Arrhythmia Essentials Brian Olshansky, MD Professor of Medicine, Cardiac Electrophysiology Section Division of Cardiology Department of Internal Medicine University of Iowa Hospitals, Iowa City, IA Mina K Chung, MD Associate Professor of Medicine Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cardiac Electrophysiology and Pacing Department of Cardiovascular Medicine, Heart and Vascular Institute Department of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Cleveland, OH Steven M Pogwizd, MD Featheringill Endowed Professor in Cardiac Arrhythmia Research Professor of Medicine, Physiology & Biophysics, and Biomedical Engineering Director, Center for Cardiovascular Biology Associate Director, Cardiac Rhythm Management Laboratory University of Alabama at Birmingham, Birmingham, AL Nora Goldschlager, MD Professor of Clinical Medicine University of California, San Francisco Chief, Clinical Cardiology Director, Coronary Care Unit ECG Laboratory and Pacemaker Clinic San Francisco General Hospital, San Francisco, CA 74769_FM00_pass2.indd i 74769_FM00_pass2.indd 74769_FM00_Printer.indd i i 9/16/10 11:12 PM 9/16/10 03/06/11 11:12 5:13 PM World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations For details and specific discount information, contact the special sales department at 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controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial Research, clinical practice, and government regulations often change the accepted standard in this field When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product This is especially important in the case of drugs that are new or seldom used Production Credits Executive Publisher: Chris Davis Editorial Assistant: Sara Cameron Senior Production Editor: Dan Stone Medicine Marketing Manager: Rebecca Rockel V.P., Manufacturing and Inventory Control: Therese Connell Composition: diacriTech, Chennai, India Cover Design: Kristin E Parker Printing and Binding: Cenveo Cover Printing: Cenveo Library of Congress Cataloging-in-Publication Data Arrhythmia essentials / Brian Olshansky [et al.] p ; cm Includes bibliographical references and index ISBN 978-0-7637-7476-9 Arrhythmia I Olshansky, Brian [DNLM: Arrhythmias, Cardiac WG 330] RC685.A65A7713 2012 616.1’28—dc22 2010038843 6048 Printed in the United States of America 15 14 13 12 11 10 74769_FM00_Printer.indd ii 03/06/11 5:13 PM Table of Contents iii TABLE OF CONTENTS PREFACE v SINUS NODE—NORMAL AND ABNORMAL RHYTHMS Normal Sinus Node Sinus Node Dysfunction, Including Sinus Bradycardia and Tachy-Brady Syndrome Sinoatrial Exit Block 13 Sinus Pause/Arrest 18 Sinus Tachycardia 20 Postural Orthostatic Tachycardia Syndrome 24 BRADYARRHYTHMIAS—CONDUCTION SYSTEM ABNORMALITIES 26 Atrioventricular Conduction Abnormalities First-Degree AV Block 27 Second-Degree AV Block—Mobitz Type I 31 Second-Degree AV Block—Mobitz Type II 35 Second-Degree AV Block—2:1 AV Block 40 High-Degree Advanced AV Block 43 Third-Degree (Complete) AV Block 47 Caveats 52 Atrioventricular Dissociation 54 Intraventricular Conduction Abnormalities Left Bundle Branch Block 56 Right Bundle Branch Block 59 Rate-Related Bundle Branch Block 63 Fascicular Block 66 Unifascicular Block 66 Bifascicular Block 70 Trifascicular Block 75 ECTOPIC COMPLEXES AND RHYTHMS 79 Premature Atrial Complexes 80 Premature Junctional Complexes 83 Premature Ventricular Complexes 85 Escape Beats, Escape Rhythms, and Accelerated Rhythms 95 Ectopic Atrial Rhythm 98 74769_FM00_Printer.indd iii Wandering Atrial Pacemaker 99 Junctional Rhythm 101 Accelerated Idioventricular Rhythm 104 TACHYCARDIA 106 Tachycardia Mechanisms 107 Narrow QRS Complex Tachycardia 108 Wide QRS Complex Tachycardia 109 SUPRAVENTRICULAR TACHYARRHYTHMIAS 115 Supraventricular Tachycardia 116 Atrial Arrhythmias 116 Atrial Fibrillation 129 Atrial Flutter 154 Atrioventricular Nodal Reentry Tachycardia 164 Junctional Tachycardia 171 Preexcitation Syndromes 173 VENTRICULAR TACHYARRHYTHMIAS 186 Nonsustained Ventricular Tachycardia 187 Sustained Ventricular Tachycardia 195 Ventricular Fibrillation 209 Specific Ventricular Arrhythmia Syndromes 213 Ventricular Tachyarrhythmias in the Setting of Structural Heart Disease 214 Ventricular Arrhythmias Associated with Ischemic Cardiomyopathy 214 Ventricular Arrhythmias Associated with Nonischemic Cardiomyopathy 214 Hypertrophic Cardiomyopathy 215 Arrhythmogenic Right Ventricular Cardiomyopathy 217 Ventricular Arrhythmias in Structurally Normal Hearts 219 Outflow Tract Ventricular Tachycardias 219 Idiopathic Left Ventricular or Fascicular Tachycardia 221 03/06/11 5:13 PM iv Arrhythmia Essentials Long QT Syndrome 221 Brugada Syndrome 224 Catecholaminergic Polymorphic Ventricular Tachycardia 227 Drug- and Metabolic-Induced Torsades de Pointes 230 Primary and Secondary Prevention of Sudden Cardiac Death 236 CARDIAC PACING AND PACEMAKER RHYTHMS 240 Pacemaker Rhythms 241 Indications for Pacing 258 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS 261 Implantable Cardioverter Defibrillators 262 Cardiac Resynchronization Therapy 267 DRUG EFFECTS AND ELECTROLYTE DISORDERS 269 Drug Toxicity 270 Digitalis Toxicity 270 Electrolyte Disorders 275 Calcium Disorders 280 74769_FM00_Printer.indd iv 10 ATHLETES AND ARRHYTHMIAS 283 11 EVALUATION OF THE PATIENT WITH SUSPECTED ARRHYTHMIAS 287 Outpatient Approach to Arrhythmia Monitoring 288 Carotid Sinus Massage 289 Electrophysiology Studies 290 Palpitations 291 Syncope 294 12 TREATMENT OF ARRHYTHMIAS 296 Pharmacologic Therapy for Clinical Arrhythmias 297 Antiarrhythmic Agents 297 Anticoagulant Drugs 309 Nonpharmacologic Therapy 311 SUGGESTED READING 314 INDEX 317 03/06/11 5:13 PM Preface v PREFACE Arrhythmia Essentials is