Where's the PAC?
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Sick Sinus Syndrome in Children
Arch Dis Child: first published as 10.1136/adc.51.2.100 on 1 February 1976. Downloaded from Archives of Disease in Childhood, 1976, 51, 100. Sick sinus syndrome in children OLIVE SCOTT, FERGUS J. MACARTNEY, and PHILIP B. DEVERALL From the Department of Paediatric Cardiology,Killingbeck Hospital, Leeds Scott, O., Macartney, F. J., and Deverall, P. B. (1976). Archives of Disease in Childhood, 51, 100. Sick sinus syndrome in children. The ages of 6 male patients with the sick sinus syndrome ranged from 10-15 years when their symptoms began. At rest all had a heart rate of 60/min or less. Two had syncopal attacks which threatened life; 1 had only attacks of dizziness; the other 3 had no syncopal attacks but had recurrent attacks of supraventricular tachycardia ('brady-tachycardia syndrome') which were more resistant to drug therapy than is usual in childhood. They were not controlled or suppressed by digoxin when it was given. Substernal pain occurred in 2 patients who had syncope. In all patients the heart rate remained inappropriately slow after exercise and atropine. Cardiac pacemakers were used in the 2 patients with life-threatening syncope. Any patient who has dizziness or syncopal attacks and an inappropriately slow heart rate should have electrocardiograms recorded at rest and after excerise to record the heart rate and to look for abnormal P-waves. Dysfunction of the sinoatrial node has been sudden death in childhood than has been previously copyright. increasingly recognized over the past few years. recognized. An awareness of the condition may Most reported cases have been in adults and only a result in more cases being diagnosed. -
Postural Heart Block*
Br Heart J: first published as 10.1136/hrt.44.2.221 on 1 August 1980. Downloaded from Case reports Br Heart J 1980; 44: 221-3 Postural heart block* PETER E SEDA, JOHN H McANULTY, C JOE ANDERSON From the Department of Medicine, University of Oregon Health Sciences Center, Portland, Oregon, USA SUMMARY A patient presented with orthostatic dizziness and syncope caused by postural heart block. When the patient was supine, atrioventricular conduction was normal and he was asymptomatic; when he was standing he developed second degree type II block and symptoms. The left bundle-branch block on his electrocardiogram and intracardiac electrophysiological study findings suggest that this heart block occurred distal to the His bundle. Orthostatic symptoms are usually presumed to be secondary to an inappropriate distribution of intravascular volume or to autonomic nervous system abnormalities. As shown in this patient, these symptoms may be the result of orthostatic heart block. Ambulatory monitoring may be useful in patients with orthostatic neurological symptoms, particularly when conduction abnormalities are present on the electrocardiogram. Orthostatic neurological symptoms usually result minute and regular, and increased to 90 beats a from inadequate cerebral perfusion caused by minute with some irregularity when he was upright. disturbances of the autonomic nervous system,'-3 The carotid pulse was normal, and there were no ineffective or inappropriate shifts in volume carotid bruits. The cardiac impulse was normal. http://heart.bmj.com/ distribution,4 or drugs.5 We report a patient with The second heart sound was paradoxically split. orthostatic dizziness and syncope caused by inter- There was a grade 2/6 apical systolic murmur. -
Basic Rhythm Recognition
Electrocardiographic Interpretation Basic Rhythm Recognition William Brady, MD Department of Emergency Medicine Cardiac Rhythms Anatomy of a Rhythm Strip A Review of the Electrical System Intrinsic Pacemakers Cells These cells have property known as “Automaticity”— means they can spontaneously depolarize. Sinus Node Primary pacemaker Fires at a rate of 60-100 bpm AV Junction Fires at a rate of 40-60 bpm Ventricular (Purkinje Fibers) Less than 40 bpm What’s Normal P Wave Atrial Depolarization PR Interval (Normal 0.12-0.20) Beginning of the P to onset of QRS QRS Ventricular Depolarization QRS Interval (Normal <0.10) Period (or length of time) it takes for the ventricles to depolarize The Key to Success… …A systematic approach! Rate Rhythm P Waves PR Interval