Arrhythmia Overview

Antonia Anna Lukito

Arrhythmia
Heart rhythm disorders (arrhythmias) are
problems that affect the electrical system, or
"wiring," of the heart muscle. Heart
arrhythmias are very common and nearly
everyone will experience an abnormal heart
rhythm some time during their lives. Most
are not serious.
Categorization
Arrhythmias can be categorized in three
main ways:
the rate (too slow or too fast);
the location (ventricles-lower chambers
of heart or atria-upper chambers); and
the beat (steady or chaotic and
irregular).
Types of Heart Rhythm Disorders
Bradycardia
Tachycardia
Premature Heart Beat
Fibrillation



Bradycardia
Describes a heartbeat that is too slow (less than 60
beats a minute).
A normal heart contracts about 100,000 times each
day, at a rate of 60 to 100 times a minute.
The weak pace may mean the heart doesn't beat
often enough to ensure blood flow.
Slow heart rates can be the result of certain
medications, congenital heart disease, or the
degenerative processes of aging.
Heart block (or AV Block) and Sick Sinus Syndrome
are forms of bradycardia.

Tachycardia
(tachy=fast) is a too-rapid heartbeat.
There are two predominant types of tachycardia:
supraventricular tachycardia (SVT) and ventricular
tachycardia (VT).
The most common type of SVT is atrial fibrillation, an
irregular and rapid heartbeat in the upper chambers of the
heart (or atria).
At times, ventricular tachycardia (VT) can change without
warning into a deadly arrhythmia called ventricular
fibrillation (VF).
It is the number one cause of sudden cardiac arrest. Within
seconds, an individual loses consciousness and, without
immediate emergency treatment, will die within minutes.

Premature Heart Beat
Occurs when the heart's regular rhythm is
interrupted by early or premature beats.
It may feel as if the heart has skipped a beat.
Usually it is not serious.
If the beat arises from locations in the atria
(upper chambers) it is called premature atrial
beat.
Premature ventricular beats (also called
premature ventricular contractions or PVCs)
arise from the ventricles (lower chambers).
Fibrillation
Describes a heartbeat that is chaotic, or
irregular, and may seem to skip beats or beat
out of rhythm. This occurs when a chamber
of the heart goes into spasm and fails to
pump.
There are two types of fibrillation: atrial
fibrillation and ventricular fibrillation
Treatment Options
Lifestyle Changes
Medications
Cardiac Ablation
Electronic Devices
Implanted Cardioverter Defibrillators (ICDs)
Pacemakers
Devices for Heart Failure
Surgery


Lifestyle Changes
Since other heart disorders increase the risk
of developing arrhythmias, lifestyle changes
often are recommended.
In addition, improving health can lesson the
symptoms of arrhythmias and other heart
disorders as well as prove beneficial to
overall patient health
Medications
Medications can control abnormal heart
rhythms or treat related conditions such as
high blood pressure, coronary artery disease,
heart failure, and heart attack.
Drugs also may be administered to reduce
the risk of blood clots in patients with certain
types of arrhythmias
MANAGEMENT OF TACHY-ARRHYTHMIAS
Tachyarrhythmia
Supraventricular
Paroxysmal supraventricular tachycardias
Atrial fibrillation
Atrial flutter
Multifocal atrial tachycardia
Junctional tachycardia
Sinus tachycardia
Ventricular
Ventricular tachycardia ( 5 beats at 120 bpm; non-
sustained <30s, sustained >30s; monomorphic, polymorphic;
with pulse, pulseless)
Ventricular fibrillation
MANAGEMENT OF TACHY-ARRHYTHMIAS
Diagnosis
Obtain a 12-lead ECG
Echo may be necessary to exclude structural heart disease
? invasive electrophysiological study
Acute treatment
If in doubt and patient, treat as VT. If patient haemodynamically unstable,
immediate DC cardioversion/defibrillation
Active seek out and treat causes (acute coronary syndrome, acute
respiratory insufficiency of various aetiologies, sepsis, electrolytes)
Correct electrolytes : keep serum K > 4 mmol/L and Mg > 2 mmol/L
Narrow Complex Tachy-arrhythmias
Haemodynamic unstable
Immediate DC cardioversion (50J for PSVT/A flutter; 200J for AF)
Haemodynamic stable
Vagal maneouvres
Carotid Massage
IV adenosine 6 mg (ATP=10mg)---2 min---6 mg(10)---2 min---12 mg(20)
IV Verapamilm 5mg over 3-5 mins, to maximum 15 mg
IV Amiodarone (loading dose of 150mg over 10 mins, may repeat if failed to rate control;
followed by infusion 30 mg/hour) caution side effects
If failed to rate-control with amiodarone may consider other anti-arrhythmics eg
Diltiazem (0.25 to 0.35 mg/kg loading followed by infusion 5-15 mg/hour) caution
hypotension
IV Beta- blockers (metoprolol titrate 0.5-1mg, esmolol 0.5mg/kg/min for one min followed by
0.05-0.2mg/kg/min) caution hypotension
IV Digoxin (1 mg over 24 hours in increments of 0.25 to 0.5 mg, followed by 0.125 mg to 0.25
mg daily)
Wide Complex Tachy-arrhythmias
Haemodynamic unstable
Immediate DC cardioversion start at 100J, increase if
unsuccessful
Defibrillation according to ACLS protocol for VF and pulseless
VT
Haemodynamic stable
SVT (see above)
VT or uncertain
IV Amiodarone (loading dose of 150mg over 10 mins, may repeat if
failed to rate control; followed by infusion 30 mg/hour)

