Cardiac DysrhythmiasCardiac DysrhythmiasOf Ventricular OriginOf Ventricular Origin

Ectopic Ventricular Ectopic Ventricular DysrhythmiasDysrhythmias

Premature Ventricular Premature Ventricular Contractions (PVC’s)Contractions (PVC’s)

Ventricular TachycardiaVentricular Tachycardia Ventricular FibrillationVentricular Fibrillation

Premature Ventricular Premature Ventricular ContractionsContractions

PVC’s Occur In Normal Hearts PVC’s Occur In Normal Hearts As Well As Those With PathologyAs Well As Those With Pathology

People With Thousands Of PVC’s People With Thousands Of PVC’s Per Day Can Be NormalPer Day Can Be Normal

PVC’s Can Also Be An Ominous PVC’s Can Also Be An Ominous Sign Of DiseaseSign Of Disease

Characteristics Of PVC’s Are :Characteristics Of PVC’s Are :PVC’s Are Premature BeatsPVC’s Are Premature BeatsThe P Wave Is AbsentThe P Wave Is AbsentQRS Complex Is Wide & BizarreQRS Complex Is Wide & BizarreA Compensatory Pause Follows A Compensatory Pause Follows

The PVCThe PVC

Premature Ventricular ContractionsPremature Ventricular Contractions

Premature Ventricular ContractionsPremature Ventricular Contractions

PVC’s May Appear RandomlyPVC’s May Appear Randomly PVC’s May Appear In PatternsPVC’s May Appear In Patterns

BigeminyBigeminyTrigeminyTrigeminy

BigeminyBigeminy

BigeminyBigeminy

TrigeminyTrigeminy

QuadrigeminyQuadrigeminyCoupletsCoupletsTripletsTriplets

CoupletsCouplets

TripletsTriplets

Couplets Are Scary But Triplets Couplets Are Scary But Triplets Are Really FrighteningAre Really Frightening

Triplets Are A Hair’s Breath Away Triplets Are A Hair’s Breath Away From Ventricular TachycardiaFrom Ventricular Tachycardia

Multiform PVC’sMultiform PVC’s

Rules Of MalignancyRules Of Malignancy

An Ordering System For An Ordering System For Grading The Severity Of Grading The Severity Of Ventricular EctopiesVentricular Ectopies

From Least Severe To From Least Severe To Most SevereMost Severe

Frequent Single Focus PVC’sFrequent Single Focus PVC’s Runs Of PVC’sRuns Of PVC’s

QuadrigeminyQuadrigeminyTrigeminyTrigeminy BigeminyBigeminy

Appearance Of Multifocal PVC’sAppearance Of Multifocal PVC’s RT On T PhenomenonRT On T Phenomenon Ventricular TachycardiaVentricular Tachycardia Ventricular FibrillationVentricular Fibrillation

RT On T PhenomenonRT On T Phenomenon

Thought To Be Very DangerousThought To Be Very Dangerous

A PVC Occurs During A PVC Occurs During Ventricular DepolarizationVentricular Depolarization

RT On T PhenomenonRT On T Phenomenon

Why Is It Dangerous ?Why Is It Dangerous ?• The Cardiac Cells Are Various The Cardiac Cells Are Various

Stages Of Depolarization - Some Stages Of Depolarization - Some Have Repolarized While Others Have Repolarized While Others Are In Various Stages Of Are In Various Stages Of RepolarizationRepolarization

• A Stimulus That Occurs Before A Stimulus That Occurs Before Repolarization Is Finished Will Set Repolarization Is Finished Will Set Off A Disorganized Electrical Off A Disorganized Electrical Response To The Stimulus & May Response To The Stimulus & May Set The Heart Up For A Malignant Set The Heart Up For A Malignant Ventricular Ectopy Like V-Tach Ventricular Ectopy Like V-Tach Or V-Fib.Or V-Fib.

ExerciseExercise

Can I Exercise A Patient Who Is Can I Exercise A Patient Who Is Having PVC’s ?Having PVC’s ?