P and QRS Correlation QRS Rate Pacemaker A rather ill patient……… Very apparent inferolateral STEMI……with less apparent complete heart block RATE . Fast vs Slow . QRS Width Narrow QRS Wide QRS Narrow QRS Wide QRS Tachycardia Tachycardia Bradycardia Bradycardia Regular Irregular Regular Irregular Sinus Brady Idioventricular A-Fib / Flutter Bradycardia w/ BBB Sinus Tach A-Fib VT PVT Junctional 2 AVB / II PSVT A-Flutter SVT aberrant A-Fib 1 AVB 3 AVB A-Flutter MAT 2 AVB / I or II PAT PAT 3 AVB ST PAC / PVC Stability Hypotension / hypoperfusion Altered mental status Chest pain – Coronary ischemic Dyspnea – Pulmonary edema Sinus Rhythm Sinus Rhythm P Wave PR Interval QRS Rate Rhythm Pacemaker Comment . Before . Constant, . Rate 60-100 . Regular . SA Node Upright in each QRS regular . Interval =/< leads I, II, . Look . Interval .12- .10 & III alike .20 Conduction Image reference: Cardionetics/ http://www.cardionetics.com/docs/healthcr/ecg/arrhy/0100_bd.htm Sinus Pause A delay of activation within the atria for a period between 1.7 and 3 seconds A palpitation is likely to be felt by the patient as the sinus beat following the pause may be a heavy beat. -
A Comparison of T-Wave Alternans, Signal Averaged Electrocardiography and Programmed Ventricular Stimulation for Arrhythmia Risk Stratification Michael R
View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Journal of the American College of Cardiology Vol. 36, No. 7, 2000 © 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00 Published by Elsevier Science Inc. PII S0735-1097(00)01017-2 A Comparison of T-Wave Alternans, Signal Averaged Electrocardiography and Programmed Ventricular Stimulation for Arrhythmia Risk Stratification Michael R. Gold, MD, PHD, FACC,* Daniel M. Bloomfield, MD, FACC,† Kelley P. Anderson, MD, FACC,‡ Nabil E. El-Sherif, MD, FACC,§ David J. Wilber, MD, FACC, William J. Groh, MD, FACC,†† N. A. Mark Estes, III, MD, FACC,# Elizabeth S. Kaufman, MD, FACC,†† Mark L. Greenberg, MD, FACC,** David S. Rosenbaum, MD, FACC** Baltimore, Maryland; New York, and Brooklyn, New York; Pittsburgh, Pennsylvania; Chicago, Illinois; Indianapolis, Indiana; Boston, Massachusetts; Cleveland, Ohio; Lebanon, New Hampshire OBJECTIVES The goal of this study was to compare T-wave alternans (TWA), signal-averaged electro- cardiography (SAECG) and programmed ventricular stimulation (EPS) for arrhythmia risk stratification in patients undergoing electrophysiology study. BACKGROUND Accurate identification of patients at increased risk for sustained ventricular arrhythmias is critical to prevent sudden cardiac death. T-wave alternans is a heart rate dependent measure of repolarization that correlates with arrhythmia vulnerability in animal and human studies. Signal-averaged electrocardiography and EPS are more established tests used for risk stratification. METHODS This was a prospective, multicenter trial of 313 patients in sinus rhythm who were undergoing electrophysiologic study. T-wave alternans, assessed with bicycle ergometry, and SAECG were measured before EPS. -
Cardiology- the ABC's of the PQRST
Cardiology- the ABC’s of the PQRST Heather Carter LVT, VTS (Anesthesia & Analgesia) Introduction Understanding cardiology can provide the anesthetist with the ability to trouble shoot and treat various problems. Knowing when and how to treat a bradycardia versus a tachycardia can ensure a smooth anesthetic event. Origin of the Heartbeat http://i.pinimg.com/736x/9b/70/59/9b7059c20a452fc655a26e9e3e4b40ad.jpg Understanding the origin of the heartbeat can help the anesthetist know when and how to identify a potential problem. An ECG complex consists of a PQRST complex. The sinoatrial node (SA) is the pacemaker of the heart and produces the P wave. The QRS wave is produced by the atrioventricular node (AV). The P wave in an ECG complex indicates atrial depolarization. The QRS is responsible for ventricular depolarization and the T wave is ventricular repolarization. If a P wave is absent there is a lack of atrial depolarization. This is also known as atrial standstill. P waves that are combined in the QRS complexes are indicative of ventricular tachycardia or a junctional tachycardia. Present P waves that are without a QRS are indicative of an atrial depolarization that has not been conducted through the AV node. A QRS complex without a P wave demonstrate premature or escape beats. Essentials Arrhythmias can be identified with ease if several essentials are in place. ECG leads should be placed correctly: White- Right forelimb Black- Left forelimb Green- Right hind limb Red- Left hind limb Determining the paper speed (25mm/sec vs 50mm/sec) will also help the anesthetist determine if a bradycardia or tachycardia is present. -