a comprehensive, yet practical handbook that provides an approach to patients who have cardiac arrhythmias, including those arrhythmias that occur in specific clinical settings The book is meant to be used to help assess and manage patients with virtually all arrhythmias and related symptoms and includes treatment strategies that may be considered To this end, we have focused on a step-by-step approach for ease of use The book is divided into chapters that include sinus node function, bradycardias, tachycardias, heart block, normal and abnormal pacemaker and implantable defibrillator function, and special arrhythmia-related topics such as syncope, palpitations, arrhythmias in the athlete, and other clinical conditions of importance Provided also is a section that summarizes available drugs useful to treat patients with cardiac arrhythmias Each chapter is accompanied by illustrative electrocardiograms and, where thought to be useful, practical algorithms that help delineate an organized approach to arrhythmia diagnosis and management This is the first practical handbook written on this topic that is aimed at practicing clinicians of all specialties, that is based on a contemporary approach, and that focuses on new and advanced therapeutic options and technologies We believe that the reader will refer to this book often and find it to be compelling, concise, comprehensive, and relevant It is hoped that this book will find its way to a lab coat pocket and be available on patient care units rather than sit on the library bookshelf 74769_FM00_Printer.indd v 03/06/11 5:13 PM vi Arrhythmia Essentials ABBREVIATIONS 1° AVB 2° AVB 3° AVB AAT AED AF AFL AIVR ART ARVC first-degree atrioventricular block second-degree atrioventricular block third-degree atrioventricular block automatic atrial tachycardia automatic external defibrillator atrial fibrillation atrial flutter accelerated idioventricular rhythm atrial reentrant tachycardia arrhythmogenic right ventricular cardiomyopathy AT atrial tachycardia ATP antitachycardia pacing AV atrioventricular AVB (or AV atrioventricular block Block) AVNRT atrioventricular node reentry tachycardia AIVR accelerated idioventricular rhythm AVRT atrioventricular reentry tachycardia BBB bundle branch block BBRVT bundle branch reentrant ventricular tachycardia BP blood pressure bpm beats per minute CABG coronary artery bypass graft CAD coronary artery disease CHB complete heart block CHF congestive heart failure COPD chronic obstructive pulmonary disease CPVT catecholaminergic polymorphic ventricular tachycardia CRT cardiac resynchronization therapy CSM carotid sinus massage DAD delayed afterdepolarizations EAD early afterdepolarizations EAR ectopic atrial rhythm ECG electrocardiogram EP electropyhsiology EPS electrophysiology study HCM hypertrophic cardiomyopathy ICD implantable cardioverter defibrillator 74769_FM00_Printer.indd vi ILR ILVT implantable loop recorder idiopathic left ventricular tachycardia INR international normalized ratio IST inappropriate ST JT junctional tachycardia LAFB left anterior fascicular block LBB left bundle branch LBBB left bundle branch block LPFB left posterior fascicular block LQTS long QT interval syndrome LV left ventricle LVEF (or EF) left ventricular ejection fraction LVH left ventricular hypertrophy MAO monoamine oxidase MAT multifocal atrial tachycardia MI myocardial infarction MVP mitral valve prolapse NSR normal sinus rhythm NSVT nonsustained ventricular tachycardia NYHA New York Heart Association PAC premature atrial contractions PAD premature atrial depolarization PJC premature junctional complex PJRT permanent junctional reentrant tachycardia PM pacemaker PMT pacemaker-mediated tachycardia POTS postural orthostatic tachycardia syndrome PRN pro rata nata (as needed) PT prothrombin time PTT partial thromboplastin time PVARP postventricular atrial refractory period PVC premature ventricular contraction RBB right bundle branch RBBB right bundle branch block RV right ventricle RVOT right ventricular outflow tract SA sinoatrial SB sinus bradycardia 03/06/11 5:13 PM Abbreviations SND SNRT SVT TdP TEE TIA sinus node dysfunction sinus node reentry tachycardia supraventricular tachycardia torsades de pointes transesophageal echocardiogram transient ischemic attack 74769_FM00_Printer.indd vii TTE VF VT WAP WCT WPW vii transthoracic echocardiogram ventricular fibrillation ventricular tachycardia wandering atrial pacemaker wide complex tachycardia Wolff-Parkinson-White 03/06/11 5:13 PM 74769_FM00_Printer.indd viii 03/06/11 5:13 PM Chapter Sinus Node—Normal and Abnormal Rhythms Chapter Sinus Node—Normal and Abnormal Rhythms Normal Sinus Node Sinus Node Dysfunction, Including Sinus Bradycardia and Tachy-Brady Syndrome Sinoatrial Exit Block Sinus Pause/Arrest Sinus Tachycardia Postural Orthostatic Tachycardia Syndrome 74769_CH01_Printer.indd 13 18 20 24 30/04/11 1:13 AM Index Inappropriate shocks, ICDs, minimizing 262 Inappropriate sinus tachycardia 6, 20 Infiltrative cardiomyopathies, first-degree AV block management 28t Infra-Hsian Wenckebach block, Mobitz type I second-degree AV block and 31 Inotropic drugs, myocardial infarction and 23t Interpolated premature ventricular complexes 84 Intraventricular conduction abnormalities bifascicular block 70, 70–74 fascicular block 66 left bundle branch block 56–59 rate-related bundle branch block 63, 65–66 right bundle branch block 59–62 trifascicular block 75–78 unifascicular block 66 Ischemic cardiomyopathy management of nonsustained monomorphic/polymorphic VT and 190t reducing risk of recurrent episodes of 237 therapy for 95t ventricular arrhythmias associated with 213, 214 Isoproterenol avoiding, for acute MI with AV block 41 