(BQ) Part 1 book Clinical arrhythmology presents the following contents: Anatomical and electrophysiological considerations, clinical aspects and mechanisms of cardiac arrhythmias; diagnosis, prognosis and treatment of arrhythmias.
Clinical Arrhythmology Clinical Arrhythmology, First Edition Antoni Bayés de Luna © 2011 John Wiley & Sons Ltd Published 2011 by John Wiley & Sons Ltd ISBN: 978-0-470-65636-5 Bayes_ffirs.indd i 1/27/2011 2:46:24 PM Companion website This book is accompanied by a companion website: www.wiley.com/go/bayes/arrhythmology The website includes: Helpful Multiple Choice Questions Updates from the author Bayes_ffirs.indd ii 1/27/2011 2:46:24 PM CLINICAL ARRHYTHMOLOGY Antoni Bayés de Luna Director of Cardiology, Hospital Quirón, Barcelona Emeritus Professor of Cardiology, Universitat Autònoma de Barcelona Honorary Director, Cardiology Service Hospital de la Santa Creu i Sant Pau, Barcelona Spain With the collaboration of: Diego Goldwasser, Xavier Viđolas, Miquel Fiol, Iwona Cygankiewicz, Javier García Niebla, Andrés Pérez Riera, Pedro Iturralde, Ramon Oter, Antoni Bayés Genís, Ramon Brugada, Wojciech Zareba A John Wiley & Sons, Ltd., Publication Bayes_ffirs.indd iii 1/27/2011 2:46:24 PM This edition first published 2011 © 2011 by John Wiley & Sons, Ltd Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book This publication is designed to provide accurate and authoritative information in regard to the subject matter covered It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom Library of Congress Cataloging-in-Publication Data Bayés de Luna, Antoni Clinical arrhythmology / Antoni Bayés de Luna ; with the collaboration of Diego Goldwasser [et al.] p ; cm Includes bibliographical references and index ISBN 978-0-470-65636-5 (hardcover : alk paper) Arrhythmia Heart–Electric properties I Goldwasser, Diego II Title [DNLM: Arrhythmias, Cardiac–diagnosis Arrhythmias, Cardiac–physiopathology Arrhythmias, Cardiac–therapy Cardiac Electrophysiology Electrocardiography–methods WG 330] RC685.A65B39 2011 616.1′28–dc22 2010036364 A catalogue record for this book is available from the British Library This book is published in the following electronic formats: ePDF 9781444391725; Wiley Online Library 9781444391749; ePub 9781444391732 Set in 9/12pt Photina MT by SPi Publisher Services, Pondicherry, India 2011 Bayes_ffirs.indd iv 1/27/2011 2:46:25 PM Contents Foreword by Dr Valentin Fuster vii Foreword by Dr Pere Brugada i Terradellas ix Preface x Recommended General Bibliography xii PART I Anatomical and Electrophysiological Considerations, Clinical Aspects, and Mechanisms of Cardiac Arrhythmias Chapter Clinical Aspects of Arrhythmias Definition of arrhythmia Classification Clinical significance and symptoms The importance of clinical history and physical examination in diagnosis and assessment of arrhythmias 20 The importance of surface ECG and other techniques 22 Electrocardiographic diagnosis of arrhythmias: preliminary considerations 24 References 27 Chapter Anatomic and Electrophysiologic Basis 29 Anatomic basis 29 Electrophysiologic characteristics 38 References 57 Chapter Electrophysiologic Mechanisms 59 Mechanisms responsible for active cardiac arrhythmias 59 Mechanisms leading to passive arrhythmias 78 References 90 PART II Diagnosis, Prognosis and Treatment of Arrhythmias Chapter Active Supraventricular Arrhythmias 95 Premature supraventricular complexes 95 Sinus tachycardia 98 Monomorphic atrial tachycardia 105 Junctional reentrant (reciprocating) tachycardia 116 AV junctional tachycardia due to ectopic focus 125 Chaotic atrial tachycardia 127 Atrial fibrillation 128 Atrial flutter 156 Supraventricular tachyarrhythmias and atrial wave morphology: monomorphic and polymorphic morphology 166 Differential diagnosis of supraventricular tachyarrhythmias with regular RR intervals and narrow QRS 168 Electrocardiographic diagnosis of the paroxysmal supraventricular tachycardias: a sequential approach 169 References 174 Chapter Active Ventricular Arrhythmias 181 Premature ventricular complexes 181 Ventricular tachycardias 190 Ventricular flutter 220 Ventricular fibrillation 220 References 225 Chapter Passive Arrhythmias 230 Escape complex and escape rhythm 230 Sinus bradycardia due to sinus automaticity depression 230 Sinoatrial block 232 v Bayes_ftoc.indd v 1/25/2011 9:11:07 PM