Sinus arrhythmia
- P for every QRS but R-R varies
- All PQRS complexes look the same--rate is just what is varying
- SA node rate varies w/ respiration
- HR increases w/ inspiration, decreases w/ exhalation
- Vagal tone--fit, brachycephalic, chronic bronchitis
- Eye/abdominal surgery
- Atropine
- No treatment required
- Not normal in cats--only dogs
- All PQRS complexes look the same--rate is just what is varying
- HR increases w/ inspiration, decreases w/ exhalation
- Atropine

Wandering atrial pacemaker
- P waves from outside SA node
- Variable morphology/amplitude of P wave
- Usually goes in nice wave pattern (+, -, +, etc.)
- Variable P-R interval
- Increased vagal tone usually
- No hemodynamic consequences--no treatment
- Usually goes in nice wave pattern (+, -, +, etc.)

Sinus bradycardia
- Rate
- Outside the heart--drugs, lytes, thyroid, vagal tone--eye/gut, respiratory, lesions, idiopathic (atropine test)
- Atropine test: kills vagal tone--> HR goes up
- Drugs: digoxin (causes any arrhythmia), xylazine, beta blockers, lidocaine
- Inside the heart--fibrosis, infect, trauma, neoplasia, idio
- Signs if > 6-8 s
- Exercise animal to make sure HR goes up (could just have a normally slow HR)
- Atropine test: kills vagal tone--> HR goes up
- Drugs: digoxin (causes any arrhythmia), xylazine, beta blockers, lidocaine
- Signs if > 6-8 s

Treatment for sinus bradycardia?
- Remove the cause
- Correct the drug dose/use
- Lower the K
- Treat the hypothyroid
- Atropine or glycopyrrolate test
- + = look for vagal problems
- Terbutaline/isoproterenol/isopropamide/ probanthine
- Need to counteract PNS--can't block it so increase SNS instead
- - = pacemaker if clinical
- Correct the drug dose/use
- Lower the K
- Treat the hypothyroid
- + = look for vagal problems
- Terbutaline/isoproterenol/isopropamide/ probanthine
- Need to counteract PNS--can't block it so increase SNS instead
- - = pacemaker if clinical
Pacemaker
- Pulse generator
- Pacing leads endo/epicardial
- Transvenous (through jugular vein--> bottom of right heart)
- Epicardial
- Transdiaphragmatic
- Demand; exercise
- Infection; scarring; twitching; arrhythmias; effusion
- Cannot re-use human pacemakers
- Transvenous (through jugular vein--> bottom of right heart)
- Epicardial
- Transdiaphragmatic
Sinus arrest
- Failure of SA node--1/more beats
- Drugs/lytes/vagal tone, etc. as before
- > 6 s = signs
- Atropine test, check lytes; treat as you would for sinus arrhythmia

Junctional (nodal)/ventricular escape beats
- Keeps circulation going to brain (keeping animal alive) when the sinus beat fails to materialize
- Normal QRS but no P wave = junctional
- Abnormal QRS + no P wave = ventricular
- Junctional escape will occur first, then ventricular (often if junctional doesn't work)

Which monitor can be used to record junctional/ventricular escape beats?
- Holter/cardiac event monitor--continuous recording, only remembers last 30-60 sec; hit button to record last minute to permanent memory
What is the treatment of junctional/ventricular escape beats?
Positive chronotropes/pacemaker
Hyperkalemia
- Renal failure; ATE; hyperadrenocorticism; crush
- Raises resting membrane potential--> heart fibrillates
- Bradycardia
- T waves tall
- P waves disappear
- Prolonged QRS
- Sinusoidal shape
- Bicarb/glucose, Ca glutonate for treatment
- Give fluids that don't contain K
- Boluses of glu better than insulin--glu raises insulin levels
- Bicarb works if underlying cause is acidemia
- Ca effusion to lower resting membrane potential
- T waves tall
- P waves disappear
- Prolonged QRS
- Sinusoidal shape
- Give fluids that don't contain K
- Boluses of glu better than insulin--glu raises insulin levels
- Bicarb works if underlying cause is acidemia
- Ca effusion to lower resting membrane potential

AV block
- Delay or failure of transmission at the AV node
- Outside heart--drugs, lytes, thyroid, vagus
- Inside--ischemia, -itis, neo, trauma, genes, idio
1st degree AV block
- PR > 0.13s/0.09s
- Usually drugs or vagal tone
- No treatment--monitor
- Usually drugs or vagal tone

2nd degree AV block--Mobitz type I
- Intermittent failure of conduction
- Mobitz type I
- PR interval increases until QRS dropped--Wenkebach
- Vagal tone/drugs
- P wave consistent = sinus perfectly fine
- QRS not responding consistently = intermittent AV block
- Can hear clinically--watch chest to differentiate from sinus arrhythmia
- PR interval increases until QRS dropped--Wenkebach
- Vagal tone/drugs
- QRS not responding consistently = intermittent AV block

2nd degree AV block--Mobitz type II
- No PR changes before dropped QRS
- Node disease
- Ratio-- P : QRS

2nd degree AV block--high grade node disease
- Can't tell if it's Mobitz type I or II
- Only 1 normal beat before dropped beat
- High grades more likely to develop into type III down the road (= BAD) --> poor prognosis

3rd degree AV block
- No AV conduction
- P waves and escape beats
- AV/junctional (40-60 bpm)
- Ventricular < 40 -- bizarre-looking
- Completely independent of each other
- Give atropine test, check lytes
- Usually ends up being disease of AV node
- Damaged--> replaced by fibrous tissue
- AV/junctional (40-60 bpm)
- Ventricular < 40 -- bizarre-looking
- Completely independent of each other
- Usually ends up being disease of AV node
- Damaged--> replaced by fibrous tissue