electrophysiology studies and 290 long QT syndrome and 235t symptomatic-acute sinus node dysfunction and 11t Isorhythmic AV dissociation 49, 96 IST See Inappropriate sinus tachycardia Isthmus-dependent right atrial flutters 158 Itraconazole, TdP potential and 231 Ivabradine, POTS management and 25 J-ervell and Lange-Nielsen syndrome 201, 221, 236t Junctional escape rhythm, therapy for 97t Junctional rhythm 102, 101–103 accelerated 102 74769_IDXx_Printer.indd 329 329 description 101 therapy for and specific clinical presentations with 103t Junctional tachycardia 171, 171–172 approach to management 171 associated conditions 171 clinical symptoms and presentation 171 description 171 digitalis toxicity and 270 therapy for 172t K -ayexalate 280 Kearns-Sayre syndrome 259 Kent bundle, tachycardias and preexcitation syndrome related to 173 Ketoconazole, TdP potential and 231 L-AFB See Left anterior fascicular block LBBB See Left bundle branch block LBBB morphology BBRVT 214 LBBB morphology tachycardias, morphology criteria for 111, 113 Left anterior fascicular block 68 management of 69t Left bundle branch block 56–59 alternating right bundle branch block and 62t, 66t approach to management 56 associated conditions 56 characteristics of 57 clinical symptoms and presentation 56 description 56, 59 evaluating for SHD 60 management of 58t Left posterior fascicular block 69 management of 69t Left ventricle, premature ventricular complexes originating from 90 Lenegre’s disease 65 Lev’s disease 65 LGL syndrome See Lown-Ganong-Levine syndrome Lidocaine for clinical arrhythmias 305–306 long QT syndrome and 235t polymorphic VT, acute therapy and 206t PVCs, post-MI management and 92 30/04/11 1:34 AM 330 Arrhythmia Essentials SB in setting of acute myocardial infarction and 12t sustained ventricular tachycardia and 205t ventricular tachycardia and 203 wide QRS complex tachycardia and 114 Liquid protein diets, TdP potential and 231 Lithium, sinus bradycardia and Long QT interval polymorphic ventricular tachycardia 201 Long QT interval syndrome 221, 223, 224, 284 athlete’s heart and 284 drug toxicity and 270 ECG abnormalities in athletes and 285 evaluation of 224 forms of 221 management of 232t palpitations evaluation and 292 sudden cardiac death and 239 syncope and 295 “Lower loop reentry” tachycardias 158 Lown-Ganong-Levine syndrome 180 preexcitation therapy for 183t LPFB See Left posterior fascicular block LQT1 221, 235t LQT2 221, 235t LQT3 221, 236t LQTS See Long QT interval syndrome LV fascicular tachycardia 200 LV pacing, unintended, pacemaker malfunction 254 Lyme disease, Mobitz type I second-degree AV block and 31 M-acroreentrant atrial tachycardias 123 Magnesium sulfate for clinical arrhythmias 306 ventricular fibrillation and 213 Magnet rate, of pacing system 242 Mahaim fiber, unique properties of 178 MAT See Multifocal atrial tachycardia Maze procedure, atrial fibrillation and 139, 145t, 146t 74769_IDXx_Printer.indd 330 Metabolic-induced Torsades de Pointes 230–232 Methamphetamine, ventricular fibrillation and 212 Methyldopa, POTS management and 25 Methylphenidate, POTS management and 25 Metoprolol atrial fibrillation and 143t atrial tachycardia and 119t automatic atrial tachycardia and 122t AVNRT therapy and 168t for clinical arrhythmias 297 orthodromic AVRT: acute therapy and 183t symptomatic sinus tachycardia therapy and 22t Mexiletine for clinical arrhythmias 306–307 long QT interval syndrome and 235t MI See Myocardial infarction Mobitz type I second-degree AV block 31–34 approach to management 33 associated conditions 31 clinical symptoms and presentation 33 description 31 management of 33–35t myocardial infarction 34t outpatient-asymptomatic 33t outpatient-symptomatic 33-34t post-op 35t pre-op 34t Mobitz type II second-degree AV block 35–39 narrow QRS 31 wide QRS 33 approach to management 37 associated conditions 35 clinical symptoms and presentation 37 description 35 flow chart for evaluation/ treatment of 39 management of 37–38t MI 38t outpatient-asymptomatic 37t outpatient-symptomatic 37t 30/04/11 1:34 AM Index post-op 38t pre-op 38t with narrow QRS 35 with wide QRS 37 Minute ventilation sensors 241 Mobitz type I second-degree AV block, digitalis toxicity and 270 Monomorphic ventricular tachycardias 111, 195, 200 description 187 nonsustained, management of 190–193t Monophasic shocks, ICDs 262 Morphine, SB in setting of acute myocardial infarction and 12t Moxifloxacin, TdP potential and 231 Multifocal atrial rhythm (or chaotic atrial mechanism) 102 Multifocal atrial tachycardia 126–129, 127 approach to management 128 associated conditions 128 clinical symptoms and presentation 128 description 126 multifocal atrial rhythm vs 102 therapy for 128–129t wandering atrial pacemaker vs 99 Myocardial infarction accelerated idioventricular rhythm therapy and 105t acute, atrial tachycardia and 118 atrial flutter therapy and 163t atrial tachycardia therapy and 119t automatic atrial tachycardia therapy and 123t AVNRT therapy and 170t bifascicular block management and 73t complete heart block management and 53t delayed afterdepolarizations and 107 ectopic atrial rhythm therapy and 99t escape beats and rhythms therapy and 97t fascicular block management and 67t first-degree AV block management and 29t 74769_IDXx_Printer.indd 331 331 high-degree advanced AV block management and 46t junctional rhythm therapy and 103t junctional tachycardia therapy and 172t left bundle branch block management and 58t management of nonsustained monomorphic/polymorphic VT and 190t Mobitz type I second-degree AV block management and 33–35t Mobitz type II second-degree AV block management and 37–38t multifocal atrial tachycardia and 128t post-MI palpitations evaluation and 292 