Yes, You Can Exercise A Patient Yes, You Can Exercise A Patient Having PVC’s. However, They Having PVC’s. However, They Should Only Be Occasional Should Only Be Occasional Single Focus Single PVC’s.Single Focus Single PVC’s.

If The Exercise Regimen Makes If The Exercise Regimen Makes The Incidence Of PVC’s Occur The Incidence Of PVC’s Occur More Often Or If The PVC’s More Often Or If The PVC’s Become More Malignant, Become More Malignant, Exercise Should Be Terminated.Exercise Should Be Terminated.

A Person Should Not be A Person Should Not be Exercised When They Are Exercised When They Are Displaying Multiforme PVC’s Or Displaying Multiforme PVC’s Or Any PVC Rhythm (Bigeminy, Any PVC Rhythm (Bigeminy, etc.) Until Cleared By Their etc.) Until Cleared By Their CardiologistCardiologist

The ACSM GuidelinesThe ACSM Guidelines

The ACSM Guidelines State :The ACSM Guidelines State :If There Is A “Noticeable If There Is A “Noticeable Change In Heart Rhythm”….Change In Heart Rhythm”….

...or “Signs Of Poor Perfusion: ...or “Signs Of Poor Perfusion: Light Headedness, Confusion, Light Headedness, Confusion, Ataxia, Pallor, Cyanosis, Nausea, Ataxia, Pallor, Cyanosis, Nausea, Or Cold & Clammy Skin” Then Or Cold & Clammy Skin” Then

STOP THE EXERCISESTOP THE EXERCISE !!! !!!

Table 3-10, pp 42, 5Table 3-10, pp 42, 5th th editionedition

Ventricular TachycardiaVentricular Tachycardia

Ventricular Tachycardia Is Ventricular Tachycardia Is Defined As A Run Of Three Or Defined As A Run Of Three Or More Consecutive PVC’sMore Consecutive PVC’s

The Rate Is Usually Between The Rate Is Usually Between 100-200 BPM100-200 BPM

Short Runs Of V-Tach Will Short Runs Of V-Tach Will Make The Patient Feel :Make The Patient Feel :DizzyDizzyHave PalpitationsHave PalpitationsFeel FaintFeel FaintBe Short Of BreathBe Short Of Breath

Sustained Runs OF V-Tach Will Sustained Runs OF V-Tach Will Render The Patient Unconscious Render The Patient Unconscious Because The Cardiac Output Is Because The Cardiac Output Is So Negatively Effected As To So Negatively Effected As To Decrease Perfusion To The Brain Decrease Perfusion To The Brain & The Heart.& The Heart.

Ventricular TachycardiaVentricular Tachycardia

Ventricular Tachycardia Will Ventricular Tachycardia Will Degenerate Quickly Into Degenerate Quickly Into Ventricular FibrillationVentricular Fibrillation

The Patient In V-Tach Must Be The Patient In V-Tach Must Be Supported With CPR Methods & Supported With CPR Methods & Must Be Cardioverted Electrically Must Be Cardioverted Electrically Or Pharmacologically Out Of This Or Pharmacologically Out Of This Fatal RhythmFatal Rhythm

Both V-Tach & V-Fib Are Both V-Tach & V-Fib Are Absolute Medical Emergencies Absolute Medical Emergencies Requiring High Level Medical Requiring High Level Medical ManagementManagement

Ventricular FibrillationVentricular Fibrillation

V-Fib Is Seen In Hearts That Are V-Fib Is Seen In Hearts That Are DyingDying

Electrical Activity is Completely Electrical Activity is Completely ChaoticChaotic

No Meaningful Cardiac Output No Meaningful Cardiac Output Is OccurringIs Occurring

V-Fib Is Characterized By :V-Fib Is Characterized By :No True QRS ComplexesNo True QRS ComplexesA Wandering Or Undulating BaselineA Wandering Or Undulating BaselineNo Recognizable Atrial Wave FormsNo Recognizable Atrial Wave FormsNo Recognizable T WavesNo Recognizable T Waves

