Introduction to Arrhythmias: Difference between revisions
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Arrhythmias (non-normal heart rhythms) can be a challenge to the person who tries to understand them. But with a systematical approach, diagnosis is often less difficult than it seems at the beginning. | Arrhythmias (non-normal heart rhythms) can be a challenge to the person who tries to understand them. But with a systematical approach, diagnosis is often less difficult than it seems at the beginning. | ||
A good stepwise approach to interprete the heart rhythm is to follow these steps: | A good stepwise approach to interprete the heart rhythm is to follow these steps: | ||
* '''Cherchez le P''', French for ''find the P waves''. | * '''Cherchez le P''', French for ''find the P waves''. | ||
| Line 17: | Line 16: | ||
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? In short: | ** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? In short: | ||
** What is the [[Conduction|PR interval]] and does it change? | ** What is the [[Conduction|PR interval]] and does it change? | ||
*What is the ventricular [[Rate|heart rate]]? | *What is the '''ventricular [[Rate|heart rate]]'''? | ||
**>100 bpm = tachycardia | **>100 bpm = tachycardia | ||
**<60 bpm = bradycardia | **<60 bpm = bradycardia | ||
**are there extra beats? -> [[Ectopic Beats]] | **are there extra beats? -> [[Ectopic Beats]] | ||
* What is the [[Conduction|QRS width]]? | * What is the '''[[Conduction|QRS width]]'''? | ||
*If the QRS < 120ms (i.e. a narrow complex), then it is either a [[Sinus node rhythms and arrhythmias|sinus arrhythmia]], [[Supraventricular Rhythms|supraventricular rhythm]] or a [[Junctional Tachycardias|junctional tachycardia]]. In tachycardias, this [[Media:narrow_tachycardia_flow.png|'''flowchart''']] will lead to the right diagnosis.<cite>ESCnarrowQRS</cite> | *If the QRS < 120ms (i.e. a narrow complex), then it is either a [[Sinus node rhythms and arrhythmias|sinus arrhythmia]], [[Supraventricular Rhythms|supraventricular rhythm]] or a [[Junctional Tachycardias|junctional tachycardia]]. In tachycardias, this [[Media:narrow_tachycardia_flow.png|'''flowchart''']] will lead to the right diagnosis.<cite>ESCnarrowQRS</cite> | ||
*If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[Intraventricular Conduction|bundle branch block]]. This is a challenging difficulty in arrhythmia diagnosis, therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] might help, which incoporates the Brugada criteria for VT.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite> In the editorial on that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite> | *If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[Intraventricular Conduction|bundle branch block]]. This is a challenging difficulty in arrhythmia diagnosis, therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] might help, which incoporates the Brugada criteria for VT.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite> In the editorial on that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite> | ||
Revision as of 16:41, 1 February 2009
| Author(s) | J.S.S.G. de Jong | |
| Moderator | J.S.S.G. de jong | |
| Supervisor | ||
| some notes about authorship | ||
Arrhythmias (non-normal heart rhythms) can be a challenge to the person who tries to understand them. But with a systematical approach, diagnosis is often less difficult than it seems at the beginning.
A good stepwise approach to interprete the heart rhythm is to follow these steps:
- Cherchez le P, French for find the P waves.
- Do you see P waves? Leads II and V1 are often most suitable to find P waves.
- What is the rate of the P waves?
- What is the P wave morphology?
- What is the relationship between P waves and QRS complexes?
- Is there a 1:1 relation between P waves and QRS complexes? If not there may be AV dissociation due to a Ventricular arrhythmia or AV block
- Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? In short:
- What is the PR interval and does it change?
- What is the ventricular heart rate?
- >100 bpm = tachycardia
- <60 bpm = bradycardia
- are there extra beats? -> Ectopic Beats
- What is the QRS width?
- If the QRS < 120ms (i.e. a narrow complex), then it is either a sinus arrhythmia, supraventricular rhythm or a junctional tachycardia. In tachycardias, this flowchart will lead to the right diagnosis.ESCnarrowQRS
- If the QRS > 120ms it is either a ventricular tachycardia or a supraventricular rhythm with additional bundle branch block. This is a challenging difficulty in arrhythmia diagnosis, therefore a flowchart might help, which incoporates the Brugada criteria for VT.Brugada Another method to discriminate VT from SVT has been proposed by Vereckei et al.vereckei In the editorial on that paper an excellent review is given on the subject by Dendi and Josephson.dendi
- What is the clinical setting?
- A wide complex tachycardia in a hemodynamically instable 70 year old man with previous myocardial infarction should be concidered a ventricular tachycardia until proven otherwise
- A wide complex tachycardia in a 24 year old women with recurrent spells of tachycardia the respond to vagal manouevres is most likely an AVNRT with aberrant conduction.
References
<biblio>
- ESCnarrowQRS pmid=14563598
- Brugada pmid=2022022
- vereckei pmid=17272358
- dendi pmid=17317697
</biblio>