it is very important topic for ICCU

1. Management of a case of rhythm disturbance in ICCU : supra-ventricular tachyarrhythmia Dr Jayanta paul Final year PGT , Medicine dept Burdwan medical college

3. Atrial fibrillation

4. ECG Diagnosis Of Atrial Fibrillation. • Irregularly irregular RR intervals • Absence of P waves • Irregular fibrillatory wave forms (best seen in V1)

5. Atrial fibrillation with rapid ventricular response in a 76-year-old man with breathlessness. Note the irregularly irregular ventricular rhythm. Sometimes on first look, the rhythm may appear regular, but on closer inspection it is clearly irregular.

6. Atrial fibrillation with pre-existing LBBB in a 60-year-old woman with hypertension Sometimes this can be confused with ventricular tachycardia, but closer inspection can identify the irregularity. The irregularly irregular rhythm suggests AF. Features of typical left bundle branch block include wide QRS (> 120 ms), no secondary R wave in lead V1, and no lateral Q waves.

7. Wolff-Parkinson-White syndrome with atrial fibrillation in a 47-year-old man with a long history of palpitations and, lately, blackouts. Note the irregularly irregular, wide complex tachycardia. Impulses from the atria are conducted to the ventricles via either both the AV node and accessory pathway (producing a broad fusion complex), or just the AV node (producing a narrow complex without a delta wave), or just the accessory pathway (producing a very broad “pure” delta wave). People who develop this rhythm and have very short RR intervals are at higher risk of VF.

9. Laboratory Tests :--- 1. Thyroid Studies 2. Complete Blood Count 3. Drug Levels 4. Coagulation Studies 5. Cardiac Markers 7. Tests For Pulmonary Embolism 6.Echocardiography Digoxin toxicity (but not digoxin use) is a relative contraindication to electrical cardioversion/defibrillation, as case reports of asystole after such attempts to treat tachydysrhythmias in this setting have occurred.40 Obtain a protime (PT) and international normalized ratio (INR) if the patient is on warfarin Up to 20% of patients who present with acute MI will develop AF in close proximity to the acute MI. … ..ECG changes suspicious for ischemia or underlying heart disease … ..Significant risk factors for CAD … ..possible angina (chest pain, pressure, significant dyspnea, CHF, etc.). It is important to note that a transthoracic echo is inadequate for the exclusion of clot, as it cannot visualize the left atrial appendage very well . a screening TSH should be obtained in older patients (> 55) with NOAF. classic signs and symptoms (like buggy eyes,sweating, tremors, or diarrhea).

12. RATE VERSUS RHYTHM CONTROL W HICH IS SUPERIOR ? AFFIRM Trial RACE Trail AF-CHF Trail STAF Trail PIAF trail Management of atrial fibrillation

13. N Engl J Med. 2002 Dec 5;347(23):1825-33. A comparison of rate control and rhythm control in patients with atrial fibrillation. Wyse DG , Waldo AL , DiMarco JP , Domanski MJ , Rosenberg Y , Schron EB , Kellen JC , Greene HL , Mickel MC , Dalquist JE , Corley SD ; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators . Source AFFIRM Clinical Trial Center, Axio Research, 2601 4th Ave., Ste. 200, Seattle, WA 98121, USA. Abstract BACKGROUND: There are two approaches to the treatment of atrial fibrillation: one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm, and the other is the use of rate-controlling drugs, allowing atrial fibrillation to persist. In both approaches, the use of anticoagulant drugs is recommended. METHODS: We conducted a randomized, multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death. The primary end point was overall mortality. RESULTS: A total of 4060 patients (mean [+/-SD] age, 69.7+/-9.0 years) were enrolled in the study; 70.8 percent had a history of hypertension, and 38.2 percent had coronary artery disease. Of the 3311 patients with echocardiograms, the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent. There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy (mortality at five years, 23.8 percent and 21.3 percent, respectively; hazard ratio, 1.15 [95 percent confidence interval, 0.99 to 1.34]; P=0.08). More patients in the rhythm-control group than in the rate-control group were hospitalized, and there were more adverse drug effects in the rhythm-control group as well. In both groups, the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic. CONCLUSIONS: Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this group of high-risk patients.

