ECG Quiz

Accelerated Idioventricular Rhythm Arrhythmogenic Right Ventricular Dysplasia (ARVD) Ashman Phenomenon Asystole Atrial Fibrillation Atrial Flutter Atrial Tachycardia Atrioventricular Block Atrioventricular Dissociation Atrioventricular Nodal Reentry Tachycardia Brugada Syndrome Bundle Branch Block Carotid Sinus Hypersensitivity Digitalis Toxicity Electrical Alternans First Degree Heart Block (First-Degree Atrioventricular Block) Holiday Heart Syndrome Idioventricular Rhythm Junctional Escape Rhythm Junctional Trigeminy Long QT Syndrome Lown-Ganong-Levine Syndrome Multifocal Atrial Tachycardia Pacemaker AV Sequential Pacemaker - Single Chamber - Atrial Pacemaker - Single Chamber -Ventricular Premature Atrial Complex Premature Junctional Complex Premature Ventricular Complex Paroxysmal Supraventricular Tachycardia Premature Ventricular Contraction Pulseless Electrical Activity Second Degree Heart Block Type II (Second-Degree Atrioventricular Block) Second Degree Heart Block 2 to 1 Conduction Block Sinus Bradycardia Sinus Node Dysfunction Second Degree Heart Block Type I Sinus Arrhythmia Sinus Bradycardia Sinus Tachycardia ST Segment Depression Third Degree Heart Block Torsade de Pointes Ventricular Fibrillation Ventricular Premature Complexes Ventricular Tachycardia Wolff-Parkinson-White Syndrome

Cardiology: The study and treatment of heart disorders. Arrhythmia: An abnormal heart rhythm. In an arrhythmia the heartbeats may be too slow, too rapid, too irregular, or too early. Rapid arrhythmias (greater than 100 beats per minute) are called tachycardias. Slow arrhythmias (slower than 60 beats per minute) are called bradycardias. Irregular heart rhythms are called fibrillations (as in atrial fibrillation and ventricular fibrillation). When a single heartbeat occurs earlier than normal, it is called a premature contraction. Accelerated Idioventricular Rhythm Premature Atrial Complex Accelerated Junctional Rhythm Junctional Tachycardia Accelerated Idioventricular Rhythm Normal Sinus Rhythm Atrial Fibrillation Correct:Accelerated Idioventricular Rhythm

Asystole Premature Ventricular Complex Atrial Fibrillation Asystole Ventricular Tachycardia Pacemaker AV Sequential Sinus Exit Block

Atrial Fibrillation Atrial Bigeminy Premature Ventricular Complex Ventricular Fibrillation Atrial Fibrillation Normal Sinus Rhythm Sinus Arrest Correct:Atrial Fibrillation

Atrial Flutter Atrial Flutter Third Degree Heart Block Sinus Tachycardia Second Degree Heart Block Type I Premature Ventricular Complex Sinus Arrhythmia Correct:Atrial Flutter

Bundle Branch Block Atrial Flutter Premature Ventricular Complex Premature Vent. Complex: Bigeminy Bundle Branch Block Atrial Fibrillation Junctional Trigeminy Correct:Bundle Branch Block

First Degree Heart Block Supraventricular Tachycardia First Degree Heart Block Accelerated Idioventricular Rhythm Junctional Escape Rhythm Ventricular Tachycardia Premature Vent. Complex: Bigeminy Correct:First Degree Heart Block

Idioventricular Rhythm Premature Ventricular Complex Ventricular Tachycardia Torsade de Pointes Idioventricular Rhythm Premature Junctional Complex Third Degree Heart Block Atrial Trigeminy Correct:Idioventricular Rhythm

Junctional Escape Rhythm Third Degree Heart Block Pacemaker - Single Chamber - Atrial Normal Sinus Rhythm Junctional Escape Rhythm Atrial Flutter Accelerated Idioventricular Rhythm Correct:Junctional Escape Rhythm

Junctional Trigeminy Junctional Trigeminy Premature Atrial Complex Third Degree Heart Block ST Segment Depression Atrial Fibrillation Pacemaker - Single Chamber -Ventricular Correct:Junctional Trigeminy

Normal Sinus Rhythm Normal Sinus Rhythm Pacemaker - Failure to Capture Ventricular Tachycardia Atrial Flutter Premature Ventricular Complex Pacemaker - Single Chamber - Atrial Correct:Normal Sinus Rhythm

Pacemaker - Single Chamber - Atrial Pacemaker - Single Chamber - Atrial Premature Ventricular Complex Normal Sinus Rhythm Second Degree Heart Block Type I Atrial Fibrillation Junctional Escape Rhythm Correct:Pacemaker - Single Chamber - Atrial

Pacemaker AV Sequential Premature Vent. Complex: Trigeminy Idioventricular Rhythm First Degree Heart Block Pacemaker - Failure to Pace Pacemaker AV Sequential Premature Atrial Complex Correct:Pacemaker AV Sequential

Second Degree Heart Block Type II Pacemaker - Single Chamber - Atrial Normal Sinus Rhythm Atrial Flutter Second Degree Heart Block Type II Sinus Tachycardia Ventricular Fibrillation

Premature Junctional Complex Pacemaker AV Sequential Wolff-Parkinson-White Syndrome Second Degree Heart Block Type I Premature Junctional Complex Pacemaker - Single Chamber -Ventricular Premature Ventricular Complex Correct:Premature Junctional Complex

