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ECG and Arrythmias - Coggle Diagram

- - - - Travel hx
      - Sick contacts
      - Infective sympptoms
      - Automimmune symptoms
  - - - High dose obuprofen 600-800 QDS plus PPI for 1-2 weeks
      - Colchicine 0.5mg BD for 3 months
    - - Avoid high intensity exercise for 3 months
    - - Prednisolone
      - Steroid sparing agent - Azathioprin or IL 1 inhibiotrs (anakinra)
    - - Risk of arrhythmia - telemetry
- - - - Superior portion of crista terminalus meeting SVC
    - - Autodepolarises - pacemaker activity of the heart
    - - Vagal tone
      - Medication
      - Blood pressure
      - Electrolytes
    - - Pacemaker cells
        
        Autodepolarise
        
        Ca2+ / K+ dependent
      - Ventricular cells
        
        Require activation
        
        Na+ / K+
      - Drug Targets differ
  - - - Atrial Contraction
    - - Right atrium→ Bachmann's bundle → Left atrium
    - - Upright in ALL LEADS
      - Can be biphasic in V1 (up and down)
    - - No atrial contration
      - Disease / Causes
        
        Sinus node disease - SA fires but atria fibrosed
        
        Afib - no meaningful atrial contraction to give P Wave
  - - - Delay between onsen of atrial depolarisation and ventricular depolarisation
    - - 120-200msec
    - - Conduction system disease
  - - - Pacemaker capability but normally influenced by rate of sinus node
    - - Tirangle of Koch delineated by septal leaflet of TV, tendon of Todaro and ostium of the coronary sinus
    - - AV node → Bundles of His → Left and right bundles → Purkinjie Fibres → Ventricular depolarisation
  - - - Ventricular depolarisation
    - - 80-120ms
      - Longer / Broad - think bundle branch blocks
        Look at V1 and V6 to determine RBBB or LBBB
  - - - Ventricle repolarising
    - - T wav upright in ost leads
      - Normal variant Inverted T wave in
        
        V1
        
        Lead III
        
        AVR
      - ST segment should be isoelectric
    - - Myocardial injury
        
        Ischaemia
        
        Cardiomyopathy
        
        Pericarditis
    - - Repolarisation abnormalisties
        
        Long QT syndrome
        
        Electrolyte abnormalitiess
        
        QTc prolonging drugs
    - - STEMI
  - - - Lead I / Lead II upright and positive
    - - Lead I positive
        Lead II negative
    - - Lead I negative
        Lead II positive
- - - - Combinations of atrial and ventricular contraction
    - - Conduction through ventricular myocardium is sluggish
    - - IF QRS all positive or all negative from v1-v6 - VT
  - - - Previous ischaemic cardiomyopathy / heart attack
      - Non ischaemic cardiomyopathy
  - - - Synchronise to R wave with defibrillator
      - If you shock V wave you get VF
    - - Acute ischaemia
      - R on T phenomenon
      - Electrolyte discturbance
      - Long QT syndrome
  - - - DCCV
    - - IV Amiodarone
        
        Dose
        
        150mg over 10 min then 150mg over 50 min then 900mg over24 hours
      - Procainamide
      - IV metoprolol 5mg
      - IV MgSO$ , replace with KCL if K<4 (~4.5)
      - If unsuccessful - cardioversion
    - - VT with structurally abnormal hear require ICD
  - - - Young
      - Respond well to ablation
      - Do not need ICD
- - - - Goal
        
        Normally attempt to maintain Sinus Rhythm (SR)
  - - - Consider CArdioverion (Electric / pharmacological)
      - Rationale:
        Extremely low risk of stroke
        Requires reliable historian
    - - Rate control
        
        Commence DOAC
        
        Bring back in a couple weeks for cardioversion
      - Rationale:
        High risk of clot in left atrial appendage and stroke if immediately cardioverted
  - - - Needs MgSO4 before due to risk of TdP
      - Can be used in most pts
      - MOA
        
        Class II antiarrhythmic
        
        K+ channel blocker
      - Particularly good for organised arrhythmias
      - Cardioverts within 30in
    - - MOA
        
