Cardiology - Arrhythmias

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Cardiology - Arrhythmias

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Sinus Bradycardia – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: Heart rate <60 beats per minute (bpm) at rest.Assess for symptoms: Lightheadedness, syncope.Identify potential causes: High vagal tone (e.g., well-trained athletes), local ischemia, infiltrative disease, hypothyroidism, hypothermia, stroke.Review medication list: Exclude drug effects as an etiology.Assess for sinus pauses: Note if >3 seconds while awake.DiagnosticsElectrocardiography (ECG).Ambulatory ECG Monitoring (Holter): To correlate symptoms with heart rhythm.Event Recorder: If episodes are infrequent, to document rhythm during symptoms.Implantable Loop Recorder: For very infrequent symptoms.Treadmill Testing: To distinguish true chronotropic incompetence (blunted HR response to exercise) from high vagal tone (appropriate HR increase with exercise).Carotid Sinus Massage (CSM): May be useful to establish symptom-rhythm correlation in suspected SA nodal dysfunction.Electrophysiologic (EP) Testing: Usually not necessary in most cases. Reserved for a smaller group of patients in whom the arrhythmia mechanism cannot be determined by noninvasive means.TherapyCorrectable Conditions: Address all correctable conditions (e.g., hypothyroidism) and stop all potentially causative drugs.No specific therapy for asymptomatic patients.Permanent Pacing: Indicated for symptomatic patients.Dual-chamber pacemakers are frequently implanted due to concern of concomitant disease in more distal conduction system, even though a single-chamber atrial pacemaker may suffice.Disposition / ConsultsAdmission: Not explicitly stated for uncomplicated asymptomatic sinus bradycardia, but consider if symptomatic or pauses are significant.Consult Cardiology: For pacemaker implantation in symptomatic patients.Tachycardia Bradycardia Syndrome – Quick Clinical Action GuideInitial EvaluationConfirm presence of sinus or other bradycardia alternating with rapid supraventricular tachycardias (SVTs), most often atrial fibrillation (AF).Assess for symptoms: Lightheadedness, syncope (most often caused by bradycardia or offset pauses).Define offset pause: Duration between termination of AF or atrial flutter and return of sinus rhythm.DiagnosticsElectrocardiography (ECG).Ambulatory ECG Monitoring (Holter).Event Recorder / Implantable Loop Recorder: For symptom-rhythm correlation.TherapyMedical control of rapid arrhythmia: Often limited by worsening bradycardia.Pacemakers: Used to prevent bradycardia.Allow titration of medications to slow conduction through the AV node and prevent episodes of rapid ventricular rate during AF.Disposition / ConsultsConsult Cardiology/Electrophysiology: For management of complex arrhythmias and pacemaker implantation.Sinoatrial Exit Block – Quick Clinical Action GuideInitial EvaluationFirst-degree SA exit block: Cannot be diagnosed on surface EKG as it involves delayed but present conduction.Second-degree SA block: Marked by intermittent block out of the SA node and resultant dropped P waves on EKG.Third-degree SA block (complete sinus arrest): Manifests as complete block of sinus impulses out of the SA node.DiagnosticsElectrocardiography (EKG): To identify dropped P waves (second-degree) or complete sinus arrest (third-degree).Ambulatory ECG Monitoring (Holter).Event Recorder / Implantable Loop Recorder: To correlate symptoms with bradycardia.TherapySymptom alleviation is the principal goal.Asymptomatic patients rarely warrant intervention.Address all correctable conditions and stop all potentially causative drugs.Permanent Pacing: Mainstay of treatment for symptomatic sinus node dysfunction. Dual-chamber pacemakers are frequently implanted.Disposition / ConsultsConsult Cardiology: For pacemaker implantation in symptomatic patients.First-Degree Atrioventricular Block – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: PR interval on ECG is prolonged (>200 milliseconds), but a preserved 1:1 relationship between atria and ventricles.Identify site of block: Most often in the AV node; absence of BBB or wide QRS makes infra-Hisian block less likely.Assess for symptoms: Rarely symptomatic, but may cause palpitations, cough, dyspnea, chest discomfort, dizziness, or syncope (pacemaker syndrome–like symptoms due to simultaneous atrial and ventricular contraction).Review medication list: Identify AV nodal blocking agents.TherapyRarely warrants treatment.Cessation of nodal blocking agents.Vagolytic maneuvers (e.g., exercise, atropine): Should decrease PR interval if AV node is site of delay. Exacerbation or underlying bundle branch disease may reflect infranodal delay.Permanent Pacing: Only rarely indicated for symptomatic patients with a pacemaker syndrome-like constellation of symptoms.Disposition / ConsultsObservation: For most asymptomatic patients.Second-Degree Atrioventricular Block, Mobitz Type I (Wenckebach) – Quick Clinical Action GuideInitial EvaluationConfirm ECG diagnosis: Gradual prolongation of ...