15. RATE CONTROL STRATEGIES Rate control with pharmacological therapy is the main stay of therapy for persistent & permanent cases of atrial fibrillation. Target HR - 80 to 100 bpm Precautions -- Beware agents which may cardiovert Atrial Fib >48 hours. Risk of embolic complications.

20. Rhythm control

21. Am J Cardiol. 2003 Mar 20;91(6A):15D-26D. Old and new antiarrhythmic drugs for converting and maintaining sinus rhythm in atrial fibrillation: comparative efficacy and results of trials. Naccarelli GV , Wolbrette DL , Khan M , Bhatta L , Hynes J , Samii S , Luck J . Source Division of Cardiology and the Penn State Cardiovascular Center, Penn State University College of Medicine, The Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, USA. gnaccarelli@psu.edu

22. Abstract In managing atrial fibrillation (AF), the main therapeutic strategies include rate control, termination of the arrhythmia, and the prevention of recurrences and thromboembolic events. Safety and efficacy considerations are important in optimizing the choice of an antiarrhythmic drug for the treatment of AF. Recently approved antiarrhythmics, such as dofetilide, and promising investigational drugs, such as azimilide and dronedarone, may change the treatment landscape for AF. For medical conversion of recent-onset AF, class IC antiarrhythmic drugs, administered as an oral bolus, have been demonstrated to be the most efficacious pharmacologic conversion agents. Intravenous ibutilide and oral dofetilide both have efficacies superior to placebo in controlled trials for converting persistent AF. Comparative trials in paroxysmal AF have demonstrated that flecainide, propafenone, quinidine, and sotalol are equally effective in preventing recurrences of AF. Amiodarone has been demonstrated to be more efficacious than propafenone or sotalol in the Canadian Trial of Atrial Fibrillation. In persistent AF, twice-daily dofetilide has been shown to be as or more effective than low-dose sotalol given twice daily for the maintenance of sinus rhythm in patients with AF. Trials have demonstrated that subjective adverse effects are less frequent with class IC drugs, sotalol, and dofetilide compared with such drugs as quinidine. In patients without structural heart disease, flecainide, propafenone, and D,L-sotalol are the initial drugs of choice, given their reasonable efficacy, low incidence of subjective side effects, and lack of significant end-organ toxicity.

23. Treating AF in patients with left ventricular dysfunction can be difficult because of associated electrophysiologic derangements, potential proarrhythmic concerns, and negative inotropic effects of antiarrhythmics. Some data exist suggesting that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can prevent AF either by preventing atrial dilation and stretch-induced arrhythmias or by blocking the renin-angiotensin system. In post-myocardial infarction patients, D,L-sotalol, dofetilide, and amiodarone-and in congestive heart failure patients, amiodarone and dofetilide-have demonstrated neutral effects on survival in controlled trials. In the Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF-STAT), amiodarone lowered the frequency of AF development and improved left ventricular ejection fraction over time. In CHF-STAT, there was lower mortality in patients who converted from AF to sinus rhythm. Dofetilide decreased rehospitalization for congestive heart failure in the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) trials. Neutral effects on survival and favorable hemodynamics have positioned amiodarone and dofetilide as the antiarrhythmics of choice in patients with left ventricular dysfunction. In post-myocardial infarction patients, sotalol is an additional agent to consider for treatment of AF in this setting

25. External defibrillation

27. Termination of AF by electrical defibrillator acutely may be warranted based on clinical parameters and/or hemodynamic status. Confirmation of appropriate anticoagulation must be documented unless symptoms and clinical status warrant emergent intervention. Direct current transthoracic cardioversion during short-acting anesthesia is a reliable way to terminate AF. Conversion rates using a 200-J biphasic shock delivered synchronously with the QRS complex typically are >90%.

