-on-Line, David C. Chung, MD
Third Degree Heart Block aka Complete Heart Block No signals get through from A to V Substitute, slower pacemaker spot takes over AV dissociation Rate of escape rhythm depends on location
Pacemaker - Works for All Types of Bradycardia Pacemaker Right Atrium Right Ventricle
Fast Heart Rhythms
From the Atria Atrial Fibrillation Atrial Flutter Atrial Tachycardia
From A-V Connections AV Node Reentry (AVNRT) AtrioVentricular Reciprocating Tachycardia using Accessory Pathway (AVRT) Fascicular Tachycardia
From the Ventricles Focal Ventricular Tachycardia (and PVCs) Scar-based Ventricular Tachycardia
Premature Atrial Beat (PAC)
Premature Ventricular Beats (PVCs)
Extra Beats or Skipped Beats?
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation Slow V.rate
Atrial Fibrillation Fast V.rate
Sustained Automatic VT
Taking an Arrhythmia History When did symptoms start happening? How long do symptoms last? How often do episodes occur? Do they start and stop suddenly? Is the heartbeat regular or irregular? Any other symptoms at same time? Lightheadedness or fainting? Pattern? Time? Exercise/rest? Have you taken your pulse during a spell?
What Triggers Fast Rhythms? Stress Fright Fatigue Dehydration Illness After exercise At rest (in bed) Thyroid or endocrine problems Menstrual cycle Caffeine Alcohol Stimulants Sudafed Albuterol (Ventolin) Caffeine pills Diet medications Heart conditions Electrical abnormalities since birth
Making the Diagnosis ECG in office or emergency room 24 hour Holter monitor 30 day event monitor Smart phone application Implantable loop monitor Exercise stress test Refer to an electrophysiologist
ECG in ER
30-day Event Monitor
30-day Event Monitor
AliveCor Application
Implantable Loop Monitor
Treatment Options Depends on diagnosis and severity No treatment needed Change in behavior (cut down caffeine, etc.) PRN Medication as needed for symptoms Daily Medication(s) B-blocker, AV node blockers, Antiarrhythmic meds Anticoagulant for a.fib, a.flutter Catheter ablation procedure Pacemaker implantation for bradyarrhythmias ICD implantation for life-threatening VT/VF
Thank You! Joshua M. Cooper, MD Email: joshua.cooper@tuhs.temple.edu