Re-entry ventricular arrhythmia - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
History of previous MI Cardiac arrhythmias are produced by one of three mechanisms which are enhanced automaticity, triggered activity, or reentry. When an impulse doesn't die after propagation and when it continues to excite the heart even when the refractory period ended causes re-entry induced arrhythmia . Atrial fibrillation, atrial flutter, atrioventricular (AV) nodal reentry, ventricular tachycardia after myocardial infarction (MI) and ventricular fibrillation are common arrhythmias which are produced by this mechanism. Atrioventricular reentrant tachycardia (AVRT) is a reentrant tachycardia which results due to having 2 pathways one being normal and the other one being an accessory pathway. Atrioventricular node re-entrant tachycardia (AVNRT) caused by re-entry within the the atrioventricular (AV) node. History of previous MI
Cardiac arrhythmias are produced by one of three mechanisms which are enhanced automaticity, triggered activity, or reentry. When an impulse doesn't die after propagation and when it continues to excite the heart even when the refractory period ended causes re-entry induced arrhythmia . Atrial fibrillation, atrial flutter, atrioventricular (AV) nodal reentry, ventricular tachycardia after myocardial infarction (MI) and ventricular fibrillation are common arrhythmias which are produced by this mechanism. Atrioventricular reentrant tachycardia (AVRT) is a reentrant tachycardia which results due to having 2 pathways one being normal and the other one being an accessory pathway. Atrioventricular node re-entrant tachycardia (AVNRT) caused by re-entry within the the atrioventricular (AV) node.
Feeding problems, Irritability, Increased sweating in an infant These symptoms suggestive of congestive cardiac failure in an infant because tachy-arrhythmia in an infant can cause heart failure. Feeding problems, Irritability, Increased sweating in an infant
These symptoms suggestive of congestive cardiac failure in an infant because tachy-arrhythmia in an infant can cause heart failure.
Palpitations Sensation of pounding of the heart is due to abnormal rhythm Palpitations
Sensation of pounding of the heart is due to abnormal rhythm
Light-headedness/ Syncope Due to cerebral hypo-perfusion due to extreme tachycardia Light-headedness/ Syncope
Due to cerebral hypo-perfusion due to extreme tachycardia
Chest pain Can be due to ischaemia or palpitations it self Chest pain
Can be due to ischaemia or palpitations it self
Anxiety Due to palpitations Anxiety
Due to palpitations
Sudden death catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited disease causing episodes of syncope, seizures, or sudden death Sudden death
catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited disease causing episodes of syncope, seizures, or sudden death

Clinicals - Examination

Fact Explanation
Tachycardia When caused by electrical reentry or abnormal automaticity and this results in tachycardia Tachycardia
When caused by electrical reentry or abnormal automaticity and this results in tachycardia
Hypotension Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia, and this could result in hypotension Hypotension
Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia, and this could result in hypotension
Tachypnoea Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and this could result in increased respiratory rate Tachypnoea
Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and this could result in increased respiratory rate
Diaphoresis Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion and resultant increased sweating Diaphoresis
Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion and resultant increased sweating
Pallor Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion and pallor Pallor
Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion and pallor
Diminished level of consciousness Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion to brain and diminished level of consciousness Diminished level of consciousness
Sometimes patients may present with haemodynamic instability due to prolonged arrhythmia, particularly tachycardia and reduced cardiac output due to tachycardia result in poor perfusion to brain and diminished level of consciousness
Elevated jugular venous pressure with cannon a waves This is only observed if sinus rhythm is preserved in atria Elevated jugular venous pressure with cannon a waves
This is only observed if sinus rhythm is preserved in atria
Murmers If the underlying pathology for arrhythmia is valvular diseases murmurs may be heard. Murmers
If the underlying pathology for arrhythmia is valvular diseases murmurs may be heard.
Displaced apex Due to cardiomegaly due to underlying ischaemic heart disease Displaced apex
Due to cardiomegaly due to underlying ischaemic heart disease
Rales on respiratory system examination If the arrhythmia leads to congestive cardiac failure, auscultation of lungs may reveal rales Rales on respiratory system examination
If the arrhythmia leads to congestive cardiac failure, auscultation of lungs may reveal rales
Varying intensity of the first heart sound Due to asynchrony of atria and ventricles. Varying intensity of the first heart sound
Due to asynchrony of atria and ventricles.

