15 EKG Others

Pathogenesis

  • small depolarization occuring in atrium irregularly, some reach AV and generate QRS, others reach AV during refractory
  • result: random QRS

  • bottom: normal
  • top: AFIB, bumps before QRS but not organized regular bumps. QRS at irregularly irregular (irregular and no pattern to the irregularity)

  • bumps are actually T waves, not P

Types and Symptoms

  • young pts: healthy AV node, fast

  • aortic stenosis: need preload to generate enough output to get past stenosis
  • stiff ventricles: need atrial kick to fill the stiff ventricles
  • can see cardiogenic shock during Afib

  • arrhythmia itself usually not life threatening, thrombus is
  • blood flow slower during afib

  • splenic infarct

  • when both mitral stenosis and afib, refractory to treatment
  • many drugs only test with pts with non-valvular afib

  • HR has to be rapid to cause cardiomyopathy
  • untreated afib for weeks: EF decline

Risks

  • HF: high pressures in RA and RV
  • echocardiogram: key test, determine if enlarged heart

  • elderly with PNA
  • pain after trauma

Treatment

  • echo: exclude structural heart disease
  • rate control first
  • surgery last resort

Rate

  • 1st thing to do after pt present with afib and fast HR: decrease HR
  • will still have irregular rhythm, but good HR
  • pt will feel much better with slower HR
  • for elderly, usually all that's done

  • Irregularly irregular static: beta blockers are useful in atrial fibrillation and flutter
  • Metronome: beta blockers prevent rapid ventricular response in atrial fibrillation and flutter ("rate control") (increase AV node refractory period, slow ventricular response rate)

  • Illuminated top: non-dihydropyridine CCBs treat supraventricular arrhythmias (e.g. atrial fibrillation with RVR)
  • Irregularly irregular signal: non-dihydropyridine CCBs are useful in atrial fibrillation (and flutter)
  • Metronome: non-dihydropyridines prevent rapid ventricular response in atrial fibrillation and flutter ("rate control")

  • DJ foxglove: digoxin has antiarrhythmic properties
  • Vegas: digoxin exerts direct parasympathomimetic effects via direct stimulation of the vagus nerve -> (more at) AV nodal inhibition
  • Irregularly irregular signal: digoxin is useful in atrial fibrillation (and flutter) (1st goal is rate not rhythm)
  • Metronome: digoxin prevents rapid ventricular response in atrial fibrillation and flutter ("rate control")

Rhythm

  • if still symptoms after slow rate

  • synchronized shock, if not can land on T wave = VFIB

  • reduced risk of converting back

  • Amigo: amiodarone (class III antiarrhythmic)
  • "till I die": -tilide suffix shared by dofetilide and ibutilide (class III antiarrhythmics)
  • Soda: sotalol (class III antiarrhythmic)
  • Muted bugle: sotalol is also a beta blocker (-lol suffix)
  • Heart illuminated on top and bottom: class III antiarrhythmics treat both supraventricular arrhythmias and ventricular arrhythmias
  • Irregularly irregular signal: class III antiarrhythmics treat atrial fibrillation (and flutter)
  • Converting the signal: class III antiarrhythmics can restore and maintain normal sinus rhythm in atrial fibrillation and flutter

  • Class IC antiarrhythmics: propafenone, flecainide
  • Flakes: flecainide (class IC antiarrhythmic)
  • purple phone: propafenone (class IC antiarrhythmic)
  • Illuminated top and bottom of heart: class IC antiarrhythmics treat supraventricular and ventricular arrhythmias
  • Irregularly irregular signal: class IC antiarrhythmics treat atrial fibrillation (and flutter)
  • Converting the signal: class IC antiarrhythmics can restore and maintain normal sinus rhythm in atrial fibrillation and flutter

  • spontaneous back to sinus

  • if pt has hypotension/shock with afib: emergent cardioversion

Anticoagulation

  • Big GATOR: arGATROban and dabiGATRAN are direct thrombin inhibitors
  • Banned foXes: direct factor Xa inhibitors rivaroXaBAN and apiXaBAN
  • Directly grabbing foX: factor Xa inhibitors bind directly
  • Open mouth: factor Xa inhibitors are oral medications
  • Irregularly irregular TV signal: direct Xa inhibitors are used for long term anticoagulation in atrial fibrillation

