Arrhythmias

Dr. Serkan Yüksel

 Arrhythmias
• Normal cardiac function relies on the flow of
electric impulses through the heart
• Abnormalities of electrical rhythm are known
as arrhythmias or dysrhythmias
• Range from palpitations to very severe
symptoms of low cardiac output and death
• Abnormally slow rhythms bradycardias
• Fast rhythms are known as tachycardias
• Disorders of heart rhythm result from
alterations of
– impulse formation
– impulse conduction
– both
 Normal Impulse Formation
• Electrical impulse in heart arises from the
intrinsic automaticity of specialized cardiac cells.
• Automaticity a cell’s ability to depolarize itself
to a threshold voltage to generate a spontaneous
action potential
• The cells of the specialized conducting system do
possess natural automaticity and are therefore
termed pacemaker cells SA node, AV nodal
region, Ventricular conducting system
 Altered Impulse Formation
• Arrhythmias may arise from altered impulse
formation at the SA node or from other sites
including the specialized conduction pathways or
regions of cardiac muscle.
• The main abnormalities of impulse initiation that
lead to arrhythmias are;
– Altered automaticity (of the SA node or latent
pacemakers within specialized conduction system )
– Abnormal automaticity in atrial and ventricular
myocytes
– Triggered activity
 Increased SA Node Automaticity
• The most important modulator of normal sinus
automaticity is the autonomic nervous system
• Sympathetic stimulation acts through B1
adrenergic receptors
• Sympathetic activity increases SA node
automaticity both by increasing the rate of
pacemaker depolarization and by causing the
action potential threshold to become more
negative
 Decreased SA Node Automaticity
• Via the reduced sympathetic stimulation and
increased activity of parasympathetic nervous
system
• Cholinergic stimulation via the vagus nerve
acts at the SA node to reduce the probability
of pacemaker channels being open
– A more negative maximum diastolic potential
– A less negative threshold level
 Decreased SA Node Automaticity
• Result in
– slowing of the intrinsic firing rate
– reduced heart rate
• Different regions of the heart have different
sensitivities to parasympathetic stimulation.
• The SA node and AV node are the most
sensitive followed by atrial tissue. The
ventricular conducting system is the least
sensitive.
 Enhanced Automaticity of Latent
Pacemakers
• A latent pacemaker can assume control of impulse
formation if it develops an intrinsic rate of
depolarization faster than that of the sinus node
• Ectopic beat; the impulse is premature relative to the
normal rhythm
• Escape beat is late and terminates a pause caused by
a slowed sinus rhythm
• Ectopic beats may arise in several circumstances e.g;
high catecholamine concentrations, also by
hypoxemia, ischemia, electrolyte disturbances, and
certain drug toxicities
 Abnormal Automaticity
• Myocardial cells outside the specialized
conduction system acquire automaticity and
spontaneously depolarize
• If the rate of depolarization of such cells
exceeds that of the sinus node, they
transiently take over the pacemaker function
and become the source of an abnormal
ectopic rhythm.
 Triggered Activity
• Under certain conditions, an action potential
can “trigger” abnormal depolarizations that
result in extra heart beats or rapid
arrhythmias.
• This process may occur when the first action
potential leads to oscillations of the
membrane voltage known as
afterdepolarizations
 Triggered Activity
• 2 types afterdepolarization
– Early occurs during the repolarization phase of the
inciting beat
– Delayed occur shortly after repolarization has been
completed
• Early afterdepolarizations ->polymorphic VT
(Torsades de pointes)
• Delayed afterdepolarizations digitalis
intoxications or during marked catecholamine
stimulation
 Altered Impulse Conduction
• Conduction blocks generally slow the heart
rate bradyarrhythmias
• Under certain circumstances, the process of
reentry can ensue and produce abnormal fast
rhythms tachyarrhythmias
• A propagating impulse is blocked when it
encounters a region of the heart that is
electrically unexcitable.
 Altered Impulse Conduction
• Conduction block;
– Transient or permanent
– Unidirectional or bidirectional
– Functional (drugs) or fixed (fibrosis or scarring)
• Conditions cause conduction Block;
– ischemia, fibrosis, inflammation and certain drugs
• Conduction block in AV node or His-Purkinje
system AV block
 Unidirectional Block and Reentry
• Reentry; an electrical impulse circulates repeatedly
around a reentry path, recurrently depolarizing a
region of cardiac tissue.
