Fatima’s Arrhythmic Case

Fatima’s Arrhythmic Case

1. Classification of arrhythmias

   • According to anatomical site
     • Supraventricular (narrow QRS)
       • Atrial extrasystole
         • ECG pattern
           • abnormal beat arises from the atrium before the expected sinus beat
       • Supraventricular tachycardia
         • cause
           • Ectopic focus
         • ECG pattern
           • Rregular
           • 150-250 BPM
           • Abnormal P wave shape
         • treatment
           • vagal maneuver
       • Atrial flutter
         • ECG pattern
           • Saw-toothed
           • Atrail rate 250-350 BPM
       • Atrial fibrillation
         • ECG pattern
           • absent P wave
           • Irregular irregular, of RR wave
     • Ventricular (wide QRS)
       • Ventricular tachycardia
         • cause
           • ectopic focus
         • ECG pattern
           • three or more beats of ventricular origin in succession
       • Ventricular fibrillation
         • Cause
           • several ectopic foci in ventricles
         • No pattern in ECG
           • No pulse
         • Most serious (cause death)
   • According to the mechanism
     • Disturbance of impulse formation:
       • Abnormal sinus rhythms
         • Sinus Tachycardia
           • Causes
             • Physiological
               • Physical exercise
             • Pharmacological
               • Anticholinergic drugs (atropine)
             • pathological
               • Thyrotoxicosis, Anaemia
           • ECG pattern
             • 1:1 P:QRS
             • Regular
             • 100-200 BPM
         • Sinus Bradycardia
           • Causes
             • Physiological
               • in athletes, at deep sleep
             • Pharmacological
               • Beta blockers
             • pathological
               • Hypothyroidism, sick sinus syndrome
           • ECG pattern
             • less than 60 BPM
             • Regular
             • 1:1 P:QRS
       • Shift of the pacemaker
     • Disturbance of impulse conduction
       • Atrioventricular block
         • First Degree
           • ECG pattern
             • 1:1 P:QRS
             • Regular
             • PR interval > 0.2 sec; > 5 small boxes
         • Second Degree
           • Mobitz 1
             • Cause
               • AV node abnormality
             • ECG pattern
               • Progressive increase in PR interval until one QRS is dropped
           • Mobitz 2
             • Cause
               • bundle of His block
             • ECG pattern
               • normal P-R interval
               • 2: 1 or 3: 1 P:QRS
                 • = dropped a beat
         • Third Degree
           • ECG pattern
             • Dissociation between P wave and QRS
       • Bundle branch block
         • Right
         • Left

2. Pharmacological managment

   • Antiarrhythmic Drugs
     • Class I drugs
       • use
         • Suppress ventricular arrhythmias
       • mechanism
         • Sodium channels blockers
     • Class II drugs
       • use
         • inhibit AV node
       • mechanism
         • β-adrenoceptors blockers
       • example
         • Propranolol
     • Class III drugs
       • mechanism
         • Prolongs refractory period
           • K+ channel blocker
       • example
         • Amiodarone
     • Class IV drugs
       • mechanism
         • Calcium channel blockers
       • example
         • Verapamil
     • Class V drugs
       • mechanism
         • Muscarinic antagonist
       • example
         • Adenosine
     • others
       • Atropine
         • mechanism
           • Anticholinergic drug
         • use
           • Increase heart rate in bradycardia and heart blocks
       • Digitalis
         • use
           • Inhibit AV node; treat atrial fibrillation
         • mechanism
           • inhibit Na+\K+ pump
             • shorten the refractory period
   • Anticoagulant drugs
     • Heparin
       • Structure
         • polysaccharides
           • water-soluble
             • safe at pregnancy
       • Actions & Uses
         • Increases the activity of antithrombin 3
           • inhibit factor 5 & Thrombin (f 2)
         • prophylaxis against deep vein thrombosis
       • Administration
         • Intravenously
           • immediate effect
             • ER, Post-operation
       • Metabolism
         • Heparin is metabolized in the liver by heparinase
         • excreted in the urine
       • Adverse effects
         • Bleeding
     • Warfarin
       • Structure
         • lipid souluble
           • pass placenta
             • could cause teratogenicity
       • Action & uses
         • inhibit Vitamin K
           • Inhibit Factors 2,7,9,10
         • for patients of Artificial Valve or Atrail fibrillation
           • because congestion can lead to couglation
           • whose risk for a stroke is high
       • Administration
         • orally
           • Low therapeutic index
           • 100% bioavailability
       • Adverse Effect
         • Bleeding
         • teratogenicity

3. Clinical Presentation

   • Palpitation
     • Definition
       • Intermittent “pounding,” sensation in the chest.
       • During rest
     • Etiology
       • cardiac (43%)
     • Cardiac causes
       • Regular
         • supraventricular and ventricular tachycardias
       • Irregular
         • atrial fibrillation
     • other causes
       • tobacco, caffeine, atropine, thyroxine, cocaine
   • Dizziness
     • Causes
       • orthostatic hypotension
       • cardiac dysrhythmia
       • medication effects & others
     • Cardiac mechanism
       • Insufficient cardiac output
         • insufficient oxygen to the brain

4. Thrombosis As An Arrhythmic Complication

   • Types of Thrombus
     • Pale Thrombus
       • Mainly  platelet
       • Cardiac chambers or arteries
     • Red Thrombus
       • Fibrin,RBCs, WBCs and  platelets
       • veins
     • Mixed Thrombus
       • Alternating layers of platelets + fibrin, RBCs
       • In heart or  aorta

5. Public health approach to atrial fibrillation

   • Define the problem
   • Identify risk and protective factors
     • congestive heart failure
     • diabetes mellitus
     • obesity
     • alcohol consumption
     • hypertension
   • Develop and test prevention strategies
   • Ensure widespread adoption