Contents vi Atrial block 233 Atrioventricular block 236 Ventricular blocks 242 Cardiac arrest 248 The pacemaker electrocardiography 248 Clinical, prognostic, and therapeutic implications of passive arrhythmias 257 References 264 Chapter Analytical Study of an Arrhythmia 266 Determining the presence of a dominant rhythm 266 Atrial waves analysis 266 QRS complex analysis 269 Atrioventricular relationship analysis 270 Premature complex analysis 270 Pauses analysis 270 Delayed complex analysis 270 Analysis of the P wave and QRS-T complexes of variable morphology 271 Repetitive arrhythmias analysis: bigeminal rhythm 272 Differential diagnosis between several arrhythmias in special situations 274 References 277 PART III The ECG and Risk of Arrhythmias and Sudden Death in Different Heart Diseases and Situations Chapter Ventricular Pre-Excitation 281 Concept and types of pre-excitation 281 WPW-type pre-excitation 281 Atypical pre-excitation 291 Short PR interval pre-excitation 292 References 293 Chapter Inherited Heart Diseases 295 Introduction 295 Cardiomyopathies 295 Specific conduction system involvement: Lenegre syndrome 308 Ionic channel disorders in the absence of apparent structural heart disease: channelopathies 308 References 331 Chapter 10 Other ECG Patterns of Risk 338 Severe sinus bradycardia 338 Bayes_ftoc.indd vi Advanced interatrial block with left atrial retrograde conduction 338 High-risk ventricular block 340 Advanced atrioventricular block 345 The presence of ventricular arrhythmias in chronic heart disease patients 347 Acquired long QT 349 Electrical alternans 351 Other electrocardiographic patterns of risk for sudden death 351 Risk of serious arrhythmias and sudden death in patients with normal or nearly normal ECG 355 References 357 Chapter 11 Arrhythmias in Different Heart Diseases and Situations 360 Ischemic heart disease 360 Heart failure 367 Valvular heart disease 372 Congenital heart disease 372 Hypertensive heart disease 374 Myocarditis 375 Cor pulmonale 375 Pericardial disease 375 Sudden death in other heart diseases 375 Sudden infant death syndrome 376 Athletes 376 Alcohol intake 378 Special situations 379 Sudden death in apparently healthy people 381 References 381 Appendix 386 A-1 Introduction 386 A-2 Calculation of sensitivity, specificity, and predictive value 386 A-3 Diagnostic techniques 388 A-4 Therapeutic techniques 401 A-5 Antiarrhythmic agents 409 A-6 Classification of the recommendations for diagnostic and therapeutic procedures and level of evidence (AHA/ESC/ACC Guidelines) 414 References 416 Index 419 Plate section following the Index Companion website www.wiley.com/go/bayes/ arrhythmology 1/25/2011 9:11:07 PM Foreword By Dr Valentin Fuster When I received the manuscript from Antoni Bayés de Luna and his collaborators to write a foreword for this book, I realized with a glance what a great opportunity this work provides This has been the rule in books published by Antoni Bayés de Luna; they appear when they are needed most I still remember his book on electrocardiology, which explained the technique of “Electrocardiography” for beginners in a way that was not only concise but very thorough This book has been translated into eight languages and remains very successful throughout the world This also occurred with his book on “Sudden death”, as well as his correlations between electrocardiography and cardiovascular magnetic resonance imaging But for now I would like to talk about Clinical Arrhythmology, which is what interests us most The current books on arrhythmias mainly explain the great technological advances being achieved in diagnosis and, in particular, the interventionist treatment of cardiac arrhythmias However, most of these books fail to examine the clinical aspects closely enough and not emphasize the crucial role for diagnosis of the surface electrocardiogram, nor they discuss how the clinical cardiologist or family doctor, or even the emergency medicine doctor, might proceed once this diagnosis is performed, in order to rapidly and efficiently treat the specific arrhythmias in the clinical context in which they appear The book is full of the experience of Antoni Bayés de Luna teaching electrocardiology and arrhythmias in the style of Paul Puech, Leo Schamroth, and Charles Fisch, with an updated state-of-theart of the management of arrhythmias