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.
{{authors|
 
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]
First look at the heart rate:
|moderator= [[user:Drj|J.S.S.G. de jong]]
*>100 bpm = tachycardia
|supervisor=
*<60 bpm = bradycardia
}}
*are there extra beats? -> [[Ectopic Beats]]
[[Image:Atrial_ventricular.png|thumb|300px|Arrhythmias can be subdivided into supraventricular, nodal and ventricular arrhythmias]]
 
Arrhythmias (non-normal heart rhythms) can be a challenge to understand, but with a systematic approach, diagnosis is often less difficult than it may appear at first.
Secondly it is important to assess the origin of the arrhythmia:
*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]]
A good stepwise approach to interpret the heart rhythm is to follow these steps:
*If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[bundle branch block]]
*Is this my patient's ECG or is this an artifact? (applies especially in stressfull situations)
 
*What is the '''ventricular [[Rate|heart rate]]'''?
Normal heart rhythm is explained in:
**>100 bpm = tachycardia
*[[Sinus node rhythms and arrhythmias]]
**<60 bpm = bradycardia
 
**Are there extra beats? -> [[Ectopic Beats]]
Non-normal heart rhythms (arrhythmias) are described in:
* '''Cherchez le P''', French for ''find the P waves''.
*[[Supraventricular Rhythms]]
** Do you see P waves? Leads II and V1 are often most suitable to find P waves.
*[[Junctional Tachycardias]]
** What is the [[rate]] of the P waves?
*[[Ventricular Arrhythmias]]
** What is the [[P wave morphology]]?
*[[AV Conduction]]
* What is the '''relationship between P waves and QRS complexes'''?
*[[Genetic Arrhythmias]]
** Is there a 1:1 relation between P waves and QRS complexes? If not there may be [[AV dissociation]] due to a [[Ventricular Arrhythmias]] or [[AV Conduction|AV block]]
*[[Pacemaker]]
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave?
 
** What is the [[Conduction|PR interval]] and does it change?
*Flowchart: [[media:wideQRS_tachycardia_flow.png|Approach to the Wide Complex Tachycardia]]
* What is the '''[[Conduction|QRS width]]'''?
*Flowchart: [[Media:narrow_tachycardia_flow.png|Approach to the Narrow Complex Tachycardia]] Adapted from <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:Svt_algorythm_en.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 diagnosis. Therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] which incoporates the Brugada criteria for VT should be used.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite>In that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite>
* What is the '''[[Heart axis|Heart Axis]]''' and did it change?
** If the heart axis turns significantly when compared to the heart axis during sinus rhythm a ventricular origin of the rhythm is more likely.
* What is the '''clinical setting'''?
** A wide complex tachycardia in a hemodynamically unstable 70-year-old man with previous myocardial infarction should be considered a [[Vt|ventricular tachycardia]] until proven otherwise
** A wide complex tachycardia in a 24-year-old woman with recurrent spells of tachycardia that respond to vagal maneuvers is most likely an [[AVNRT]] with aberrant conduction.


{{box|
==References==
==References==
<biblio>
<biblio>
#ESCnarrowQRS pmid=14563598
#ESCnarrowQRS pmid=14563598
#Brugada pmid=2022022
#vereckei pmid=17272358
#dendi pmid=17317697
</biblio>
</biblio>
}}
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