        K+ channel blocker - 1.5 channel blocker only present in atrium
      - Cardioverts within 30min
      - Avoid in pt with HF
    - - Can give 150mg IV or 200-300mg PO pending weight
      - Pill in pocket dose
    - - Infusion
      - Many s/e
      - Takes up to 12hr to cardiovert
      - Useful in HFrEF
    - - 4 weeks DOAC regardless of CHADVASC score due to LAA stunning
      - Indefinite anticoagulation in CHADVASC >2
        Consider in 1 in men and 2 in women
  - - - 1️⃣ Line
      - Aim HR <110bpm
      - Can give IV metoprolol of very rapid rates
      - s/e
        
        Significantly drop BP
    - - Verapamil / Diltiazem
      - Indx
        
        Intolerant to Beta blockers and LVEF >40%
    - - Can be added - acute management of HR
      - Dose
        
        Loaded 500-1000mg divided doses
      - Advantage
        
        Will not drop BP
        
        Useful if hypotensive / septic
      - Intercations
        
        Verapamil/Diltiazem - P-Glycoprotein inhibitor will increased digoxin concentration - Digoxin toxicity
      - Prerequisites
        
        Normal renal fx
        
        Normal Electrolytes
  - - - Flecanide / Propafenone
      - Prerequisites
        
        Normal LVEF
        
        Must be given with AV nodal blocking agent due to risk of atrial flutter with 1:1 condution
      - c/i
        
        LVH
        
        CAD
        
        CAST trial shows increased ventricular arrhythmias in pts with structural heart disease
    - - Dose
        
        Start 80mgBD
      - S/e
        
        Increased risk of QTc prolongation
      - Monitoring
        
        Needs inpatient monitoring to start
      - C/i
        
        CKD - renally cleared
    - - Many side effects - often temporal
    - - Use
        
        Elderly pts with paroxysmal AF
      - Avoid
        
        HF
        
        Abormal LFTs
        
        Persistent / permenant Afib
- - - - Atropine
        
        MOA
        
        Blocks AV node
        
        Admin
        
        Wide bore canular 3 way tap
        
        c/i
        
        Athma - bronchoconstriction
        
        Wolf-Parkinson-White Syndrome
        
        Heart transplants
        Heart denervated - very sensitive to atropine - prolonged asystole - causes AV block
  - - - Bypass tract connects atria and ventricles
  - - - Carotid sinus massage or Valsalva
      - Blocks AV node
      - Caution
        
        Elderly|
        
        Carotid disease
    - - Dose
        
        6/12/18mg
      - Admin
        
        Green IVC with 3 way tap to facilitate rapid flush
        
        Elevate arm
        
        Needs cardiac monitor
      - Rapid onset / offset
      - C/i
        
        Asthma
        
        Cardiac Transplant
        
        WPW
        
        Risk of inducing AF nad subsequently VF down AP
      - Use
        
        Can be tehrapeutic if arrhythmia is AV node dependent or diagnostic - unmask AF or AT waves
        
        Can Differentiate SVT with aberrance ant VT
    - - Block AV node
      - 2.5mg
    - - Block AV node
      - 5mg
    - - Flecainide
      - Amiodarone
      - Ibutilide
  - - - Delta wave - slurred upstroke up QRS
      - Short PR
    - - Blocked AV node + Bypass track
      - Blocking AV node acn induce Afib → Blocked AV + Bypass tract → Rapid condution of Afib to ventricles → Vfib → Sudden cardiac death
    - - Cardioversion
- - - - Start negative become positive
- - - - Reciprocal ST depression
      - ST elevation
    - - V1 - V4
        
        Anterior
      - V5 & V6
        
        Low lateral
      - Lead I & AVL
        
        High lateral
      - Lead 2 Lead 3 & AVF
        
        Inferior wall
        
        RCA in 80% - right coronary dominant
        20% left circumflex
    - - Within 30 min PCI centre → PCI
      - More than 30 in PCI centre → Thombolysis
    - - ST depression in V2 & V3
      - Tall broad R wave in V2, V3
      - Dominant R wave in V2
      - Uprught Terminal T wave in V2 / V3
    - - Benign early repolarisation in young / fit pts
        