This book is filled with advice on how to diagnose and effectively treat arrhythmias with classic knowledge that, at the same time, is up-to-date, using many references from 2010 Antoni Bayés de Luna emphasizes the necessity to consult and use the medical guidelines of the scientific societies, while at the same time giving a personal touch derived from his considerable experience This is especially present in Chapter 1, where he emphasizes the importance that history taking and physical examination still have when diagnosing and treating arrhythmias He gives a series of recommendations that state the necessity to know heart anatomy and physiology well, in addition to outlining how to approach a case with arrhythmias I also consider the updated physiopathologic mechanisms of arrhythmias to be of great interest Later on, in the second part of the book, all the different clinical, electrocardiographic, prognostic, and management aspects of different arrhythmias are clearly commented on The third part deserves close study because it is where sudden death, being the most important complication of arrhythmia, is examined and discussed in different heart diseases and situations I feel that this book demonstrates the great authority of the author, as well as his deep knowledge of clinical arrhythmia and electrocardiography, great didactic capabilities and many years of experience in this field I am sure it will be extremely useful for doctors who are first faced with cardiac arrhythmias, not only in the diagnosis but also in obtaining a clear idea as to how to focus management of the condition, including the last advances in the treatment through ablation techniques and pacemaker and defibrillator implantation in different types of arrhythmias I would like to offer my wholehearted congratulations to Antoni Bayés de Luna for providing all his personal experience in a subject of great clinical importance and based on the crucial value placed on the history taking and especially the surface vii Bayes_fbetw.indd vii 1/27/2011 3:25:00 PM viii Foreword electrocardiogram in the diagnosis and management of cardiac arrhythmias I predict that this book will be a huge success because of its usefulness and timeliness It will make diagnosis and treatment of different cardiac arrhythmias much easier for students, doctors, and even specialists, without the apprehension often generated in the medical community Dr Valentin Fuster Director, Mount Sinai Heart Center, New York Professor of Medicine, Mount Sinai School of Medicine Past President, American Heart Association Past President, World Heart Federation Bayes_fbetw.indd viii 1/27/2011 3:25:00 PM Foreword By Dr Pere Brugada i Terradellas When Professor Antoni Bayés de Luna placed kg of printed material in my hands, I immediately knew what was happening: the “master of masters” had struck again Undoubtedly, it was a new book And undoubtedly, it was a book related to electrocardiology, the great love of his life Knowing him as I have for so many decades, I did not doubt that the manuscript I was now holding had been written to fill a gap in medical knowledge But what could Antoni have written now that he had not already written? His various books on electrocardiography, published in the most common languages, are known by every admirer of the electrical activity of the heart No cardiologist has described the electrocardiogram in as much detail as he His daily work has consisted of the nearly impossible job of dissecting the electrical activity of the heart And this all without electrocuting himself! I looked carefully at the title on the first page and those kg soon became lighter: Clinical Arrhythmology Here was the big secret Finally, the book that describes the mechanisms, diagnostic clues, and management of cardiac arrhythmias written by the clinical cardiologist for the clinical cardiologist Thanks to great advances in the study of cardiac electrophysiology, arrhythmia mechanisms are well understood today However, the general cardiologist, the internist, and the general practitioner must depend continuously on the electrocardiogram to define the swelling mechanism in any cardiac rhythm disorder Combining clinical and electrophysiologic knowledge with an updated approach of medical management, to produce an integrated textbook of clinical arrhythmology