permanent cardiac pacing contraindications for 260 permanent cardiac pacing indications for 259 premature atrial complexes therapy and 82t premature junctional complexes therapy and 85t right bundle branch block management and 62t sinoatrial exit block, sinus pause management and 16t sinus bradycardia and sinus node dysfunction management and 12t sinus tachycardia management and 22t trifascicular block management and 77t VT chronic management in setting of 204 Myocardial ischemia, palpitations evaluation and 293 Myocarditis, sudden death in athletes and 284 Myopotential inhibition 250 Myxomatous mitral valve degeneration, ruptured, sudden death in athletes and 284 30/04/11 1:34 AM 332 N acetylprocainamide, Arrhythmia Essentials TdP potential and 231, 307 Narcotics, sudden death in athletes and 285 Narrow QRS complex junctional escape rhythm, congenital complete AV block with 49 Narrow QRS complex tachycardia 108–109 NASPE policy conference, arrhythmias in athletes and 284, 285 Neurocardiogenic syncope 294 permanent cardiac pacing contraindications for 260 permanent cardiac pacing indications for 259 sinus pause/arrest and 18 symptomatic bradycardia and Nocturnal sudden cardiac death, Brugada syndrome and 224 Nonconducted premature junctional complexes, therapy for 85t Nonischemic cardiomyopathy 92 management of nonsustained monomorphic/polymorphic VT and 190t reducing risk of recurrent episodes 237 ventricular arrhythmias associated with 213, 214–215 Nonischemic dilated cardiomyopathy/dysplasia, ventricular fibrillation and 212 Non-isthmus-dependent macroreentrant atrial tachycardia 158 Nonsustained monomorphic and polymorphic ventricular tachycardia management of 190–193t hypertrophic cardiomyopathy 192t ischemic cardiomyopathy 191t myocardial infarction 192t nonischemic cardiomyopathy 191t normal LV function 190–191t post-op 193t pre-op 193t Nonsustained ventricular tachycardia 187–194, 188 74769_IDXx_Printer.indd 332 approach to management 189 associated conditions 187 clinical presentation and symptoms 187 defined 187 description 187 evaluation and treatment of 194 Normal sinus node Normal sinus rhythm (NSR) approach to management characteristics of clinical symptoms and presentations 2, defined with sinus arrhythmia NSVT See Nonsustained ventricular tachycardia O-bstructive sleep apnea, sinus arrhythmia and Octreotide, POTS management and 25 Organophosphates, TdP potential and 231 Orthodromic AV reciprocating tachycardia 173 Outflow tract ventricular tachycardias 200, 219, 220 Out-of-hospital cardiac arrest 237–239 Oversensing 249, 250 Oversensing, pacing system 242 P-acemaker malfunction end of life 253, 256 unintended LV pacing 254 Pacemaker-mediated tachycardia 242, 250, 252 Pacemaker mimic: artifact 257 Pacemaker rhythms 241–257 biventricular pacing 255 dual-chamber pacing: atrial and ventricular paced 245 dual-chamber pacing: atrial sensed, ventricular paced 246 failure to capture (ventricle) 247 myopotential inhibition 250 normal atrial pacing (AAI or AAI(R)) 243 normal ventricular pacing (VVI or VVI(R)) 244 30/04/11 1:34 AM Index oversensing 249 pacemaker malfunction: end of life 256 pacemaker malfunction: unintended LV pacing 254 pacemaker-mediated tachycardia 252 pacemaker mimic: artifact 257 undersensing (failure to sense) 248 upper rate pacing with atrial tachycardia 251 Pacemakers atrial fibrillation and 139 implantable cardioverter defibrillators vs 261 Pacing indications 258–260 for permanent cardiac pacing 258–260 AV block 258–259 bifascicle block 259 carotid sinus syndrome 259 neurocardiogenic syncope 259 post-MI 259 to prevent tachyarrhythmias 259 sinus node dysfunction 259 systolic heart failure 260 for temporary transvenous cardiac pacing 258 Pacing systems, codes for description of 241 PACs See Premature atrial complexes Palpitations 291–293 approach to evaluation 292–293 arrhythmias and 292 associated causes and conditions 291–292 management approach 293 symptoms of 290 Paroxysmal atrial fibrillation 132, 151, 161 Paroxysmal atrial tachyarrythmias, with periods of bradyarrhythmia Paroxysmal junctional tachycardia, therapy for 172t Pentamidine, TdP potential and 231 Permanent cardiac pacing contraindications for 260 indications for 258–260 AV block 258–259 carotid sinus syndrome 259 neurocardiogenic syncope 259 post-MI 259 74769_IDXx_Printer.indd 333 333 to prevent tachyarrhythmias 259 sinus node dysfunction 259 systolic heart failure 260 Permanent junctional reciprocating tachycardia 180, 181, 184t Permanent pacemakers arrhythmia evaluation and 290 Class I, symptomatic-chronic sinus node dysfunction and 12t indications for 139 Persistent atrial tachyarrhythmias, with periods of bradyarrhythmia Phenobarbital, POTS management and 25 Phenothiazines, TdP potential and 231 Phenytoin, long QT interval syndrome and 235t PJCs See Premature junctional complexes PJRT See Permanent junctional reciprocating tachycardia PMT See Pacemaker-mediated tachycardia Polymorphic nonsustained ventricular tachycardia, approach to management 189 Polymorphic ventricular tachycardias 111, 195, 197, 201 description 187 nonsustained, management of 191–193t Post-myocardial infarction, premature ventricular complexes and management of 92 Post-op accelerated idioventricular rhythm therapy 105t atrial flutter therapy 164t atrial tachycardia therapy 121t automatic atrial tachycardia therapy 123t AVNRT therapy 170t bifascicular block management 73t complete heart block management 54t ectopic atrial rhythm therapy 99t escape beats and rhythms therapy 98t fascicular block management 67t first-degree AV block management 29t high-degree advanced AV block management 47t 30/04/11 1:34 AM 334 Arrhythmia Essentials junctional rhythm therapy 103t