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ECG in Ventricular arrhythmias Dr Mostafa Hekmat CardiologistElectrophysiologist.

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Presentation on theme: "ECG in Ventricular arrhythmias Dr Mostafa Hekmat CardiologistElectrophysiologist."— Presentation transcript:

1 ECG in Ventricular arrhythmias Dr Mostafa Hekmat CardiologistElectrophysiologist

2 A look at ventricular arrhythmias Ventricular arrhythmias originate in the ventricles below the bundle of His. Ventricular arrhythmias originate in the ventricles below the bundle of His. They occur when electrical impulses depolarize the myocardium using a different pathway from normal impulses They occur when electrical impulses depolarize the myocardium using a different pathway from normal impulses Dr Hekmat 2

3 A look at ventricular arrhythmias Ventricular arrhythmias appear on an ECG in characteristic ways. Ventricular arrhythmias appear on an ECG in characteristic ways. The QRS complex is wider than normal because of the prolonged conduction time through the ventricles The QRS complex is wider than normal because of the prolonged conduction time through the ventricles Dr Hekmat 3

4 A look at ventricular arrhythmias The T wave and the QRS complex deflect in opposite directions because of the difference in the action potential during ventricular depolarization and repolarization. The T wave and the QRS complex deflect in opposite directions because of the difference in the action potential during ventricular depolarization and repolarization. P wave is absent because atrial depolarization doesn’t occur P wave is absent because atrial depolarization doesn’t occur Dr Hekmat 4

5 No kick from the atria When electrical impulses are generated from the ventricles instead of the atria, atrial kick is lost When electrical impulses are generated from the ventricles instead of the atria, atrial kick is lost Cardiac output decreases by as much as 30%. Cardiac output decreases by as much as 30%. Patients with ventricular arrhythmias may show signs and symptoms of cardiac decompensation, including hypotension, angina, syncope, and respiratory distress. Patients with ventricular arrhythmias may show signs and symptoms of cardiac decompensation, including hypotension, angina, syncope, and respiratory distress. Dr Hekmat 5

6 Potential to kill Although ventricular arrhythmias may be benign, they’re potentially deadly because the ventricles are ultimately responsible for cardiac output. Although ventricular arrhythmias may be benign, they’re potentially deadly because the ventricles are ultimately responsible for cardiac output. Rapid recognition and treatment of ventricular arrhythmias increases the chance for successful resuscitation Rapid recognition and treatment of ventricular arrhythmias increases the chance for successful resuscitation Dr Hekmat 6

7 Premature ventricular contraction A PVC is an ectopic beat that may occur in healthy people without causing problems. A PVC is an ectopic beat that may occur in healthy people without causing problems. PVCs may occur singly, in clusters of two or more, or in repeating patterns, such as bigeminy or trigeminy PVCs may occur singly, in clusters of two or more, or in repeating patterns, such as bigeminy or trigeminy When PVCs occur in patients with underlying heart disease, they may indicate impending lethal ventricular arrhythmias When PVCs occur in patients with underlying heart disease, they may indicate impending lethal ventricular arrhythmias Dr Hekmat 7

8 Premature ventricular contraction PVCs are usually caused by electrical irritability in the ventricular conduction system or muscle tissue. PVCs are usually caused by electrical irritability in the ventricular conduction system or muscle tissue. This irritability may be provoked by anything that disrupts normal electrolyte shifts during cell depolarization and repolarization This irritability may be provoked by anything that disrupts normal electrolyte shifts during cell depolarization and repolarization Dr Hekmat 8

9 Premature ventricular contraction Electrolyte imbalances, such as hypokalemia, hyperkalemia, hypomagnesemia, and hypocalcemia Electrolyte imbalances, such as hypokalemia, hyperkalemia, hypomagnesemia, and hypocalcemia Metabolic acidosis Metabolic acidosis Hypoxia Hypoxia Myocardial ischemia and infarction Myocardial ischemia and infarction Drug intoxication, particularly cocaine, amphetamines, and tricyclic antidepressants Drug intoxication, particularly cocaine, amphetamines, and tricyclic antidepressants Enlargement of the ventricular chambers Enlargement of the ventricular chambers Increased sympathetic stimulation Increased sympathetic stimulation Myocarditis Myocarditis Caffeine or alcohol ingestion Caffeine or alcohol ingestion Proarrhythmic effects of some antiarrhythmics Proarrhythmic effects of some antiarrhythmics Tobacco use. Tobacco use. Dr Hekmat 9

