Cardiac Arrhymias

6Cardiac Arrhythmias

ROBERT J. THOMAS, SUDHANSU CHOKROVERTY,MEETA BHATT, AND TAMMY GOLDHAMMER

The polysomnogram (PSG) provides a good opportunityto evaluate cardiac rhythms. Although medically threaten-ing abnormalities are seen less frequently today than in thepast, sleep specialists and technicians must be able to rec-

ognize the basic abnormalities. The following 1Q PSG seg-ments show some of the cardiac arrhythmias seen duringovernight PSG recording.

171

172 Cardiac Arrhythmias

Alte» - HOST v 1.6.03 FUlplronlca C 2001

STAG

txar.so

FIGURE 6-1. Severe disease-related bradyarrhythmia in rapid eye movement (REM) sleep, A 56-year-old man with severe daytimesleepiness. The left side of the snapshot shows a heart rate less than 50, the termination of an apnea, and severe hypoxia (saturation inthe mid-70s). Just prior to the arousal, there is a 4-second period with no electrocardiographs (EKG) rhythm (possible sinus arrest orsinoatrial exit block), followed by a ventricular escape, and post-arousal tachycardia, with a near doubling of heart rate. The EKG Rwave amplitude also shows fluctuations that track respiratory effort: This EKG-derived respiration signal is secondary to changes in thecardiac axis generated by positional variation of the heart in the thoracic cavity associated with respiration.

Cardiac Arrhythmias 173

SAO2

Vtot

Vest

STM5I

Mta«-HOSTylJB.03 Rnapteonka O2001

3 S S S S S S S S S S S S S S S S S S S S S S S S S

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 99 98 99 98 98 98

941 1176 902 1059 1255 941 1137 980 1059 1020

REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM REM

10- 15" 20" 25" 30"

FIGURE 6-2. Ventricular ectopy in REM sleep. Bigeminy and trigeminy is noted in this 26-year-old woman who presented withnonhypoxic obstructive sleep-disordered breathing. This finding was not seen in non-REM (NREM) sleep. There was excessive use ofcaffeine (four to five large cups of strong coffee across the day). The patient has no palpitations during the day or night.


BODY

C4A1

C3A2

O2A1

O1A2

ROC

LOG

CHIN

EKG

RR

R-LEG

L-LEG

IPAP

EPAP

SNOR

ABce - HOST v 1.8.03 Raspironlcs C 2001

SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR 5R SR SR

4-1,6

8 8 /

0 0 0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0 0 0 0 0 0 0 0 0 0

D O O O O O O O O O O O O O O Q O O O O O O O O O O O

3 0 0

3 0 0

98 98 98 98 98 98 98 98 99 98 98 98 98 98 98 99 99 99 99 99 59 99 99

SA02

Vtot

Vest

STAG

-39 -39 -39 -39 -39 -39 -39 -39 -39 -39

NK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK WK

4:37:51 AM 10" 15" 20" 25" 30"

FIGURE 6-3. Second-degree heart block, Wenckebach. Progressive increase in PR interval preceding dropped beats in a 48-year-oldpatient with delayed sleep phase syndrome, seen unchanged during wake and sleep. This is an innocent arrhythmia and requires notreatment.


BOD:

:«AJ

C3JL

32U

OLBL

iOC

LOC

am

EX

JR

R-LI

Cr-U

Alic« 3 v 1.20 a«althdyn» (e) *pr»co

H^WH^^V^><tM*fi~*t*iiWi/hti^^**P**<I*V+M^WW^^

*^^

uuv^wul-Jv^AJv^v-v^M^i i i . i i i i i i i . i i i i i f i i i f

SHOI

no*

H&F

I.I 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 1.1

THO

IBD

SAO;

SJIO2 )

O n M M M M M M M M M M M M N M M N JS >S »! 55 JS »S » >S M 95 »* >«

5:58:51 5" 10" 15" 20" 25- 30"RAW DATA

FIGURE 6-4. Supraventricular tachycardia. Atrial tachycardia with varying block or a run of atrial flutter with varying block. Theabrupt change in P wave morphology is not associated with any change in QRS morphology. The ability of a single EKG channel inprecisely determining the origin of rhythms can be limited. This patient was not on any medication such as digitalis.

C4-A1

01-A2

Q2-A1

R-EOG

L-EOG

CHN

BCD

Nual Prinure

CHEST

ABDOMEN

SaQ2 +SO.D»*s.o

(Rem

WvWvWfifrJP^i**^^

FIGURE 6-5. REM-bradyarrhythmia. A 26-year-old asymptomatic man presented for the evaluation of snoring. Complete heartblock.

