Phys · cardiovascular
Arrhythmias and Conduction Disease
Also known as arrhythmia · SVT · supraventricular tachycardia · AVNRT · AVRT · VT · ventricular tachycardia · Torsades de pointes · atrial flutter · heart block · AV block · Mobitz · bradycardia · sick sinus syndrome · bundle branch block · bifascicular block · pacemaker · ICD · adenosine · cardioversion
Consultant-physician-depth guide to tachy- and bradyarrhythmias — the stability rule, SVT and adenosine, AF rate/rhythm strategy and anticoagulation evidence, VT and Torsades, ICD primary prevention, heart block and pacing decisions, and conduction disease — structured for FRACP DWE and DCE preparation.
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FRACP DWEFRACP DCEMRCP Part 2MRCP PACESABIM Internal Medicine
Red flags
- Any tachyarrhythmia with shock, pulmonary oedema, ischaemic chest pain or reduced conscious level — synchronised cardioversion now, drugs later
- Wide-complex tachycardia in structural heart disease — treat as VT; verapamil can kill
- Pre-excited AF (irregular wide-complex tachycardia with varying QRS width) — AV nodal blockers contraindicated
- Polymorphic VT with a long QT — Torsades: stop the offending drug, give magnesium, do not reach for amiodarone
- Syncope with bifascicular block or documented Mobitz II/complete heart block — asystole risk, pacing decision
Arrhythmias and Conduction Disease
Meet the patient
A 72-year-old on the ward two days after a bowel resection is suddenly breathless with a regular narrow-complex tachycardia at 170. He is talking, but his systolic pressure is 86 and his chest is tight. The registrar reaches for adenosine.[1]
The move that wins is the one the stability rule dictates — synchronised cardioversion, not a drug. Before you name any rhythm, judge the blood pressure, the chest, the lungs and the conscious level: adverse features buy the rhythm a shock regardless of its name.[1]
References25ShowHide
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- [2]Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society J Am Coll Cardiol, 2016.PMID 26409259
- [3]Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) Eur Heart J, 2020.PMID 31504425
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- [17]Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction N Engl J Med, 2002.PMID 11907286
- [18]Drew BJ, Ackerman MJ, Funk M, et al. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation Circulation, 2010.PMID 20142454
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- [20]Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial N Engl J Med, 1991.PMID 1900101
- [21]Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society Circulation, 2019.PMID 30586771
- [22]Glikson M, Nielsen JC, Kronborg MB, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy Eur Heart J, 2021.PMID 34455430
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