is a challenge few would take on For this, a clinical and scientific tenacity is required that only a chosen few possess, one of whom is Professor Antoni Bayés de Luna These thoughts crossed my mind during the minutes I used to look through the manuscript Antoni, aware of my love for his work, asked if I would like to write a foreword for this book Absolutely! I said, I would it with great pleasure, in order to thank him on behalf of myself and many others for his great efforts in teaching, and for the numerous hours of pleasant reading he has given us To thank him for the great care he has always taken with his books, including this one, naturally, to offer us clear outlines accompanied by greatly didactic diagrams, which are a pleasure to read and study Clinical Arrhythmology is obligatory reading for any physician directly or indirectly related to disorders of cardiac rhythm, including cardiologists, internists, sports medicine doctors, and general practitioners They will find in this book that combination of clinical experience and great electrocardiographic skills is the best way to approach successfully the diagnosis and treatment of cardiac arrhythmias It is also a superb resource for paramedics who may be faced with cardiac arrhythmias Professor Bayés de Luna must be congratulated on his magnificent effort and the excellent end result of this book Dr Pere Brugada i Terradellas Scientific Director, Centro UZ Brussel Cardiovascular Centre, Brussels, Belgium ix Bayes_fbetw.indd ix 1/27/2011 3:25:00 PM Electrocardiographic Diagnosis of Arrhythmias 166 A B C Ablation cath Figure 4.68 Ablation of a typical atrial flutter A: The tracings II and III indicate the presence of a typical atrial flutter that ceases and turns into sinus rhythm after the ablation of the cavum-tricuspid isthmus B: Anatomic scheme of the cavum-tricuspid isthmus, where the ablation of the typical flutter is performed between the opening of the tricuspid valve and the inferior vena cava C: An oblique left anterior projection shows the intracavitary catheters The multipolar catheter (20 poles) surrounds the right atrium and records all electrical activity The mapping-ablation catheter is placed in the cavum-tricuspid isthmus to perform a “linear” ablation b The presence of 1×1 flutter is a real emergency The ventricular rate is usually higher than 230 bpm c If the AV conduction is fixed in the ECG, the RR intervals and the FR intervals are regular The conducted “F” wave has an FR interval of ≥0.20 s (Figure 4.63B) d In Figure 4.69 different types of monomorphic atrial waves of supraventricular tachycardias can be seen e In Tables 4.4 and 4.5, the most important electrocardiographic characteristics for the differential diagnosis of paroxysmal supraventricular tachycardias with a regular RR interval and narrow QRS complex are shown Bayes_c04.indd 166 Supraventricular tachyarrhythmias and atrial wave morphology: monomorphic and polymorphic morphology Monomorphic atrial morphology (Figure 4.69) ● Monomorphic atrial morphology can be caused by craniocaudal or caudocranial activation ● The cases with craniocaudal activation include the following types of morphologies: Sinus P wave in cases the case of sinus tachycardia (Figure 4.69A) P′ wave of the monomorphic atrial tachycardia (MAT) (Figure 4.69C) “F” waves of common flutter (counter clockwise activation) (Figure 4.69D) “F” waves of reverse flutter (clockwise activation) (Figure 4.69E) Y 1/22/2011 7:01:36 PM Active Supraventricular Arrhythmias 167 Figure 4.69 Different morphologies of monomorphic atrial waves A: Sinus P wave B: Monomorphic atrial tachycardia due to ectopic focus (MAT-EF) with 1×1 conduction C: MAT-EF with 2×1 atrioventricular (AV) conduction D: “F” waves of common flutter with variable AV conduction E: “F” waves of reverse flutter with a 3×1 conduction F: Retrograde P′ in case of AVRT (junctional reciprocating tachycardia-accessory pathway) G: Atypical flutter waves with variable conduction Bayes_c04.indd 167 1/22/2011 7:01:36 PM 168 Electrocardiographic Diagnosis of Arrhythmias Atrial waves of atypical atrial flutter can also be found (Figure 4.69G) If there is some degree of AV block, the RR intervals may sometimes be irregular (Figure 4.69D and G) Cases of caudocranial atrial activation corre● spond to: The P′ waves that are seen in junctional