CHEST

ABDOMEN

StGQ

FIGURE 6-6. Postarousal tachycardia. A 36-year-old woman presents for the. evaluation of excessive sleepiness in the setting of refrac-tory depression. This pattern of postaronsal bursts of heart rate increase was noted throughout the study. Such cyclic variations in heartrate have been used to develop EKG-based screening tools for sleep-disordered breathing. One disadvantage of such tools is that sever-ity information cannot be assessed from the degree of heart rate change, and some patients with the worst disease (e.g., heart failure)may show very little RR variability.


BOOY SRSRSRSRSR3RSRSRSRSRSRSRSRSRSRSRSRSR3RSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSRSR

C4A1

C3A2

O1A1

O2A2

ROC

LOG

CHIN

EKG

Alice - HOST v 1.8.03 Resplronlcs O 2001

Mffl kAVH^W^

Irt/vJ irJ^

/WAyX. r^/^J^^M^^^^

ff^jy^f v^v^^^^wV^^

i^j^^^jj^ ^^j^t^tj^j^^^

L-LEG

FLOW

NAF

ABD

SAO2

STAG~S5~

3(T

FIGURE 6-7. EKG-derived respiration signal. Cyclic variation in RR amplitude (rather than interval) induced by respiratory-relatedfluctuations in cardiac positions. This signal has also been evaluated as a noninvasive EKG-derived method to assess sleep respiration.The disadvantages are similar to RR variability—it is rarely as prominent as in this sample.


Montage:

F3-C3

F7-T3

T3-T5

T5-01

F4-C4

F8-T4

T4-T6

T6-02

C3-A2

C4-A1

LT EOG

RT EOG

Chin EMG

PSG Umbs-PFLOW High Cut: 70 Hz Low Cut: 0.53 Hz Sensitivity: 7 jiV/mm Speed: 30 s/page

•>^f*J**^l>v»tSv«ir~**<^^

A'-JI<WVV/.s/»»'VwAMvrV/A»*A/^^

Vv•A^»•^»^w^*"V*^<^•'•vA/WV\ ^

Lt. Tib EMG

Rt. Tib EMG

P FLOW

Oronasal

Chest

Abdomen

Snore

EKG

Heart RateUnscored

Us bpm |43 tpm 42 bpm |42 bpm

FIGURE 6-8. Venfricu/ar premature contractions. A 30-second epoch from an overnight PSG study of a 40-year-old woman with ahistory of restless legs syndrome reveals the presence of ventricular ectopic beats. The patient reported occasional palpitations. This phe-nomenon may be rate dependent, and a faster heart rate may not be associated with the ventricular ectopic beats. Sinus arrhythmia isalso noted.


Montage: PSG limbs-PFLOW High Cut: 70 Hz Low Cut: 0.53 Hz Sensitivity: 7 iiV/nrn Speed: 30 s/page

F3-C3

F7-T3

T3-T5

T5-01

F4-C4

F8-T4

T4-T6

T6-O2

C3-A2

C4-A1

LT EOG

Chin EMG

ivrnvf1^^^lW^Uw^^v4^vW^^

Lt. Tib EMG

Rt . Tib EMG

P FLOW

Chest

Abdomen

Snore

EKG

FIGURE 6-9. Atrial fibrillation. A 47-year-old man with a history of atrial fibrillation was referred for evaluation of sleep apnea. A 30-second epoch of REM sleep from an overnight PSG demonstrates the presence of atrial fibrillation. The association of sleep apnea andrecurrence/triggering of atrial fibrillation has been reported.


High Cut: 50 Hz Low Cut;: 0.53 Hz Sensitivity: 7 ^V/mm Speed: 30 s/page

LOC/A2

ROC/A1

Chin-EMG

C3-A2

*'Wl\jt<^

K^^^VV^^

01-A2

02-Al

ECG

4^fM^M't^^^

lU^^Mww^JI^J^^

•v*tWtfW>^

/v^--n

Lt Leg EMG

Rt Leg EMG

O2 0.0 1pm0 cm H2OUnscored

FIGURE 6-10. Aberrant conduction. A 51-year-old woman was referred for the evaluation of sleep apnea. A 30-second epoch from thePSG shows premature ventricular complexes with slight widening of the QRS but maintained axis. This may be an aberrant beatsecondary to ajunctional ectopic.

Cardiac Arrhymias

Documents

Transcript of Cardiac Arrhymias