T Wave Alternans After Sotalol: Evidence for Increased Sensitivity to Sotalol After Conversion from Atrial fibrillation to Sinus Rhythm
Heart 1998;80:303–306 303 CASE REPORT Heart: first published as 10.1136/hrt.80.3.303 on 1 September 1998. Downloaded from T wave alternans after sotalol: evidence for increased sensitivity to sotalol after conversion from atrial fibrillation to sinus rhythm H L Tan, A A M Wilde Abstract inhomogeneous distribution of repolari- A 64 year old woman with an 11 year sation controlling ion channels to induce Department of history of paroxysmal atrial fibrillation repolarisation abnormalities that may Cardiology, University of Amsterdam, presented to the emergency room because lead to torsade de pointes. Academic Medical of palpitations that had started two weeks (Heart 1998;80:303–306) Center, Amsterdam, previously. She had used sotalol 80 mg Netherlands once daily for three years without any epi- Keywords: T wave alternans; long QT syndrome; HLTan sodes of proarrhythmia or other adverse torsade de pointes; sotalol; atrial fibrillation Department of eVects. However, she developed pro- Cardiology, Heart nounced T wave alternans with giant Lung Institute, Utrecht inverted T waves and excessive QT pro- The ECG T wave reflects cardiac repolarisa- University Hospital, longation following sotalol administration tion. Its broad inscription results from the tem- Utrecht, Netherlands one day after conversion from atrial A A M Wilde poral inhomogeneity with which repolarisation fibrillation to sinus rhythm. This case proceeds through the heart. T wave changes, demonstrates bizarre T wave changes, T Correspondence to: including T wave inversion and T wave altern- Dr H L Tan, Department of wave alternans, and extreme QT prolon- ans, have been subdivided into primary and Cardiology, Academic gation following sotalol administration Medical Center, secondary forms. -
Basic Cardiac Rhythms – Identification and Response Module 1 ANATOMY, PHYSIOLOGY, & ELECTRICAL CONDUCTION Objectives
Basic Cardiac Rhythms – Identification and Response Module 1 ANATOMY, PHYSIOLOGY, & ELECTRICAL CONDUCTION Objectives ▪ Describe the normal cardiac anatomy and physiology and normal electrical conduction through the heart. ▪ Identify and relate waveforms to the cardiac cycle. Cardiac Anatomy ▪ 2 upper chambers ▪ Right and left atria ▪ 2 lower chambers ▪ Right and left ventricle ▪ 2 Atrioventricular valves (Mitral & Tricuspid) ▪ Open with ventricular diastole ▪ Close with ventricular systole ▪ 2 Semilunar Valves (Aortic & Pulmonic) ▪ Open with ventricular systole ▪ Open with ventricular diastole The Cardiovascular System ▪ Pulmonary Circulation ▪ Unoxygenated – right side of the heart ▪ Systemic Circulation ▪ Oxygenated – left side of the heart Anatomy Coronary Arteries How The Heart Works Anatomy Coronary Arteries ▪ 2 major vessels of the coronary circulation ▪ Left main coronary artery ▪ Left anterior descending and circumflex branches ▪ Right main coronary artery ▪ The left and right coronary arteries originate at the base of the aorta from openings called the coronary ostia behind the aortic valve leaflets. Physiology Blood Flow Unoxygenated blood flows from inferior and superior vena cava Right Atrium Tricuspid Valve Right Ventricle Pulmonic Valve Lungs Through Pulmonary system Physiology Blood Flow Oxygenated blood flows from the pulmonary veins Left Atrium Mitral Valve Left Ventricle Aortic Valve Systemic Circulation ▪ Blood Flow Through The Heart ▪ Cardiology Rap Physiology ▪ Cardiac cycle ▪ Represents the actual time sequence between -
The Frequency of Rhythm and Conduction Abnormalities and Benefits of 24-Hour Holter Electrocardiogram on Detecting These Abnormalities