Bradyarrhythmia
Heart rate < 60 bpm
Sinus node dysfunction (sinus bradycardia, sinus
pause, sick sinus syndrome)
AV node dysfunction (1
st
, 2
nd
, 3
rd
degree AV block)
Actively seek and eliminate causes (ICU mediated,
extrinsic)
ICU vagally mediated causes
Intubation, suctioning, increased intracranial pressure,
urination, defaecation, vomiting , stretching

Extrinsic causes
Drugs (antiarrhythmic agents)
Electrolytes (K, Mg, Ca)
Hypothyroidism
Hypothermia
Sepsis
Specific infection (eg. endocarditis)
AMI (inferior AMI related AV blocks often transient;
Anterior AMI related AV blocks often irreversible)

Bradyarrhythmia
Acute treatment
May not need immediate treatment if haemodynamically stable
Correct electrolytes
Treat if
Symptomatic sinus bradycardia (hypotension, ischaemia, escape ventricular
arrhythmia)
Ventricular asystole
Symptomatic AV block (2nd degree Type I or 3rd degree with narrow-complex
escape rhythm)
Give
Atropine: IV 0.6 mg (max 3 mg)
Isoprenaline: Infusion at 0.5 10 mcg/min (caution in ischaemic heart disease)
Pacing: for symptomatic bradycardia.
Types including transcutaneous/epicardial/transvenous/permanent
PACING
Indications for urgent transcutaneous pacing
1. Sinus bradycardia with symptoms (SBP <80mmHg) unresponsive to
drug therapy
2. Mobitz type II 2
nd
degree AV block
3. 3
rd
degree heart block
4. Bilateral BBB (alternating BBB or RBBB with alternating
LAFB/LPFB)
5. Newly acquired or age indeterminate bifascicular block (LBBB,
RBBB with LAFB or LPFB) with 1
st
degree AV block
Because transcutaneous pacing may be uncomfortable, especially
when prolonged, it is intended to be prophylactic and temporary.
Refer to cardiologist for transvenous pacing in patients who
require ongoing pacing and in those with a very high probability of
requiring pacing
Indications for temporary transvenous pacing