reentrant tachycardias with an accessory pathway (AVRT) (Figure 4.69F) Some cases of junctional tachycardias due to ectopic focus with retrograde atrial activation Cases of monomorphic atrial tachycardias that originate in the lower part of the atria (Figure 4.69B) Polymorphic atrial morphology Rapid supraventricular rhythms with polymorphic atrial wave include: Chaotic atrial tachycardia (Figure 4.31) Atrial fibrillation (Figure 4.36 and 4.37) On some rare occasions, atrial flutter “F” waves can suddenly change the morphology (Figure 4.28B), or show waves in some leads that look like atrial flutter and sometimes like atrial fibrillation (fibrilloflutter) (Figure 4.41) Differential diagnosis of supraventricular tachyarrhythmias with regular RR intervals and narrow QRS Paroxysmal tachycardias In Tables 4.4 and 4.5, the electrocardiographic characteristics of the different paroxysmal supraventricular tachycardias with narrow QRS complexes are explained Figure 4.69 shows examples of the different atrial activation waves seen in these tachycardias We will comment on some of the characteristics of atrial activation activity used to make the differential diagnosis shown in Table 4.4 1) In the junctional reentrant tachycardia with an accessory pathway (AVRT), the atrial activity is behind the QRS complex with a relation of P′-QRS complex > QRS complex-P′ In AVNRT the P′ is hidden within the QRS complex, or stuck to the end of the QRS, simulating an S or r′ wave The P′ wave that initiates the tachycardia (craniocaudal) is different in both types from the caudocranial types described below (Figures 4.16–4.18) Bayes_c04.indd 168 2) In junctional tachycardia due to ectopic focus (JT-EF), the P′wave is frequently dissociated (Figure 4.27) If the atrial rhythm is flutter, the AV dissociation is manifested by regular RR intervals and different FR intervals (Figure 4.28B), and if the atrial rhythm is fibrillation, the “f ” waves are accompanied by regular RR intervals (Figure 4.28A) Meanwhile, if the P′ is not dissociated, it is frequently not seen because it is hidden in the QRS complex However, if the retrograde conduction is faster or slower than the anterograde conduction, the P′ wave will be seen before the QRS complex, but with a very short P′R, or just after the QRS complex In any case, the P′ wave has a caudocranial polarity (negative in II, III, and VF) and the first atrial depolarization, first P′, has the same morphology as the others 3) In monomorphic atrial tachycardia (MAT) due to atrial macro-reentry or to an ectopic focus, the P′ wave that starts the tachycardia is the same as the following waves and appears before the QRS complex, usually with P′-QRS < QRS-P′ The P′ R interval is often short (Figures 4.12 and 4.19D) Sometimes there is a second- or third-degree AV block (Figures 4.13–4.14) If the AV block is first degree P′QRS may be > QRSP′ If the P′ is negative in II, III, and VF, as happens in JT-EF, the P′R is not usually as short as in JT-EF 4) In atrial flutter with a regular ventricular rate, some flutter waves tend to be presumed rather than seen If the ECG is carefully observed, in cases of 2×1 flutter in lead V1, one of each of the two “F” waves (Figures 4.56 and 4.57), can simulate r′ The same thing occurs in the case of AVNRT (Figure 4.17) In slow flutter with 2×1 block, one P wave may be hidden in the QRS or at the end of QRS, and the other mistaken for a sinus P wave (Figure 4.20) 5) Finally, sinus tachycardia must not be forgotten, although its presentation is not usually paroxysmal and the heart rate is not very high except during exercise or emotions (Figures 4.7 and 4.8) (see Sinus tachycardia: clinical presentation) If atrial activity can be seen, verifying that it has sinus polarity, this will strongly support the diagnosis Sometimes the sinus P wave is hidden in the preceding T wave The diagnosis may be made with careful observation of the ECG, and the performance of simple maneuvers (i.e breathing) (Figure Z 1/22/2011 7:01:37 PM Active Supraventricular Arrhythmias 4.10) Sometimes it is necessary to amplify the waves or to filter the T wave, which allows us to see the P wave hidden in the T wave (Figure A-13), or to use leads such as the Lewis lead (see Appendix A-3, Other surface techniques to register electrical cardiac activity) Incessant tachycardias The differential