ORIGINAL ARTICLE East J Med 24(3): 303-309, 2019 DOI: 10.5505/ejm.2019.31932 The Frequency of Rhythm and Conduction Abnormalities and Benefits of 24-Hour Holter Electrocardiogram on Detecting These Abnormalities In Patients With Acute Rheumatic Fever Serdar Epçaçan*, Yasemin Nuran Dönmez University of Health Sciences, Van Training and Research Hospital, Department of Pediatric Cardiology, Van, Turkey ABSTRACT During the acute phase of acute rheumatic fever (ARF), cardiac arrhythmias and conduction disorders may occur. Standard electrocardiogram (ECG) may be insufficient in the cases of possible paroxysmal rhythm or conduction abnormalities. The aim of this study is to evaluate arrhythmias and conduction disorders and benefits of 24-hour Holter ECG on detecting these disorders in children with ARF. Two hundred and ten patients who were diagnosed with ARF during a four-year period, were retrospectively analyzed. Demographic characteristics, clinical, laboratory, and echocardiographic findings of the patients were evaluated. Standard ECG and 24-hour Holter analysis were examined. First (47.8%), second (6.9%) and third degree (4.3%) atrioventricular (AV) blocks, bundle branch blocks (9.8%), intermittent pre-excitation (1.1%), accelerated nodal rhythm (15.2%), supraventricular (10.9%) and ventricular premature contractions (8.7%), as well as supraventricular (3.3%) and ventricular tachycardia (1.1%) were detected with 24 -hour Holter ECG. Frequency of both rhythm and conduction abnormalities were detected higher with Holter ECG than 12-lead ECG, and this was statistically significant (p<0.05). Second degree type II AV block and non-sustained supraventricular tachycardia as well as intermittent complete AV block were detected on 24-hour Holter analysis in patients with normal initial standard ECG. -
Answer: E) Atrial Fibrillation with Complete Heart Block Teaching Point
Answer: e) Atrial fibrillation with complete heart block Teaching Point: A slow regular ventricular rate in a patient with concurrent atrial fibrillation, as seen in this ECG, is diagnostic of complete heart block. Atrial fibrillation creates a diagnostic dilemma for identifying AV nodal disease or block. Close scrutiny should be placed on R-R intervals to identify patterns or regularity (1). Clinicians should be wary of a regular heart rate in a patient with persistent atrial fibrillation, especially in those using digitalis. If an AV nodal block is identified, it may be transient, and a search for reversible causes is indicated as in all cases of complete heart block prior to pacemaker placement. Electrolyte abnormalities, ischemia, and medications remain the leading reversible causes (2,3). The patient in this case was transferred to the Emergency Department and admitted for further observation. Ischemia was ruled out. Carvedilol was held, and he was diuresed. He continued to demonstrate adequate chronotropic response with exertion. The complete heart block soon resolved, and he was diuresed to euvolemia. Pacemaker placement was deferred given the transient nature of the AV block in the context of recent beta-blocker usage. He was discharged home with continuous heart rhythm monitoring without any further evidence of complete heart block. References: 1. Urbach JR, Grauman JJ, Straus SH. Quantitative Methods for the Recognition of Atrioventricular Junctional Rhythms in Atrial Fibrillation. Circulation. 1969; 39: 803- 817. 2. Kojic EM, Hardarson T, Sigfusson N, Sigvaldason H. The prevalence and prognosis of third-degree atrioventricular conduction block: the Reykjavik study. J Intern Med. -
Revisiting Electrocardiographic Wolff-Parkinson-White Pattern
The Journal of Medical Research 2020; 6(4): 114-116 Review Article Revisiting Electrocardiographic Wolff-Parkinson-White Pattern JMR 2020; 6(4): 114-116 1 2 July- August Pradnya Brijmohan Bhattad , Vinay Jain ISSN: 2395-7565 1 Resident, Department of Internal Medicine, East Tennessee State University, Tennessee (TN), USA © 2020, All rights reserved 2 Attending Radiologist, Department of Radiology, James H. Quillen Veterans Affairs Medical Center, Mountain www.medicinearticle.com Home, Tennessee (TN), USA Received: 14-06-2020 Accepted: 18-07-2020 Abstract Electrocardiographic features of a short PR interval, a delta wave, and a wide QRS complex constitutes a Wolff- Parkinson-White (WPW) pattern. Asymptomatic electrocardiographic findings are defined as a WPW pattern. Symptomatic patients with these electrocardiographic features have WPW