Investigations - Diagnosis

Fact Explanation
Electrocardiography (ECG This is important to diagnose the specific arrhythmia which could be atrial fibrillation, atrial flutter, atrioventricular (AV) nodal reentry, ventricular tachycardia or ventricular fibrillation Electrocardiography (ECG
This is important to diagnose the specific arrhythmia which could be atrial fibrillation, atrial flutter, atrioventricular (AV) nodal reentry, ventricular tachycardia or ventricular fibrillation
Echocardiography Echocardiography could be helpful to show any valvular defects, hypokinetic segments suggestive of previous MI, chamber size and function and ejection fraction. Echocardiography
Echocardiography could be helpful to show any valvular defects, hypokinetic segments suggestive of previous MI, chamber size and function and ejection fraction.
Cardiac imaging studies When echocardiography results are inconclusive, to detect structural heart diseases this is done Cardiac imaging studies
When echocardiography results are inconclusive, to detect structural heart diseases this is done
Monitoring devices Halter monitoring, implantation of a loop recorder are monitoring devices used to assess patients with history of syncope but when the resting ECG is normal Monitoring devices
Halter monitoring, implantation of a loop recorder are monitoring devices used to assess patients with history of syncope but when the resting ECG is normal
Myocardial biopsy This could be important to diagnose hypertrophic cardiomyopathy, arrhythmogenic right ventricular disease or sarcoidosis, amyloidosis Myocardial biopsy
This could be important to diagnose hypertrophic cardiomyopathy, arrhythmogenic right ventricular disease or sarcoidosis, amyloidosis
Electrophysiological studies (EPS) When a patient has a history of myocardial infarction, or has clinical symptoms of VT rarely these tests are done Electrophysiological studies (EPS)
When a patient has a history of myocardial infarction, or has clinical symptoms of VT rarely these tests are done

Investigations - Management

Fact Explanation
Electrocardiography (ECG) To assess for development of any other life threatening arrhythmias such as ventricular fibrillation, and to see the arrhythmias induced by drug therapy. Electrocardiography (ECG)
To assess for development of any other life threatening arrhythmias such as ventricular fibrillation, and to see the arrhythmias induced by drug therapy.
Echocardiography To assess for ejection fraction, for the possibility of congestive cardiac failure as consequence later Echocardiography
To assess for ejection fraction, for the possibility of congestive cardiac failure as consequence later
Liver function tests To see any amiodarone induced liver damage with long term amiodarone therapy Liver function tests
To see any amiodarone induced liver damage with long term amiodarone therapy
Chest x ray To see any amiodarone induced lung changes with long term amiodarone therapy Chest x ray
To see any amiodarone induced lung changes with long term amiodarone therapy
Thyroid profile To see any amiodarone induced hyper/hypothyroidism with long term amiodarone therapy Thyroid profile
To see any amiodarone induced hyper/hypothyroidism with long term amiodarone therapy
Venography Obstruction of the access vein is a known complication of both permanent pacemaker and implantable cardioverter defibrillation implantation, therefore this could be done prior to implantation Venography
Obstruction of the access vein is a known complication of both permanent pacemaker and implantable cardioverter defibrillation implantation, therefore this could be done prior to implantation
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen To assess fitness for anesthesia Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen
To assess fitness for anesthesia
Full blood count To exclude anaemia prior to any caridac surgery. Full blood count
To exclude anaemia prior to any caridac surgery.
Coagulation studies To exclude any coagulopathy prior to any cardiac surgery. Coagulation studies
To exclude any coagulopathy prior to any cardiac surgery.
Genetic testing for familial disorders Long QT syndrome, ARVD, or dilated or hypertrophic cardiomyopathy, Catecholaminergic Polymorphic Ventricular Tachycardia have inherited etiologies therefore, genetic testing is done. Genetic testing for familial disorders
Long QT syndrome, ARVD, or dilated or hypertrophic cardiomyopathy, Catecholaminergic Polymorphic Ventricular Tachycardia have inherited etiologies therefore, genetic testing is done.
Electrocardiography To see any features of long QT syndrome, Brugada syndrome in an asymptomatic patient who has a family history of VT or sudden death Electrocardiography
To see any features of long QT syndrome, Brugada syndrome in an asymptomatic patient who has a family history of VT or sudden death
Echocardiography To carry out screening in families who might be affected with hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy which may lead to VT Echocardiography
To carry out screening in families who might be affected with hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy which may lead to VT
Treadmill testing To see any features of exercise induced long QT syndrome, in an asymptomatic patient who has a family history of VT or sudden death Treadmill testing
To see any features of exercise induced long QT syndrome, in an asymptomatic patient who has a family history of VT or sudden death