Pacemaker - Single Chamber -Ventricular Pacemaker - Single Chamber -Ventricular Accelerated Junctional Rhythm Junctional Trigeminy Atrial Tachycardia Supraventricular Tachycardia Premature Junctional Complex Correct:Pacemaker - Single Chamber -Ventricular

Premature Ventricular Complex Premature Ventricular Complex ST Segment Elevation Accelerated Junctional Rhythm Second Degree Heart Block Type I Ventricular Tachycardia Second Degree Heart Block Type II Correct:Premature Ventricular Complex

Second Degree Heart Block 2 to 1 Conduction Block Second Degree Heart Block 2 to 1 Conduction Block Premature Atrial Complex Normal Sinus Rhythm Idioventricular Rhythm Atrial Fibrillation Premature Ventricular Complex Correct:Second Degree Heart Block 2 to 1 Conduction Block

Second Degree Heart Block Type I First Degree Heart Block Premature Ventricular Complex Atrial Tachycardia Second Degree Heart Block Type I Atrial Fibrillation Sinus Bradycardia Correct:Second Degree Heart Block Type I

Sinus Arrhythmia Premature Junctional Complex ST Segment Elevation Atrial Flutter Sinus Arrhythmia Pacemaker - Single Chamber -Ventricular Premature Ventricular Complex Correct:Sinus Arrhythmia

Sinus Bradycardia Sinus Bradycardia Ventricular Fibrillation Second Degree Heart Block Type I Supraventricular Tachycardia Pacemaker - Failure to Capture ST Segment Elevation Correct:Sinus Bradycardia

Sinus Tachycardia Sinus Tachycardia Idioventricular Rhythm Third Degree Heart Block Sinus Arrhythmia Supraventricular Tachycardia Premature Vent. Complex: Trigeminy Correct:Sinus Tachycardia

ST Segment Depression ST Segment Depression First Degree Heart Block Premature Atrial Complex Normal Sinus Rhythm Atrial Fibrillation Sinus Arrhythmia Correct:ST Segment Depression

Premature Atrial Complex Premature Junctional Complex Premature Atrial Complex First Degree Heart Block Sinus Tachycardia Junctional Escape Rhythm Atrial Bigeminy Correct:Premature Atrial Complex

Third Degree Heart Block Sinus Arrest Atrial Fibrillation Third Degree Heart Block Asystole Atrial Bigeminy Wandering Atrial Pacemaker Correct:Third Degree Heart Block

Ventricular Fibrillation Second Degree Heart Block Type I Pacemaker Rhythm Ventricular Tachycardia Torsade de Pointes Ventricular Fibrillation Idioventricular Rhythm Sinus Arrhythmia Correct:Ventricular Fibrillation

Wolff-Parkinson-White Syndrome Pacemaker - Single Chamber - Atrial Premature Vent. Complex: Bigeminy Premature Atrial Complex Premature Ventricular Complex Wolff-Parkinson-White Syndrome First Degree Heart Block Correct:Wolff-Parkinson-White Syndrome

1-20

1 Idioventricular Rhythm Ventricular Fibrillation Atrial Tachycardia First Degree Heart Block Junctional Escape Rhythm Sinus Bradycardia Correct:Ventricular Fibrillation

2 Premature Vent. Complex: Bigeminy Ventricular Tachycardia Torsade de Pointes Sinus Exit Block Sinus Arrest Second Degree Heart Block Type I Premature Ventricular Complex Correct:Ventricular Tachycardia Torsade de Pointes

3 Normal Sinus Rhythm Premature Ventricular Complex Pacemaker - Failure to Capture Sinus Exit Block Premature Atrial Complex Junctional Bigeminy Correct:Premature Atrial Complex

4 Ventricular Tachycardia Polymorphic Premature Atrial Complex Ventricular Fibrillation Atrial Fibrillation First Degree Heart Block Atrial Flutter Correct:Ventricular Fibrillation

5 Ventricular Fibrillation Pacemaker - Single Chamber - Atrial Atrial Bigeminy Premature Ventricular Complex Atrial Tachycardia Premature Atrial Complex Correct:Premature Ventricular Complex

6 Junctional Escape Rhythm Third Degree Heart Block Premature Atrial Complex Atrial Trigeminy Atrial Tachycardia Bundle Branch Block

7 Atrial Flutter Normal Sinus Rhythm Atrial Tachycardia Pacemaker - Single Chamber - Atrial Junctional Tachycardia Premature Junctional Complex Correct:Normal Sinus Rhythm

8 Premature Ventricular Complex Sinus Arrhythmia ST Segment Elevation Atrial Fibrillation Ventricular Tachycardia Polymorphic Pacemaker - Single Chamber -Ventricular Correct:Ventricular Tachycardia Polymorphic

9 Premature Ventricular Complex Atrial Tachycardia Sinus Tachycardia Sinus Arrest Second Degree Heart Block Type II Second Degree Heart Block Type I Correct:Sinus Tachycardia

10 Normal Sinus Rhythm Ventricular Flutter Atrial Flutter Premature Ventricular Complex Atrial Trigeminy Atrial Fibrillation Correct:Premature Ventricular Complex

11 Pacemaker - Single Chamber - Atrial Premature Ventricular Complex Sinus Arrest Accelerated Junctional Rhythm Normal Sinus Rhythm Premature Atrial Complex Correct:Normal Sinus Rhythm

12 Ventricular Fibrillation Ventricular Tachycardia Junctional Trigeminy Premature Vent. Complex: Bigeminy Third Degree Heart Block Accelerated Idioventricular Rhythm Correct:

