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Ventricular Arrhythmia

Ventricular arrhythmia is a term encompassing various forms cardiac rhythm abnormalities originating from the ventricular system. Electrocardiography is used to confirm the diagnosis and the type of arrhythmia, but a detailed morphological and biochemical workup is necessary in order to determine the underlying cause, as most severe forms, such as ventricular fibrillation, can be fatal.


Presentation

The clinical presentation depends on the underlying subtype of arrhythmia [1] [2]:

  • Outflow tract arrhythmia (OTA) - Developing on the grounds of aberrant cyclic adenosine monophosphate (cAMP) activity, this type is most frequently encountered in individuals between 20-40 years, with a slight predilection toward female gender [1]. Symptoms seem to be aggravated by emotional stress or exertion, most common being palpitations, dyspnea, chest pain and syncope [1]. Cardiac arrest has been rarely associated with OTA [1].
  • Ventricular tachycardia (VT) - Defined as 3 or more ventricular beats at a heart rate of more than 120 beats per minute [3], VT is strongly associated with heart disease (eg. myocardial infarction, cardiomyopathies), while electrolyte abnormalities (hypokalemia or hypomagnesemia) or metabolic changes, including acidosis or hypoxemia, can also induce VT [3]. Monomorphic or polymorphic (the ectopic beat arises from one or multiple foci) and sustained or nonsustained subtypes exist. Nonsustained forms may be asymptomatic, as they are of short duration, but sustained VT is universally symptomatic, manifesting with palpitations, hemodynamic instability, and sudden cardiac death [3], which is not uncommon in severe structural heart disease (SHD).
  • Long QT and Brugada syndromes - Two ventricular arrhythmias induced by genetic events present usually in early life (mean onset of symptoms in long QT syndrome is 12 years of age) manifest through syncope, seizures, palpitations, and cardiac arrest [1] [3]. The nocturnal appearance of symptoms is characteristic of Brugada syndrome [3].
  • Ventricular fibrillation - Considered as the most severe form of arrhythmia, chaotic ventricular conduction leads to immediate syncope and death within minutes without adequate therapeutic measures [3].
Falling
  • Blood pressure tends to fall, and heart failure follows. Sustained ventricular tachycardia is also dangerous because it can worsen until it becomes ventricular fibrillation —a form of cardiac arrest.[merckmanuals.com]
  • The QT interval is markedly prolonged (at least 600ms), with each PVC falling on the preceding T wave ( ‘R on T’ phenomenon). This ECG is extremely high risk for TdP – in fact this patient had a TdP cardiac arrest shortly after this ECG was taken.[lifeinthefastlane.com]
  • The QTc interval in men decreases at puberty and then gradually increases as androgen levels fall ; this is also the reason women typically have a longer QT interval than men.[pharmaceutical-journal.com]
  • Such patients when they experience VT can try vagal maneuvers at home or even try to fall asleep in hopes that the VT will go away on its own.[heartracing.com]
  • Given the potential risk for hemodynamically compromising ventricular arrhythmias during exercise stress testing (particularly when exercise stress testing for CPVT), we advise the presence of physically capable personnel to prevent the patient from falling[doi.org]
Episodic Weakness
  • Abstract Andersen-Tawil Syndrome (ATS) is a rare potassium channel disorder, characterized by episodic weakness, ventricular arrhythmias and dysmorphic features (short stature, scoliosis, clinodactyly, hypertelorism, small or prominent low set ears, micrognathia[ncbi.nlm.nih.gov]
  • In addition, all 8 probands experienced episodic weakness. These kindreds likely represent a genetically heterogeneous group. Cardiac action potential simulation.[dx.doi.org]
Multiple Congenital Anomalies
  • Patients with 15q24 microdeletion syndrome exhibit distinct dysmorphic features, microcephaly, variable developmental delay, multiples congenital anomalies while individuals with reciprocal 15q24 microduplication syndrome show mild developmental delay[ncbi.nlm.nih.gov]
Heart Disease
  • A total of 123 consecutive patients confirmed ischemia heart disease with ICD were examined. After device implantation, the occurrence of appropriate ICD therapy was noted.[ncbi.nlm.nih.gov]
  • disease, or positive family history.[symptoma.com]
  • Patients with structural heart disease and dual-chamber ICDs underwent 5min baseline right ventricular (V) near-field and atrial (A) electrogram (EGM) recording.[ncbi.nlm.nih.gov]
  • Inflammatory, rheumatic and valvular heart diseases 11.1 Myocarditis 11.2 Endocarditis 11.3 Rheumatic heart disease. 11.4 Pericarditis 11.5 Cardiac sarcoidosis 11.6 Valvular heart disease 12.[escardio.org]
Ventricular Bigeminy
  • In this paper, we propose a new method for detection and classification of shockable ventricular arrhythmia (VT/VF) and non-shockable ventricular arrhythmia (normal sinus rhythm, ventricular bigeminy, ventricular ectopic beats, and ventricular escape[ncbi.nlm.nih.gov]
  • . - ventricular bigeminy is the occurrence of a PVC every other beat, trigeminy is every third beat, quadrigeminy every fourth beat. The main point with these types is that the PVC’s are more frequent in these circumstances.[heartpoint.com]
  • Example 5 R on T phenomenon: There is sinus rhythm with frequent PVCs in a pattern of ventricular bigeminy. The QT interval is markedly prolonged (at least 600ms), with each PVC falling on the preceding T wave ( ‘R on T’ phenomenon).[lifeinthefastlane.com]
  • The term “ventricular bigeminy” refers to alternating normal sinus and premature ventricular complexes. Three or more successive premature ventricular complexes are arbitrarily defined as ventricular tachycardia.[aafp.org]
  • bigeminy " PVCs that occur at intervals of 2 normal beats to 1 PVC are termed "PVCs in trigeminy" Three premature ventricular grouped together is termed a "run of PVCs" in general, runs lasting longer than three beats with an increased heart rate are[en.wikipedia.org]
Irregular Heart Rhythm
  • Ventricular Fibrillation (VF) is a rapid, irregular heart rhythm caused by abnormal electrical signals from the ventricles (lower chambers of the heart). Most cardiac arrest patients suffer from ventricular fibrillation (VF).[altabatessummit.org]
  • AFib is the most common form of serious arrhythmia, or irregular heart rhythm. If you receive an AFib classification and you have not been diagnosed with AFib, you should talk to your doctor.[support.apple.com]
Brachydactyly
  • The patient had brachydactyly and his second fingers and toes were longer than the others, a finding consistent with PHP. Laboratory tests detected hypomagnesemia, as well as elevated levels of creatine kinase and lactate dehydrogenase.[ncbi.nlm.nih.gov]
Osteoporosis
  • INTRODUCTION: Bisphosphonates, including ibandronate, are used in the prevention and treatment of osteoporosis.[ncbi.nlm.nih.gov]
Psychomotor Retardation
  • We report the first case of a 10 year-old girl presenting mild developmental delay, psychomotor retardation, epilepsy, ventricular arrhythmia, overweight and idiopathic central precocious puberty. 180K array-CGH analysis identified a 1.38 Mb heterozygous[ncbi.nlm.nih.gov]
Seizure
  • Patients usually present with hypocalcemia-induced seizures or tetany, whereas no case of hypocalcemia-induced cardiac arrhythmia in PHP has been described to date.[ncbi.nlm.nih.gov]
  • Long QT and Brugada syndromes - Two ventricular arrhythmias induced by genetic events present usually in early life (mean onset of symptoms in long QT syndrome is 12 years of age) manifest through syncope, seizures, palpitations, and cardiac arrest.[symptoma.com]
  • If the ventricular tachycardia persists longer, patients may then manifest a generalized seizure. In both syncope and seizure presentations, the heart eventually catches itself, reverts back to normal sinus rhythm, and the "spell" stops.[sads.org]
  • […] disorder should be suspected when the electrocardiogram shows characteristic QT abnormalities, or when there is a family history of long QT syndrome or of an event that raises suspicion of long QT syndrome, such as sudden death, syncope, or ill-defined “seizure[mdedge.com]
  • Primary symptoms of long QT syndrome may include palpitations, syncope and seizures.[pharmaceutical-journal.com]
Encephalopathy
  • The presence of profound anoxic encephalopathy and acute renal failure requiring dialysis were significant prognostic factors.[ncbi.nlm.nih.gov]
  • STXBP1 Encephalopathy with Epilepsy Yannay Khaikin and Saadet Mercimek-Mahmutoglu. Initial Posting: December 1, 2016.[ncbi.nlm.nih.gov]
Neglect
  • The aim of this study was to review this often-neglected topic, which is of special importance in the CKD population. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
Hyperactivity
  • The phenotype of impaired parasympathetic responsiveness and sympathetic hyperactivity in experimental animal models is also well documented in large scale human studies in the setting of heart failure and myocardial infarction, and is predictive of morbidity[ncbi.nlm.nih.gov]