        J wave
      - Pericarditis
        
        Convex of saddle shaped STE
      - Normal in LBBB
        
        Apply Sgarbossa's criteria
      - Ventricular aneurysm
  - - - Statin
        
        High intensity statin
        
        Atorvastatin 80mg / Rosuvastatin 40mg
      - IV morphine
        
        2.5mg - 10g
        
        Tx pain supresses sympathetic nervous system
      - Nitrates
        
        Unlikely to be of benefit in occlusive MI
        
        Can relieve pain in vasospasm / non-occulsive MI
        
        Avoid in RV infartion
      - O2
        
        Only if SpO2 <94% to avoid free radicals
      - DAPT Loading
        
        Ticagrelor 180mg / Prasugrel 60mg
        Clopidogrel if higher bleeding risk, elderly pt - 600mg/300mg
        
        Aspirin 300mg
    - - PCI
      - Thrombolysis
        
        Always clopidogrel
        
        IV heparin
    - - DAPT
        
        Aspirin for Life
        
        P2Y12 ihibitor for 12months (or 6 if bleeding risk)
      - PPI
        
        While on dapt - aspirin
        
        Pantoprazole
      - ACEi/ARB
        
        Aids cardiac remodelli g
      - β blocker
        
        Only if reduced LVEF or arrhytmia
        
        No routine benefit if EF normal per REDUCE-MI trial
      - Additional
        
        HFrEF
        
        MRA
        
        SGLT2i
        
        ARNI
      - Conservative
        
        Smoking cessation
        
        Cardiac rehab
      - High Intensity Statin
        
        Max tolerated dose indefinitely
        
        Target LDL <1.4
      - Follow up
        
        Clinic 6-8 week post discharge
  - - - T wave inversion
      - Biphasic T wave
- - - - Sawtooth pattern
      - Regularly Irregular
      - Constant activation of atrium in a flutter wave around atrium
        Continous reentry circuit
        Conterclockwise
    - - Can be resistent to AV nodal blockades
        Beta blockers
        CCB
      - Often need cardioversion & antiarrhythmic drugs
      - Ablation
      - Oral anticoagulation
      - Rate control
  - - - No meaningful P waves
      - Fibrillating isoelectric line
      - Irregularly irregualr
    - - Anticoagulation
      - Rate control
    - - Abnormal firing from pulmonary veins
  - - - Inverted P wave - atrial depolarisation is not coming form high up in RA at SA node - ectopic source causing atrial tachycardia
      - Inverted P waves
- - - - Clock at level of AV node
    - - Does not require pacing in absence of symptoms
    - - Progressive prolongation of PR interval with a non conductedP wave
    - - Fit atheletes with high vagal tone
      - Sleep apnoea
  - - - No progressive PR lengthening with sudden unexpexted non conducted P wave
      - Can be 2:1, 3:1, 4:1 etc
      - Conducted PR interval is stable indicating intermittent conduction
    - - Block below AV node
    - - Requires pacemaker implantation
      - High risk of developing complete HB
  - - - No relationship between P wave and QRS
      - HR dependant of ventricular pacemaker capabilities (20-40bpm but variable)
      - Wide / Broad QRS (activation from below level of Bundle of His - inefficienct and broad - escape rhythm)
    - - Speed up AV nodal conduction
        
        Isoprenaline
        
        Dobutamine
      - Pacemaker
      - Trasvenous pace maker wire into right ventricle
      - Transcutaneous pacing to defibrillator machine
- - - - V1 WiLLiAM V6
      - Broad QRS > 120ms
      - V1 negative QRS Complex
      - V6 positive QRS complex
      - Left axis deviation
      - Discordant ST changes
        Negative QRS : ST elevation and positive T wave
        Positive QRS: ST depression and T wave inversion
    - - Common in older pt
      - Abnormal in young person
    - - Conduction system disease
      - Cardiomyopathy
    - - Echo - invx cardiomyopathy
  - - - V1 MaRRoW V6
      - Broad QRS > 120ms
      - V1 positive QRS
      - 3.
      - Normal axis
        If axis deviation - left anterior or left posterior fascicle is dead - bifasicular block - conduction disease
    - - RV strain
      - Right ventricular hypertrophy
      - RV failure
      - ASD
  - - - PR >200ms
    - - syncope -> Pacemaker
- - - - Better in context of ischaemic VT