PACs

PVCs

Found in the neck

Associated with pounding in the neck

Due to dissociation of atrial and ventricular contractions

• Short PR 
• Delta wave 

• Generally benign and do not require treatment 
• Occasionally might need a beta-blocker 

• Treatment is aimed at eliminating the cause of tachycardia

• Patients with this usually have a history of excercise, anxiety, febrile illness, dehydration, anemia, hyperthyroidism...etc. 

• Emergent:  If hemodynamically compromised, emergent DC cardioversion is indicated 
• Urgent:  Focus is on rate control + anti-coagulation

               -Beta-blockers + Ca++ channel blockers are used (IV)

               -Digoxin in patients ONLY w/systolic HF

• Non-urgent:  Cardioversion → if that fails → rate control + anticoagulation (Beta-blockers or CCB +/- digoxin in systolic failure) → amiodarone if rate not controlled → anti-coagulation to prevent thromboembolism (ASA + Warfarin/dabigatran/aixaban/rivoroxaban) 
• Elective cardioversion, anti-arrhythmics, surgical treatment of Atrial Fib 

Can perform safely in symptomatic if:

• First episode is less than 48 hours or..
• Patient has been on anti-coagulants for 3 weeks prior
• Patient has a TEE immediately prior to cardioversion that shows a lack of thrombus 

Patient MUST remain on anti-coagulatant for 4 weeks after cardioversion until mechanical atrial function normalizes

• Ibutilide (Class III)
• Amiodarone (Class III)
• Additional agents are Class-1C drugs (flecainide and propafenone) and Class-III drugs (amiodarone, dronederone, dofetilide) 

• Surgical maze procedure (requires opening of the chest), only done with open heart surgery
• Catheter ablation
• AV-nodal ablation + pacemaker implantation (last resort therapy for reduction of symtoms in refractory A-fib).  Completely eliminates conduction through AV-node and causes life-long pacemaker dependency.  

***More difficult to control than atrial fib***

• Atrial flutter ablation HIGHLY successful; preferred over long-term anti-arrhythmic drugs 
• Beta-blockers, Ca channel blockers +/- digoxin for rate control 
• DC cardioverion for hemodynamically unstable 
• Chemical cardioversion w/amiodarone or ibuilide 
• Antri-arrhythmic drugs (but remember these have a lot of toxicities) 

• Beta-blockers + Ca channel blockers for rate control 
• Cardioversion or anti-arrhythmic (rare) 

• Acute treatment is sustained w/IV-adenosine
• Chronic treatment w/daily Beta-blocker or Ca-channel blocker
• Catherter ablation is effective and realatively low risk and preferrered to anti-arrhythmics 
• Class-1C anti-arrhythmics are preferred if you are going to use anti-arrhythmics 

• AV-Nodal Reentrant Tachcardia (flecainide) if catheter ablation is not effective or unable to be used 

Wide complex, fast, irregular rhythm in young patient is probably WPW w/A-fib and MUST be treated aggressively

• Acute:  IV-Procainamide for acute termination (DC cardioversion is an option) 

AVOID AV-nodal blocking medication such as beta-blockers, Ca-channel blockers, digoxin, and ESPECIALLY ADENOSINE in acute AVRT due to risk of accelerating the arrhythmia through the accessory pathway 

• Chronic:  When in sinus rhythm, low dose daily beta-blocker can be a preventative medication 
• Definitive:  Ablation is very effective and preferred over anti-arrhytmics 

• Threshold for therapy is very high b/c this is usually benign 
• Chronic beta-blocker therapy can be initiated if symptoms are servere 

• Urgent or emergent synchronized cardioversion of wide-complex tachycardia 
• IV-magnesium (if hypomagnesemia)
• Hypokalemia can also cause this 
• Definitive:  ICD should be considered in patient's with structural heart disease 

***Treat this because this can become torsades de pointes after having a prolonged QT syndrome***

• Premature atrial contractions (PACs)
• Premature ventricular contractions (PVCs) 

• Emergent:  If hemodynamically compromised DC cardioversion indicated
• Urgent:  Focus on rate control w/ beta-blockers/calcium channel blockers or digoxin ONLY in patients w/systolic heart failure 
• Non-urgent: Oral beta-blockers or CCB +/- digoxin, amiodarone (if other measures fail).  Anticoagulation to prevent thromboembolism (ASA, warfarin, dabigatran, apixaban, rivoroxaban) 
• DC Cardioversion 
• Anti-arrhythmics: chemical cardioversion w/IV ibutilide or amiodarone (class-III). Or additional oral agents for sinus rhythm w/class-1C (flecainide or propafenone) and class-III (amiodarone, dronederone, dofetilide).  Do NOT use class 1C w/structural heart disease of prior MI 
• Surgical treatment:  Surgical maze procedure, catheter ablation, AV-nodal ablation w/pacemaker

Atrial-flutter 

**These patients are going to be more symptomatic and maintain higher heart rates than pts w/A-fib**

• Narrow complex 
• Inverted P-wave in II, III, and aVF 
• RP < PR 

• Wide complex 
• AV dissociation (p-wave independent of QRS) 
• Negative concordance (all precordial QRS deflections are in the same direction)
• Axis is -90 to -180 in the prescence of LBBB morphology
• Fusion or capture beats 

Suggests supraventricular trachycardias such as:

AV-nodal tachycardia 

Bypass track tachycardia

Supra-ventricular arrhythmias:

• AV-nodal tachycardia 

Ventricular pre-mature depolarization

AV-Nodal tachycardia (AVNRT)

***This is NOT the same thing as AVRT which is going to have the "frog neck" and cannon-A wave***

Most likely:

• Supraventricular tachycardia w/bypass tract (WPW)
• AV-nodal tachycardia 

• Atrial tachycardia 
• Atrial fibrillation 

• Paroxysmal supraventricular tachycardia 
• Ventricular tachycardia 

• Atrial fibrillation
• Atrial flutter
• Tachycardia w/variable block 

Short PR interval

Delta waves

Left ventricular hypertrophy

Atrial premature depolarization 

Ventricular premature depolarization 

Left bundle-branch block w/positive axis

Idiopathic ventricular tachycardia 

Right ventricular outflow tract type 

Ventricular premature depolarizations

Right bundle-branch block 

Negative axis 

Idiopathic ventricular tachycardia 

Left ventricular type 

Ventricular premature depolarizations

Non-sustained or sustained ventricular tachycardia 

Ventricular premature depolarizations

Polymorphic ventricular tachycardia 

Inverted T wave in V2 

With or without epsilon wave

Acute treatment of AVNRT

**Do NOT confuse this with AVRT (WPW)**

The use of adenosine or any medication that blocks AV conduction in AVRT is actually contraindicated!!!