28. Recurrence after external defibrillation

29. J Am Coll Cardiol. 2007 Apr 17;49(15):1642-8. Epub 2007 Apr 2. Association between C-reactive protein and recurrence of atrial fibrillation after successful electrical cardioversion: a meta-analysis. Liu T , Li G , Li L , Korantzopoulos P . Source Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China. Abstract OBJECTIVES: We conducted a systematic review and meta-analysis of observational studies to examine the association between baseline C-reactive protein (CRP) levels and the recurrence of atrial fibrillation (AF) after successful electrical cardioversion (EC). BACKGROUND: Current evidence links AF to the inflammatory state. Inflammatory indexes such as CRP have been related to the development and persistence of AF. However, inconsistent results have been published with regard to the role of CRP in predicting sinus rhythm maintenance after successful EC. METHODS: Using PubMed, the Cochrane clinical trials database, and EMBASE, we searched for literature published June 2006 or earlier. In addition, a manual search was performed using all review articles on this topic, reference lists of papers, and abstracts from conference reports. Of the 225 initially identified studies, 7 prospective observational studies with 420 patients (229 with and 191 without AF relapse) were finally analyzed. RESULTS: Overall, baseline CRP levels were greater in patients with AF recurrence. The standardized mean difference in the CRP levels between the patients with, and those without AF was 0.35 units (95% confidence interval 0.01 to 0.69); test for overall effect z-score = 2.00 (p = 0.05). The heterogeneity test showed that there were significant differences between individual studies (p = 0.02; I(2) = 60.2%). Further analysis revealed that differences between the CRP assays possibly account for this heterogeneity. CONCLUSIONS: Our meta-analysis suggests that increased CRP levels are associated with greater risk of AF recurrence, although there was significant heterogeneity across the studies. The use of CRP levels in predicting sinus rhythm maintenance appears promising but requires further study

30. Factors Associated With Failed Cardioversion. • Underlying illness—congestive heart failure, thyrotoxicosis, valvular disease • Dilated left atrium • Longer duration of atrial fibrillation • Too low energy • Technique • Other patient factors

31. J Interv Card Electrophysiol. 2005 Aug;13 Suppl 1:61-6. Internal defibrillation: where we have been and where we should be going? Lévy S . Source Division of Cardiology, School of Medicine, University of Marseille, Chemin des Bourrellys, Marseille, France. samuel@samuel-levy.com Abstract Internal cardioversion has been developed as an alternative technique for patients who are resistant to external DC cardioversion of atrial fibrillation (AF) and was found to be associated with higher success rates . It used initially high energies (200-300 J) delivered between an intracardiac catheter and a backplate. Subsequent studies have shown that it is possible to terminate with energies of 1 to 6 Joules, paroxysmal or induced AF in 90 percent of patients and persistent AF in 75 percent of patients, using biphasic shocks delivered between a right atrium-coronary sinus vectors. Consequently, internal atrial defibrillation can be performed under sedation only without the need for general anesthesia. Recently developed external defibrillators, capable of delivering biphasic shocks, have increased the success rates of external cardioversion and reduced the need for internal cardioversion. However, internal defibrillation is still useful in overweight or obese patients, in patients with chronic obstructive pulmonary disease or asthma who are more difficult to defibrillate, and in patients with implanted devices which may be injured by high energy shocks . Low energy internal defibrillation has also proven to be safe and this has prompted the development of implantable devices for terminating AF. The first device used was the Metrix system, a stand-alone atrial defibrillator (without ventricular defibrillation) which was found to be safe and effective in selected groups of patients. Unfortunately, this device is no longer being marketed. Only double chamber defibrillators with pacing capabilities are presently available: the Medtronic GEM III AT, an updated version of the Jewel AF and the Guidant PRIZM AVT. These devices can be patient-activated or programmed to deliver automatically ounce atrial tachyarrhythmias are detected, therapies including pacing or/and shocks. Attempts to define the group of patients who might benefit from these devices are described but the respective role of atrial defibrillators versus other non-pharmacologic therapies for AF, such as surgery and radiofrequency catheter ablation, remains to be determined. Advantages and limitations or atrial defibrillators and approaches to reduce shock related discomfort which may be a concern in some patients, are reviewed. Studies have shown that despite shock discomfort, quality of life was improved in patients with atrial defibrillators and the need for repeated hospitalizations was reduced. The cost of these devices remains a concern for the treatment of a non-lethal arrhythmia. Attention that atrial defibrillators will receive from cardiologists and from the industry in the future, will depend of the long-term results of other non-pharmacological options and of the identification of the group of AF patients which will require restoration and maintenance of sinus rhythm. But there is no doubt that selected subsets of patients with AF could benefit from atrial defibrillation