13 Premature Vent. Complex: Bigeminy Atrial Fibrillation Pacemaker - Failure to Capture Sinus Tachycardia Sinus Bradycardia Accelerated Junctional Rhythm Correct:Pacemaker - Failure to Capture

14 Atrial Flutter Atrial Fibrillation Sinus Arrest Premature Ventricular Complex Supraventricular Tachycardia Ventricular Tachycardia Monomorphic Correct:Supraventricular Tachycardia

15 Ventricular Fibrillation Supraventricular Tachycardia Second Degree Heart Block 2 to 1 Conduction Block Premature Ventricular Complex Pacemaker AV Sequential Ventricular Tachycardia Correct:Ventricular Fibrillation

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Question #1 Your answer was Ventricular Fibrillation Evaluation: Correct. Answer score: 4 points Question #2 Your answer was Ventricular Fibrillation Evaluation: Correct. Answer score: 4 points Question #3 Your answer was Ventricular Tachycardia Torsade de Pointes Evaluation: Correct. Answer score: 4 points Question #4 Your answer was Premature Atrial Complex Evaluation: Correct. Answer score: 4 points Question #5 Your answer was Ventricular Fibrillation Evaluation: Correct. Answer score: 4 points Question #6 Your answer was Premature Ventricular Complex Evaluation: Correct. Answer score: 4 points Question #7 he correct answer is Atrial Tachycardia Question #8 Your answer was Normal Sinus Rhythm Evaluation: Correct. Answer score: 4 points Question #9 Your answer was Ventricular Tachycardia Polymorphic Evaluation: Correct. Answer score: 4 points Question #10 Your answer was Sinus Tachycardia Evaluation: Correct. Answer score: 4 points Question #11 Your answer was Premature Ventricular Complex Evaluation: Correct. Answer score: 4 points Question #12 Your answer was Normal Sinus Rhythm Evaluation: Correct. Answer score: 4 points Question #13 The correct answer is Junctional Trigeminy with muscle tremors Question #14 The correct answer is Junctional Trigeminy with muscle tremors Question #15 Your answer was Pacemaker - Failure to Capture Evaluation: Correct. Answer score: 4 points Question #16 Your answer was Supraventricular Tachycardia Evaluation: Correct. Answer score: 4 points Question #17 Your answer was Supraventricular Tachycardia Evaluation: Correct. Answer score: 4 points Question #18 Your answer was Ventricular Fibrillation Evaluation: Correct. Answer score: 4 points Question #19 Your answer was Ventricular Fibrillation Evaluation: Correct. Answer score: 4 points Question #20 The correct answer is Atrial Fibrillation Answer score: -1 points

