- Arrhythmias

PR <200; QRS <120; QT <400 (2 Large Boxes)**********************

-Little Marks =Vertical Dashes on ECG represent 3sec; 2 Dashes =6secs; count the QRS in 6sec x10 =Irregular Heart Rate
If Rhythm is Regular then we can Count Boxes b/w R-R and divide 300/Boxes
Sinus TachyCardia= all durations are Normal; Normal PR, QRS, QT but Rate is 101-150
SupraVent Tachy: Rate =150-220; Impulses don’t originate from the SA Node but from Around the AV Node
=due to ReEntry or inc Automaticity; Paroxysmal =Accessory Pathway; AFib; Flutter?
P wave is often buried in the T Waves… so it looks weird
AFib =Irregularly Irregular; no pattern, P wave quivers; QRS RR Intervals Varry
Aflutter= Sawtooth =Regular Atrial Rate; Vent Rate is Regular if all Impulses are Conducted through AV Nodes; There can be
1 or upto 6 P waves before each QRS; P waves are present but are too fast so Atria don’t contract properly
VTach =QRS are like unequal sine waves; no p
VFib =kind of like unequal sine waves; no p or QRS
SA Block: Impulse doesn’t go from SA node to AV Node =P wave is dropped randomly**
AV Block: QRS is dropped
1st Degree =Slow Conduction; 2nd Degree =Intermittent; 3rd Degree =No Conduction
1st Degree Heart Block: PR >200; 2nd Degree Type 1 =Progressively inc PR; Type 2 =Constant PR w Dropped Beat
3rd Degree =Regular P and Regular RR; QRS is due to Back up Pace Maker; P & R are completely unrelated. QRS can be
narrow or wide depending on the Location of Back up pacemaker of Ventricles; Rx w PaceMaker & Atropine if Symptoms

Sinus BradyCardia can be Asymptomatic or Dizziness, Light Headedness, Hypotn, Syncope, Angina, CHF
-IV Atropine =First Line Rx=> inc HR & BP
-if no response: give Epi or Dopamine or Transcutaneous Pacing
-Adenosine used for SVT**
-Amiodarone for Both SVT & VT
-Glucagon =inc cAMP; used for BB or CCB OverDose
-NE used for severe Hypotn & Septic Shock
suicide attempt: Pt had hypotn, AV block, Wheezing*** =B Blocker =dec cAMP
-also causes HypoGlc (dec Hepatic GNG, inc Insulin Resistance), HyperK; Neuro =Delirium, Seizures
-Rx: IV Fluids + Atropine =1st Line; then IV Glucagon to inc cAMP if ProFound Hypotn
-also give IV Ca, Vasopressors =Epi & NE; Insulin + Glc
Impaired SA Automaticity =Sick Sinus Synd =Fibrosis of SA =can have Brady alternating w Tachy;
Sinus Pauses, Arrest; Palpitations, Syncope
Insert Pacemaker in Sick Sinus Synd or 2nd or 3rd Degree Heart Block
**Procainamide =in WPW Synd, Vent & SupraVent Arrhythmias
Wiki: ElectroPhysiologic study (EPS) with ablation is the first-line treatment for symptomatic WPW syndrome
WPW =bypass AV Node =directly Connect Atria w Vent; Short PR <0.12; Delta Wave =curve b4 QRS, Wide QRS,