32. ANTI - COAGULATION THERAPY

34. CHADS2 score (2001) / CHA2DS2-VASc(2010) C-- Cardiac failure H-- Hypertension A-- Age D-- Diabetes S-- Stroke V– vascular disease( prior myocardial infarction , perferal vascular disease, aortic plaque ) Sc -- sex category Score = 0-1 Score = 2 or more than 2 Target INR-- 2-3

39. Direct thrombin inhibition

40. RE-LY ( Randomized Evaluation of Long-term Anticoagulation Therapy ) is an international multicenter study (18,113 patients from 967 centers in 44 countries) that demonstrated the ability of dabigatran to reduce the occurrence of both stroke and hemorrhage in patients who had atrial fibrillation (AF) with high risks of stroke compared with patients who received warfarin. From Japan, 326 patients were randomized in RE-LY. RE-LY (Randomized Evaluation of Long-term Anticoagulation Therapy) study

42. 1. Ximelagatran was as effective as warfarin in reducing stroke/systemic emboli in the elderly (2.23%/y with ximelagatran vs 2.27%/y with warfarin) as in younger patients (1.25%/y vs 1.28%/y). 2. Total bleeds were significantly lower with ximelagatran compared with warfarin in elderly (40% vs 45%, P=0.01) and younger (27% vs 35%, P<0.001) patients. 3. Raised alanine aminotransferase values (>3-fold elevation) among ximelagatran patients were more common in older (7.5% old vs 5.3% young) patients, particularly women (9.5% elderly women vs 6.1% elderly men). 4. In high-risk elderly AF patients, ximelagatran is as effective as warfarin with less bleeding, but alanine aminotransferase elevations are common, particularly in elderly women. Oral DTIs for stroke prevention show promise in elderly patients Stroke. 2007 Nov;38(11):2965-71. Epub 2007 Sep 20. Direct thrombin inhibition and stroke prevention in elderly patients with atrial fibrillation: experience from the SPORTIF III and V Trials. Ford GA , Choy AM , Deedwania P , Karalis DG , Lindholm CJ , Pluta W , Frison L , Olsson SB ; SPORTIF III, V Investigators . Source Institute for Ageing and Health, University of Newcastle upon Tyne, Newcastle upon Tyne, England.

43. When compared with men with AF, women in these studies were older and had more stroke risk factors. Women were more prone to anticoagulant-related bleeding; the higher rate of thrombo-embolism among women was related to more frequent interruption of anticoagulant therapy Eur Heart J. 2006 Aug;27(16):1947-53. Epub 2006 Jun 14. Anticoagulation in women with non-valvular atrial fibrillation in the stroke prevention using an oral thrombin inhibitor (SPORTIF) trials. Gomberg-Maitland M , Wenger NK , Feyzi J , Lengyel M , Volgman AS , Petersen P , Frison L , Halperin JL . Source Department of Medicine, Section of Cardiology, University of Chicago Hospitals, University of Chicago, 5841 S Maryland Avenue, MC2016, Chicago, IL 60637, USA. mgomberg@medicine.bsd.uchicago.edu

44. Antiarrhythmic effect of statin therapy

45. 1. Atrial fibrillation (AF) is the most common clinical arrhythmia. Recent investigations have suggested that inflammation might have a role in the pathophysiology of AF. 2. In this review, the association between inflammation and AF, and the effects of several agents that have anti-inflammatory actions, such as statins, polyunsaturated fatty acids, corticosteroids and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been investigated World J Cardiol. 2010 Aug 26;2(8):243-50. Atrial fibrillation and inflammation. Ozaydin M . Source Mehmet Ozaydin, Department of Cardiology, School of Medicine, Suleyman Demirel University, 32040, Isparta, Turkey.