What is arrhythmia? What's a normal heartbeat? What causes arrhythmia? What are the signs and symptoms of arrhythmia? What are the risk factors for arrhythmia? How is arrhythmia diagnosed? What are the treatment options for arrhythmia? What are the complications of arrhythmia? What is arrhythmia? An arrhythmia is an irregular heartbeat - the heart may beat too fast (tachycardia), too slowly (bradycardia), too early (premature contraction) or too irregularly (fibrillation). Arrhythmias are heart-rhythm problems - they occur when the electrical impulses to the heart that coordinate heartbeats are not working properly, making the heart beat too fast/slow or inconsistently. Many heart arrhythmias are harmless. We all occasionally experience irregular heartbeats, which may feel like a racing heart or fluttering. Some arrhythmias, however, especially if they veer too far from a normal heartbeat or result from a weak or damaged heart, may cause troublesome and even potentially fatal symptoms. Rapid arrhythmias are called tachycardias, while slow ones are called bradycardias. Irregular arrhythmias - when the heartbeat is irregular - are called fibrillations, as in atrial or ventricular fibrillation. When a single heartbeat occurs earlier than it should it is called premature contraction. The English word "arrhythmia" comes from the Greek word rhymos, meaning "rhythm", the Greek suffix a (letter "a" added to the beginning of a word) means "loss" - put together they mean "loss of rhythm". What are the signs and symptoms of arrhythmia?Some patients may have no symptoms at all. A doctor may detect a sign of arrhythmia during a routine examination. (The patient detects/feels a symptom, and other people, such as the doctor or other members of the household, detect a sign). Even if a patient notices symptoms, it does not necessarily mean there is a serious problem. Ironically, some patients with life-threatening arrhythmias may have no symptoms, while others with symptoms may not have a serious problem. Symptoms of tachycardia include: (Sometimes there are no symptoms) ¦Breathlessness ¦Dizziness ¦Syncope (fainting, or near-fainting) ¦Fluttering in the chest ¦Lightheadedness ¦Sudden weakness Symptoms of bradycardia include: (Sometimes there are no symptoms) ¦Angina (chest pain) ¦Concentration problems ¦Confusion ¦Difficulties when exercising ¦Dizziness ¦Fatigue (tiredness) ¦Lightheadedness ¦Palpitations ¦Shortness of breath ¦Syncope (fainting or near-fainting) Symptoms for atrial fibrillation (these often develop rapidly): (Sometimes there are no symptoms) ¦Angina (chest pains) ¦Breathlessness ¦Dizziness ¦Palpitations ¦Syncope (fainting, or near-fainting) ¦Weakness What's a normal heartbeat? Your heart is made up of four chambers — two upper chambers (atria) and two lower chambers (ventricles). The rhythm of your heart is normally controlled by a natural pacemaker (the sinus node) located in the right atrium. The sinus node produces electrical impulses that normally start each heartbeat. From the sinus node, electrical impulses travel across the atria, causing the atria muscles to contract and pump blood into the ventricles. The electrical impulses then arrive at a cluster of cells called the atrioventricular node (AV node) — usually the only pathway for signals to travel from the atria to the ventricles. The AV node slows down the electrical signal before sending it to the ventricles. This slight delay allows the ventricles to fill with blood. When electrical impulses reach the muscles of the ventricles, they contract, causing them to pump blood either to the lungs or to the rest of the body. In a healthy heart, this process usually goes smoothly, resulting in a normal resting heart rate of 60 to 100 beats a minute. Conditioned athletes at rest commonly have a heart rate less than 60 beats a minute because their hearts are so efficient. Types of arrhythmias Doctors classify arrhythmias not only by where they originate (atria or ventricles) but also by the speed of heart rate they cause: •Tachycardia (tak-ih-KAHR-dee-uh). This refers to a fast heartbeat — a resting heart rate greater than 100 beats a minute. •Bradycardia (brad-e-KAHR-dee-uh). This refers to a slow heartbeat — a resting heart rate less than 60 beats a minute. Not all tachycardias or bradycardias mean you have heart disease. For example, during exercise it's normal to develop a fast heartbeat as the heart speeds up to provide your tissues with more oxygen-rich blood. During sleep or times of deep relaxation, it's not unusual for the heart beat to be slower. Tachycardias in the atria Tachycardias originating in the atria include: •Atrial fibrillation. Atrial fibrillation is a rapid heart rate caused by chaotic electrical impulses in the atria. These signals result in rapid, uncoordinated, weak contractions of the atria. The chaotic electrical signals bombard the AV node, usually resulting in an irregular, rapid rhythm of the ventricles. Atrial fibrillation may be temporary, but some episodes won't end unless treated. Atrial fibrillation may lead to serious complications such as stroke. •Atrial flutter. Atrial flutter is similar to atrial fibrillation. The heartbeats in atrial flutter are more-organized and more-rhythmic electrical impulses than in atrial fibrillation. Atrial flutter may also lead to serious complications such as stroke. •Supraventricular tachycardia. Supraventricular tachycardia is a broad term that includes many forms of arrhythmia originating above the ventricles (supraventricular) in the atria or AV node. •Wolff-Parkinson-White syndrome. In Wolff-Parkinson-White syndrome, a type of supraventricular tachycardia, there is an extra electrical pathway between the atria and the ventricles, which is present at birth. However, you may not experience symptoms until you're an adult. This pathway may allow electrical signals to pass between the atria and the ventricles without passing through the AV node, leading to short circuits and rapid heartbeats. Tachycardias in the ventricles Tachycardias occurring in the ventricles include: •Ventricular tachycardia. Ventricular tachycardia is a rapid, regular heart rate that originates with abnormal electrical signals in the ventricles. The rapid heart rate doesn't allow the ventricles to fill and contract efficiently to pump enough blood to the body. Ventricular tachycardia can often be a medical emergency. Without prompt medical treatment, ventricular tachycardia may worsen into ventricular fibrillation. •Ventricular fibrillation. Ventricular fibrillation occurs when rapid, chaotic electrical impulses cause the ventricles to quiver ineffectively instead of pumping necessary blood to the body. This serious problem is fatal if the heart isn't restored to a normal rhythm within minutes. Most people who experience ventricular fibrillation have an underlying heart disease or have experienced serious trauma, such as being struck by lightning. •Long QT syndrome. Long QT syndrome is a heart disorder