10 Premature ventricular contraction PVCs are significant for two reasons. PVCs are significant for two reasons. 1, they can lead to more serious arrhythmias, such as ventricular tachycardia or ventricular fibrillation. 1, they can lead to more serious arrhythmias, such as ventricular tachycardia or ventricular fibrillation. The risk of developing a more serious arrhythmia increases in patients with ischemic or damaged hearts. The risk of developing a more serious arrhythmia increases in patients with ischemic or damaged hearts. 2,PVCs also decrease cardiac output, especially if the ectopic beats are frequent or sustained. 2,PVCs also decrease cardiac output, especially if the ectopic beats are frequent or sustained. Decreased cardiac output is caused by reduced ventricular diastolic filling time and a loss of atrial kick Decreased cardiac output is caused by reduced ventricular diastolic filling time and a loss of atrial kick Dr Hekmat 10

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12 PVC PVCs look wide and bizarre and appear as early beats causing atrial and ventricular irregularity. PVCs look wide and bizarre and appear as early beats causing atrial and ventricular irregularity. The P wave is usually absent. The P wave is usually absent. Retrograde P waves may be stimulated by the PVC and cause distortion of the ST segment. Retrograde P waves may be stimulated by the PVC and cause distortion of the ST segment. The PR interval and QT interval aren’t measurable on a premature beat, The PR interval and QT interval aren’t measurable on a premature beat, QRS complex in the premature beat exceeds 0.12 second. QRS complex in the premature beat exceeds 0.12 second. The T wave in the premature beat has a deflection opposite that of the QRS complex. The T wave in the premature beat has a deflection opposite that of the QRS complex. Dr Hekmat 12

13 R-on-T When a PVC strikes on the downslope of the preceding normal T wave it can trigger more serious rhythm disturbances When a PVC strikes on the downslope of the preceding normal T wave it can trigger more serious rhythm disturbances Because the cells haven’t fully repolarized, VT or VF can result Because the cells haven’t fully repolarized, VT or VF can result Dr Hekmat 13

14 The pause that compensates Interval between two normal sinus beats containing a PVC equals two normal sinus intervals. Interval between two normal sinus beats containing a PVC equals two normal sinus intervals. Dr Hekmat 14

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19 An interpolated PVC Dr Mostafa Hekmat 19

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21 Multiform Dr Mostafa Hekmat 21

22 Couplet Dr Hekmat 22

23 Bigeminy Dr Hekmat 23

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26 CLINICAL FEATURES The prevalence of premature complexes increases with The prevalence of premature complexes increases with Age Age Male gender Male gender Hypokalemia Hypokalemia PVCs are more frequent in the morning in patients after MI PVCs are more frequent in the morning in patients after MI This circadian variation is absent in patients with severe left ventricular dysfunction. This circadian variation is absent in patients with severe left ventricular dysfunction. Dr Mostafa Hekmat 26

27 The importance of PVCs Depends on the clinical setting Depends on the clinical setting In the absence of underlying heart disease, the presence of PVCs usually has no impact on longevity or limitation of activity In the absence of underlying heart disease, the presence of PVCs usually has no impact on longevity or limitation of activity Antiarrhythmic drugs are not indicated Antiarrhythmic drugs are not indicated Patients should be reassured if they are symptomatic Patients should be reassured if they are symptomatic Dr Mostafa Hekmat 27

28 Identifying idioventricular rhythm Dr Hekmat 28

29 Accelerated idioventricular rhythm Dr Hekmat 29

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31 Torsades de pointes Dr Hekmat 31

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33 Torsades de pointes Is a special form of polymorphic ventricular tachycardia Is a special form of polymorphic ventricular tachycardia The rate is 150 to 250 beats/minute, usually with an irregular rhythm, and the QRS complexes are wide with changing amplitude. The rate is 150 to 250 beats/minute, usually with an irregular rhythm, and the QRS complexes are wide with changing amplitude. Dr Hekmat 33