46. 1. Inflammation appears to play a significant role in the initiation and perpetuation of AF as well as the prothrombotic state associated with AF. 2. Inflammatory biomarkers (C-reactive protein and interleukin-6) have been shown to be associated with the future development, recurrence and burden of AF, and the likelihood of successful cardioversion 3. Animal and clinical studies have evaluated statins, angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, and corticosteroids for the treatment or prevention of AF J Cardiovasc Electrophysiol. 2010 Sep;21(9):1064-70. doi: 10.1111/j.1540-8167.2010.01774.x. Update on the association of inflammation and atrial fibrillation. Patel P , Dokainish H , Tsai P , Lakkis N . Source Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA.

47. 1. Overall, the use of statins was significantly associated with a decreased risk of AF compared with control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18 to 0.85, p = 0.02). 2. Benefit of statin therapy seemed more marked in secondary prevention of AF (OR 0.33, 95% CI 0.10 to 1.03, p = 0.06) than for new-onset or postoperative AF (OR 0.60, 95% CI 0.27 to 1.37, p = 0.23). 3. Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF in patients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome. J Am Coll Cardiol. 2008 Feb 26;51(8):828-35. Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials. Fauchier L , Pierre B , de Labriolle A , Grimard C , Zannad N , Babuty D . Source Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France. lfau@med.univ-tours.fr

48. Our meta-analysis suggests that increased CRP levels are associated with greater risk of AF recurrence, although there was significant heterogeneity across the studies. The use of CRP levels in predicting sinus rhythm maintenance appears promising but requires further study J Am Coll Cardiol. 2007 Apr 17;49(15):1642-8. Epub 2007 Apr 2. Association between C-reactive protein and recurrence of atrial fibrillation after successful electrical cardioversion: a meta-analysis. Liu T , Li G , Li L , Korantzopoulos P . Source Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China.

49. Angiotensin-converting enzyme inhibitors and angiotensin receptor blocker in atrial fibrillation

50. ACEIs/ARBs are effective for primary prevention and secondary prevention of AF. They decrease the incidence of AF especially in patients with hypertension, patients with chronic heart failure and those with AF. Eur J Clin Invest. 2011 Jan 20. doi: 10.1111/j.1365-2362.2010.02460.x. [Epub ahead of print] Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers decrease the incidence of atrial fibrillation: a meta-analysis. Huang G , Xu JB , Liu JX , He Y , Nie XL , Li Q , Hu YM , Zhao SQ , Wang M , Zhang WY , Liu XR , Wu T , Arkin A , Zhang TJ .

51. new drug to treat patients with acute onset atrial fibrillation.

52. Dronedarone was approved by the US Food and Drug Administration on July 2, 2009. 1. It is a deiodinated derivative of amiodarone that has no organ toxicity. 2. Its use will likely extend to both atrial and ventricular arrhythmias. 3. Dronedarone has multiple actions (all 4 Von Williams class effects). 4. Unlike amiodarone, it does not have the iodine moiety. 5. The lack of iodination may offer a better side-effect profile. Dronedarone has been shown to (1) have antiadrenergic effects, (2) prolong atrial and ventricular refractory periods, and (3) prolong atrioventricular node conduction as well as the paced QRS complex. 5. In animal models, dronedarone has been shown to decrease ischemia-induced ventricular arrhythmias. 6. The clinical effects of dronedarone are currently being examined in patients with atrial fibrillation and in patients with ICDs.

53. 1 . Vernakalant is a sodium and ultra-rapid potassium channel blocker with atrial selective effects. In 2 clinical studies evaluating use of intravenous vernakalant in cardioversion of patients with recent-onset AF, 2. vernakalant improved the chance of restoration of normal sinus rhythm (combined results 51% vs 3.8% with placebo; p < 0.001). 3. In postoperative AF, intravenous vernakalant also improved the chance of restoration of normal sinus rhythm (45% vs 15% with placebo; p = 0.0002). 4. Early Phase 2 studies demonstrated that oral vernakalant 300 mg or 600 mg twice daily successfully maintained sinus rhythm compared with placebo. 5.No proarrhythmias relating to vernakalant have been reported to date. Common adverse effects include dysgeusia, sneezing, and paresthesia Ann Pharmacother. 2008 Apr;42(4):533-42. Epub 2008 Mar 11. Vernakalant in the management of atrial fibrillation. Cheng JW . Source Massachusetts College of Pharmacy and Health Sciences, Brigham and Women's Hospital, Boston, MA 02115, USA. judy.cheng@mcphs.edu