• Two critical conditions for reentry are;
– Unidirectional block
– Slowed conduction through the reentry path
• These conditions commonly occur in regions where
fibrosis has developed, such as infarction scars.
• Reentry around a distinct anatomic pathway usually
appears as a monomorphic tachycardia eg VT
 Bradyarrhythmias
• heart rate < 60 /min
• arise from;
– Disorders of impulse formation
– Impaired impulse conduction
 Sinus Bradycardia
• slowing of the normal heart rhythm, as a
result of decreased firing of the SA node
• normally seen at rest or during sleep
• Pathologic sinus bradycardia
– intrinsic SA node disease aging, ischemic heart
disease or cardiomyopathy
– extrinsic factors that affect the node
medications, metabolic causes
 Sick Sinus Syndrome
• Intrinsic SA node dysfunction that causes
periods of inappropriate bradycardia
• common in elderly patients who are also
susceptible to SVTs most commonly AF
bradycardia-tachycardia syndrome
• thought to result from atrial fibrosis that
impairs function of the SA node and
predisposes to AF and flutter
 Escape Rhythms
• Cells in AV node and His Purkinje system
suppressed during sinus rhythm
• If SA node activity is impaired or If there is a
block escape rhythms emerge from more
distal latent pacemakers
 Escape Rhythms
• Junctional escape beats arise from the AV
node or proximal bundle of His normal,
narrow QRS complex and when they occur in
sequence, appear at a rate of 40-60/min
junctional escape rhythm
• the QRS complexes are not preceded by
normal P waves (usually inverted [negative] in
II, III, aVF)
 Escape Rhythms
• Ventricular escape rhythms slower (30-40 /
min) and widened QRS complexes
• morphology of QRS complexes depends on
the site of origin of the escape rhythm
• Junctional and ventricular escape rhythms are
protective back up mechanisms maintain a
heart rate and cardiac output when the sinus
node or normal AV conduction fails
 Atrioventricular Conduction System
• includes the AV node, bundle of His, and left and
right bundle branches
• Impaired conduction between atria and ventricles
can result in three degrees of AV conduction
block;
– First Degree AV block
– Second Degree AV block
• Mobitz Type I
• Mobitz Type II
– Third Degree AV block (Complete heart block)
 First Degree AV Block
• prolongation of the normal delay between
atrial and ventricular depolarization
• PR interval is lengthened (>0.2 sec)
• 1:1 relationship between P waves and QRS
complexes is preserved
• the impairment of conduction is usually
within the AV node
 Causes
Reversible Structural
• heightened vagal tone • Myocardial infarction
• transient AV nodal • Chronic degenerative
ischemia diseases of conduction
• Medications system (aging)
– Beta blockers
– Ca channel blockers
– digitalis
– other antiarrhythmics
 Second Degree AV Block
• intermittent failure of AV conduction, resulting in
some P waves not followed by a QRS complex
• Mobitz Type I (Wenckebach) the degree of AV
delay gradually increases with each beat until an
impulse is completely blocked
• A QRS does not follow a P wave for a single beat
• ECG shows a progressive increase in the PR
interval from one beat to the next until a single
QRS is absent
 Second Degree AV Block
• Mobitz Type II sudden intermittent loss of
AV conduction, without preceding gradual
lengthening of the PR interval
• the block may persist for two or more beats
 Third Degree AV Block
• complete failure of conduction between the
atria and ventricles complete heart block
• the most common causes in adults; acute MI
and chronic degeneration of the conduction
pathways with age
• atria and ventricles are electrically
disconnected
• there is no relationship between P waves and
QRS complexes
 Description of Abnormal Rhythms
• Rate;
– Tachycardia or Bradycardia
• Regularity;
– Regular or Irregular
• QRS width;
– Narrow or Wide
• QRS morphology;
– Monomorphic or Polymorphic
 Tachyarrhythmias
• heart rate is > 100 /min for 3 three beats or
more
• result from
– enhanced automaticity
– triggered activity
– reentry
• categorized as;
– Supraventricular
– Ventricular
Supraventricular Tachyarrhythmias
Regular Irregular
Multifocal
Sinus
Atrial
Tachycardia