Kaplan: If hemodynamically stable, use Procainamide. Avoid digoxin, beta blockers, and calcium-channel blockers, as they can
inhibit conduction in the normal conduction pathway. If the patient is hemodynamically unstable, then immediate electrical
Cardioversion is indicated. Ablation is used as defnitive treatment.
Tobacco, Alcohol, Caffeine & Stress=> Premature Atrial Contractions
-B Blockers given if Symptomatic
Holter =used to Identify Intermittent Arrhythmias in pts w Palpitations, Syncope;
EchoCardio = Looks for Valvular, Structural or F'nal Abnormality; if there is a Murmur, Heart Failure, CAD
1st Degree AV Block =Regular inc PR Interval; inc Risk of AFib, Heart Failure, Mortality
=Benign if QRS Normal =only PR is Prolonged; Delayed Conduction in AV Node
***if QRS Duration also Prolonged >120 then Conduction delay is below the AV Node in Bundle Branches;
can prgress to 2nd or 3rd Degree Block and should do ElectroPhysio Testing to determine the site;
-can be intermittent; pt can have normal HR on Presentation
-do Electro-Physiologic Testing for PaceMaker Insertion
1st Degree: Delayed Transmission from Atria to Vent >200 msecs; long PR but it is Constant; 1P for every QRS
2nd Degree =Mobitz 1 =Progressive Prolongation of PR then a dropped QRS Complex
=Benign & Transient Arrhythmia; Block is in AV Node
 -avoid drugs that inc AV Delay =Digoxin, CCB, BB (also avoided in WPW); Improves w Atropine
-Measure PR Interval Just Before =Longer & After =Shorter; the Dropped QRS
-Constant PP, increasing PR & then Dropped R Beat
-Can cause dec CO, Syncope in Elderly w HF; Benign & Asymptomatic in Young ppl
Mobitz 2 AV Block =no progressive widening of PR; PR is Always Constant; QRS dropped suddenly;
-inc risk of 3rd Degree Block; Rx =Pace Maker
-block is in Bundle of His; below the AV Node; Improves w Vagal Maneuvers??
3rd Degree =Complete Block; P waves entirely unrelated to QRS; P-P & R-R intervals =constant
Complete Heart Block can lead to Angina, Arrhythmias or Asystole; immediately insert Temporary Pacemaker
& Fix Reversible Causes eg MI, Inc Vagal Tone due to Pain, HyperK, AV Blockers =Propranolol, Verapamil;
-Check Cardiac Enzymes; do Catheterization
3rd Degree =Complete AV Block ECG =Regular P Waves Temporaly UnRelated to QRS;
P waves can be Before, After or Burried in QRS
R-R Interval is also Constant but Independent of P Waves =P-QRS Dissociation
Adenosine, B Blockers, Digoxin worsen the Block and are ContraIndicated
**T wave Inversion =Myocardial Ischemia =check Cardiac Enzymes & do Catheterization
S wave in lead I (indicating a rightward shift of QRS axis) with Q wave and T inversion in lead III. It is the classical ECG pattern of Acute Pulmonary Emb
Adenosine inh L Ca Channels; dec Conduction Velocity; Terminates ReEntrant Tachycardia

