Cardiac Arrythmias Abebaw

Cardiac arrhythmias
(Dysrhythmias)
The normal heart rhythm
(normal sinus rhythm),
impulse arise from the sino-
atrial node, the normal
electrical activity in the heart
The Conduction System of the Heart
3
Definitions
• Arrhythmia( Dysrhythmias) is a disorder of heart

beat that includes a disturbance of rate, or rhythm
or both.
• It is caused by disturbances in automaticity,

conductivity (more commonly) or both
Arrhythmia( Dysrhythmias)…
• Dysrhythmias are named

according to :-
• the site of origin of the
impulse and
• mechanism of
conduction involved.
• The site of origin are:

• SA node
• Atria
• AV junction
• AV node and
• ventricles
Arrhythmia( Dysrhythmias)…
The mechanisms of conductions are:-

bradycardia,
tachycardia,
flutter,
fibrillation,
premature beats, and
heart blocks.
• Arrhythmias are identified by electrocardiogram (ECG)

• Some arrhythmias are life threatening while, other
are relatively minor.
Types of dysrhythmias
1. Sinus mode dysrhythmias:

• sinus rhythm refers to the normal impulse
formation beginning in the SA node and,
• in adults having a rate between 60 and 100 per

minutes
Sinus mode dysrhythmias…
A. Sinus Tachycardia:
• Refers to a sinus rhythm with a ventricular rate
exceeding 100 beats per minute
• produced in response to enhanced automaticity in
the SA-node.
• Is associated with situations in which O2 demand is
increased such as
• exercise
• emotional stress,
• pain
• fever
Sinus tachycardia …
Sinus Tachycardia…
• ingestion of stimulants:-
e.g coffee, tea,
• drugs (e.g atropine, catecholamines, alcohol),
• anemia,
• thyrotoxicosis,
• hypovolemia,
• congestive heart failure,
• anxiety,
• exertion etc.
Pathophysiology
• Increased heart rate  decreased
diastolic filling time in ventricles  decreased
cardiac out put (Co)
• If it persist and the heart is unstable to compensate

for the decreased ventricular filling  decreased
coronary artery perfusion  angina pectoris pain,
acute pulmonary edema.
Treatment
• Eradicate the cause
• Propranolol- blocks the effects of adnergic fibers to

reduce heart rate.
Sinus mode dysrhythmias…
B. Sinus bradycardia
• Refers to a sinus rhythm with a rate of 40 -
60bpm or less in response to depressed
automaticity in the SA node.
• Rhythm and other characteristics are normal
except the rate.
• Normally it is frequently occurs in young
adults, especially in well trained athletes
during rest, common at night.
Sinus bradycardia
Sinus bradycardia…
Can be occurred by a variety of conditions

including:-
• Eye manipulations, increased intracranial
pressure, myxedema, hypothermia, sepsis, vagal
stimulation, vomiting and
• administration of parasympathomimetic drugs,
beta-adnergic blocking drugs and
• commonly in acute myocardial infarction,
• in digital toxicity and
• after surgical damage to the SA-node
Sinus bradycardia…
• Treatment:
• Identify and remove the cause
• Atropine – is drug of choice
• block the vagal stimulation to increase the rate
• Electrical pacing- if the problem persists.
• Digoxin – if it is severe
2. Atrial Dysrhythmias
• Atrial Dysrhythmias are disturbances in electrical

activity arising from the atria other than the SA-
node
• they result in the generation of premature beats,

as well as a variety of abnormal rhythms.
• These includes:
Atrial Dysrhythmias…
A. Premature Atrial Complex (PAC):
• The contractions originate in an ectopic focus in

the atrium in allocation other than the SA-node
with in the left and right atrium.
• The rate is 60-100bpm and irregular or there

may be pulse deficit. ( fewer beats than normal
heart beats)
Premature Atrial Complex (PAC)…
• May occur due to irritability (automaticity) of the atrial

muscle caused by :-
• caffeine, alcohol, nicotine
• stretched atrial myocardium as in congestive heart
failure
• stress/ anxiety
• decreased K+,
• atrial ischemia, injury
• infarction or hyper metabolic states
• Treatment- generally directed at removing the underlying

cause
B. Paroxysmal Atrial Tachycardia(PAT):

• Is an arrhythmia with abrupt onset and abrupt
termination of the rate that originate in an ectopic
focus any where in the atria.
• Termination is usually followed by a brief period of
asystole.
• The rate is 100-300, and is regular rhythm
• Treatment- directed first to decrease the rate and
normalize rhythm
Atrial tachycardia …
C. Atrial fibrillation
• Is the total disorganization of atrial electrical
activity with out effective atrial contraction.
• Is the most common dysrhythmia that causes
patients to seek medical attention
• It may start and stop suddenly
• The arrhythmia may be chromic or intermittent
multiple impulse.
Atrial fibrillation…
• It is usually associated with :-

