Introduction to Arrhythmias: Difference between revisions

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Introduction to Arrhythmias (view source)

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[[Image:VT_SVT_LBBB_WCT.svg|thumb|Morphologic criteria to differentiate between SVT vs. VT in a wide complex tachycardia. This is part of the [[media:wideQRS_tachycardia_flow.png|wide complex tachycardia flowchart]]]]
[[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 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 understand, but with a systematic approach, diagnosis is often less difficult than it may appear at first.  
 
==Interpretation of the heart rhythm==
A good stepwise approach to interpret the heart rhythm is to follow these steps:
A good stepwise approach to interprete the heart rhythm is to follow these steps:
*Is this my patient's ECG or is this an artifact? (applies especially in stressfull situations)
*What is the '''ventricular [[Rate|heart rate]]'''?
**>100 bpm = tachycardia
**<60 bpm = bradycardia
**Are there extra beats? -> [[Ectopic Beats]]
* '''Cherchez le P''', French for ''find the P waves''.  
* '''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.
** 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 [[rate]] of the P waves?
** What is the [[P wave morphology]]?
** What is the [[P wave morphology]]?
* What is the relationship between P waves and QRS complexes?
* What is the '''relationship between P waves and QRS complexes'''?
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? In short: is there a 1:1 relation 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 Arrhythmias]] or [[AV Conduction|AV block]]
** 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?
** What is the [[Conduction|PR interval]] and does it change?
*What is the ventricular [[Rate|heart rate]]?
* What is the '''[[Conduction|QRS width]]'''?
*>100 bpm = tachycardia
**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>
*<60 bpm = bradycardia
**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>
*are there extra beats? -> [[Ectopic Beats]]
* What is the '''[[Heart axis|Heart Axis]]''' and did it change?
* What is the [[QRS morphology]]?
** 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?
* 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.
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]]. 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>


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==References==
==References==
<biblio>
<biblio>
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#dendi pmid=17317697
#dendi pmid=17317697
</biblio>
</biblio>
}}
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