that carries an increased risk of fast, chaotic heartbeats. The rapid heartbeats, caused by changes in the electrical system of your heart, may lead to fainting, and can be life-threatening. In some cases, your heart's rhythm may be so erratic that it can cause sudden death. You can be born with a genetic mutation that puts you at risk of long QT syndrome. In addition, several medications may cause long QT syndrome. Some medical conditions, such as congenital heart defects, may also cause long QT syndrome. Bradycardia — a slow heartbeat Although a heart rate below 60 beats a minute while at rest is considered bradycardia, a low resting heart rate doesn't always signal a problem. If you're physically fit, you may have an efficient heart capable of pumping an adequate supply of blood with fewer than 60 beats a minute at rest. In addition, certain medications used to treat other conditions, such as high blood pressure, may lower your heart rate. However, if you have a slow heart rate and your heart isn't pumping enough blood, you may have one of several bradycardias, including: •Sick sinus syndrome. If your sinus node, which is responsible for setting the pace of your heart, isn't sending impulses properly, your heart rate may be too slow (bradycardia), or it may speed up (tachycardia) and slow down intermittently. Sick sinus syndrome can also be caused by scarring near the sinus node that's slowing, disrupting or blocking the travel of impulses. •Conduction block. A block of your heart's electrical pathways can occur in or near the AV node, which lies on the pathway between your atria and your ventricles. A block can also occur along other pathways to each ventricle. Depending on the location and type of block, the impulses between the upper and lower halves of your heart may be slowed or blocked. If the signal is completely blocked, certain cells in the AV node or ventricles can make a steady, although usually slower, heartbeat. Some blocks may cause no signs or symptoms, and others may cause skipped beats or bradycardia. Slower heart rates or a conduction block may cause symptoms of fatigue, dizziness or fainting. Premature heartbeats Although it often feels like a skipped heartbeat, a premature heartbeat is actually an extra beat. Even though you may feel an occasional premature beat, it seldom means you have a more serious problem. Still, a premature beat can trigger a longer lasting arrhythmia — especially in people with heart disease. Premature heartbeats are commonly caused by stimulants, such as caffeine from coffee, tea and soft drinks; over-the-counter cold remedies containing pseudoephedrine; and some asthma medications. What are the causes of arrhythmia? Many things can lead to, or cause, an arrhythmia, including: A heart attack that's occurring right now Air pollution Alcohol abuse Blocked arteries in your heart (coronary artery disease) Certain dietary supplements and herbal treatments Certain prescription medications Changes to your heart's structure, such as from cardiomyopathy Diabetes Drinking too much alcohol or caffeine Drug abuse Electrical shock Excessive coffee consumption Heart disease High blood pressure Hyperthyroidism (an overactive thyroid gland) Scarring of heart tissue from a prior heart attack Smoking Stress Underactive thyroid gland (hypothyroidism) The electrical impulses that cause the heart to contract must follow a precise pathway for it to work properly. Any interruption to these impulses can result in arrhythmia. The human heart consists of four chambers - the chambers on each half of the heart form two adjoining pumps, with the atrium (upper chamber) and the ventricle (lower chamber). When a heartbeat occurs the less muscular and smaller atria contract and fill the relaxed ventricles with blood. The contraction starts when a small group of cells in the right atrium (the sinus node) send an electrical impulse which causes the right and left atria to contract. The impulse then moves to the atrioventricular node (at the center of the heart) on the pathway between the atria and ventricles. From here the impulse leaves the atrioventricular node, travels through the ventricles, causing them to contract and pump blood - this blood pumps throughout the body. For a person with a healthy heart the process works properly and he/she should have a heart rate of between 60 and 100 beats per minute when resting. The fitter you are the lower your resting heart rate. Olympic athletes, for example, will usually have a resting heart rate of less than 60 beats per minute because their hearts are very efficient. A healthy person will hardly ever suffer from long-term arrhythmia unless he/she has an external trigger, such as drug abuse or an electric shock. If there is an underlying problem, however, the electrical impulses may not be able to travel through the heart correctly, increasing the likelihood of arrhythmia. Arrhythmia development can occur if a condition has changed the structure of the heart, due to: ¦Reduction in blood supply - a drop in blood supply to the heart can alter the ability of heart cells and tissue to conduct electrical impulses. Damaged or destroyed heart tissue - if heart tissue has died or is damaged the way electrical impulses spread in the heart can be affected. Heart structure alterations can be caused by: ¦CAD (coronary artery disease) - this is when the arteries in the heart narrow, often resulting in a heart attack (some of the heart muscle dies because of a lack of blood flow). Heart attacks cause scarring of the heart tissue. Scarred heart tissue interfere with the proper movement of electrical impulses which make the heart beat. The heart may beat too fast (ventricular tachycardia) or irregularly (ventricular fibrillation). Cardiomyopathy - disease of the myocardium (heart muscle). The walls of the ventricles may stretch or enlarge, or the left ventricle wall may thicken and constrict. The heart's blood-pumping efficiency is affected, often resulting in heart tissue damage. Valvular heart diseases - if the heart valves narrow or leak the heart muscle can stretch and thicken. If valves are tight or leaking there is a significant risk of developing arrhythmia. Arrhythmias are classified according to two factors: Where they originate - the atria or ventricles. The heart rate - fast (tachycardia - over 100 beats per minute), slow (bradycardia - less than 60 beats per minute). High or slow heart beats do not necessarily mean there is heart disease. Our heart rate increases during exercise - this is normal. Some extremely fit athletes have a resting heart rate of less than 60 beats per minute. Tachycardia in the atria: Atrial fibrillation - this means irregular beating of the atrial chambers - usually fast. Atrial fibrillation is a common type of arrhythmia and mainly affects elderly patients. A person's risk of developing atrial fibrillation increases significantly after the age of 60; especially if he/she had hypertension or some other heart