junctional tachycardia therapy 172t left bundle branch block management 59t Mobitz type I second-degree AV block management 35t Mobitz type II second-degree AV block management 38t nonsustained monomorphic/polymorphic VT therapy 193t premature atrial complexes therapy 83t premature junctional complexes therapy 85t premature ventricular complexes therapy 95t right bundle branch block management 63t sinoatrial exit block, sinus pause management 16t sinus node dysfunction management 13t trifascicular block management 77t 2:1 AV block management 43t Postural orthostatic tachycardia syndrome 24–25 approach to management 25 clinical symptoms and presentation 25–26 description 24 sinus tachycardia and 20 Post-ventricular atrial refractory period 242 POTS See Postural orthostatic tachycardia syndrome Preexcitation syndromes 173–185 approach to management 182 associated conditions 182 clinical symptoms and presentation 182 description 173, 178, 180 therapy for 183–184t AF with ventricular preexcitation and controlled ventricular rates without hemodynamic instability 183t AF with ventricular preexcitation and rapid ventricular rates: acute therapy, unstable 183t antidromic AVRT: acute therapy 183t long-term therapy: WPW syndrome due to accessory pathway 183–184t 74769_IDXx_Printer.indd 334 Lown-Ganong-Levine syndrome (with SVTs) 184t Mahaim fiber tachycardias 184t orthodromic AVRT: acute therapy 183t PJRT 184t Pregnancy AVNRT therapy and 170t sinus tachycardia and 22t Premature atrial complexes, 81, 80–83 See also Atrial fibrillation with aberrancy 81 approach to management 78 associated conditions 80 blocked 81 clinical symptoms and presentation 80–82 description 80 therapy and specific clinical presentations 82–83t highly symptomatic 82t MI 83t mild or no symptoms 82t nonconducted (“blocked”) PACs 83t post-op 83t pre-op 83t triggers atrial fibrillation 82t Premature junctional complexes 83–85, 84 approach to management 85 associated conditions 85 clinical symptoms and presentation 85 description 83 therapy for 85t Premature ventricular complexes 85–95 Premature ventricular complexes approach to management 91–92 nonischemic cardiomyopathy 92 no structural heart disease 91–92 post-MI 92 summary 92 associated conditions 86 with bigeminy and trigeminy 88 clinical symptoms and presentation 91 description 85–86 digitalis toxicity and 270 with fusion complexes 87 30/04/11 1:34 AM Index interpolated 87 originating from left ventricle 90 originating from right ventricular outflow tract 89 therapy for and specific clinical presentations with 93–95t asymptomatic 94t hypertrophic cardiomyopathy 94t idiopathic dilated cardiomyopathy 94t ischemic cardiomyopathy 94t MI 94t post-op 95t pre-op 95t symptomatic 93–94t Premature ventricular contraction, palpitations evaluation and 293 Pre-op accelerated idioventricular rhythm therapy 103t atrial flutter therapy 163t atrial tachycardia therapy 121t automatic atrial tachycardia therapy 123t AVNRT therapy 170t bifascicular block management 73t complete heart block management 54t ectopic atrial rhythm therapy 99t escape beats and rhythms therapy 98t fascicular block management 67t first-degree AVB management 29t high-degree advanced AV block management 47t junctional rhythm therapy 103t junctional tachycardia therapy 172t left bundle branch block management 58t Mobitz type I second-degree AV block management 34t Mobitz type II second-degree AV block management 38t nonsustained monomorphic/polymorphic VT therapy 193t premature atrial complexes therapy 83t premature junctional complexes therapy 85t 74769_IDXx_Printer.indd 335 335 premature ventricular complexes therapy 95t right bundle branch block management 62t sinoatrial exit block, sinus pause management and 16t sinus node dysfunction management and 13t trifascicular block management 77t 2:1 AV block management 42t Primary dysautonomic postural orthostatic tachycardia syndrome 24 PR interval, in first-degree AV block 27 Proarrhythmias 309 Procainamide antidromic AVRT, acute and 183t atrial fibrillation and 136, 137, 138, 144t, 145t atrial flutter therapy and 162t, 164t atrial reentrant tachycardia and 125t Brugada syndrome and 224, 226 avoidance of 227 for clinical arrhythmias 307 drug toxicity and 270 His-Purkinje system, Mobitz type II second-degree AV block and 37 Mahaim fiber tachycardias and 183t preexcitation therapy and 182t sinus pause/arrest and 18 sustained ventricular tachycardia and 205t TdP potential and 231 ventricular preexcitation and 182 ventricular tachycardia and 201 wide QRS complex tachycardia and 109 Propafenone atrial fibrillation and 136, 138, 143t, 145t, 146t atrial flutter therapy and 162t atrial reentrant tachycardia and 125t atrial tachycardia and 119t automatic atrial tachycardia and 122t Brugada syndrome and, avoidance of 227 for clinical arrhythmias 307–308 His-Purkinje system, Mobitz type II second-degree AV block and 35 30/04/11 1:34 AM 336 Arrhythmia Essentials Mahaim fiber tachycardias and 183t normal LV function, nonsustained monomorphic/polymorphic VT and 190t premature ventricular complexes and 93t sinus pause/arrest and 18 symptomatic-acute sinus node dysfunction and 11t ventricular preexcitation and 182 Propranolol atrial fibrillation and 143t for clinical arrhythmias 300 Pseudoephedrine, palpitations and 292 Pseudo “pacemaker syndrome,” 101 Pseudo-P-pulmonale, hypokalemia and 275 PVARP See Post-ventricular atrial refractory period PVCs See Premature ventricular complexes PV intervals, pacing 242 P waves in ectopic atrial rhythm 98 high-degree AV block and 43, 45 morphologies in multifocal atrial tachycardia 126 in normal sinus rhythm in premature junctional complexes 83, 84 severe hyperkalemia and loss of 278 in sinus