Management - Supportive

Fact Explanation
Acute management of ventricular tachycardia in an unstable patient. Synchronized direct current (DC) cardioversion is used in patients with unstable monomorphic VT and unstable polymorphic VT is treated with immediate defibrillation Acute management of ventricular tachycardia in an unstable patient.
Synchronized direct current (DC) cardioversion is used in patients with unstable monomorphic VT and unstable polymorphic VT is treated with immediate defibrillation
Acute management with drugs in a stable patient with ventricular tachycardia Intravenous (IV) procainamide, sotalol, Lidocaine is used in a stable patient Acute management with drugs in a stable patient with ventricular tachycardia
Intravenous (IV) procainamide, sotalol, Lidocaine is used in a stable patient
Initial management in a hemodynamically stable patient with supraventricular tachycardia with vagal maneuvers Vagal maneuvers such as placing an ice bag to the face, which is considered effective in infants, Valsalva maneuver in adults are done. Carotid sinus massage is also effective. These result in reduction of tachycardia with vagal stimulation Initial management in a hemodynamically stable patient with supraventricular tachycardia with vagal maneuvers
Vagal maneuvers such as placing an ice bag to the face, which is considered effective in infants, Valsalva maneuver in adults are done. Carotid sinus massage is also effective. These result in reduction of tachycardia with vagal stimulation
Initial pharmacological therapy in a stable patient with supraventricular tachycardia Adenosine is the first-line agent with Procainamide and esmolol for resistant cases Initial pharmacological therapy in a stable patient with supraventricular tachycardia
Adenosine is the first-line agent with Procainamide and esmolol for resistant cases
Dietary management low-cholesterol diets, low-salt diets, or both are recommended for patients with VT. Avoidance of caffeine which is a stimulant is also advised. Dietary management
low-cholesterol diets, low-salt diets, or both are recommended for patients with VT. Avoidance of caffeine which is a stimulant is also advised.
Activity Increased sympathetic tone during strenuous physical exertion can stimulate a VT. Therefore it's better avoided Activity
Increased sympathetic tone during strenuous physical exertion can stimulate a VT. Therefore it's better avoided
Patient education patient education regarding nature, course, prognosis of disease, the precautions after starting anti arrhythmic therapy, or ICD implantation is needed. Patient education
patient education regarding nature, course, prognosis of disease, the precautions after starting anti arrhythmic therapy, or ICD implantation is needed.
Patient identification When a patient presents with syncope, cardiac arrest, patient identification with a bracelet/ diagnosis card is helpful for further management Patient identification
When a patient presents with syncope, cardiac arrest, patient identification with a bracelet/ diagnosis card is helpful for further management

Management - Specific

Fact Explanation
Anti arrhythmic drug therapy ACC/AHA/ESC guidelines recommend combination of amiodarone and beta blockers when symptoms do not respond to beta blocker or when there's myocardial infarction resulting in ventricular dysfunction. In patients with heart failure beta receptor–blocking drugs (metoprolol, carvedilol, and bisoprolol), Angiotensin-converting enzyme inhibitors (ACEI), Aldosterone antagonists are used Anti arrhythmic drug therapy
ACC/AHA/ESC guidelines recommend combination of amiodarone and beta blockers when symptoms do not respond to beta blocker or when there's myocardial infarction resulting in ventricular dysfunction. In patients with heart failure beta receptor–blocking drugs (metoprolol, carvedilol, and bisoprolol), Angiotensin-converting enzyme inhibitors (ACEI), Aldosterone antagonists are used
Radiofrequency catheter ablation Cardiomyopathy, bundle-branch block, and and myocardial infarction causing a dysfunctional ventricles benefit from this Radiofrequency catheter ablation
Cardiomyopathy, bundle-branch block, and and myocardial infarction causing a dysfunctional ventricles benefit from this
Implantable cardioverter defibrillator implantation When a patient has hemodynamically unstable VT, unexplained syncope, familial sudden death syndromes ICD implantation may be beneficial. Implantable cardioverter defibrillator implantation
When a patient has hemodynamically unstable VT, unexplained syncope, familial sudden death syndromes ICD implantation may be beneficial.

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