Tachycardia

Reentrant
Atrial
SVTs (AVNRT,
fibrillation
AVRT)

Focal Atrial
Tachycardia

Atrial Flutter
 Sinus Tachycardia
• SA node discharge rate > 100/min (100-180)
with normal P waves and QRS complexes
• often results from
– increased sympathetic tone
– decreased vagal tone
• appropriate physiologic response to exercise
• sympathetic stimulation in pathologic
conditions fever, hypoxemia,
hyperthyroidism, hypovolemia and anemia
 Atrial Premature Beats
• originate from automaticity or reentry in an
atrial focus outside the SA node
• often exacerbated by sympathetic stimulation
• On ECG; APB appears as an earlier than
expected P wave with an abnormal shape
• the QRS complex that follows the P wave is
usually normal, resembling the QRS during
sinus rhythm
 Atrial Premature Beat
• If the abnormal focus fires very soon after
previous beat, resulting in a blocked impulse that
does not conduct to the ventricles blocked APB
• If the ectopic focus fires just a bit later in diastole,
it may conduct through the AV node but
encounter portions of the His-Purkinje system
that are still refractory impulse is conducted
more slowly produce wider QRS complexes
APB with aberrant conduction
 Atrial Flutter
• characterized by rapid, regular atrial activity at a
rate of 180 to 350/min
• many of these impulses are not conducted to
ventricles slower ventricular rate
• e.g; Atrial rate 300/min, 2:1 block V rate 150 /
min
• Vagal maneuvers decrease AV nodal conduction
increase the degree of block slow the ventricular
rate better visualization of underlying atrial
activity
 Atrial Flutter
• In the common form; the circuit is the atrial
tissue along the tricuspid valve annulus
• Because the large part of atrium is
depolarized throughout the cycle, P waves
often have a sinusoidal or “sawtooth”
appearance
• usually associated with areas of atrial scarring
from disease, prior heart surgery, or ablation
procedures
 Atrial Fibrillation
• chaotic rhythm with an atrial rate so fast
(350-600 discharges/min) that distinct P waves
are not discernible on the ECG
• only some of the depolarizations are conducted
to ventricles in a very irregular fashion
irregularly irregular rhythm
• average ventricular rate in untreated AF is
140-160 /min
• discrete P waves are not visible on ECG, the
baseline shows low amplitude undulations
punctuated by QRS complexes and T waves
 Atrial Fibrillation Mechanism
• multiple wandering reentrant circuits within the
atria
• often initiated by rapid firing of foci in sleeves of
atrial muscle that extend into the pulmonary veins
• AF is often associated with RA or LA enlargement
• HF, HT, CAD and Pulmonary disease increase
atrial pressure promote AF
• Thyrotoxicosis and alcohol consumption
precipitate AF in some people
 Atrial Fibrillation
• Potentially dangerous, because;
– rapid ventricular rates may compromise cardiac
output hypotension and pulmonary congestion
– absence of organized atrial contraction promotes
blood stasis in the atria increased risk of
thrombus formation (particularly in LA
appendage) cause stroke
 Paroxysmal Supraventricular
Tachycardias
• PSVTs are manifested by
– sudden onset and termination
– atrial rates between 140-250/min
– narrow (normal) QRS complexes unless aberrant
conduction is present
• Mechanism; most often reentry involving the AV
node, atrium and ventricle
• Less common causes; Enhanced automaticity
and triggered activity in the atrium or AV node
 AV Nodal Reentrant Tachycardia
• AVNRT is the most common form of PSVT in
adults
• The atrial extensions of AV node constitute
two (or more) potential pathways for
conduction through the AV node;
– slow
– fast conducting pathways
 AVNRT
• ECG; a regular tachycardia with normal width
QRS complexes
• P waves may not be apparent; because
retrograde atrial depolarization typically
occurs simultaneously with ventricular
depolarization
• P is hidden in the QRS complex
Atrioventricular Reentrant Tachycardias
• AVRTs are similar to AVNRTs except that one limb
of the reentrant loop is constituted by an
accessory pathway (bypass tract)
• Accessory Pathway; an abnormal band of
myocytes that spans the AV groove and connects