  • Irregularly irregular signal: warfarin is used for long term anticoagulation in atrial fibrillation. Abnormal heart can increase thrombus formation

  • even in sinus rhythm, not completely normal atria, some risk of stroke
  • can have short asymptomatic afib

Surgery

  • aka afib ablation

  • in many cases afib initiated by PA travel to atria
  • treat afib by catheters that burn myocyte around PA, create small area of nonconducting scar

AFLUT

  • circuit in RA going around and around, each time generate sawtooth pattern, some are conducted to V

  • sawtooth EKG

  • special catheter, burn line of myocyte in atrium, disrupt electrical signal
  • much easier than AFIB ablation

AVNRT

  • normally: single speed at AV
  • AVNRT: dual pathways

  • people develop tissues in AV that conduct at different speed
  • activity comes from SA, splits into slow and fast pathway
  • fast pathway sends signal down AV and also another one back to slow pathway, cancel out with slow pathway
  • sinus rhythm: signals cancel out, person asymptomatic

  • dual pathway and PAC
  • signal down dual pathway at time when fast pathway is refractory (long RF period)
  • slow pathway recover quickly
  • activity go down slow pathway, once reach bottom, fast pathway recovered, so go back up fast and down from slow
  • result: reentrant circuit, tachycardic rhythm

  • AV nodal reentry tachycardia
  • no p waves: rhythm generated by AV node
  • when it comes back up, sends retrograde up to atrium = P wave
  • narrow QRS: still using AV
  • fast HR

  • feel heart pounding
  • conduction in slow pathway is already slow, if slow down more = block
  • vagal maneuver: hold breath, slow down heart with increased parasympathetic
  • adenosine: very flushed and chest discomfort

  • recurrent: BB, CCB, slow AV
  • if med fail, surgical

  • Swing dancing: adenosine (a purine nucleoside with antiarrhythmic properties)
  • Purine shaped gate: adenosine is a purine nucleotide
  • A1 Swing: adenosine activates inhibitory A1 receptors on the myocardium and at the SA and AV nodes
  • Falling calci-yum ice cream: activation of A1 receptors suppresses inward Ca2+ current (hyperpolarization, suppressed Ca2+ dependent AP
  • Banana flying out of cup: activation of A1 receptors increases outward K+ current (hyperpolarization, suppressed Ca2+ dependent AP)
  • Note shaped dance floor: adenosine inhibits the AV nodes (decreased AV conduction, prolonged AV refractory period)
  • Disconnected bottom of heart: adenosine decreases atrioventricular conduction
  • Dilated coronary crown: adenosine causes coronary dilation (mediated by A2 receptors)
  • Illuminated #1 top of heart: adenosine is a first line agent for acute treatment of supraventricular arrhythmias (e.g. PSVT)

WPW

  • pt: extra piece of tissue (bypass track, white cursor) capable of conducting electricity between atria/ventricles in both directions
  • electric current will go down AV node but also through atrium to bypass track = early deflection, delta wave

  • P before every QRS, but QRS begins as soon as P ends
  • very short PR
  • inferior lead deep Q
  • portion at different angle
  • early activation of ventricle via bypass track

  • different from AV nodal re-entrant tachycardia
  • ortho: "correct"
  • antidromic: go down bypass tract, initiate ventricles abnormally, wide QRS

  • pattern: asymptomatic
  • syndrome: symptoms

  • Illuminated top and bottom of heart: class IA antiarrhythmics treat supraventricular and ventricular arrhythmias
  • White wolf pack: class IA antiarrhythmics treat Wolff-Parkinson-White (WPW) syndrome (a type of SVT) (extra pathway stopped)

  • AFIB, if slow conduction through AV node, more impulse sent through bypass tract
  • highly complex management (electric cardioversion or ibutilide/procainamide). Not important