The Patient Must Be Supported The Patient Must Be Supported By CPR Methods & Must Be By CPR Methods & Must Be Electrically Cardioverted Out Of Electrically Cardioverted Out Of This Rhythm Or Death EnsuesThis Rhythm Or Death Ensues

Ventricular FibrillationVentricular Fibrillation

ExerciseExercise

Exercise Cannot be Sustained In Exercise Cannot be Sustained In Patients With V-Tach Or V-Fib Patients With V-Tach Or V-Fib Because 99.99 % Of The Time Because 99.99 % Of The Time They Will Be They Will Be UnconsciousUnconscious - - Exercise Is Never An OptionExercise Is Never An Option

Atrioventricular BlocksAtrioventricular Blocks

First Degree AV BlocksFirst Degree AV Blocks Second Degree AV BlocksSecond Degree AV Blocks

• Mobitz Type I (Wenckebach Block)Mobitz Type I (Wenckebach Block)

• Mobitz Type IIMobitz Type II Third Degree AV BlocksThird Degree AV Blocks

First Degree AV BlocksFirst Degree AV Blocks

Characterized By :Characterized By :• Prolonged PR Interval Prolonged PR Interval >> 5 mm 5 mm

• Every QRS Is Preceded By A P WaveEvery QRS Is Preceded By A P Wave

• Every QRS Is NormalEvery QRS Is Normal

• No Dropped BeatsNo Dropped Beats

First Degree AV BlockFirst Degree AV Block

First Degree AV BlockFirst Degree AV Block

Causes :Causes :Drug ToxicityDrug ToxicityIschemic Heart Disease Of The Ischemic Heart Disease Of The

Heart’s Conduction SystemHeart’s Conduction SystemMyocarditisMyocarditis

First Degree AV Block Does First Degree AV Block Does Appear In Healthy Individuals Appear In Healthy Individuals As Well As In Those With As Well As In Those With Ischemic Heart DiseaseIschemic Heart Disease

ExerciseExercise

Can I Exercise A Patient In First Can I Exercise A Patient In First Degree AV Block ?Degree AV Block ?

Yes, But The Rhythm Must Not Yes, But The Rhythm Must Not Degenerate During Exercise To Degenerate During Exercise To Second Degree AV Block.Second Degree AV Block.

Also, The Rhythm Had To Have Also, The Rhythm Had To Have Been Present Before Exercise Been Present Before Exercise Started. If A Patient Is Normal Started. If A Patient Is Normal On Their EKG Before Exercise On Their EKG Before Exercise & Degenerates Into First Degree & Degenerates Into First Degree AV Block, Exercise Must Stop !! AV Block, Exercise Must Stop !!

First Degree AV Block Is First Degree AV Block Is Generally Not Considered To Be A Generally Not Considered To Be A Highly Malignant DysrhythmiaHighly Malignant Dysrhythmia

Second Degree AV Block Second Degree AV Block Mobitz Type I Or A Mobitz Type I Or A Wenckebach BlockWenckebach Block

Second Degree AV Block Or A Second Degree AV Block Or A Mobitz Type I AV Block Is Mobitz Type I AV Block Is Characterized By :Characterized By :• Progressively Lengthening PR IntervalProgressively Lengthening PR Interval

• A Sudden Dropped QRS ComplexA Sudden Dropped QRS Complex

• Return Of A Normal RhythmReturn Of A Normal Rhythm

• A Repeating CycleA Repeating Cycle

Mobitz Type I Mobitz Type I

ExerciseExercise

Can I Exercise A Patient In A Can I Exercise A Patient In A Mobitz Type I Second Degree Mobitz Type I Second Degree AV Block ?AV Block ?

Yes, Providing The Dysrhythmia Yes, Providing The Dysrhythmia Does Not Degenerate During Does Not Degenerate During Exercise.Exercise.

The Patient Must Also Have The Patient Must Also Have Been Cleared For ExerciseBeen Cleared For Exercise

A Problem Does Exist With A A Problem Does Exist With A Mobitz Type I AV Block !!Mobitz Type I AV Block !!

