ARRHYTHMIAS RECOGNITION AND TREATMENT IN GENERAL PRACTICE

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1 ARRHYTHMIAS RECOGNITION AND TREATMENT IN GENERAL PRACTICE Koh Kok Wei MBBS MRCP Cardiology Fellow Electrophysiology and Cardiac Pacing Unit

2 Outline Cardiovascular Updates for Doctors & Allied Healthcare Normal heart rhythm Incidental findings Irregular heart beat Slow heart beat Fast heart beat

3 Aim at the end of lecture (~ 20mins) To distinguish normal vs abnormal ECGs Normal ECG Abnormal ECG

4 Normal ECG BPM Normal axis Normal P waves PR ms QRS ms Normal T waves

5 Normal ECG Positive Negative Transition from negative to positive Quick screen on axis

6 Normal ECG Positive Negative Biphasic Quick screen on P wave

7 Common presenting symptoms Palpitation Missed beat or extra beat Giddiness Syncope Dyspnea Chest discomfort Seizure

8 Scenario 35 year-old gentleman, had cough and runny nose. Also noted pricking chest pain

9 Incidental findings Sinus arrhythmia P-P interval gradually lengthens and shortens in a cyclical fashion Normal sinus P waves with a constant morphology Constant P-R interval

10 Incidental findings Sinus bradycardia big boxes = 50 bpm Can be asymptomatic, commonly in athletes Patient may be on beta-blockers, calcium channel blockers

11 Incidental findings Right bundle branch block Can be asymptomatic, 0.8% in healthy population Maybe associated with HPT, ASD, IHD

12 Incidental findings First degree AV Block Enhanced vagal tone (for example in athletes) Drugs: beta blocker, CCB

13 Irregular heart beat Premature Atrial Contraction Early abnormal P-wave Next normal P- wave comes later Premature atrial beat Exact cause of PAC is unclear May be asymptomatic or felt missed beat Maybe associated with alcohol, caffeine, salbutamol etc

14 Irregular heart beat Premature Ventricular Contraction Early broad complex Next normal P- wave on time May be asymptomatic or felt missed beat, discomfort Benign causes: idiopathic, alcohol, caffeine, salbutamol, hyperthyroidism

15 Worrying if A lot of PVCs Multifocal PVCs Associated with chest pain, syncope, dyspnea Family history of sudden cardiac death Causes: IHD, myocarditis, cardiomyopathy, inherited arrhythmia syndromes

16 Further investigations in GP setting CXR

17 Further investigations in GP setting 24-Holter Monitoring

18 Irregular heart beat Atrial fibrillation Irregular RR interval No obvious P waves

19 Atrial fibrillation Assess thromboembolic stroke risk

20 Atrial fibrillation Assess thromboembolic stroke risk

21 Atrial fibrillation Options of OAC: Dabigatran (Pradaxa) Apixaban (Eliquis) Rivaroxaban (Xarelto) If CHADS2 is 1, may want to calculate detail CHA2DS2VASc score

22 Atrial fibrillation Rate control Aim resting HR <100 bpm Drugs commonly used Beta blockers (BB) ND-CCB (diltiazem, verapamil) Digoxin Combination of BB + digoxin Amiodarone

23 Atrial fibrillation How to calculate rate? By manual palpation of the pulse By ECG 1 big box = 0.2s 5 big boxes = 1.0s 30 big boxes = 6.0s Calculate total QRS within 30 big boxes 8 QRS in 6 seconds (x 10) 80 QRS in 60 seconds 80 beats per minute!

24 Slow heart beat Do you know that a Galapagos tortoise s heart beats about 6-20 bpm?

25 Slow heart beat Sinus Node Dysfunction Sinus bradycardia Exercise stress test may unmasked chronotropic incompetence May need permanent pacemaker

26 Slow heart beat Sinus Node Dysfunction Sinus arrest Need permanent pacemaker

27 Slow heart beat Sinus Node Dysfunction Sinoatrial block May be symptomatic or asymptomatic Exercise stress test may unmasked chronotropic incompetence

28 Slow heart beat AV block Second degree Type 1 (Wenckebach) Normal in athletes, on drugs: BB, CCB Reassurance

29 Slow heart beat AV block Complete AV Block Usually very symptomatic Permanent pacemaker required Unless in asymptomatic congenital CHB with no structural heart disease

30 Slow heart beat AV block Second degree Type 2 May be symptomatic or asymptomatic Important to recognize Precursor to disaster Need permanent pacemaker

31 Slow heart beat Atrial fibrillation Slow ventricular response Stop BB, digoxin, CCB May need permanent pacemaker

32 Fast heart beat

33 Fast heart beat Narrow complex tachycardia Sinus tachycardia Fever, pain, anxiety, emotional stress

34 Fast heart beat What can you do in GP setting? Reassurance, treat underlying cause Pulse rate diary Fever, pain, anxiety, emotional stress

35 Fast heart beat Narrow complex tachycardia Atrial tachycardia

36 Fast heart beat Narrow complex tachycardia Atrial tachycardia

37 Fast heart beat Narrow complex tachycardia SVTs: AVNRT, AVRT Acute Management carotid sinus massage, exposure of the face to ice water, Valsalva maneuver, coughing IV adenosine, verapamil, amiodarone Long term Management Beta-blocker CCB EP Study and RF Ablation

38 Fast heart beat Narrow complex tachycardia Atrial flutter 4:1 AV conduction ~ 75bpm 2:1 AV conduction ~ 150bpm

39 Fast heart beat Narrow complex tachycardia Atrial flutter post adenosine 4:1 AV conduction ~ 75bpm Acute Management Usually well tolerated if rate controlled IV amiodarone may revert to SR BB, CCB for rate control DC Cardioversion Long term Management RF Ablation superior than medical therapy Consider OAC if CHADS > 1 in persistent/paroxysmal atrial flutter

40 Fast heart beat Narrow complex tachycardia Atrial fibrillation

41 Fast heart beat Broad complex tachycardia Ventricular tachycardia until proven otherwise Basic life support, ACLS DC cardioversion! Call ambulance Two large bore IV branula

42 Fast heart beat Sometimes, palpitation or tachycardia terminates before ECG is done What to look for?

43 Fast heart beat Delta waves WPW syndrome

44 Fast heart beat Cardiomyopathic changes HCM, DCM

45 Fast heart beat Brugada syndrome

46 Fast heart beat QTc 654ms 600ms 840ms Long QT acquired, inherited

47 Fast heart beat Long QT precursor to Torsade de Pointes

48

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