problem. Instead of producing a single, strong contraction, the chamber fibrillates (quivers). In some cases the heartbeat of a person with atrial fibrillation can go up to 350 beats per minute, and even 500 or 600. Over the medium or long-term atrial fibrillation can cause stroke, as well as some other serious conditions. Atrial flutter - the difference between atrial flutter and fibrillation is that flutter is well organized while fibrillation is not. Atrial flutter can come and go, as can atrial fibrillation. Atrial flutter can be serious. A patient with atrial flutter will typically experience 250 to 350 beats per minute. Supraventricular tachycardia (SVT) - a regular, abnormally rapid heartbeat caused by rapid firing of electrical impulses from a focus above the atrioventricular node (in the heart). It is called SVT because the rapid heartbeat originates above the ventricles of the heart. The patient experiences a burst of accelerated heartbeats that can last from a few seconds to some hours. These bursts often occur when the electrical impulse from a heartbeat starts to circle through the extra pathway. Typically, a patient with SVT will have a heart rate of between 160 and 200 beats per minute. SVT can be caused by an underlying heart condition. Young people with normal hearts may experience SVT (racing heart) - however, although it may feel uncomfortable, it is not usually life-threatening. Wolff-Parkinson-White (WPW) syndrome - there is an extra electrical connection inside the heart that acts as a short circuit, resulting in an abnormally fast heart beat (sometimes irregular). This syndrome can be life-threatening, although it is unusual. Tachycardia in the ventricles: ¦Ventricular tachycardia - abnormal electrical impulses that start in the ventricles cause abnormally fast heart beating. Typically, the heart will have a scar from a previous heart attack, which forces the electrical signal to travel around it. Usually, the ventricle will contract more than 200 times a minute. Ventricular tachycardia (VT) affects people with heart-related problems, such as scars or ventricle muscle damage caused by artery disease or a heart attack. There are two types of VT: Unsustained VT - this lasts for up to about 30 seconds and is usually harmless. However, there is a risk of longer-lasting VT eventually. ¦Sustained VT - this is longer-lasting and is a medical emergency. Ventricular fibrillation - irregular heart rhythm consisting of very rapid, uncoordinated fluttering contractions of the ventricles (lower chambers of the heart). The ventricles do not pump blood properly (they quiver uselessly instead). Blood pressure drops dramatically, depriving vital organs, including the brain, of their essential blood supply. The majority of patients lose consciousness fairly quickly and require emergency medical assistance, including CPR (cardiopulmonary resuscitation). Patients who receive CPR until their heart can be shocked back into a normal rhythm with a defibrillator have much better survival rates. If the patient does not receive CTP or defibrillation he/she will die within minutes. Ventricular fibrillation is usually associated with some kind of heart disease. Ventricular fibrillation is often triggered by a heart attack. Long QT syndrome - a heart rhythm disorder that may sometimes cause rapid, uncoordinated heartbeats. The name of the syndrome comes from the QT segment in the tracing on the electrocardiogram, which lasts slightly longer in the syndrome than normal. The rapid heartbeats can result in fainting, which may be life-threatening. In severe cases the heart rhythm may become so chaotic that it causes sudden death. Some people inherit a faulty gene which increases their risk of developing Long QT syndrome. A significant number of medications may also cause Long QT syndrome. Bradycardia (heart beats abnormally slowly) A slow heartbeat (under 60 beats per minute) does not necessarily mean there is a problem. A physically fit person with a healthy, strong heart may have a low resting heart rate, lower than 60 beats per second, and be in the best of health. Bradycardia is a problem if the heart is faulty and does not pump enough blood; examples include: ¦Sick sinus - a problem with the sinus node of the heart. The sinus node is the heart's natural pacemaker. If it does not function properly the patient's resting heart rate may be abnormally low (bradycardia). If the sinus node functions properly, sick sinus may be caused by scarring near the sinus node which undermines the movement of electrical impulses. Conduction block - a block of the electrical pathways of the heart. This can occur in or close to the atrioventricular node, located on the pathway between the atria and the ventricles. The block may be along the other pathways to each ventricle. The electrical impulses between the upper and lower halves of the heart may be slowed or blocked; this depends on the type of block and where it is. If the signal is totally blocked, some cells in the atrioventricular node or ventricles can make a steady but slower heartbeat. The patient may experience skipped heartbeats or bradycardia - sometimes there are no symptoms at all. Premature heartbeats - this occurs in the ventricles and comes before the ventricles have had time to fill with blood after a regular heartbeat. A premature heartbeat occurs between two normal heartbeats. However, the patient will feel he/she has skipped a heartbeat. In most cases the occasional premature beat is nothing to worry about. However, it can trigger a longer-lasting arrhythmia - this is especially the case if the patient has heart disease. What are the risk factors for arrhythmia? Old age - the heart inevitably weakens as we get old and loses some of its flexibility - this affects the conduction of electrical impulses. Inherited gene defects - people who are born with a heart abnormality have a higher risk of developing arrhythmia. Heart problems - people with heart problems, narrowed arteries, those who have had a heart attack, heart valves that do not function properly, previous heart surgery, and cardiomyopathy, are more likely to develop arrhythmia. Hypothyroidism or hyperthyroidism - people with a thyroid gland problem are more likely to develop arrhythmia. Medications - some prescription medications, as well as OTC drugs, such as cough and cold drugs containing pseudoephedrine may help in the development of arrhythmia. Hypertension - people with high blood pressure are much more likely to develop coronary artery disease and other heart problems which result in the improper conduction of electrical impulses. Obesity - obesity is linked to a huge number of health problems, including diabetes type 2, cancer, cardiovascular disease, heart disease, and arrhythmia. Uncontrolled diabetes - a patient with uncontrolled diabetes is significantly more likely to develop arrhythmia compared to a patient who has his diabetes under control (receives proper treatment). Obstructive