Bahir Dar University
College of Medicine and
Health Sciences
Department of
Pharmacy
Integrated Therapeutics
2
Arrhythmia
Submit to: Endalamaw Aschale ( B.Pharm, MSc )
Submission date:7/06/2017
2
GROUP MEMBERS
1. Mastewal Dagninet BDU1404608
2.Mekdelawit kassaye BDU1405051
3. Melkamu Fasikaw BDU1404583
4.Mengesha Kassaw BDU1403653
5. Mulualem yihunie BDU 1404208
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Arrhythmia
Arrhythmia
02/15/2025
Outline
4
Introduction
Definition
Etiology
Pathophysiology
Types
Clinical Presentation
DIAGNOSIS
Treatment
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Introduction
5
Arrhythmia is loss of cardiac rhythm, especially
irregularity of heartbeat
Can be physiological as well as pathological
Arrhythmias may require treatment if:
Rhythms that are too rapid, too slow, or
asynchronous leading to reduced cardiac output
Has potential to precipitate more serious or
even lethal rhythm disturbances
Asymptomatic or minimally symptomatic
arrhythmias should not be treated with drugs
Anti-arrhythmic drugs can precipitate lethal
arrhythmias 02/15/2025
Definition
6
Cardiac arrhythmia is a group of conditions
in which the electrical activity of the heart is
irregular or is faster or slower than normal
occur when the heart’s electrical
impulses are generated or conducted
abnormally.
Although many arrhythmias may be
asymptomatic, some can lead to
symptoms (e.g. palpitations, dizziness,
syncope complications (stroke, heart
failure, sudden cardiac death).
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Etiology of cardiac arrhythmias
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Abnormal rhythmicity of the pacemaker
Shift of the pacemaker from the sinus
node to another place of the heart
Blocks of different points in the spread of
the impulse through the heart
Abnormal pathways of impulse
transmission through the heart
Spontaneous generation of spurious
impulses in almost any part of the heart.
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Pathophysiology of
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Arrhythmia
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Cardiac Arrhythmias: Types
10
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Heart block
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I. Block at the level of AV node
A. First degree heart block: every atrial
depolarization is followed by conduction to
ventricle but delay. ECG changes
prolongation of PR interval to more than
0.22 second
B. Second degree heart block: some P waves
conducted but other not. ECG changes every
second or third P wave conducted to the
ventricles
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12
C. Third degree heart block (complete heart block)
Rate: Atrial: 60–100 bpm; ventricular: 40–60 bpm
Rhythm: Usually regular, but atria and ventricles
act independently. It occurs when all atrial activity
fails to conduct to the ventricle so the Bundle of
His will be responsible form generation of
impulses.
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13
Caused by:
Acute myocardial infarction, calcify aortic
stenosis, cardiomyopathy, drugs (digoxin).
Block below AV node:
A. block at Bundle of His
B. Block at the branches (Right or Left
branch)
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Sinus rhythm
14
It is caused by the changes of number of impulses emitted
form SA node. Heart rates more than 100/min is called
(tachycardia), while less than 60/min is called
(bradycardia). It is usually of two types:
1. Sinus bradycardia:
Causes:
A. Extrinsic causes: hypothermia, hypothyroidism,
and raised intra cranial pressure, drugs (beta-blockers,
digitalis, and anti-arrhythmic drugs).
B. Intrinsic causes:
acute ischemia, infarction of SA node. ECG changes:
Prolonged R-R interval.
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Sinus rhythm...
15
2. Sinus tachycardia: causes A. acute
causes:
exercise, emotion, pain, fever, acute heart
failure,
B. chronic causes: pregnancy, anemia,
hyperthyroidism, excess catecholamine.
ECG:
short R-R interval.
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Ectopic beat (premature beat)
16
A premature contraction is contraction of
heart before the time that normal
contraction would have been expected.
Most premature contraction result from
ectopic foci in the heart, which emits
abnormal impulses at odd time during
cardiac rhythm.
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17
Possible causes of ectopic foci
Local area of ischemia
Small calcified plaques at different points in the
heart, which press against the adjacent cardiac
muscle so some fibers are irritated
Toxic irritation of the AV node, Purkinje system,
or myocardium caused by drugs, nicotine, or
caffeine. If an irritable ectopic focus discharges
once, the result is ectopic beat. If the ectopic foci
discharge repetitively at rate higher than that of
SA node, it produces rapid, irregular tachycardia
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Ectopic beat...
18
It could be:
1. Atrial ectopic: The ECG changes are:
The P wave of this beat occurs too soon in the
heart cycle,
The P-R interval is shortened, indicating that
the ectopic origin of the beat is near the A-V
node
The interval between the premature and the
next
succeeding contraction is slightly prolonged,
which is called (compensatory pause).