diagnosis of incessant supraventricular tachycardias must be made mainly between the incessant monomorphic atrial tachycardia due to ectopic focus (MAT-EF) and the incessant junctional reentrant tachycardia (I-JRT) Both show a P′RP′R), except in some cases with a first-degree AV block Monomorphic atrial tachycardia (Figure 4.12) Atrial activity can be very high, but is usually below 180 bpm and has a different morphology from the sinus P wave, except in the rare cases in which the atrial focus is very close to sinus node (parasinus) In the majority of cases, the distance of RP′>P′R (Figures 4.19 and 4.69B), although, as we have already mentioned in sinus tachycardia, there can be exceptions if the P′ wave falls into the AV junctional relative refractory period Exceptionally in cases of junctional tachycardia due to ectopic focus (JT-EF) (see later) Tachycardias with the P′ wave after the QRS complex (RP′RP′ (Figures 4.16, 4.18A and C, and 4.19C) In junctional tachycardia due to ectopic focus (JT-EF), the conduction to the atria may be 1×1 on some occasions In these situations, and also in the accelerated idiojunctional rhythms, the P′ wave may be: 1) after the QRS complex, if the retrograde conduction is slower than the anterograde, 2) hidden within the QRS complex, or 3) situated before the QRS complex This occurs more frequently in the slow or mildly accelerated AV junctional rhythms due to ectopic focus (Figure 4.29) Atrial flutter with 1×1 atrioventricular conduction When the flutter waves have a 1×1 AV conduction, the flutter rate is usually slow, reaching around 200–240 bpm This occurs when the “F” waves are slowed down because of drugs or associated heart disease Sometimes the same patient can show different types of AV conduction (Figure 4.64) Usually, it is very difficult to distinguish from other types of paroxysmal tachycardia with only one ECG We have already mentioned that the slow flutter (≈200 bpm) and the monomorphic atrial tachycardia (MAT) with a similar rate are impossible to distinguish with a surface ECG In fact, atypical flutter and MATMR may be considered the same arrhythmia To make the differential diagnosis between 1×1 flutter with a rate around 200 bpm and very fast paroxysmal AV junctional reentrant tachycardia, it is very useful to perform a CSM or other similar maneuvers In cases of atrial flutter, the CSM can slow the AV conduction and induce AV block, whereas in paroxysmal reentrant junctional tachycardia, the CSM can suppress the tachycardia or have no effect (Table 1.4 and Figure 1.16) It must be taken into account that atrial flutter generally appears in elderly people or in young patients with heart disease, especially after surgery for congenital defects In contrast, paroxysmal junctional reentrant tachy- Bayes_c04.indd 171 171 cardias are habitually seen in young people without heart disease B Situations in which the atrioventricular relation is not 1×1 With complete AV dissociation Junctional tachycardia due to ectopic focus (JT-EF) with complete AV dissociation (regular RR intervals dissociated from the atrial activity) The rate of the QRS complexes can be relatively fast (150–180 bpm), but the sinus or non-sinus atrial activity is dissociated from the JT-EF (QRS complex conducted from the AV junction) (AV dissociation) (Figures 4.13, and 4.27, 4.28) Without complete AV dissociation Atrial flutter with fixed AV relation that is not 1×1, but frequently 2×1 and sometimes also 3×1 or 4×1, but not usually more The average ventricular rate depends on the degree of AV block The atrial activity and “F” waves are fast, between 200 and 300 bpm, without an isoelectric line between “F” waves in leads II, III, and VF (Figures 4.57–4.61) If the atrial activity is slower than 200 bpm, it is probably a monomorphic atrial tachycardia with an AV block (Figure 4.69C) Non-visible atrial activity ● Relatively often, it is difficult to determine where the atrial activity is in the surface ECG, either because it is hidden in the QRS complex (Figure 4.19A) or the T wave (Figure 4.10) Sometimes atrial activity is not visible (unapparent voltage) because of atrial fibrosis (concealed sinus rhythm or atrial flutter) (Bayés de Luna, 1978) The concealed rhythm may be also seen in patients with irregular heart rate (atrial flutter or fibrillation) (see later) Often, the