• advanced age,
• valvular and coronary artery disease,
• moderate or heavy ingestion of alcohol,
• open heart surgery
• Thrombi may form in the atria as a result of ineffective atrial

contraction, so an emboli clot may pass to the brain causing
stroke.
• There is usually pulse deficit
• Atrial rate 300 to 600bpm
• Ventricular rate 120 to 200bpm
• Ventricular and atrial rhythm are highly irregular

because AV-node is unable to conduct the multiple
impulse.
• Treatment- direct towards removing the causes and

some may not need treatment.
• Drugs used are- digitalis, quinidine, beta-
blockers etc.
• Vagal stimulation
• Electro cardioversion – synchronized
administration of shock during QRS complex of
cardiac cycle
3.Junctional Dysrhythmias:
• A. Premature junctional complex:-
• It occurs when an impulse start in the AV-

nodal area before the normal sinus impulse
reaches the AV-node. Means arrhythmia
originates in area of AV node.
• Are less common than premature atrial

complex (PACs).
Premature junctional complex…
Clinically associated with:-

• Digital toxicity, congestive heart failure, acute
myocardial infarction (MI), dysfunction of AV-
node, acute rheumatic fever, and open heart
surgery
Ventricular and atrial rhythm are regular.

Premature junctional complex…
Treatment:
• Atropine – for junctional escape rhythm (heart late is 40 to

60bpm)
• -adnergic blockers, calcium channel blockers, and

amiodarone- are used for accelerated junctional rhythm
(HR=60 to 100bpm). And junctional tacky cardia (HR= 100 to
140bpm).
• Withheld digoxin – if digoxin toxicity
• No need of cardioversion (DC) because can cause

thromboembolism
Junctional Dysrhythmias…
B. Atrioventricular Nodal Reentry Tachycardia:-

• It occurs when each time the impulse is conducted
through the AV-node and
• it is also conducted down in to the ventricles,

causing a fast ventricular late.
Atrioventricular Nodal Reentry
Tachycardia….
Factors associated are includes:-

• Caffeine, nicotine, hypoxemia, stress, coronary
artery disease, and cardiomyopathy.
• Ventricular and atrial rhythm are regular
• Atrial rate between 150 to 250bpm, ventricular rate

between 75 to 250 bpm
Atrioventricular Nodal Reentry
Tachycardia…
• Treatment
• Vagal maneuvers- carotid massages (stimulate
parasympathetic nerve to decrease impulse).
• Breath holding, and immersing the face in the water
 increase parasympathetic stimulation  slower
conduction through the AV-node
• Drugs such as:- adenosine, verapamil, or diltiazem
• Cardioversion- is the treatment of choice if patient
unstable or does not respond to the medication
4. Heart blocks
A. First degree AV-block

• Is a type of AV block in which every impulse
is conducted to the ventricles, but the
duration of AV-conduction is prolonged
(>0.20sec).
• It is a warning sign of a serious form of AV
block
• Rate is 60-100bpm
• Usually treatment is not necessary
Heart blocks…
B. Second degree AV block

• Is a type of AV block in which there is
intermittent impulse conduction between
atria and ventricles.
• The majority of impulses are conducted to

the ventricles, occasionally impulses are
either unable to pass the AV-node or once
past the AV-node, are prevented from
reaching the ventricles.
Second degree AV block…
• Ventricular rate is 30 to 55bpm; atrial rate is 2x to

4x faster than the ventricle.
• Treatment:
• Atropine and isoproterenol-to increase the heart
rate
• Remove the cause- rule out digitalis toxicity
• Pace maker
Heart blocks…
C. Third degree AV block (complete heart block).
• There is no conduction between the atria

sand ventricles (completely blocked)
• Some rhythm escapes from either the
junctional or the ventricular area takes over
as the pacemaker.
• Atrial rate is 60-100bpm
Third degree AV block (complete heart block)…
• Ventricular rate is - 40-60bpm if the escape rhythm is

junctional
• 15 – 40bpm if escape rhythm originates in the ventricles
Treatment
• Pacemaker insertion
• Atropine and isoproterenol is temporary treatment to
increase HR
5. Ventricular Dysrhythmias:
• Ventricular dysrhythmias are rhythm disturbances

that originate with in the ventricles.
• It may include isolated ectopic beats, paroxysms of

ectopy, or sustained rhythms.
• Ventricular dysrhythmias are caused by alterations

in automaticity, conductivity or both.
Ventricular Dysrhythmias…
• They are clearly more dangerous and clinically significant than

most atrial dysrhythmias.
• Their occurrence is more likely in the setting of
• organic heart disease,
• myocardial ischemia, and
• electrolyte disturbances,
• anxiety,
• caffeine,
• exercise,
• high alcohol intake
• These includes:-
A. Premature ventricular contractions (PVCs):-
• Describes ectopic impulses that arise from with in the