AFib =check TSH & T4 Levels to screen for Occult HyperThyroidism =mcc of AFib**
-Irregularly Irregular Rhythm =Varrying R-R Intervals; no P Waves**
AFib =no P waves; irregular QR
Vagal Maneuvers used to Determine Location of Abnormality in 2:1 AV Block
Holter is done in Dizziness, Syncope
Cardiac Sarcoidosis: Granulomas in Myocardium=> Arrhythmia 2:1 Block, LBBB; Heart Failure;
-pulse was 35; had multiple Syncopic Episodes; pt also had Uveitis; Dyspnea, Lung Opacities
FA: widespread noncaseating granulomas; hilar and mediastinal adenopathy on CT; restrictive lung disease (interstitial fbrosis), erythema nodosum, lupus
pernio (skin lesions on face resembling lupus), Bell palsy, uveitis, hypercalcemia. Treatment: steroids (if symptomatic).
AV Block & Syncope after Infective EndoCarditis =PeriValvular Abscess extending into Cardiac Conduction Pathways

AFib on ECG: Irregularly Irregular Rhythm, No P waves, Narrow QRS; if Pulse >100=means Rapid Vent Response
Rapid Vent Response in AFib means Rapid Vent Rate=> InEffective Beating, dec CO
-Control Ventricular Rate w B Blockers, Diltiazem, Digoxin + AntiCoag if CHADS Score >1
- Maintain Rhythm w Amiodarone, Flecainide if Recurrent Symptomatic Episodes
=Palpitations, Light-Headedness, Dyspnea Angina, CHF
CardioVersion in HemoDynamically Unstable (Confusion, Hypotn, Chest Pain & PEdema) pts w MI or CHF
- Cardioversion =give shock during QRS; -if Shock is Given during Repol (after QRS)=> it will ppt VFib
AFib if Stable then give BB or CCB =Rate Control
if VFib or Pulseless VT then do Defibrillation =Shock @ Random Point
Amiodarone if Vent Arrhythmias =Wide QRS or to maintain Sinus Rhythm in Chronic Afib;
Kaplan: Cardioversion can Displace Thrombus so if pt had AFib for >48hrs then do TEE to see if there is Thromb
Paroxysmal SupraVent Tachycardia =Narrow Complex; Adenosine or Carotid Massage slows AV Node
& Interrupts Reentry Pathway & Terminates it; Not Effective LongTerm for AFib
Lidocaine =for Vent Arrhythmias
Rate Control= B Blockers, CCB, Digoxin; Rhythm Amiodarone…?
pt w Thyrotoxicosis develops palpitations & has HR =125; Rx w Propranolol; it also dec T4=> T3 Conversion
AFiib is usually limited to Atria cuz normally AV Node blocks the extra Impulses
WPW has Accessory Pathway that ByPasses AV Node; AFib in WPW is a Life Threatening Emerg**
=>Very Rapid Vent Response=> deteriorates into VFib
-Rx: Stable pt: Rhythm Control w IV Ibutilide or Procainamide
Unstable AFib pt=> CardioVersion
**Avoid AV Blockers =Verapamil, B Blockers, Digoxin, Adenosine; they inc Conduction through Accessory Pathway**
pt had AFib; Htn & Ejection Fraction of 35%; Global HypoKinesis; LA & LV Dilatation; MR; CHF
 =TachyCardia **Induced Myopathy***; MR is due to LV Dilatation =Fnal MR
-Prolonged period of Rapid Vent Rate =Chronic TachyCardia causes LV Dilation & MyoCardial DysFn
-leads to CHF & Palpitations; do ECG & Echo to Rule out other causes of LV DysFn & Exclude CAD
-Rate & Rhythm Control can restore LV Fn; AV Blockers, Catheter Ablation
pts w lone AFib are generally aged <60 and by definition have a Chads Vasc score of 0. no need for A/Coag
Amiodarone given for Rhythm Control in Recurrent Symptomatic Episodes of AFib
AntiPlatelet =Clopidogrel or Aspirin Therapy is used for CAD; less effective in ThromboEmbolic Prophylaxis
Give Warfarin instead
WPW Synd: PreExcitation of Ventricles; Slurred Initial Upstroke of QRS =Delta Wave;
Short PR <120**; Wide QRS >120
-Delta Wave is visible once we Slow the Rhythm; not during SVT
-Accessory pathway that bypasses AV Node and directly connects Atria w Ventricles =Bundle of Kent
-ReEntrant SVT if Retrograde Conduction from Vent into Atria
Long QT >450**; leads to Torsades
HypoK=> low T wave, high U wave

Lidocaine used for Vent Arrhythmias

Flecainide & Propafenone =Class 1C =Slowest rate of Drug Dissociation from Na Channel
-in pts w Faster Heart Rates drug has less time to dissociate=> higher # of Blocked Channels
=> progressive dec in Conduction & Widening of QRS =Use Dependence**
Digoxin: inh Na/K Pump=> inc Na inside=> inc Ca inside;
**Delayed After Depol =small Spike After Action Pot’l is complete =due to inc Ca =due to Digoxin Toxicity
-Slow AV =inc PR
Digitalis=> inc Ectopy in Atria & Vent=> Atrial (or Vent) Tachycardia =150-250; not AFib; not Fluter =250-350
-it also inc Vagal Tone & cause AV Block
**This Combination is Fairly Specific for Digitalis**
Digoxin toxicity: N,V,D, dec Appetite; Arrhythmias =Palpitations; Vision*** Changes =Scotomas, Blurring, Blindness
-Acute Dig Toxicity =GI: N,V, Pain, Anorexia
-Chronic Digoxin Tox =Neuro =Fatigue, Confusion, Disorientation & Visual =Yellow Vision, Scotoma, Blindness
-it is Renally Excreted; Renal Injury =dec Dig Excretion
Excessive Diuretic use =vol Depletion; Renal Injury
-Loop diuretics=> HypoK=> also inc Dig Toxicity
Amiodarone, Verapamil, Propafenone, Quinidine can inc Digoxin levels
-dec Digoxin dose by 50% when starting these; check Dig Levels weekly
Mobitz Type 2 Block =pathology below** AV Node =not affected by Dig

