Difference between revisions of "Introduction to Arrhythmias"

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[[Image:VT_SVT_LBBB_WCT.svg|thumb|300px|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]]]]
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[[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.
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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.  
 
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A good stepwise approach to interprete the heart rhythm is to follow these steps:
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A good stepwise approach to interpret the heart rhythm is to follow these steps:
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*Is this my patient's ECG or is this an artifact? (applies especially in stressfull situations)
 
*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]]
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**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.
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* 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:Svt_algorythm_en.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: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 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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**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?
 
* 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.
 
** 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 instable 70 year old man with previous myocardial infarction should be concidered a [[ventricular tachycardia]] until proven otherwise
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** 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 women with recurrent spells of tachycardia the respond to vagal manouevres is most likely an [[AVNRT]] with aberrant conduction.
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** 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|
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{{box|
 
==References==
 
==References==
 
<biblio>
 
<biblio>

Latest revision as of 13:35, 3 November 2012

Author(s) J.S.S.G. de Jong
Moderator J.S.S.G. de jong
Supervisor
some notes about authorship
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.

A good stepwise approach to interpret 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 heart rate?
    • >100 bpm = tachycardia
    • <60 bpm = bradycardia
    • Are there extra beats? -> Ectopic Beats
  • 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?
  • What is the QRS width?
  • What is the 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 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.


References

Error fetching PMID 14563598:
Error fetching PMID 2022022:
Error fetching PMID 17272358:
Error fetching PMID 17317697:
  1. Error fetching PMID 14563598: [ESCnarrowQRS]
  2. Error fetching PMID 2022022: [Brugada]
  3. Error fetching PMID 17272358: [vereckei]
  4. Error fetching PMID 17317697: [dendi]
All Medline abstracts: PubMed | HubMed