34 Torsades de pointes This arrhythmia may be paroxysmal, starting and stopping suddenly, and may deteriorate into ventricular fibrillation This arrhythmia may be paroxysmal, starting and stopping suddenly, and may deteriorate into ventricular fibrillation Reversible causes Reversible causes Amiodarone, ibutilide, erythromycin, haloperidol, droperidol, and sotalol Amiodarone, ibutilide, erythromycin, haloperidol, droperidol, and sotalol Myocardial ischemia and electrolyte abnormalities, such as hypokalemia, hypomagnesemia, and hypocalcemia Myocardial ischemia and electrolyte abnormalities, such as hypokalemia, hypomagnesemia, and hypocalcemia Dr Hekmat 34

35 Ventricular fibrillation Electrical activity in the ventricles Electrical activity in the ventricles Electrical impulses arise from many different foci. Electrical impulses arise from many different foci. It produces no effective muscular contraction and no cardiac output. It produces no effective muscular contraction and no cardiac output. Dr Hekmat 35

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37 Ventricular tachycardia Three or more PVCs occur in a row and the ventricular rate exceeds 100 beats/minute Three or more PVCs occur in a row and the ventricular rate exceeds 100 beats/minute VT is an extremely unstable rhythm. VT is an extremely unstable rhythm. It can occur in short, paroxysmal bursts lasting fewer than 30 seconds and causing few or no symptoms. It can occur in short, paroxysmal bursts lasting fewer than 30 seconds and causing few or no symptoms. Alternatively, it can be sustained, requiring immediate treatment to prevent death, even in patients initially able to maintain adequate cardiac output Alternatively, it can be sustained, requiring immediate treatment to prevent death, even in patients initially able to maintain adequate cardiac output Dr Hekmat 37

38 Ventricular tachycardia Conditions that can cause ventricular tachycardia include: Conditions that can cause ventricular tachycardia include: MI MI Coronary artery disease Coronary artery disease Valvular heart disease Valvular heart disease Heart failure Heart failure Cardiomyopathy Cardiomyopathy Electrolyte imbalances such as hypokalemia Electrolyte imbalances such as hypokalemia Drug intoxication from digoxin (Lanoxin), procainamide, Quinidine, or Cocaine Drug intoxication from digoxin (Lanoxin), procainamide, Quinidine, or Cocaine Proarrhythmic effects of some antiarrhythmics Proarrhythmic effects of some antiarrhythmics Dr Hekmat 38

39 Unpredictable V-tach A patient may be stable with a normal pulse and adequate hemodynamics or unstable with hypotension and no detectable pulse. A patient may be stable with a normal pulse and adequate hemodynamics or unstable with hypotension and no detectable pulse. Because of reduced ventricular filling time and the drop in cardiac output, the patient’s condition can quickly deteriorate to ventricular fibrillation and complete cardiac collapse Because of reduced ventricular filling time and the drop in cardiac output, the patient’s condition can quickly deteriorate to ventricular fibrillation and complete cardiac collapse Dr Hekmat 39

40 Ventricular tachycardia The ventricular rate is usually rapid—100 to 250 beats/minute. The ventricular rate is usually rapid—100 to 250 beats/minute. The P wave is usually absent but may be obscured by the QRS complex. The P wave is usually absent but may be obscured by the QRS complex. Retrograde P waves may be present. Retrograde P waves may be present. The QRS complex is wide and bizarre, usually with an increased amplitude and a duration of longer than 0.12 second. The QRS complex is wide and bizarre, usually with an increased amplitude and a duration of longer than 0.12 second. Dr Hekmat 40

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42 VT + RBBB (1) the QRS complex is monophasic or biphasic in V1, with an initial deflection different from that of the sinus-initiated QRS complex (1) the QRS complex is monophasic or biphasic in V1, with an initial deflection different from that of the sinus-initiated QRS complex (2) the amplitude of the R wave in V1 exceeds the R ′ (2) the amplitude of the R wave in V1 exceeds the R ′ (3) a small R and large S wave or a QS pattern in V6 may be present. (3) a small R and large S wave or a QS pattern in V6 may be present. Dr Mostafa Hekmat 42