AFib is mcc caused by Foci in Pulm Veins**; Irregular RR, Narrow QRS
Rx =Catheter Ablation
AV ReEntry Tach =ReEntry via Accessory Bypass Tract =WPW
AV Nodal ReEntry Tach =2 separate Pathways in AV Node; Regular Rhythm, Narrow QRS, Absent P; Rate >140
MultiFocal Atrial Tach =by Pulm Disease
Paroxysmal SVT mcc due to Accessory Conduction Pathways & Re entry through AV Node
-AV Node has Fast & Slow Pathways; Normally Impulse Flows via Fast Pathway;
Slow is Suppressed due to Refractory Period
=If a PreMature Beat occurs @ a Critical Time when Fast Pathway is in Refractory Period but Slow is not
then Impulse Starts Traveling through Slow and Returning through Fast =ReEntry
- Vagal Maneuvers Suppress AV Node & abort SVT
=[Valsalva, Carotid Sinus Massage, Immersion in Cold Water, Orbital Pressure]
-Adenosine =short acting AV Node Blocker
Sinus Tachycardia w Electrical Alterans* =specific for Large Pericardial Effusion
=Beat to Beat Variation in QRS Axis & Amplitude** =due to Swinging Motion of Heart in Fluid
-perform Emergency Pericardiocentesis
-URInfection=> Pericarditis
Wide Complex =Vent Tach =Problem in Ventricles; Rx w Amiodarone
Narrow complex =SVT =any tachy originating above His Bundle =AFib, Flutter, AV Nodal ReEntry (2 pathways within AV);
AV ReEntry (accessory outside AV Node); Junctional; Paroxysmal means sudden SVT
-SVT =P waves burried under QRS; can Appear as Inverted P Waves =or Spikes** on QRS; R-R is Constant
=>Lightheadness, SOB, Sweating, Pain
IV Adenosine =Dx & Rx of Narrow Complex Tach =Slows Sinus Rate, AV Conduction & causes AV Block
so Vent Slow Down and P Waves become Easy to Identify; Differentiates Flutter vs AFib
Sinus Tach =Normal P wave Relation w QRS; P waves are NOT Burried** under QRS
NitroGlycerin used for PEdema, Ischemia, Htn Urgency

AmioDarone is used to Rx Vent Arrhythmias after Ischemic CardioMyoPathy or CAD

-pt had CHF + VTach=> was given AntiArrhythmic 6 months ago; now has SOB
Amiodarone=> Interstitial Pneumonitis =Progressive Dyspnea, Dry Cough, Restrictive Lung Disease
Reticular or Ground Glass Opacities; dec DLCO;
-other Resp Side Effects =ARDS, Diffuse Alv Hemorrhage
-his Jugular Veins are flat & no Edema so it is not worsening of CHF*
Tricuspid Regurg=> RHFailure=> JVD, Megaly, Edema
Amiodarone=> ARDS; Chronic Interstitial Pneumonitis =Pulm InFiltrates
-look out for signs of Cough, Fever, Dyspnea
-get Chest X Ray and PFT to see baseline Lung Fn
-also can cause Long QT, inc Trans-Aminases =Liver
-pt had poor MEMORY, FATIGUE, Wt Gain =Amiodarone HypoThyroidism
it also causes inc LFT =HepatoToxicity; Heart Block, Long QT; Eye Deposits; Optic Neuropathy
Hydralazine=> Salt & Fluid Retention, Edema, Palpitations, Orthostatic Hypotn, Drug Induced Lupus
ApiXaBan is used for AFib or DVT
Carvidilol =Beta & Alpha Blocker used for CHF
Long QT Synd=> Syncope, Arrhythmias, Sudden Cardiac Death; LightHeadedness, Palpitations
-Refrain from Vigorous Exercise
-Maintain Normal Levels of Ca, Mg, K and Avoid Drugs that block K Channels
-B Blockers =shortens QT** & Blunts Exertional HR; + PaceMaker** prevent Cardiac Arrest
-B Blockers & CCB treat HCM

Torsades =Twisting of the Points

-occurs due to Long QT; due to Moxifloxacin, Fluconazole
-can Degenerate to VFib or Sudden Cardiac Death
-Rx: DeFib if Unstable; MgSO4 if Conscious & Stable; RemoVe Cause

pt had CHF; was given Loop Diuretics=> HypoK & HypoMg=> V Tach + inc Digoxin Side Effects =V Tach
-order Serum K & Digoxin Levels
Avoid B Blockers in Acute Decompensated HF; but can be given after Preload reduction w Diuretics
Metolazone =Thiazide
Pts on Sotalol to be admited to Hosp & monitor Rhythm; it Causes Torsades
Ca-Gluconate used in CardioToxicity due to HyperK =Peaked T, inc PR & QRS;
Na-HCO3 used in Quinidine causing Torsades; or Cardiac Arrest due to HyperK; TCA; Met Acidosis
Wide QRS TachyCardia: Stable pts managed w AntiArrhythimcs =Amiodarone**, Procainamide, Sotalol, Lidocaine
-Synchronized CardioVersion if Persistent TachyArrhythmia w Severe Symptoms
=AMS, HF, Pulm Edema, Ischemia or Hemodynamically Unstable =Hypotn, Shock
HemoDynamic Instability =low BP, Cold Extremities
Sustained MonoMorphic V Tach: wide QRS** w Fusion Beats =diagnostic; SVT has Narrow QRS**
-Fusion Beats =Impulse Coming from 2 Focci =Atria & Vent combines and results in a
Hybrid of Narrow & Wide QRS; always Preceded by P Wave (cuz Atrial Beat needs to be present to combine)
Wide Complex: can be SVT w Aberrancy or a VTach
Esmolol =ultra short acting, used for SVT =AFib, Flutter, ATach; who have Hypotn and can not Tolerate CCB & BB
Digoxin =used to Rate Control in SVT; Especially if pt also has Systolic Failure**
Synchronized CardioVersion is done in AFib w Rapid Response or MonoMorphic VT
PolyMorphic VT =Torsades =Multiple QRS Morphologies; inc Risk in Long QT Drugs; stop those, give IV Mg**