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Ectopic beat...
19
2. ventricular ectopic:
ECG changes:
Premature beats that originate in an
ectopic ventricular focus usually have
bizarrely shaped prolonged and high
voltage QRS complex
The P wave is usually buried in the QRS of
the extra-systole
The T wave has an electrical potential
polarity opposite to the QRS
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Tachy arrhythmias:– Defined by a resting
heart rate exceeding 100 bpm.
Brady arrhythmias:– Defined by a resting
heart rate below 60 bpm in adults.
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Tachy-arrhythmia
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Cardiac arrhythmia is a disturbance in
electrical rhythm of the heart; this may be
paroxysmal or continuous, and may cause
sudden death, syncope, heart failure
palpitation, or no symptoms. There are two
mechanisms for tachycardia:
1. Increase automaticity (increase slop
angle): when the tachycardia is sustained by
repeated spontaneous de-polarization of an
ectopic focus or single cell.
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Tachy-arrhythmia...
22
There are two mechanisms for tachycardia:
1. Increase automaticity (increase slop
angle): when the tachycardia is sustained by
repeated spontaneous de-polarization of an
ectopic focus or single cell.
2. Re-entry: when the tachycardia is initiated
by an ectopic beat but sustained by a closed
loop or re-entry circuit. Most tachy-
arrhythmias are due to re-entry.
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Tachy-arrhythmia...
23
Causes of re –entry(circus movement)
• Long pathway around the circle
• Decreased velocity of conduction
• Shortened refractory period of the
muscle
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Tachy-arrhythmia...
24
The types of tachy-arhythmias are:
I. Atrial tachy-arrhythmias:
Causes: ischemic heart disease, Mitral
valve
disease, rheumatic heart disease,
hypertension,
cardio-myo-pathy, thyro-toxicosis, atrial
septal
defect, acute and chronic alcohol abuse
pulmonary embolus. 02/15/2025
Tachy-arrhythmia...
25
A. Atrial fibrillation: ECG: normal but
irregular
QRS, there are no P waves but base line
may
show irregular fibrillation waves.
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Tachy-arrhythmia...
26
B. Atrial flutter: ECG: regular saw-tooth-
like atrial flutters waves (F waves)
between QRST complexes; with rate about
300 beat/min. the QRS conducted150 if
every other one is conducted.
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Tachy-arrhythmia...
27
C. Atrial tachy-cardia: An ectopic arial
tachycardia due to increase automaticity
is
rare but is sometimes is manifestation of
digitalis toxicity. Rate: 150–250 bpm,
Rhythm: Regular P Waves: Normal
(upright
and uniform) but differ in shape from
sinus
P waves
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28
Tachy-arrhythmia...
II. Ventricular tachy-arrhythmia:
A. Ventricular tachycardia: it is usually a serious condition
because:
This type of tachycardia dose not occurs unless
considerable ischemic damage is present in the ventricles
Ventricular tachycardia frequently initiates the lethal
condition of ventricular fibrillation
Cardiac output is decreased. The ECG changes including: a
series of ventricular premature beats occurring one after
another without any normal beat interspersed so QRS
morphology is regular, the rate is between (140-220/min).
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Tachy-arrhythmia...
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B. Ventricular fibrillation:
The effects of ventricular fibrillation: The fibrillating
ventricles, like the fibrillating atria, look like a quivering
"bag of worms". The fibrillating ventricles cannot pump
blood effectively and circulation of the blood stops.
ventricular fibrillation that last more than a few
minutes is fatal.
The most common cause of sudden death in patients
with myocardial infarction is ventricular fibrillation.
The ventricular fibrillation can often be stopped and
converted to normal sinus rhythm by mean of electrical
shock.
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Clinical Presentation
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▶ Supraventricular tachycardias:
▶No symptoms to minor palpitations or
irregular pulse to severe and even life-
threatening symptoms
▶Dizziness or acute syncopal episodes,
symptoms of HF, anginal chest pain, or a
choking or pressure sensation during the
tachycardia episode
▶ AF or atrial flutter:
▶Similar to SVTs, but syncope is uncommon
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▶Embolic stroke
DIAGNOSIS
31
The surface electrocardiogram (ECG) is
the cornerstone of diagnosis for cardiac
rhythm disturbances.
Proarrhythmia can be difficult to
diagnose because of the variable nature
of underlying arrhythmias.
TdP is characterized by long QT intervals
or prominent U waves on the surface
ECG
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32
Specific maneuvers may be required to
delineate the etiology of syncope associated with
bradyarrhythmias.
Diagnosis of carotid sinus hypersensitivity can be
confirmed by performing carotid sinus massage
with ECG and blood pressure monitoring.