ventricles (from single focus or multiple foci)
• Rate 60-100bpm and irregular. In absence of disease, are

not serious but in patient with MI it may need more
aggressive therapy.
Treatment
• Lidocaine – is the drug of choice
• - Most commonly used for immediate, short, term
therapy.
• Procainamide- is second drug of choice.
Premature ventricular contraction/PVC
B. Ventricular tachycardia
• It occurs when 3 or more consecutive PVCs occurs with a
rate of >100bpm.
• Are extremely dangerous and are considered emergency
• Rate- not measurable and irregular (110-250bpm)
Treatment
• Antidysrhythmia: Lidocaine, procainamide, bretylium.
• Defibrillation
• Cardioversion for un stable patients.
Monomorphic Ventricular tachycardia
C. Ventricular fibrillation (VF)

• Is a severe derangement of the heart rhythm,
which generates little or no blood flow and
usually fatal with in 3-5minutes unless
terminated.
• It represents the firing of multiple ectopic foci in
the ventricle
• No effective contraction occur
• No audible heart beat or palpable pulse
• Rate 100-250bpm and regular or irregular
Ventricular fibrillation
Ventricular fibrillation (VF)…
• Occurs in acute MI, myocardial ischemia, CAD,

cardiomyopathy, cardiac catheterization, accidental electric
shock, hyperkalemia, hypoxemia, acidosis and drug toxicity
Treatment
• Immediate cardiopulmonary resuscitation (CPR) and
• initiation of advanced cardiac life support (ACLS) with the
use of defibrillation and
• definitive drug therapy.
D. Ventricular asystole (cardiac stand still)
• It represents a situation of clinical cardiac arrest

characterized by a total absence of both
electrical and mechanical activity of the heart.
• Is usually due to advanced cardiac disease, a

severe cardiac conduction system disturbance,
or end stage congestive heart failure.
Ventricular asystole (cardiac stand still)…
• It is a lethal dysrhythmia with poor prognosis that

requires an immediate treatment
Treatment
• Cardiopulmonary resuscitation (CPR)
• IV therapy with epinephrine or atropine.
The
End
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Cardiac arrhythmias

• Arrhythmia( Dysrhythmias) is a disorder of heart

• It is caused by disturbances in automaticity,

• Dysrhythmias are named

• The site of origin are:

The mechanisms of conductions are:-

• Arrhythmias are identified by electrocardiogram (ECG)

1. Sinus mode dysrhythmias:

• in adults having a rate between 60 and 100 per

• If it persist and the heart is unstable to compensate

• Eradicate the cause

• Propranolol- blocks the effects of adnergic fibers to

Can be occurred by a variety of conditions

• Atrial Dysrhythmias are disturbances in electrical

• they result in the generation of premature beats,

A. Premature Atrial Complex (PAC):

• The contractions originate in an ectopic focus in

• The rate is 60-100bpm and irregular or there

• May occur due to irritability (automaticity) of the atrial

• Treatment- generally directed at removing the underlying

B. Paroxysmal Atrial Tachycardia(PAT):

• It is usually associated with :-

• Thrombi may form in the atria as a result of ineffective atrial

• There is usually pulse deficit

• Atrial rate 300 to 600bpm

• Ventricular rate 120 to 200bpm

• Ventricular and atrial rhythm are highly irregular

• Treatment- direct towards removing the causes and

• A. Premature junctional complex:-

• It occurs when an impulse start in the AV-

• Are less common than premature atrial

Clinically associated with:-

Ventricular and atrial rhythm are regular.

• Atropine – for junctional escape rhythm (heart late is 40 to

• -adnergic blockers, calcium channel blockers, and

• Withheld digoxin – if digoxin toxicity

• No need of cardioversion (DC) because can cause

B. Atrioventricular Nodal Reentry Tachycardia:-

• it is also conducted down in to the ventricles,

Factors associated are includes:-

• Ventricular and atrial rhythm are regular

• Atrial rate between 150 to 250bpm, ventricular rate

A. First degree AV-block

B. Second degree AV block

• The majority of impulses are conducted to

• Ventricular rate is 30 to 55bpm; atrial rate is 2x to

C. Third degree AV block (complete heart block).

• There is no conduction between the atria

• Ventricular rate is - 40-60bpm if the escape rhythm is

• 15 – 40bpm if escape rhythm originates in the ventricles

• Ventricular dysrhythmias are rhythm disturbances

• It may include isolated ectopic beats, paroxysms of

• Ventricular dysrhythmias are caused by alterations

• They are clearly more dangerous and clinically significant than

A. Premature ventricular contractions (PVCs):-

• Describes ectopic impulses that arise from with in the

• Rate 60-100bpm and irregular. In absence of disease, are

C. Ventricular fibrillation (VF)

• Occurs in acute MI, myocardial ischemia, CAD,