atrial activity is generally seen during the longer pauses, at least in some leads, although there may be exceptions (Figure 4.62) ● In the presence of rapid regular supraventricular rhythms (tachycardia or flutter with fixed AV conduction) without apparent atrial activity, the following must be considered The P′ wave of junctional reentrant tachycardia of AVNRT type or one of two “F” waves of a 2×1 flutter can simulate the last part of the QRS complex and create a morphology similar to 1/22/2011 7:01:37 PM 172 Electrocardiographic Diagnosis of Arrhythmias a partial RBBB (Figures 4.17 and 4.57) Obviously, in the case of 2×1 atrial flutter, the other “F” wave will be clearly seen, and this will help to make the diagnosis (Figure 4.57) It is necessary to make sure that the P′ wave is not masked in the T wave, modifying it in a very subtle manner This can happen frequently in all types of regular tachycardias that have been mentioned, including sinus tachycardia Sometimes, with simple maneuvers, such as deep breathing, the rate of the tachycardia is modified and the atrial activity is clearly seen (Figure 4.10) The fact that the tachycardia rate is clearly modified with breathing makes it quite possible that it is of sinus origin However, this can also happen in monomorphic atrial tachycardias due to ectopic focus, but not in reentrant tachycardias from any origin, which follow the rule of all or nothing: either they cease, for example, with compression of the carotid sinus, or nothing happens (Figures 1.16 and 4.70, and Table 1.4) This difficulty may be overcome when ECG devices include P wave amplification and also T wave filtering, which will allow us to see the P, P′, or “F” waves hidden in the T wave (www.gem-med com), or with the use of special recording leads (Lewis lead) (see Appendix A-3, Analysis of late potentials using a signal averaging electrocardiogram (SAEG) ) The response to vagal stimulation maneuvers such as CSM is very useful for differentiating types of tachyarrhythmias When no atrial activity is recorded in the presence of regular RR intervals, the compression of the carotid sinus can help establish the correct diagnosis If the tachycardia ceases, it is a paroxysmal junctional reentrant tachycardia If it does not cease, and a transient AV block is generated, the atrial waves may be seen (see Table 1.4, (Figures 1.16 and 4.70) Nevertheless, in some cases the problem is not resolved with CSM because there is not any change In this situation, previous clinical and electrocardiographic data can help determine the diagnosis Here are some examples A relatively slow heart rate (between 130 and 150 bpm) is in favor of flutter 2×1, whereas a rate higher than160 bpm is in favor of AV junctional reentrant tachycardias or atrial tachycardias Bayes_c04.indd 172 It is very difficult to distinguish slow flutter with common flutter waves from 1×1 AV conduction and fast monomorphic atrial tachycardia Observing heart rate may help If the rate is faster than 220 bpm, it is considered atrial flutter; if it is slower than 180 bpm, atrial tachycardia The borderline cases (180–220 bpm) may be referred to as “tachysystole” (see Flutter “F” waves) On the other hand, slow flutter (i.e at 220 bpm) with 2×1 conduction, the most frequent situation, can be mistaken for sinus tachycardia at 110 bpm It is useful to observe the changes of heart rate during exercise or over a period of 24 h If there is a gradual increase in heart rate with exercise, or it changes over time but never abruptly, the rhythm is sinus If the rate is fixed during 24 h or changes abruptly with exercise, it is most likely ectopic (flutter) (Figure 4.20) Supraventricular tachycardias with irregular RR intervals (Table 4.2 and Figure 4.71) Generally, QRS complexes are narrow, although sometimes isolated or repetitive wide QRS complexes may be seen This leads us to make a differential diagnosis between aberrancy and ectopy of the wide QRS complexes (see atrial fibrillation, ECG diagnosis) If they are repetitive with irregular RR intervals, the most probable cause of wide QRS is aberrancy It is compulsory to make the differential diagnosis between AF of WPW syndrome and ventricular tachycardia (see before, Differential diagnosis between aberrancy and ectopy in wide QRS complexes, and Figure 4.52) We will comment on this situation