tachycardia 20 wandering atrial pacemaker and 99 Pyridostigmine, POTS management and 24 Q-RS narrow high-degree AV block with Mobitz type I second-degree AV block with 2:1 AV block with wide high-degree AV block with Mobitz type I second-degree AV block with Mobitz type II second-degree AV block with 2:1 AV block with 74769_IDXx_Printer.indd 336 45 32 40 45 32 36 36 QRS complexes paced 253 in sinus tachycardia 20 wide, sinus bradycardia with QRS widening, severe hyperkalemia and 278 Quinidine atrial fibrillation and 136, 137, 145t, 146t for clinical arrhythmias 308 digitalis toxicity and 270 drug toxicity and 270 His-Purkinje system, Mobitz type II second-degree AV block and 35 sinus pause/arrest and 18 TdP potential and 231 ventricular preexcitation and 182 R-adiofrequency ablation best candidates for 313 complications of 313 nonsustained ventricular tachycardia and 187 normal LV function, nonsustained monomorphic/polymorphic VT and 190t outflow tract VTs and 219 safety and effectiveness of 312 sustained VT, chronic prevention and 206t ventricular arrhythmias in patients with ARVC and 219 Rapid heart rates, storing in pacing systems 253 Rapid paced ventricular rates causes of 250 supraventricular tachycardia and 250 Rate-related bundle branch block 65, 63–65 approach to management 65 associated conditions 65 clinical symptoms and presentation 65 description 63 management of 66t RBBB See Right bundle branch block RBBB morphology tachycardias, morphology criteria for 111, 113 RBBB pattern, pacing complexes with 253 30/04/11 1:34 AM Index Reentry, tachycardia and 107–108 Restrictive cardiomyopathies, first-degree AV block management 28t Rheumatic fever, first-degree AV block management 29t Rhythm-control strategies, for atrial fibrillation 138–139 Right bundle branch block 61 alternating left bundle branch block and 58t, 62t approach to management 62 associated conditions 59 description 59 evaluation and treatment of 64 management of 62t plus left anterior fascicular block 71 plus left posterior fascicular block 72 symptoms and clinical presentation 62 Right ventricular cardiomyopathy, ECG abnormalities in athletes and 285 Right ventricular outflow tract, premature ventricular complexes originating from 89 Right ventricular outflow tract idiopathic VT 200, 220 Romano-Ward syndrome 201, 221, 235t S-ART See Sinoatrial node reentrant tachycardia SCN5A gene, Brugada syndrome and loss-of-function mutations in 226 Secondary postural orthostatic tachycardia syndrome 24 Second-degree AV block-2:1 AV block 40–43 approach to management 41 associated conditions 40 clinical symptoms and presentation 41 description 40 evaluation and treatment for 44 management of 41–43t AV nodal site of block suspected 41–43t inability to distinguish site of block by ECG or provocative maneuvers 42t infranodal site of block suspected 42t 74769_IDXx_Printer.indd 337 337 MI 42t post-op 43t pre-op 42t narrow QRS 40 wide QRS 40 Serotonin, athletes, arrhythmias and 284 Serotonin reuptake inhibitors, POTS management and 25 Shocks implantable cardioverter defibrillators and 259 for ventricular tachycardias 263 inappropriate, for supraventricular tachycardia 265 inappropriate, ICD 262 Short QT interval syndrome 212 Sick sinus syndrome Simvastatin 304 Single-chamber ventricular (VVI) pacing, atrial fibrillation and 139 Sinoatrial node reentrant tachycardia 118, 118 Sinoatrial (SA) exit block 6, 13–15 approach to management 14 associated conditions 14 clinical symptoms and presentation 14 description of 13–14 sinus pause management and therapy for 16t Type I (Wenckebach pattern) 14, 15, 16t Type II 14, 15, 16t Sinus arrest Sinus arrhythmia normal sinus rhythm with Sinus bradycardia approach to management 9–10 associated conditions 6, clinical symptoms and presentation defined digitalis toxicity and 270 escape rhythms with 95 with junctional escape complexes and capture beats 49 management of 10–12t with wide QRS complex 30/04/11 1:34 AM 338 Arrhythmia Essentials Sinus node, location of Sinus node dysfunction 2, 6–13 asymptomatic, therapy 10t bradycardia and pauses 19 description flowchart for evaluation/ treatment of 17 management in specific clinical circumstances heart transplant 13t MI 12t post-op 13t pre-op 13t permanent cardiac pacing contraindications for 260 permanent cardiac pacing indications for 259 sleep apnea and 10t symptomatic-acute, therapy 11t symptomatic-chronic, therapy 12t Sinus node reentry Sinus pause/arrest 6, 18, 18, 19 approach to management 18 associated conditions 18 clinical symptoms and presentation 18 description 18 digitalis toxicity and 270 Sinus pause management, sinoatrial exit block and 16t Sinus rates age and changes in Sinus tachycardia 21, 20–24 approach to management 22 associated conditions 20 clinical symptoms 22 description 20 with first-degree AV block 21 management asymptomatic 22t MI 23t post-op 23t pregnancy 24t pre-op 23t symptomatic 22t with 1° AVB 27 74769_IDXx_Printer.indd 338 Sinus tachycardia mimic, macroreentrant atrial flutter with 2:1 AV conduction 20 Sinus tachycardia with BBB, ventricular tachycardia mimic 198 Sleep apnea Mobitz type I second-degree AV block and 31 sinus arrhythmia and sinus bradycardia and sinus node dysfunction and 10t sinus pause/arrest and 18 SND See Sinus node dysfunction Soccer, sudden death in athletes and 284 Sodium channel blockers, Brugada syndrome and 224, 226 Sotalol acquired form of long QT interval syndrome and 270 arrhythmogenic right ventricular cardiomyopathy and 234t ARVC and 219 atrial fibrillation and 136, 138, 145t atrial flutter therapy and 162t atrial reentrant tachycardia and 125t atrial tachycardia and 119t automatic atrial tachycardia and 122t for clinical arrhythmias 