atrial to ventricular tissue separately from the
normal conduction tissue
• Accessory pathways allow an impulse to conduct
– from atrium to ventricle antegrade conduction
– from ventricle to atrium retrograde conduction
– in both directions
 AVRT
• Depending on the characteristic of the
pathway;
– The ventricular pre-excitation syndrome
– PSVT resulting from a concealed accessory
pathway
 Ventricular Pre-excitation Syndrome
• Wolff-Parkinson-White (WPW) Syndrome
• atrial impulses can pass in an anterograde
direction to the ventricles through the both the
AV node and the accessory pathway
• Ventricles are stimulated earlier than by normal
conduction over the AV node
• ECG;
– PR interval is short (<0.12 sec)
– QRS has a slurred rather than a sharp upstroke delta
wave
– QRS complex is widened
 WPW Syndrome
• Patients with WPW Syndrome are
predisposed to PSVTs because AP provides a
potential limb of a reentrant loop
• The most common PSVT in WPW patients is
Orthodromic AVRT (antegrad AV node,
retrograde AP)
• ECG; QRS width is normal, retrograde P waves
visible soon after each QRS complex
 WPW Syndrome
• in < 10% of patients Antidromic AVRT
(anterograde AP, retrograde AV node)
• ECG; characterized by a wide QRS complex
• Third type of arrhythmia anterograde
conduction over AP when AF or A flutter is
present Ventricular rates ≈ 300 /min may
result VF and cardiac arrest
 Concealed Accessory Pathways
• APs capable of only retrograde conduction
• During sinus rhythm, the ventricles are
depolarized normally through the AV node
alone and the ECG is normal
• result in orthodromic AVRT
 Focal Atrial Tachycardia
• Focal AT results from either automaticity of
an atrial ectopic site or reentry
• ECG; a P wave before each QRS complex but P
wave morphology is different than sinus
rhythm depolarization of atrium from
different site
• Paroxysmal or persistent
 Multifocal Atrial Tachycardia
• ECG shows an irregular rhythm with multiple
(at least three) P-wave morphologies
• caused by
– abnormal automaticity in several foci
– triggered activity
• most often in severe pulmonary disease and
hypoxemia
 Ventricular Arrhythmias
• Common ventricular arrhythmias are;
– Ventricular Premature Beats (VPB)
– Ventricular Tachycardia (VT)
– Ventricular Fibrillation (VF)
• more dangerous than SVTs
• responsible for many of the sudden cardiac
deaths
 Ventricular Premature Beats
• common, even in healthy and asymptomatic
people
• arises when an ectopic ventricular focus fires an
action potential
• On ECG; widened QRS complex and not related to
a preceding P wave
• occur in repeating patterns;
– every alternate beat is VPB bigeminy
– two normal beats precede every VPB trigeminy
– consecutive VPB; couplets or triplets
 Ventricular Tachycardia
• is a series of three or more VPBs
• divided into 2 categories;
– Sustained VT; persists for > 30 secs
– Nonsustained VT; self terminating episodes
• VT is most commonly found in;
– Myocardial ischemia, infarction
– Heart failure
– Ventricular hypertrophy
– Primary electrical diseases
– Congenital cardiac abnormalities
 VT ECG
• QRS complexes are wide (>0.12 sec)
• rate 100-200 /min
• Classification according to QRS morphology;
– Monomorphic every QRS complex is same and
rate is regular
– Polymorphic QRS complexes continually change
in shape and rate varies from beat to beat
 VT
• Monomorphic VT usually indicates a
structural abnormality reentry circuit in
region of myocardial scar
• Polymorphic VT; multiple ectopic foci or a
continually changing reentry circuit is the
cause
 VT
• Symptoms depend on the rate, duration of
the tachycardia and underlying heart disease
• Sustained VT can cause low cardiac output
resulting in loss of consciousness, pulmonary
edema or progress to cardiac arrest
 Ventricular Fibrillation
• immediately life-threatening arrhythmia
• results in disordered, rapid stimulation of the
ventricles with no coordinated contractions
• occurs in patients with severe underlying
heart disease
• major cause of mortality in Acute MI
 VF
• often initiated by an episode of VT, which
degenerates
• On ECG chaotic irregular appearance without
discrete QRS waveforms
• If untreated; VF rapidly leads to death