1. Asystole
2. Symptomatic bradycardia (includes sinus bradycardia with
hypotension and Type I 2
nd
degree AV block with hypotension
not responsive to atropine)
3. Mobitz type II 2
nd
degree AV block
4. 3
rd
degree heart block
5. Bilateral BBB (alternating BBB or RBBB with alternating
LAFB/LPFB)
6. Newly acquired or age indeterminate bifascicular block (LBBB,
RBBB with LAFB or LPFB) with 1
st
degree AV block
Monitor to ensure appropriate pacing and sensing functions and
absence of dislodgment (CXR)
Frequent (at least once per 24 hours) testing of pacing thresholds
(pacing energy is usually set at more than 3 times the threshold)
Pacemakers
Devices that "pace" the heart rate when it is
too slow (bradycardia) can take over for the
heart's natural pacemaker, the sinoatrial
node, when it is functioning improperly.
Pacemakers monitor and regulate the rhythm
of the heart and transmit electrical impulses
to stimulate the heart if it is beating too
slowly.
Oral Anticoagulant in Atrial Fibrillation
Age less than 60, no heart disease, lone atrial fibrillationtreat with aspirin.
Age less than 60, heart disease, but really no risk factorstreat with aspirin.
Age greater than 60, but no risk factorstreat with aspirin.
Add diabetes and coronary artery diseasetreat with warfarin to an INR of 2 to
3.
Age >75treat with warfarin to an INR of 2 to 3.
Other high-risk patients (heart failure, EF <0.35, thyrotoxicosis, hypertension,
rheumatic heart disease)treat with warfarin (INR 2 to 3).
Patients with mitral stenosis, prosthetic heart valvestreat with warfarin (INR 2
to 3).
Prior thromboembolic event and persistent atrial thrombustreat with warfarin
to an INR of 2.5 to 3.5.
Patients undergoing cardioversion (electrical or pharmacological)anticoagulate
patients with atrial fibrillation (of at least 48 hours' duration) for at least 3 to 4
weeks before and 3 to 4 weeks after cardioversion. Even if you do a TEE, show no
thrombus, and cardiovert the patient, you still need to anticoagulate the patient
for 3 to 4 weeks after the procedure

Electronic Devices
By delivering a controlled electric shock to
the heart, defibrillators, or cardioverters
"shock" the heart back into a normal heart
rhythm
Sometimes the devices are external, such as
in an emergency situation. Often, the
electronics are implanted in the patient's
chest
Implanted Cardioverter Defibrillators
(ICDs)
ICDs are 99 percent effective in stopping life-
threatening arrhythmias and are the most
successful therapy to treat ventricular
fibrillation, the major cause of sudden cardiac
arrest.
ICDs continuously monitor the heart rhythm,
automatically function as pacemakers for heart
rates that are too slow, and deliver life-saving
shocks if a dangerously fast heart rhythm is
detected.
Ventricular tachycardia with an ICD
Devices for Heart Failure
The U.S. Food and Drug Administration (FDA)
recently approved a special type of pacemaker
for certain patients with heart failure.
In Cardiac Resynchronization Therapy, an
implanted device paces both the left and right
ventricles (lower chambers) of the heart
simultaneously.
This resynchronizes muscle contractions and
improves the efficiency of the weakened heart
Cardiac Ablation
In this procedure, one or more flexible, thin
tubes (catheters) are guided via x-ray into the
blood vessels and directed to the heart
muscle.
A burst of radiofrequency energy destroys
very small areas of tissue that give rise to
abnormal electrical signals
Catheter Ablation
Surgery
Although surgery is sometimes used to treat
abnormal heart rhythms, it is more
commonly elected to treat other cardiac
problems, such as coronary artery disease
and heart failure.
Correcting these conditions may reduce the
likelihood of arrhythmias
Indications for surgical ablation to treat AF
Patients with symptomatic AF undergoing other
cardiac surgery
Selected patients with asymptomatic AF
undergoing cardiac surgery in whom ablation
can be performed with minimal risk
Stand-alone surgery for AF should be considered
for patients with symptomatic AF who prefer a
surgical approach, have failed one or more
attempts at catheter ablation, or are not
candidates for catheter ablation

Figure 1 The corridor procedure for AF
Lee, R. et al. (2009) Surgery for atrial fibrillation
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2009.106
Figure 2 The surgical maze
Lee, R. et al. (2009) Surgery for atrial fibrillation
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2009.106
Figure 3 Bipolar radiofrequency ablation using Cardioblate

BP2 (Medtronic,
Inc., Minneapolis, MN)
Lee, R. et al. (2009) Surgery for atrial fibrillation
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2009.106
Permission obtained from S. Klein, Medtronic, Inc., Minneapolis, MN