sleep apnea - patients with obstructive sleep apnea may experience bradycardia or atrial fibrillation more commonly than other people. Electrolyte imbalances - electrolytes are essential for the proper conduction of electricity between cells and through cells. If electrolyte levels are wrong - either too low or too high - the electrical impulses in the heart may be affected, resulting in arrhythmia. Heavy and regular alcohol consumption - people who regularly consume large quantities of alcohol are much more likely to develop atrial fibrillation. Too much caffeine - caffeine, and some other stimulants, may accelerate the heart rate and eventually cause arrhythmias. Illegal drugs - amphetamines and cocaine can cause arrhythmias, especially ventricular fibrillation. How is arrhythmia diagnosed? The doctor, a GP (general practitioner) or cardiologist (a specialist in heart and cardiovascular diseases and conditions) will try to find out what triggers the patient's arrhythmia. This will involve a detailed interview which includes the patient's medical history, family history, diet, lifestyle, etc. The following tests may be ordered: ¦Blood and urine tests - these will check the patient's blood count and liver, thyroid, and kidney function. The doctor may also want to check the blood for specific chemical markers of heart failure, such as BNP (brain natriuretic peptide) - this hormone is secreted at high levels by the heart if it is injured or overburdened, but is first identified in the brain. Serum electrolytes may also be tested to evaluate sodium and potassium levels. An ECG (electrocardiogram) - this device records the electrical activity and rhythms of the patient's heart. Electrodes are attached to the patient's skin and impulses are recorded as waves and displayed on a screen (or printed on paper). The test may also reveal any damage to the heart from a heart attack. A Holter monitor - the patient wears a portable device which records all his/her heartbeats. It is worn under the clothing and records information about the electrical activity of the heart while the patient goes about his/her normal activities for one or two days. It has a button which can be pressed if symptoms are felt - then the doctor can see what heart rhythms were present at that moment. Event recorder (event monitor) - This machine is similar to a Holter monitor, but it does not record all the heartbeats. There are two types: 1. One uses a phone to transmit signals from the recorder while the patient is experiencing symptoms. 2. The other is worn all the time for a long time; sometimes as long as a month (it must be taken off when showering or having a bath). This device is good for diagnosing rhythm disturbances that happen at random moments. An echocardiogram - this is an ultrasound scan that checks the pumping action of the patient's heart. This test also helps distinguish systolic heart failure from diastolic heart failure (the heart is stiff and does not fill properly). Sound waves are used to create a video image of the patient's heart, which helps the doctor see how well the heart is pumping. The doctor measures the percentage of blood pumped out of the patient's left ventricle (the main pumping chamber) with each heartbeat - this measurement is call the ejection fraction. An ejection fraction is a crucial measurement which determines how well the heart is pumping. A healthy heart pumps out approximately 60% of the blood that fills the ventricle with each beat - a healthy heart has an ejection factor of 60%. Chest X-ray - The images help the doctor check the state of the patient's heart and lungs. A chest X-ray may also help a doctor determine whether the patient has any congenital heart defects. Other conditions that may explain the signs and symptoms might also be detected. Tilt-table test - If the patient experiences fainting spells, dizziness or lightheadedness, and neither the ECG nor the Holter revealed any arrhythmias, a tilt-table test may be performed. This monitors the patient's blood pressure, heart rhythm and heart rate while he/she is moved from a lying down to an upright position. A healthy patient's reflexes cause the heart rate and blood pressure to change when moved to an upright position - this is to make sure the brain gets an adequate supply of blood. If the reflexes are inadequate, they could explain the fainting spells, etc. Electrophysiologic testing (or EP studies) - This is an invasive, relatively painless, non-surgical test and can help determine the type of arrhythmia, its origin, and potential response to treatment. The test is carried out in an EP lab by an electrophysiologist, and makes it possible to reproduce troubling arrhythmias in a controlled setting. During an EP study: ¦The patient is given a local anesthetic. After an initial puncture an introducer sheath is inserted into a blood vessel. A catheter is inserted through the introducer sheath and is threaded up the blood vessel, through the body and into the right chambers of the heart. The electrophysiologist can see the catheter moving up the body on a monitor. When it is inside the heart the catheter stimulates the heart and records where abnormal impulses start, their speed, and which normal conduction pathways they bypass. Treatments can be given to find out whether they stop the arrhythmia. The catheter and introducer sheaths are then removed, and the insertion site is closed up either by applying pressure to the site or with stitches. What are the treatment options for arrhythmia? Treatment for arrhythmia is only required if it is putting the patient at risk of a more serious arrhythmia or a complication. Treatment for bradycardias (heartbeat is too slow) If the bradycardia is caused by an underlying problem, such as an underactive thyroid gland, or a drug side effect, that problem needs to be treated first. If no underlying problem is found, the doctor may advise implanting a pacemaker. Pacemaker - this device replaces the job of the atrioventricular node. A pacemaker is a small device that is placed under the skin of the chest or abdomen to help control abnormal heart rhythms; it uses electrical pulses to prompt the heart to beat at a normal rate. Treatment for tachycardias (heartbeat is too fast) ¦Vagal maneuvers - certain maneuvers the patient can do himself/herself may stop an arrhythmia that starts above the lower half of the heart (SVY). This may involve the patient holding his/her breath and straining, coughing, or submerging the face in ice-cold water. The doctor, nurse or a specialized physical therapist may suggest other maneuvers. These maneuvers affect the vagal nerves and often cause the heart rate to slow down. Medications - these will not cure the patient, but are usually effective in reducing episodes of tachycardia as well as slowing the heart rate down when they occur. Anti-arrhythmic medications need to be taken correctly for best results and to avoid complications. In some cases, if the medications slow