VFib or Pulseless VTach=> do Immediate CPR & Defib (Shock @ Random Point) to Resume Circulation
-Give Epi every 3-5mins if Persistent VFib after Defibrillation & CPR
MCC of Sudden Cardiac Arrest in Adults =Sustained VT or VFib due to Acute MI
-VFib never Terminates on its own; so DeFib early**
Give Epinephrine if Asystole, PEA, VFib not Responding to DeFib
-VFib =mcc Sudden Cardiac Death during Acute MI
-pt presented after MI & became unresponsive 2hrs later; ECG showed VFib =due to Ischemia
ReEntrant Vent Arrhythmias =VFib =mcc of Cardiac Arrest Immediately Post MI
-Arrhythmias within 10mins of MI =Heterogeneity of Conduction w Marked Slowing in some Areas=> ReEntrance
-10 to 60mins after MI Arrhythmia is due to Abnormal Automaticity
AFib, Flutter or VT w Pulse =do Cardioversion if HemoDynamic Instability
VT & Torsades due to Drug Side Effect: Rx =MgSO4 but not for VFib due to MI
V Tach= Sustained Monomorphic V Tach =Wide Complex =has atleast 2 fusion beats when =capture of electrical signals
through atrium and ventricle together= forms a hybrid= see picture…
We do DeFib also in Unstable Torsades; give MgSO4 if stable
Paroxysmal SVT= Junctional, AVNRT, AVRT; do Vagal Maneuvers
AVNRT has no regular p waves as they are buried in QRS= premature atrial beat at a critical time where fast and
slow pathways form a circle
Asystole =Flat Line due to VFib =no QRS & no Pulse; but Line is not Flat; it is Wavy
Cardiac Arrest? =PulseLess Electrical Activity =Organized Electrical Activity but no Pulse or Contraction
=due to Severe Hypotn=Massive MI, Massive PEmb, Tension Pneumo, Tamponaude etc
Wiki: Cardiac Arrest =Loss of Heart F’n due to V Fib** or PEA?; Rx w Epinepherine; CPR; Treat the Cause; Asystole =Flat Line =Most Serious form of Arrest
PEA or Asystole Rx =UnInterrupted CPR w Chest Compression;
-Give VasoPressors =Epi every 5mins to maintain Coronary & Cerebral Circulation
-Correct Reversible Causes =Hypoxia, HypoVol; Acidosis, HypoK/HyperK; Tamponade; PneumoThorax
**DeFib or Cardioversion have no Role in PEA**
***PulseLess VT =is NOT PEA & it DOES Require DeFib***
-PEA =organized Rhythm but no BP or Pulse: Q Said there is no Palpable Pulse over Carotids but Cardiac Monitor showed AFib **
Mitral Stenosis= balloon; Aortic Stenosis= Replace
Regurgitant Murmur= Rx w ACEI & ARB
Radio-Radial Delay= SupraValvular AS; Cervical Rib =Thoracic Inlet Synd; Takayasu
Palpable suprasternal Thrill; unequal Carotids
Rado-Femoral Delay =CoARctation of Aorta
LAD Occlusion cuases free wall and septal rupture
RCA Occlusion causes Papillary Rupture or Displacement & MR Murmur & Pulm Edema
MR is cuased by Bicuspid Aortic Valve; Aortic Root Dilation, Rh Fever, Endocarditis
CHF => ACEI, ARB, B Blockers; Spirono; Nitrates & Hydralazine combo given in African
Viral Myocarditis= Dilated HF or Chest Pain mimicking MI
Amyloidosis=> Restrictive Myopathy=> Dilates LA=> Arrhythmia
PeriInfarction Pericarditis= <4days after MI esp if delayed Reperfusion >3hrs; avoid NSAIDs= can cause Wall Rupture by
stopping collagen deposition
Hep Jug Reflux is seen in Rt Heart Failure; Constrictive Pericard; Restrictive Myopathy
AAA Development: Age >60y/o; FHx; White Race; Atherosclerosis; Smoking
AAA Rupture: Size >5.5; Rate of Expansion >0.5/yr; Females; Htn; Smoking
Treat β-blocker overdose with saline, atropine, glucagon.