BRADY ARRHYTHMIAS

Dr. Abraham

MECHANISMS

THE PACEMAKERS

ECG

Identify Classify Rectify

SA NODE Location SA nodal artery – RCA>LCx S & PS

DISEASE Asymptomatic – ECG changes Symptomatic – tachy brady tachy – brady Overdrive suppression SA disease – brady pause arrest exit block chronotropic incompetence

SINUS PAUSE

CHRONOTROPIC INCOMPETENCE <85% predicted heart rate <100 <2 SD of expected

SA DYSFUNTION/HIGH VAGAL TONE? Block sympathetics – 0.2mg/kg

propranolol Block para – 0.04mg/kg atropine Intrinsic heart rate –

117.2-(0.53*age)

SA EXIT BLOCK

2ND DEGREE SA - MOBITZ TYPE I Type I second-degree SA block results

from progressive prolongation of SA node conduction with intermittent failure of the impulses originating in the sinus node to conduct to the surrounding atrial tissue. Second-degree SA block appears on the ECG as an intermittent absence of P waves

“WENKEBACH”

2ND DEGREE SA – MOBITZ TYPE II no change in SA node conduction before

the pause

3RD DEGREE SA BLOCK Complete or third-degree SA block

results in no P waves on the ECG

DIAGNOSIS ECG – holter loop study event monitors Chronotropic incompetence IHR Invasive testing – SNRT SACT

MANAGEMENT Exclude extrinsic causes Short term – pharmacotherapy –

atropine theophylline

isoproterenol Long term – pacemaker – SA disease Carotid

hypersensitivity

AV NODE OF KOCH AV nodal , septal perforators S & PS HIS and further down – minimal

autonomic innervation

AV BLOCK 1ST DEGREE

Mobitz type I “wenkebach”

2ND DEGREE Mobitz type II

3RD DEGREE

1ST DEGREE AV BLOCK

2ND DEGREE – MOBITZ I

2ND DEGREE – MOBITZ II

3RD DEGREE – COMPLETE AV BLOCK

DEFINITE DIAGNOSIS – “HIS” ELECTROGRAM

HIS ELECTROGRAM

MANAGEMENT Exculde functional causes

Transcutaneous Temporary Pacing Transjugular Permanent

TPI

PPI

PERMANENT PACEMAKER - CODE 1 – A, V, D, S, O 2 – A, V, D, S, O 3 – I, T, D, O 4 – R 5 – P, S, D, O

COMPLICATIONS Of the procedure Twiddler syndrome Pacemaker syndrome – fatigue neck pulsation palpitation dizziness raised JVP cannon waves CCF

INDICATIONS Class I - those for which there is evidence

or consensus of opinion that therapy is useful and effective

Class II - there is conflicting evidence or a divergence of opinion about the efficacy of a procedure or treatment II A - weight of evidence or opinion favors

treatment II B - efficacy is less well established by the

evidence or opinion of experts Class III - evidence or weight of opinion

indicates that the therapy is not efficacious or useful and may be harmful

Q & A?