What is the treatment for AV block?
- Treat the cause--stop dig, treat itis
- If symptomatic try drugs if responsive to atropine test
- Emergency isoproterenol/dopamine IV (if responsive to atropine)
- If not atropine responsive:
- Pacemaker--inc. survival over 6 months
- Need for grade III
- Won't always show clinical signs (ex: old dogs who don't exercise)
-
Pay attention to dogs with low heart rates during physical exams--normally nervous/excited
- Pacemaker--inc. survival over 6 months
- Need for grade III
- Pay attention to dogs with low heart rates during physical exams--normally nervous/excited

Sick sinus syndrome
- Abnormal sinus node and AV system
- Sinus bradycardia
- Intermittent sinus arrest/AV block
- Paroxysms of tachycardia
- Intermittent weakness/syncope
- Send home w/ monitor
- Drugs??--ventricular demand pacemaker
- Can't use drugs to treat both--one will make the other worse
- Pacemaker to treat sinus arrest, then drugs to control tachycardia
- Sinus bradycardia
- Intermittent sinus arrest/AV block
- Paroxysms of tachycardia
- Send home w/ monitor
- Can't use drugs to treat both--one will make the other worse

Sinus tachycardia
- Increased HR-- > 160-180bpm/240bpm
-
Normal P QRST
- No arrhythmia, HR just too fast
- Physiological--fear, pain
- Pathological--fever, anemia, thyroid
- Anemia--heart beat is stronger--heart must pump fewer # of RBCs harder/faster to effectively reach tissues; "waterhandle" pulses
- Common in cats with hyperthyroidism
- No arrhythmia, HR just too fast
- Anemia--heart beat is stronger--heart must pump fewer # of RBCs harder/faster to effectively reach tissues; "waterhandle" pulses
- Common in cats with hyperthyroidism

SPD's and sinus tachycardia
- Premature
- Part of the atrium depolarizes spontaneously--> can become pacemaker--> premature depolarization
- Variable P
- May be buried in T wave
- Normal QRS
- Lab/boxer--8y--66% heart disease
- Cardiomyopathy
- Neoplasia
- Re-entry
- Part of the atrium depolarizes spontaneously--> can become pacemaker--> premature depolarization
- Cardiomyopathy
- Neoplasia
- Re-entry

Diagnosis?

Supraventricular premature depolarization

What are the signs/treatment of sinus tachycardia?
- Signs occur if CO falls
- Weakness, syncope
- Treat the underlying cause
- Slow the heart
- Emergency--esmolol/diltiazam (slow; BP)
- Thump on chest, vagal maneuvers, cardioversions
- Maintenance--sotalol (oral, BID)/diltiazem
- Pathway ablation
- Weakness, syncope
- Emergency--esmolol/diltiazam (slow; BP)
- Thump on chest, vagal maneuvers, cardioversions
- Maintenance--sotalol (oral, BID)/diltiazem
- Pathway ablation
Ventricular premature depolarizations (contractions)
- Ectopic focus--ventricle
- Hypertrophy, inflammation, trauma, hypoxia, drugs, systemic conditions, anesth., etc.
-
QRS--premature + no P wave
- Wide and bizarre
- Junctional escape beats--premature = occurs after very short beat
- Wide and bizarre

Triplets and fusion beats--what do they look like?
- Mix of P wave and ectopic focus
- Might look like multiple lesions-->look for P wave to ensure fusion beat

What is this an example of?

Bigeminy
What is this?

Doublets
What are the VPD signs?
- Dropped heart sounds
- Irregular pulse
- Dropped pulses
- Rarely--weakness/syncope
- Commoner--sudden death
- Not no's
- Runs R-on-T
- Not no's
- Runs R-on-T

VPD treatment?
- Underlying disorders
- Specific therapy
- If symptomatic**
- If heart disease
- Boxer cardiomyopathy
- Doberman w/ DCM
- Aortic stenosis
- Hypertrophic cardiomyopathy
- High rate, R-on-T, too many
- If symptomatic**
- If heart disease
- Boxer cardiomyopathy
- Doberman w/ DCM
- Aortic stenosis
- Hypertrophic cardiomyopathy
- High rate, R-on-T, too many
Drugs for VPD?
-
In emergencies--parenteral
- Lidocaine
- Boluses--CRI--K and Mg?
- Procainamide--IV, IM, SC
- Esmolol IV then sotalol/propranolol
- Magnesium
- Amiadarone?
- Non-emergency/when stable
- Sotalol--contractility? (Boxers w/ ARVC)
- Mexiletine (+ beta blocker) (Dobies w/ DCM)
- Sotalol and mexiletine, beta blocker--contractility? SAS Procainamide
- Lidocaine
- Boluses--CRI--K and Mg?
- Procainamide--IV, IM, SC
- Esmolol IV then sotalol/propranolol
- Magnesium
- Amiadarone?
- Sotalol--contractility? (Boxers w/ ARVC)
- Mexiletine (+ beta blocker) (Dobies w/ DCM)
- Sotalol and mexiletine, beta blocker--contractility? SAS Procainamide
What is the treatment for VPD in cats?
- Correct underlying causes
- Initial control--propranolol/atenolol
- 2nd = lidocaine--low dose boluses--CRI
- Procainamide/quinidine
- Sotalol? Amiodarone?
- Maintenance
- Oral propranolol/atenolol
- Procainamide, quinidine
- Mexiletine
- Oral propranolol/atenolol
- Procainamide, quinidine
- Mexiletine