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CARDIAC ARRHYTHMIA
Any abnormality of cardiac rhythm is called arrhythmia
Causes:
Cardiac:
- Coronary artery disease
- Left ventricular Aneurysm
- Pericarditis
- Myocarditis
- Cardiomyopathy

Non-cardiac
- Caffeine
- Smoking
- Alcohol
- Pneumonia
- Drugs (2-Agonist, Digoxin)
- Hypoxia, Hypercapnia
- Metabolic acidosis
- Thyroid disease
- Phaeochromocytoma
Clinical presentation:
- Asymptomatic
- Palpitation
- Chest pain
- Dizziness
- Syncope
- Hypotension
- Pulmonary oedema
- Sudden death
History:
Take detailed history of palpitation, precipitating factors, onset, nature
(slow, fast, regular, irregular), duration, associated symptoms (chest
pain, dyspnoea, collapse), review drug history.

Investigations:
- CBC, Urea, Electrolytes, Glucose, Calcium, Magnesium, Thyroid
function test.
- ECG
- 24-hour ECG monitoring
- Exercise ECG
- Echocardiography
- Cardiac catheterization
- Electrophysiological studies
-

Types of arrhythmias :
1) Sinus Bradycardia
Heart rate < 60 beats per minute (bpm)

Causes:
-

during sleep
athletes
hypothermia
hypothyroidism
jaundice
raised intracranial pressure
drugs (-blocker, Digoxin)

Clinical presentation:
asymptomatic, dizziness, fatigability.

Management:
- If asymptomatic and the rate > 40 bpm no treatment is required
- If symptomatic or the rate < 40 bpm give Atropine 0.6mg IV up to
3 mg , if there is no response insert temporary or permanent pace
maker

2)2Sinus Tachycardia
Heart rate (HR) > 100 bpm
Causes :
Exercise
Excitement
2

Pregnancy
Fever
Anemia
Heart failure
Thyrotoxicosis
Drugs( 2 agonists , Atropine )

Management:
- Treat the underlying cause
- If necessary -blocker may be used

3) Atrial ectopic beats


These are caused by premature discharge of an ectopic atrial focus .
ECG shows an early and abnormal P wave followed by normal QRS complex .

Management :
blockers ( Required only if the patient is having troublesome
palpitation)

4) Ventricular ectopic beats (VEB)


May be asymptomatic or there may be a feeling of extra beat , missed beat or a
heavy beat . The pulse is irregular .
ECG shows a wide QRS with bizarre shape .
Causes :
-

Old age
Stress
Heart failure
Myocardial ischemia
MI
Myocaditis
Digoxin

Treatment :
blockers ( Required only if the patient is having troublesome
palpitation)

5) Atrial fibrillation (AF)


In this case there are multiple wavelets in the atrium each is stimulating a
portion of atrial muscles then another , then another . when this happens many
small portions of the atrial muscle will be contracting at the same time , while
equally as many other portions will be relaxing .Thus there is never a coordinate
contraction of all atrial muscle at once .
It may be paroxysmal , persistent , permanent

Causes :
-

Thyrotoxicosis
Mitral valve disease
Myocardial ischemia
Hypertension
Cardiomyopathy
Chest infection
Alcohol
Lone AF (idiopathic)

Clinical features:
May be asymptomatic
Palpitation , dyspnoea , chest pain , thromoembolism eg: CVA
The pulse is irregularly irregular
ECG shows fine oscillation of the base line (f waves) and absence of P
wave with an irregular rhythm

Treatment :
- convert to sinus rhythm either by cardioversion or by using drugs
(digoxin , blocker , amiodarone )
- if it is caused by acute event , the underlying cause should be
treated initially
- anticoagulant ( aspirin , warfarine )
6) Atrial flutter
it is almost always caused by organic disease of the heart. The atrial rate is
usually about 300 bpm.
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The ECG shows characteristically ( sawtooth ) flutter waves ( F waves ).

Treatment:
- Acute paroxysm is treated by electrical cardioversion (DC shock)
and prophylaxis with Beta-Blocker or Amiodarone.
- Rate control of chronic atrial flutter is treated with Digoxin
7) Ventricular Tachycardia:
is defined as 3 or more consecutive ventricular beats occurring at a rate of
120 / min or more. It is usually associated with underlying heart disease e.g.
ischaemia, cardiomyopathy, hypertensive heart disease.
The ECG shows a rapid ventricular rhythm with broad abnormal QRS
complexes.

Treatment:
- If there is severe hypotension urgent cardioversion is necessary
- If the patient is haemodynamically stable, treatment is usually with
i.v. Lidocaine
- Prophylaxis is with Flecainide, or Amiodarone.
- Patients who are refractory to all medical treatment may need an
implantable Defibrillator.

8) Ventricular Fibrillation:
This is a very rapid and irregular ventricular activation with no mechanical
effect and hence no cardiac output, the patient has no pulse and becomes
rapidly unconscious and respiration stops.
The ECG shows rapid oscillation with no organized QRS complex.

Treatment:
- Immediate cardioversion
- CPR