Vasovagal syncope can be diagnosed using the
upright body-tilt test.
AV block is usually categorized into three
different types (first-, second-, or third-degree AV
block).
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Clinical Presentation
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▶ Premature Ventricular Contractions:
▶Mild palpitations
▶ Ventricular tachycardia:
▶Totally asymptomatic to pulseless hemodynamic
collapse
▶ Ventricular proarrhythmia:
▶No symptoms to worsening of symptoms to
sudden death
▶ Ventricular Fibrillation:
▶Hemodynamic collapse, syncope, and cardiac
arrest 02/15/2025
Clinical Presentation
34
▶ Brady-arrhythmias
▶Symptoms suggestive of hypotension:
dizziness, syncope, fatigue, and
confusion
▶Associated with LV dysfunction:
worsening HF symptoms.
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Treatment Objectives
35
▶ Do not treat asymptomatic arrhythmias
▶ Aim of therapy:
▶Reduce ectopic pacemaker activity
▶Blockade of Na+ or Ca2+ channels,
beta receptor blockade
▶Modify conduction or refractoriness
in reentry circuits to disable circus
movement
▶ Additional objectives:
▶Prevent future episodes of 02/15/2025
arrhythmias
Treatment options of
Arrhythmia
36
General Information
▶ General
Information
Non-
pharmacologica ▶All arrhythmias
▶ Non-
l treatment need not be treated
pharmacologi
▶ Physiological
cal treatment
Pharmacological
arrhythmias
treatment
subsides by itself
▶
Pharmacologic
Referral
al treatment
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Treatment options of
Arrhythmia
37
▶ General
▶ General
Surgical Procedures:
Information Information
Radiofrequency catheter
ablation
▶ Non-
Non-
▶Cryoablation
pharmacologi
pharmacologi
Permanent
cal treatment
pacemaker
cal treatment implantation
Implantable
▶
cardio-defibrillator
▶ Pharmacologic
Carotid sinus
Pharmacologic al treatment
massage
al treatment 02/15/2025
Treatment options of
Arrhythmia
38
▶ General
▶ General
Drugs to terminate an episode
Information Information
of arrhythmia
Drugs to prevent future
▶ Non-
▶ Non-
episodes of arrhythmia
pharmacologi pharmacologi
cal treatment caltotreatment
Drug prevent development
of complications
▶
Heart failure
▶
Pharmacologic
Haemodynamic collapse
Pharmacologic al treatment
Anti-thrombotic
al treatment 02/15/2025
Classification of antiarrhythmic agents
39
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Clinical Classification: Anti-2
40 dysrhythmic drugs 0
Supraventricular Supraventricular and ventricular Ventricular
arrhythmias only arrhythmias arrhythmias only
• Adenosine • Amiodarone • Procainamide • Lidocaine
• Verapamil, • β – blockers • Disopyramide • Mexiletine
• Sotalol • Quinidine
Diltiazem • Propranolol • Flecainide
• Dronedar • Esmolol • Propafenone
one
• Digoxin
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Arrhythmias and Choice of
41 treatment
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Arrhythmias and Choice of
42 treatment
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Clinical Relevance and Management
Overview
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Risk Stratification:
The classification (by rate, site,
mechanism) helps determine the urgency
and type of intervention.
Treatment Modalities:
Medication: Antiarrhythmic agents
(classified by their action on the cardiac
action potential), beta-blockers, calcium
channel blockers, and anticoagulants
(especially in AF).
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continued...
44
Device Therapy: Pacemakers for
bradyarrhythmias and implantable
cardioverter defibrillators (ICDs) for life-
threatening ventricular arrhythmias.
Interventional Procedures: Catheter
ablation to interrupt re-entrant circuits.
Lifestyle Modification: Addressing
triggers such as electrolyte imbalances,
ischemia, or substance use.
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Conclusion
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▶ Arrhythmia is loss of cardiac rhythm, especially
irregularity of heartbeat
▶Occurs due to improper impulse formation
and/or conduction
▶ Can present asymptomatically to life
threatening condition
▶ Non-pharmacological treatment is most
effective in arrhythmia
▶ Drugs act by inhibiting either of Na+, K+, Ca2+
ions or blocking beta receptors
▶ Amiodarone is used for multiple arrhythmias
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Reference
47
American Heart Association (AHA) –
www.heart.org
Mayo Clinic – www.mayoclinic.org.
National Heart, Lung, and Blood
Institute (NHLBI) – www.nhlbi.nih.gov
UpToDate (Subscription-based, but
reliable for medical professionals) –
www.uptodate.com
PubMed (NIH National Library of
Medicine) – www.pubmed.ncbi.nlm.nih.gov
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