and discuss whether the atrial activity can be visible or not Visible atrial activity The following arrhythmias may be considered ● Atrial fibrillation (Figure 4.38) The atrial activity is fast (400–700 bpm) with irregular and changing wave morphologies (“f ” waves), and variable AV conduction ● Flutter with variable AV conduction Usually, regular flutter “F” waves can be seen (Figures 4.63A and 4.69D) ● Chaotic atrial tachycardia (Figure 4.31) Atrial rate is usually high but variable (100–200 bpm) and atrial waves have different morphologies and 1/22/2011 7:01:38 PM Active Supraventricular Arrhythmias 173 Is the atrial activity visible? Yes P or p' – Sinus or MAT with variable AV block – Chaotic atrial tachycardia (several morphologies) No F f On rare occasions Atrial flutter with variable AV block Atrial fibrillation – Concealed atrial tachycardia or flutter with variable block – Concealed atrial fibrillation Figure 4.71 Algorithm for the diagnosis of active supraventricular arrhythmias with irregular RR intervals and narrow QRS change continuously (not more than two identical P waves in a row), although they are easily identifiable (P or P′ waves), with isoelectric baselines in between them and variable AV conduction It is impossible to distinguish from atrial fibrillation using palpitation ● Sinus tachycardia or monomorphic atrial tachycardia with variable AV block Monomorphic P or P′ waves are seen with variable AV block (Figure 4.14) In addition, the presence of premature beats (atrial or ventricular extrasystoles) may explain the irregular RR in sinus tachycardia or other types of tachycardia ● Atrioventricular junctional tachycardia due to ectopic focus with variable AV conduction, or the presence of premature beats Atrial activity not clearly visible On certain rare occasions, when RR intervals are irregular, the atrial activity cannot be seen When this occurs, there is often an atrial fibrosis that initiates low voltage atrial waves (P, P′, f or F) or even invisible waves In these cases, atrial flutter with variable AV conduction or AF is usually the most common cause Generally, in lead V1 F or f, waves can be seen with a very low voltage, especially if the recordings are made using equipment provided with a wave amplifier system (Figure 4.38) without having to proceed to intracavitary recordings Bayes_c04.indd 173 Self assessment A What are the key concepts of premature supraventricular complexes (PSVC)? B Explain how PSVC conduction to the ventricles can happen in different ways C What are the factors that favor the appearance of PSVC? D Comment on the different types of sinus tachycardia and their prognostic and therapeutic implications E Explain the concept of monomorphic atrial tachycardias (MAT) F How many types of MAT are there? G How does the place of origin of the MAT-EF influence the shape of the P wave? H How you make a differential diagnosis of paroxysmal MAT due to ectopic focus? I How you make a differential diagnosis of incessant MAT due to ectopic focus? J What tachycardias are included in the concept atrioventricular (AV) junctional reentrant tachycardia ( JRT)? K How can a paroxysmal junctional reentrant tachycardia with a circuit that is exclusive to the AV junction be distinguished from one with a circuit that also involves an accessory pathway? 1/22/2011 7:01:38 PM 174 Electrocardiographic Diagnosis of Arrhythmias L What are the electrocardiographic characteristics of incessant JRT? M Should ablation always be done to cure paroxysmal JRT? N What are the electrocardiographic characteristics of the junctional tachycardia due to ectopic focus (AVNRTF)? O What are the ECG characteristics of chaotic atrial tachycardia? P Describe the initiation and perpetuation mechanisms of atrial fibrillation (AF) Q What are the characteristics of AF waves? R What is the morphology of QRS and the ventricular response in AF? S How is the differential diagnosis between AF with Wolff–Parkinson–White (WPW) syndrome and ventricular tachycardia made? T What is the prognosis of patients with AF? U What are the objectives of treatment? 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Pulmonary disorders Without findings N % 11 9 20 4 3 58.4 9.9 2.4 1. 9 1. 9 1. 5 1. 5 1 0.5 0.5 0.5 3.9 4.4 2.4 14 1. 5 1. 9 6.9 Taken from Subirana et al 2 010 anginal episodes less frequently (20%