syndrome. WPW syndrome may predispose to arrhythmias such as paroxysmal atrial tachycardia, atrial fibrillation, ventricular tachycardia. Patient’s with WPW syndrome at risk for sudden cardiac death. It is important to recognize the common electrocardiographic characteristics of WPW pattern. The advent of electrophysiological studies (EPS) and radiofrequency ablation has revolutionized the management of WPW syndrome. Keywords: Wolff-Parkinson-White Syndrome, Wolff-Parkinson-White Pattern, Pre-excitation, Accessory pathway. INTRODUCTION Wolff, Parkinson, and White described a patient series in the year 1930 who suffered from paroxysms of tachycardia with classic electrocardiographic findings which has been described as WPW pattern [1]. It is a congenital abnormality in the cardiac conduction system. WPW pattern is a ventricular pre-excitation entity wherein an accessory bypass tract known as the bundle of Kent serves as the connection between the atrial to the ventricular myocardium bypassing the atrioventricular (AV) node [2,3]. -
Management of Wolff-Parkinson-White
Management of Wolff-Parkinson-White Tachyarrhythmia Presenting as Syncope with Seizure- like Activity * * Samuel Kaplan, BS and Lindsey Spiegelman, MD *University of California, Irvine, Department of Emergency Medicine, Orange, CA Correspondence should be addressed to Samuel Kaplan at [email protected] Submitted: August 15, 2017; Accepted: September 13, 2017; Electronically Published: October 15, 2017; https://doi.org/10.21980/J8534P Copyright: © 2017 Kaplan, et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/ Empty Line Calibri Size 12 Empty Line Calibri Size 12 ABSTRACT: Audience: Emergency medicine residents and medical students. Introduction: An estimated 3% of the United States population suffers from recurrent convulsive episodes that are most often attributed to primary epileptic seizures.1 However, recent studies have estimated about 20%-30% of such episodes are associated with occult cardiac etiology,2 which carry one-year mortality rates of up to 30%.3 Cardiogenic cerebral hypoxia has been associated with a wide variety of neurologic disturbances, including dizzy spells, headache, syncope, focal motor deficit, generalized tonic-clonic seizure, confusion, dementia, and psychosis.4 Convulsive activity has tentatively been ascribed to the ensuing activation of the medullary reticular formation.5,6 This scenario is based on a patient that presented to University of California Irvine Medical Center Emergency -
Cardiac Pacing in Incomplete Atrioventricular Block with Atrial Fibrillation
Br Heart J: first published as 10.1136/hrt.35.11.1154 on 1 November 1973. Downloaded from British Heart journal, I973, 35, I154-1I60. Cardiac pacing in incomplete atrioventricular block with atrial fibrillation D. S. Reid, S. J. Jachuck, and C. B. Henderson From the Department of Cardiology, Newcastle General Hospital, Newcastle upon Tyne Three cases with a slow irregular ventricular response to atrialfibrillation, who benefitedfrom cardiac pacing, are described; two had ischaemic heart disease, and one had cardiomyopathy. In thefirst case the slow ventricu- lar response to atrialfibrillation was a result of incomplete atrioventricular nodal block, and in the other two His bundle electrograms demonstrated that the slow ventricular response was due to bilateral bundle-branch block. The association of atrial fibrillation and conduction delays in the atrioventricular node and bundle- branches is discussed. The value of His bundle recordings in the investigation of these cases is shown and the importance of cardiac pacing in treatment is stressed. Cardiac pacing is now a generally accepted method hypotension. Intravenous atropine given before transfer of treatment in patients with complete heart block or had resulted in a paroxysm of ventricular tachycardia. bilateral bundle-branch block who have Adam- On admission there was no evidence of cardiac failure Stokes attacks or a low output to and the blood pressure was I05/50 mmHg. An electro- syndrome leading cardiogram showed atrial fibrillation with an irregular angina or cardiac failure. cardiac is However, pacing ventricular response of 40 to 44 beats a minute and acute now also becoming more widely used in the treat- inferolateral myocardial infarction (Fig.