the heart down too much the patient may need to have a pacemaker. Cardioversion - if the tachycardia starts in the atria (top half of the heart) and includes atrial fibrillation, the doctor may use an electric shock to reset the heart to its regular rhythm - this is called cardioversion. It is carried out externally; the patient is usually given a drug to relax. The procedure is painless. Ablation therapy - ablation means "taking the disease away". One or more catheters go through blood vessels into the inner heart. They are placed in areas of the heart that are thought to be the sources of the arrhythmia. Electrodes at the ends of the catheter are heated. Sometimes the tips are cooled down and the problem tissue is frozen. A small spot of heart tissue is destroyed (ablated), creating an electrical block along the pathway that is causing the arrhythmia. ICD (implantable cardioverter-defibrillator) - if the patient is at high risk of developing a very fast or quivering (fibrillating) heartbeat in the ventricles, an ICD may be implanted. There are also ICDs for atrial fibrillation (quivering in the upper half of the heart). The device is implanted near the left collarbone - electrode-tipped wires go from the ICD, through veins, to the heart. The ICD monitors the heart rhythm and paces the heart, just like a pacemaker as soon as it detects an abnormally slow rhythm. Experts say that an ICD is better at significantly reducing the risk of a fatal arrhythmia than medications. Maze procedure - a series of surgical incisions are made in the atria (upper half of the heart). They then heal into scars in the atria that form boundaries that make the electrical impulses travel properly so that the heart beats efficiently. This is open-heart surgery and is usually used for patients who have not responded well enough to other treatments. Maze procedures have a good success rate. Ventricular aneurysm surgery - if an aneurysm (bulge) in a blood vessel that leads to the heart is causing the arrhythmia and other treatments did not work, a surgeon may remove the aneurysm. This surgical procedure has a good success rate - it is sometimes used if the implanted ICD or catheter ablation did not work. Coronary bypass surgery - a patient with frequent ventricular tachycardia who also has severe coronary artery disease may be advised to undergo coronary bypass surgery. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the heart muscle (myocardium). What are the complications of arrhythmia? ¦Stroke - fibrillation (quivering) means the heart is not pumping properly. This can cause blood to collect in pools where clots can form. If one of the clots dislodges it can make its way to a brain artery, blocking it and causing a stroke. Stroke can cause brain damage and can also be fatal. Heart failure - prolonged tachycardia or bradycardia can result in the heart not pumping enough blood to the body and its organs - this is heart failure. Treatment can usually help improve this. ¦Alzheimer's disease What conditions may be diagnosed with an ECG (EKG)? 1.Abnormally fast or irregular heart rhythms. 2.Abnormally slow heart rhythms. 3.Abnormal conduction of cardiac impulses, which may suggest underlying cardiac or metabolic disorders. 4.Evidence of the occurrence of a prior heart attack (myocardial infarction). 5.Evidence of an evolving, acute heart attack. 6.Evidence of an acute impairment to blood flow to the heart during an episode of a threatened heart attack (unstable angina). 7.Adverse effects on the heart from various heart diseases or systemic diseases (such as high blood pressure, thyroid conditions, etc.). 8.Adverse effects on the heart from certain lung conditions (such as emphysema, pulmonary embolus [blood clots to lung]). 9.Certain congenital heart abnormalities. 10.Evidence of abnormal blood electrolytes (potassium, calcium, magnesium). 11.Evidence of inflammation of the heart or its lining (myocarditis, pericarditis). 5 Steps to Identify Normal Sinus Rhythm 1. What is the rate? 60-100 beats per minute 2. What is the rhythm? Atrial rhythm regular Ventricular rhythm regular 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares) Interpreting EKG Rhythm Strips The Five Step Approach The five-step approach, in order of application, includes analysis of the following: 1.Heart rate 2.Heart rhythm 3.P wave 4.PR interval 5.QRS complex P wave: 5 questions to ask 1.Are P waves present? 2.Are P waves occurring regularly? 3.Is there one P wave present for every QRS complex present? 4.Are the P waves smooth, rounded, and upright in appearance, or are they inverted? 5.Do all P waves look similar? PR interval: 3 questions to ask 1.Are the PR intervals greater than 0.20 seconds? 2.Are the PR intervals less than 0.12 seconds? 3.Are the PR intervals consistent across the EKG strip? QRS complex: 3 questions to ask 1.Are the QRS complexes greater than 0.12 seconds (in width)? 2.Are the QRS complexes less than 0.06 seconds (in width)? 3.Are the QRS complexes similar in appearance across the EKG strip 5 Common Variations of a sinus rhythm: •Normal sinus rhythm (60 – 100 bpm) •Sinus bradycardia (< 60 bpm) •Sinus tachycardia ( >100 bpm) •Sinus arrhythmia (60 – 100 bpm) •Sinus pause/arrest Causes and S/S of Sinus Bradycardia Causes Hypoglycemia Hypothermia Hypothyroidism Previous cardiac history Medications Toxic exposure MI – Inferior wall involving right coronary artery Signs and Symptoms Syncope Dizziness Chest Pain Shortness of Breath Exercise Intolerance Cool, clammy skin 5 Steps to Identify Sinus Tachycardia Rhythm 1. What is the rate? 101-160 beats per minute 2. What is the rhythm? Atrial rhythm regular Ventricular rhythm regular 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares) Causes and S/S of Sinus Tachycardia Causes Damage to heart tissues from heart disease Hypertension Fever Stress Excess alcohol, caffeine, nicotine, or recreational drugs such as cocaine A side effect of medications Response to pain Imbalance of electrolytes Hyperthyroidism Signs and Symptoms Dizziness Shortness of breath Lightheadedness Rapid pulse rate vHeart palpitations Chest pain Syncope 5 Steps to Identify Sinus Arrhythmias 1. What is the rate? 60-100 beats per minutev 2. What is the rhythm?v Irregular (varies more than 0.08 sec) 3. Is there a P wave before each QRS?v Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares) 5 Steps to Identify Sinus Arrest Rhythm 1. What is the rate? Variable, depending on frequency 2. What is the rhythm? Irregular, when sinus arrest is present 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes, if QRS is present Yes, if QRS is present 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes, when present 0.06-0.12 seconds (1 ½ to 3 small squares) Causes and S/S of Sinus Pause/Arrest Causes This may occur in individuals with healthy hearts during sleep Myocarditis Cardiomyopathy MI Digitalis toxicity Age- elderly Vagal stimulation Signs and Symptoms Sometimes asymptomatic Syncope Dizziness LOC Bradycardia