Tachycardia

The atria and/or AV junction are an integral part are not involved

Supraventricular
Usually narrow QRS

Ventricular
Always wide QRS

Supraventricular tachycardia
Atrial tachycardia
Sinus tachycardia Ectopic atrial tachycardia

Atrial flutter Atrial fibrillation Tachycardias involving the AV junction

(paroxysmal - PSVT)
AV nodal reentry tachycardia AV reentry tachycardia

Sinus tachycardia
Physiological sinus tachycardia
fever, hypovolemia, anemia, hyperthyroidism, drugs (caffeine, alcohol, nicotine, aminophyllin, atropine, catecholamines, amphetamine, cocaine, cannabis) Diagnosis: normal P-morphology Treatment directed at the underlying cause, beta-blockers

Sinus tachycardia

Sinus tachycardia
Inappropriate sinus tachycardia
unrelated to, or out of proportion with the level of physical, pathological or pharmacological stress

Mechanism: enhanced automaticity and/or abnormal autonomic regulation Diagnosis: exclusion of secondary causes Treatment: beta blockers (verapamil), catheter ablation

Ectopic atrial tachycardia

Regular atrial activation (100-250/min) from an atrial focus (focal atrial tachycardia) Automatic, triggered activity, microreentry Paroxysmal or chronic Underlying cardiac abnormalities frequent (digitalis)

Focal atrial tachycardia

MAT

Atrial flutter (AFl)

Macro-reentry circuit ECG: organized atrial activity, 250-350/min,
no isoelectric baseline, varying AV block Typical (counterclocwise) Reverse typical (clockwise)

Cavotricuspid isthmus-dependent AFl

Atypical AFl

Isthmus-dependent AFl

Typical AFl

Typical AFl

Reverse typical AFl

Atrial flutter (AFl)

Clinical features
Paroxysmal or chronic Underlying cardiovascular disease in 98% In 25-35% of patients with atrial fibrillation Symptoms depend on ventricular rate

usually 2:1 (150 bpm) 1:1 conduction (exercise, Class Ic drugs, WPW syndrome)

Atrial fibrillation (AF)

Most common sustained arrhythmia

Atrial fibrillation (AF)

Mechanism

AF
Venae pulmonales

Prevalence

Atrial thrombus

Thromboembolism

Risk of stroke in AF

Paroxysmal supraventricular tachycardia (PSVT)

PSVT

AV nodal reentry tachycardia (AVNRT)

Dual AV nodal pathways
SR ES
E c h o

slow

fast

AVNRT

AVNRT

AV reentry tachycardia (AVRT) Wolf-Parkinson-White Syndrome

AV accessory pathways AVRT

manifest (WPW-sy.) concealed orthodromic antidromic

Accessory pathways

Pre-excitation
Delta wave

Pre-excitation
normal

preexcited

Pre-excitation

Orthodromic AVRT

Antidromic AVRT

Preexcited tachycardias
Atrial flutter and fibrillation, AVNRT

WPW syndrome

WPW-syndrome: Sudden death

0,0015 / year
Munger et al Circ. 1993

Ventricular tachycardia (VT): classification

Monomorphic, regular

Polymorphic, irregular

Ventricular tachycardia (VT): classification

Organic heart disease (CAD, DCM, ARVD, HCM)

Idiopathic ventricular tachycardia (RVOT, LVOT, fascicular VT)

Ventricular tachycardia (VT): classification

Non-sustained (<30 sec) Sustained (>30 sec)

Monomorphic, sustained VT in organic heart disease

Reentry
After MI 3-5%

VT after MI

Non-sustained ventricular tachycardia (nsVT)

nsVT and frequent ventricular extrasystoles (>10/hour VES) Without organic heart disease
Does not indicate risk Needs no treatment

NsVT and heart disease

IDCM

Idiopathic DCM 40% after MI 5-10%

Increased mortality (sudden cardiac death - SCD)

Doval et al. Circ. 1996

Polymorphic VT
Rapid, > 200 bpm (V flutter) Asymptomatic, (pre)syncope, VF Classified based on the QT interval

Polymorphic VT with normal QT

Acute ischemia Inherited arrhythmogenic syndromes:
Catecholaminergic polymorph VT (RyR2) Brugada syndrome (SCN5A)

Polymorphic VT with long QT: torsade de pointes

QTc > 0,45 s (men) > 0,46 s (women)

Bazzet correction: QTc=QT/RR (all in sec)

Polymorphic VT with long QT: torsade de pointes

Congenital long QT (Romano-Ward) syndrome (LQTS) Syncope and SCD LQTS genes (1-7) code for K and Na channel proteins
LQTS 1 & 2 decreased K-current, events with stress and arousal LQTS 3 - increased Na-current, events during rest

Polymorphic VT with long QT: torsade de pointes

Aquired LQTS
Electrolyte disturbances: hypokalemia, -magnesemia Bradycardia Drugs:
Antiarrhythmic (Class Ia, III) Antibiotic (macrolide) Antifungal (ketoconazole, fluconazole) Psychoactive (phenotiazine, TCA) Many more (cisapride, antihistamines, anthracyclines etc.)