54. 1. Vernakalant is available in both intravenous and oral forms. In phase II and III trials, intravenous vernakalant has been shown to be effective in terminating acute onset atrial fibrillation whose duration is >3 hours and <7 days (∼50% efficiency vs. 10% for placebo). 2. It does not appear to be effective for atrial fibrillation whose duration is >7 days, nor does it appear to be effective for atrial flutter. 3. Studies with oral vernakalant have been designed to evaluate its efficacy and safety in the prevention of atrial fibrillation recurrence. Studies to date have shown that 51% of patients were able to maintain sinus rhythm after 90 days of using oral vernakalant 50 mg/kg twice daily compared with 37% of patients receiving placebo. 4. In the clinical trials, there were minimal drug-induced ventricular arrhythmias observed Cardiol Rev. 2011 Jan-Feb;19(1):41-4. Vernakalant: a new drug to treat patients with acute onset atrial fibrillation. Tian D , Frishman WH . Source Department of Medicine, Johns Hopkins Medical School, Johns Hopkins Hospital, Baltimore, MD, USA.

55. Catheter and Surgical Ablative Therapy to Prevent Recurrent AF

56. Ablation therapy is currently considered an alternative to pharmacologic therapy in patients with recurrent symptomatic AF. Elimination of AF in 50–80% of patients with a catheter-based ablation procedure should be anticipated, depending on the chronicity of the AF Catheter ablative therapy also holds promise in patients with more persistent forms of AF and even those with severe atrial dilatation If its efficacy is confirmed with additional study, it may also afford an important alternative to His bundle ablation and pacemaker insertion. Risks pulmonary vein stenosis, atrioesophageal fistula, systemic embolic events perforation/tamponade.

57. Surgical ablation of AF is typically performed at the time of other cardiac valve or coronary artery surgery and, less commonly, as a stand-alone procedure view of the left atrium depicting the isolating lesions delivered by catheter ablation around each set of pulmonary veins. -

58. AV nodal re entry tachycardia

59. 55 y/o female with no cardiac history, but allegedly one similar episode 10 years ago when her heart “went crazy” for 20 minutes. When EMS arrives: Sudden onset of strong palpitations, dizziness, chest pain, paleness and mild diaphoresis. Blood pressure is 132/92 and the the patient has a rapid, regular pulse at around 180 beats / min . A 12 lead ECG is obtained.

61. ECG description: Regular, narrow-complex tachycardia. 150 bpm No visible P waves preceding QRS Retrograde P waves with an RP interval of 120ms. Inverted in inferior leads II, III, aVF and upright in aVR and right precordial leads V1 and V2. Also called pseudo S-waves (inferior leads) or pseudo R-waves (right precordial). Cardiac axis is normal at approx. 50°

62. Interpretation: A narrow-complex tachycardia is most likely to be supraventricular in origin, as this indicates normal His-Purkinje impulse propagation and simultaneous ventricular activation. However, there is no P wave preceding the QRS complex to indicate that a sinoatrial origin of the propagated impulse. The regularity rules out atrial fibrillation, and the fact that the P waves are not visible could of course just be due to the tachycardic rate. At a first glance we can only conclude that this is a supraventricular tachycardia. A natural next move would be to perform carotid pressure or other vagal manuevres to induce atrioventricular block in order to help us differentiate this rhythm. With the same intentions, and if carotid pressure doesn’t work, adenosine would be the drug of choice here.

63. A closer look However, differentiation stop here, as the diagnosis lies right in front of us, clearly visible in both the ECGs. Although there is no sign of atrial activity preceding the QRS, take a look after the QRS complex. In all inferior leads, II, III and aVF, an inverted P wave with an RP interval of 120 ms followes each QRS complex. The same P wave with the same RP interval can be spotted in the right precordial leads V1 and V2, as well as in aVR. Logially, the P wave is upright in these leads. This means that the atrias are depolarized in a retrograde fashion, after ventricular

64. Adenosine effect

65. Atrioventricular Nodal Reentry Tachycardia (AVNRT) Treatment & Management

66. AVNRT Patient condition Hemodynamic ally stable Hemodynamic ally unstble Vagal maneuver adenosine, calcium channel blockers (eg, diltiazem, verapamil), beta-blockers, and digitalis. Direct current (DC) synchronized cardioversion To prevent recurrence Drugs

67. Multifocal Atrial Tachycardia

68. A 52 years old male COPD patient presented with palpitation , shortness of breath, chest pain and syncopal history . On examination pulse is rapid, irregular & 1 st heart sound is variable.