43 Left Septal VT Dr Hekmat 43

44 VT + LBBB (1) the axis can be rightward, with negative deflections deeper in V1 than in V6, (1) the axis can be rightward, with negative deflections deeper in V1 than in V6, (2) a broad prolonged (more than 40 milliseconds) R wave in V1 (2) a broad prolonged (more than 40 milliseconds) R wave in V1 (3) a small Q–large R wave or QS pattern in V6 can exist (3) a small Q–large R wave or QS pattern in V6 can exist Dr Mostafa Hekmat 44

45 RVOT VT Dr Hekmat 45

46 VT QRS duration exceeding 140 milliseconds QRS duration exceeding 140 milliseconds In precordial leads with an RS pattern, the duration of the onset of the R to the nadir of the S exceeding 100 In precordial leads with an RS pattern, the duration of the onset of the R to the nadir of the S exceeding 100 Fusion beat Fusion beat Capture beat Capture beat AV dissociation has long been considered a hallmark of VT AV dissociation has long been considered a hallmark of VT Retrograde VA conduction to the atria from ventricular beats occurs in at least 25% of patients Retrograde VA conduction to the atria from ventricular beats occurs in at least 25% of patients Dr Mostafa Hekmat 46

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48 Supraventricular arrhythmia with aberrancy (1) consistent onset of the tachycardia with a premature P wave (1) consistent onset of the tachycardia with a premature P wave (2) very short RP interval (0.1 sec) (2) very short RP interval (0.1 sec) (3) QRS configuration the same as that occurring from known supraventricular conduction at similar rates (3) QRS configuration the same as that occurring from known supraventricular conduction at similar rates (4) P wave and QRS rate and rhythm linked to suggest that ventricular activation depends on atrial discharge (an AV Wenckebach block) (4) P wave and QRS rate and rhythm linked to suggest that ventricular activation depends on atrial discharge (an AV Wenckebach block) (5) slowing or termination of the tachycardia by vagal maneuvers (5) slowing or termination of the tachycardia by vagal maneuvers Dr Mostafa Hekmat 48

49 A QRS complex in V1 - V6,  either all negative or all positive  favors a VT A QRS complex in V1 - V6,  either all negative or all positive  favors a VT The presence of a 2 : 1 VA block  VT The presence of a 2 : 1 VA block  VT Positive QRS complex in V1 - V6 Positive QRS complex in V1 - V6 Can also occur from conduction over a left-sided accessory pathway. Can also occur from conduction over a left-sided accessory pathway. Supraventricular beats with aberration Supraventricular beats with aberration Triphasic pattern in V1 Triphasic pattern in V1 An initial vector of the abnormal complex similar to that of the normally conducted beats An initial vector of the abnormal complex similar to that of the normally conducted beats Wide QRS complex with long-short cycle sequence Wide QRS complex with long-short cycle sequence Dr Mostafa Hekmat 49

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56 Treatment Dr Hekmat56

57 Treatment PVCs, even in the setting of an acute MI, need not be treated unless they directly contribute to hemodynamic compromise PVCs, even in the setting of an acute MI, need not be treated unless they directly contribute to hemodynamic compromise Dr Mostafa Hekmat 57

58 Treatment Any wide QRS complex tachycardia should be treated as ventricular tachycardia until definitive evidence is found to establish another diagnosis Any wide QRS complex tachycardia should be treated as ventricular tachycardia until definitive evidence is found to establish another diagnosis Dr Hekmat 58

59 Treatment Beta blockers are often the first line of therapy. Beta blockers are often the first line of therapy. If they are ineffective, class IC drugs seem particularly successful in suppressing PVCs, If they are ineffective, class IC drugs seem particularly successful in suppressing PVCs, Flecainide and Moricizine have been shown to increase mortality in patients treated after MI Flecainide and Moricizine have been shown to increase mortality in patients treated after MI Should be reserved for patients without coronary artery disease or LV dysfunction Should be reserved for patients without coronary artery disease or LV dysfunction Amiodarone Amiodarone Should be reserved for highly symptomatic patients and those with structural heart disease. Should be reserved for highly symptomatic patients and those with structural heart disease. Dr Mostafa Hekmat 59

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