You Have To Be Concerned That You Have To Be Concerned That It Will Degenerate Into A Mobitz It Will Degenerate Into A Mobitz Type II AV BlockType II AV Block

Second Degree AV Block Second Degree AV Block Mobitz Type IIMobitz Type II

Characteristics Are :Characteristics Are :A Series Of Normal BeatsA Series Of Normal BeatsAll PR Intervals Are Normal DurationAll PR Intervals Are Normal DurationSudden Dropped Beat - No QRS Sudden Dropped Beat - No QRS Normal Rhythm Re-EstablishedNormal Rhythm Re-EstablishedCycle Begins AgainCycle Begins Again

Mobitz Type IIMobitz Type II

Mobitz Type IIMobitz Type II

Mobitz Type II AV Block Is A Mobitz Type II AV Block Is A Dangerous Dysrhythmia Because Dangerous Dysrhythmia Because Of The High Likelihood That It Of The High Likelihood That It Will Convert To A Third Degree Will Convert To A Third Degree AV Block.AV Block.

ExerciseExercise

Can I Exercise A Patient In A Can I Exercise A Patient In A Mobitz Type II AV Block ?Mobitz Type II AV Block ?

No. The Risk Is Too High That No. The Risk Is Too High That The Patient Will Convert To The Patient Will Convert To Third Degree AV Block.Third Degree AV Block.

A Patient With A Mobitz Type II A Patient With A Mobitz Type II AV Block Is Going Eventually AV Block Is Going Eventually Convert To A Third Degree Convert To A Third Degree Block & Is A Candidate For A Block & Is A Candidate For A Surgically Implanted PacemakerSurgically Implanted Pacemaker

Third Degree AV BlockThird Degree AV Block

This Is A Serious Condition In This Is A Serious Condition In Which There Is No Communication Which There Is No Communication Of The SA Node With The AV Of The SA Node With The AV Node. It Is Also Called Complete Node. It Is Also Called Complete Heart Block. Heart Block.

The Atria Beat At Their Own The Atria Beat At Their Own Rate While The Ventricles Beat Rate While The Ventricles Beat At Their Own RateAt Their Own Rate

The P Waves Appear & Are Not The P Waves Appear & Are Not Connected To Any QRS ComplexConnected To Any QRS Complex

The QRS Are Abherrantly WideThe QRS Are Abherrantly Wide Ultimate Ventricular Rate Is Ultimate Ventricular Rate Is

Often Very BradycardicOften Very Bradycardic

3rd Degree AV Block3rd Degree AV Block

Most Patients In Third Degree Most Patients In Third Degree AV Block Require The AV Block Require The Implantation Of A Pacemaker.Implantation Of A Pacemaker.

Bundle Branch BlocksBundle Branch Blocks

Right Bundle Branch BlockRight Bundle Branch BlockRSR’ (Bunny Ears) In V1-V4RSR’ (Bunny Ears) In V1-V4Loss Of The R Wave ProgressionLoss Of The R Wave ProgressionST Segment Depression In V1 - V4ST Segment Depression In V1 - V4T Wave Inversion In V1 - V4T Wave Inversion In V1 - V4Wide QRS ComplexesWide QRS Complexes

Can you exercise a patient in Can you exercise a patient in RBBB ?RBBB ?

Yes as long as they have been Yes as long as they have been cleared by their physician.cleared by their physician.

Left Bundle Branch BlockLeft Bundle Branch BlockLoss of the R wave progressionLoss of the R wave progressionHuge S waves in V1 - V4Huge S waves in V1 - V4RSR’ in V4 - V6RSR’ in V4 - V6Wide QRS complexesWide QRS complexesST segment depression in V4 - V6ST segment depression in V4 - V6T Wave inversion in V4 - V6T Wave inversion in V4 - V6

Can you exercise a person in Can you exercise a person in LBBB ?LBBB ?

Yes, as long as the patient has Yes, as long as the patient has been cleared by their physician.been cleared by their physician.