308–309 idiopathic dilated cardiomyopathy and 94t ischemic cardiomyopathy and 94t junctional rhythm and 101 Mahaim fiber tachycardias and 184t nonsustained ventricular tachycardia and 187 normal LV function, nonsustained monomorphic/polymorphic VT and 190t PJRT therapy and 184t premature ventricular complexes and 95t sinus bradycardia and sinus pause/arrest and 18 sustained VT, prior MI and 207t 30/04/11 1:34 AM Index symptomatic-acute sinus node dysfunction and 11t TdP potential and 231 ventricular preexcitation and 187 VT chronic management and 214 Spiramycin, TdP potential and 231 Sports, athletes and arrhythmias 283–286 SQTS See Short QT interval syndrome ST See Sinus tachycardia Statins, prevention of sudden cardiac death and 236 Steroids, athletes, arrhythmias and 284 Stroke anticoagulation, atrial fibrillation and 139 sinus pause/arrest and 18 Structural heart disease management of 232t palpitations evaluation and 288 specific ventricular arrhythmia syndromes in patients with 213 Subarachnoid hemorrhage, TdP potential and 230 Sudden cardiac death antiarrhythmic drugs and 309 athletes and 283 electrophysiology studies and risk assessment for 290 nocturnal, Brugada syndrome and 224 primary and secondary prevention of 236–239 Supraventricular tachyarrhythmias 115–185 atrial arrhythmias 116–121 atrial flutter 154–164 atrioventricular nodal reentry tachycardia 164–170 junctional tachycardia 171–172 preexcitation syndromes 173–185 Supraventricular tachycardia acute and chronic management of 185 athletes and 285 carotid sinus massage and 289 diagnosing 111 inappropriate ICD shock for 265 rapid paced ventricular rates and 250 right bundle branch block and 59 74769_IDXx_Printer.indd 339 339 ventricular tachycardia vs.: LBBB morphology criteria 111, 113 ventricular tachycardia vs.: RBBB morphology criteria 111, 113 Sustained monomorphic VT, reducing risk of recurrent episodes 237 Sustained ventricular tachycardia 195–209 acute management, stable and unstable 208 approach to management 203–204 acute management 203–204 chronic management 204 associated conditions 200–201 clinical presentation and symptoms 201 description 195 management of 205–207t acute therapy 205t acute therapy, MI 205t acute therapy, polymorphic VT 206t chronic prevention 206t prior MI, ischemia can be provoked 207t SVT See Supraventricular tachycardia Swimming, sudden death in athletes and 284 Syncope 294–295 approach to evaluation and management 295 defined 294 etiologies 294–295 Systolic heart failure, permanent cardiac pacing for 260 T-achyarrhythmias, preventing, permanent cardiac pacing for 259 Tachy-brady syndrome 6, atrial tachycardia and 119, 120t automatic atrial tachycardia and 121, 123t clinical symptoms and presentation junctional rhythm and 101 permanent pacemaker implantation for 139 permanent pacing and 10 sinus pause/arrest and 18 Tachycardia 106–114 30/04/11 1:34 AM 340 Arrhythmia Essentials automaticity 107 DADs 107 double 54 EADs 107 narrow QRS complex 108–109 pacemaker-mediated 252 reentry 107–108 triggered activity 107 ventricular 110 wide QRS complex 109, 111, 114 TdP See Torsades de pointes TdP VT See Torsades de pointes ventricular tachycardia TEE See Transesophageal echocardiography Temporary transvenous pacemaker, symptomatic-chronic sinus node dysfunction and 12t Tetracycline, digitalis toxicity and 270 Tetralogy of Fallot, management of 234t Theophylline junctional rhythm and 103t myocardial infarction, Mobitz type I second-degree AV block and 34t palpitations and 291 Third-degree (complete) AV block 47–51 acquired complete AV block with wide QRS ventricular escape 50 approach to management 51 associated conditions 47–51 caveats 52 clinical symptoms and presentation 51 complete AV block during atrial fibrillation 50 congenital complete AV block with narrow QRS complex junctional escape rhythm 49 description 47 evaluation/treatment of, reversible causes 55 isorhythmic AV dissociation 49 Thromboembolic risk, assessing 139, 141t Torsades de pointes 107, 202, 259, 299 catecholamine-dependent form of 201 74769_IDXx_Printer.indd 340 description 187 drug- and metabolic-induced 230, 229, 231, 232 Torsades de pointes ventricular tachycardia approach to management 189 description of and acute treatment for 227 Tracking rate, of pacing system 242 Transcutaneous pacing, symptomatic-acute sinus node dysfunction and 11t Transesophageal echocardiography, endocarditis, first-degree AV block management 28t Transvenous cardiac pacing, temporary, indications for 258 Treadmill exercise testing, arrhythmia evaluation and 289 Tricyclic antidepressants Brugada syndrome and, avoidance of 227 TdP potential and 231 Trifascicular block 75–78 with alternating LAFB and LPFB in setting of RBBB 76 approach to management 75 associated conditions 75 clinical symptoms and presentation 75 description 75 evaluating causes for 78 management of 77t Trigeminy, premature ventricular complexes with 87 Triggered atrial tachycardia 107, 118 Trimethoprim-sulfamethoxazole, TdP potential and 231 2:1 AV block See Second-degree AV block-2:1 AV block Type I sinoatrial (SA) exit block 14, 15 therapy for 16t Type II sinoatrial (SA) exit block 14, 15 therapy for 16t U-ndersensing, pacing system 242 Undersensing (failure to sense) 248 Unifascicular block 66 approach to management 67 associated conditions 67 30/04/11 1:34 AM Index clinical symptoms and presentation 67 description 66 “Upper loop reentry” tachycardias 158 Upper rate limit, of pacing system 242 Upper rate pacing, with atrial tachycardia 251 V -agotonic AV block 31 Vagotonic drugs, Brugada syndrome and, avoidance of 227 Valvular heart disease, ventricular fibrillation and 212 Vanillylmandelic acid 22 Vasopressin oral, POTS