69. 1. Irregular ventricular rate greater than 100 bpm 2. Organized and discrete P waves with at least 3 different morphologies in the same electrocardiographic lead 3. Irregular PP, PR, and RR intervals with an isoelectric baseline between the P waves

70. Treatment of MAT Administer oxygen to maintain the saturation greater than 90%, but avoid excessive oxygen in patients with known significant chronic obstructive pulmonary disease (COPD). This will avoid the theoretical problem of removing the hypoxic drive for ventilation, which can result in increased carbon dioxide retention. Establish cardiac monitor, blood pressure monitor, and pulse oximetry. Assess for and treat the underlying cardiopulmonary process, theophylline toxicity, or metabolic abnormality Administer bronchodilators and oxygen for treatment of decompensated COPD; activated charcoal and/or charcoal hemoperfusion is the therapy for theophylline toxicity When magnesium sulfate is administered to correct hypokalemia, most patients convert to normal sinus rhythm. Avoid sedatives.

71. Diltiazem and verapamil decrease the atrial activity and slow atrioventricular (AV) nodal conduction, thereby decreasing ventricular rate, but they do not return all patients to normal sinus rhythm. Diltiazem may be used as a 20-45 mg intravenous bolus and then as a 10-25 mg/h continuous infusion high-dose magnesium causes a significant decrease in the patient's heart rate and conversion to normal sinus rhythm. The dosage is 2 g intravenously over 1 minute, followed by 2 g/h infusion over 5 hours. Amiodarone (300 mg PO tid or 450-1500 mg IV over 2-24 h) has been used and has been reported to be associated with conversion to normal sinus rhythm. The success rate was 40% at 3 days with oral dosing and 75% on day 1 with intravenous dosing; however, this has been evaluated in a very small number of patients.

72. Cardioversion in MAT Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias.

73. Surgical care In patients who have persistent and recurrent episodes of MAT and problems with rate control, the AV node may be ablated using radiofrequency energy and a permanent pacemaker implanted. [22] This approach should be considered both for symptomatic and hemodynamic improvement and to prevent the development of tachycardia-mediated cardiomyopathy.

74. Atrial flutter

75. A 50 years old diabetic, hypertensive, hyperthyroid male patient presented with palpitation, fatigue or poor exercise tolerance, mild dyspnea,and presyncope. On psysical examination pulse rate 150 / min.

76. Note negative sawtooth pattern of flutter waves in leads II, III, and aVF.

78. Emergency Department Care Assess airway, breathing, and circulation. Hemodynamic concerns will dictate initial treatment Treatment options for atrial flutter include the following: Antiarrhythmic drugs/nodal agents Direct-current (DC) cardioversion Rapid atrial pacing to terminate atrial flutter Blood pressure can be supported and rate controlled with medication. Anti coagulation therapy . Look for underlying causes. At times, treatment of the underlying disorder (eg, thyroid disease, valvular heart disease) is necessary to effect conversion to sinus rhythm.

79. Cardioversion for unstable patients If the patient is unstable (eg, hypotension, poor perfusion), synchronous direct- current (DC) cardioversion is commonly the initial treatment of choice. Cardioversion may be successful with energies as low as 25 Joules, but since 100 Joules is virtually always successful, this may be a reasonable initial shock strength. If the electrical shock results in atrial fibrillation (AF), a second shock at a higher energy level is used to restore normal sinus rhythm (NSR).

80. AV-His Bundle ablation In patients who have failed antiarrhythmic therapy or who have failed RFA and who are symptomatic, palliative therapy with AV-His Bundle ablation can eliminate rapid ventricular rates, but it does require a permanent pacemaker to be placed, as this procedure creates third-degree heart block .

81. Questions ? ?