management and 25 ventricular fibrillation and 214 Ventricular arrhythmias ischemic cardiomyopathy and 213, 214 management of specific syndromes 232–236t arrhythmogenic right ventricular cardiomyopathy (dysplasia) 234t bidirectional VT 235t catecholaminergic polymorphic VT 235t hypertrophic cardiomyopathy 233t long QT syndrome 236t prior MI, discrete LV aneurysm or scar 232t structural heart disease 232t Tetralogy of Fallot 234t nonischemic cardiomyopathy and 214, 215–216 palpitations evaluation and 291 primary and secondary prevention of sudden cardiac death 236–239 in structurally normal hearts 219–239 Brugada syndrome 224–227 catecholaminergic polymorphic VT 227 drug- and metabolic-induced Torsades de pointes 230, 231–232 idiopathic left ventricular or fascicular tachycardia 221 long QT syndrome 221–224 outflow tract VTs 219, 220 74769_IDXx_Printer.indd 341 341 Ventricular escape rhythm, therapy for 97t Ventricular fibrillation 209–213, 210, 211 approach to management 212–213 associated conditions 212 atrial fibrillation with preexcitation degenerating to 180 description 209 digitalis toxicity and 271 fine vs course 229 Ventricular fibrillation mimic: artifact 212 Ventricular hypertrophy palpitations evaluation and 291 sudden death in athletes and 284 Ventricular pacing, normal, (VVI or VVI(R)) 244 Ventricular preexcitation description 173 forms of 178, 180 Ventricular rate control in AFL vs in AF 161 mainstays of 137–138 Ventricular tachyarrhythmias 186–236 nonsustained 187–194 in setting of structural heart disease 214–219 ARVC 217–219 hypertrophic cardiomyopathy 215–216 primary and secondary prevention of sudden cardiac disease 236–239 ventricular arrhythmias associated with ischemic cardiomyopathy 214 ventricular arrhythmias associated with nonischemic cardiomyopathy 214–215 ventricular arrhythmias in structurally normal hearts 219–239 specific ventricular arrhythmia syndromes 213, 233–236t sustained 195–209 ventricular fibrillation 209–213 Ventricular tachycardia 110, 196 defined 111, 187 30/04/11 1:34 AM 342 Arrhythmia Essentials digitalis toxicity and 271 electrophysiology studies and 290 right bundle branch block and 59 supraventricular tachycardia vs.: LBBB morphology criteria 111, 113 supraventricular tachycardia vs.: RBBB morphology criteria 111, 113 Ventricular tachycardia mimic hyperkalemia 199 normal sinus rhythm with artifact 200 sinus tachycardia with BBB 198 Ventricular tachycardia mimic: antidromic reentry 178, 179 Ventricular tachycardias ICD shock for 263 Ventriculophasic sinus arrhythmia Verapamil accessory pathways, SVTs and, cautionary note 178 atrial fibrillation and 134, 137, 143t, 145t atrial flutter and 161 atrial tachycardia and 119t automatic atrial tachycardia and 122t AVNRT therapy and, cautionary note 168t for clinical arrhythmias, explanation and cautionary note 301–302 digitalis toxicity and 268 IV, narrow QRS complex tachycardia and 108 junctional rhythm and 101 orthodromic AVRT: acute therapy 183t PJRT therapy and 184t sinoatrial node reentrant tachycardia and 118 sustained VT, chronic prevention and 206t symptomatic sinus tachycardia therapy and 22t ventricular tachycardia and 189 Vernakalant atrial fibrillation and 137 for clinical arrhythmias 309 VF See Ventricular fibrillation VMA See Vanillylmandelic acid VOO rate 242 74769_IDXx_Printer.indd 342 VT See Ventricular tachycardia VVI mode, normal ventricular pacing VVI pacing states VVI(R) mode, normal ventricular pacing VVI(R) pacing system 244 241 244 243 W-andering atrial pacemaker (WAP) 4, 99–100, 100 approach to management 99 associated conditions 99 clinical symptoms clinical symptoms and presentation 99 description 99 multifocal atrial rhythm vs 101 Warfarin 161, 301–302 atrial fibrillation and 131, 133, 135, 139, 140, 142t atrial flutter therapy and 161t “Warm-up phenomenon,” bursts of monomorphic VTs and 111 Wearable cardioverter defibrillators (WCDs) 236 Wenckebach AV block, description 31 Wenckebach periodicity, atrial flutter and 158 Wide QRS high-degree AV block with 44 Mobitz type I second-degree AV block with 32 Mobitz Type II second-degree AV block with 36 2:1 AV block with 40 Wide QRS complexes atrial fibrillation therapy and 147t monomorphic ventricular tachycardia and 201 sinus bradycardia with Wide QRS complex tachycardia 109, 111, 114 approach to management 114 Brugada criteria algorithm for 111, 112 diagnosis of 109 morphology criteria for LBBB pattern 111, 113 morphology criteria for RBBB pattern 101, 113 30/04/11 1:34 AM Index Wide QRS ventricular escape rhythm, acquired complete AV block with 50 Wolff-Parkinson-White (WPW) syndrome 174, 175 adenosine, atrial fibrillation and, cautionary note 109 athletes and 283 atrial fibrillation and 130, 147t intermittent preexcitation in patient with 177 with left sided accessory pathway (fused preexcitation) 176 74769_IDXx_Printer.indd 343 343 palpitations evaluation and 292 radiofrequency ablation and 312 reentry and 107 right bundle branch block vs 59 syncope and 295 Y-ohimbine palpitations and 292 POTS management and 24 Young adults, ectopic atrial rhythm in 98 30/04/11 1:34 AM ... Cataloging-in-Publication Data Arrhythmia essentials / Brian Olshansky [et al.] p ; cm Includes bibliographical references and index ISBN 978-0-7637-7476-9 Arrhythmia I Olshansky, Brian [DNLM: Arrhythmias,... PM Preface v PREFACE Arrhythmia Essentials is a comprehensive, yet practical handbook that provides an approach to patients who have cardiac arrhythmias, including those arrhythmias that occur... Abnormal Rhythms 30/04/11 1:13 AM Arrhythmia Essentials Figure 1.2 Normal Sinus Rhythm with Sinus Arrhythmia This lead II rhythm strip shows normal sinus rhythm with sinus arrhythmia, in which the P-P