Workup

Prompt diagnostic workup is mandatory in defining the exact type of arrhythmia, starting with a thorough physical examination and a detailed patient history that could reveal the presence of comorbidities, use of pro-arrhythmogenic drugs, structural heart disease, or positive family history [4]. A 12-lead electrocardiogram (ECG) should be performed immediately in patients who present with symptoms suggestive of arrhythmia, followed by a transthoracic echocardiogram in order to evaluate cardiac structure and exclude structural heart disease as a possible cause [4] [5]. ECG findings may include a widened QRS complex (both prolongation and change in shape), ST elevation and inversion of T waves in the case of ventricular tachycardia and fibrillation, while prolonged QT intervals and coving of the ST-segment are seen in long QT syndrome and Brugada syndrome, respectively [1] [4] [5]. In addition to ECG and echocardiography, laboratory workup should comprise a complete blood count, cardiac markers (troponin, creatine kinase MB, and myoglobin), serum electrolytes (potassium, sodium, magnesium, calcium) and renal function tests, to determine optimal therapy and perform electrolyte correction [3] [4]. If symptoms appear in childhood, genetic testing to confirm mutations characteristic for Brugada or long QT syndromes is necessary [4]. If the cause of arrhythmia remains unresolved, coronary arteriography, exercise stress testing and cardiac magnetic resonance imaging (MRI) have been suggested as additional diagnostic methods [4].

Wide QRS Complex
  • When confronted with a wide-QRS-complex tachycardia it can be difficult to differentiate between a supraventricular tachycardia with aberrancy or ventricular tachycardia .[en.ecgpedia.org]
  • When confronted with a wide-QRS-complex tachycardia it can be difficult to differentiate between a supraventricular tachycardia with aberrancy or ventricular tachycardia.[en.ecgpedia.org]
  • Ventricular tachycardia refers to a wide QRS complex heart rhythm — that is, a QRS duration beyond 120 milliseconds — originating in the ventricles at a rate of greater than 100 beats per minute.[healio.com]
  • Wide QRS complexes ( 120 ms). Presence of AV dissociation. Fusion beats. Retrograde ventriculoatrial conduction may occur, which can generate an ECG complex similar to PSVT with aberrant conduction.[patient.info]
  • "A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex". Circulation. 83 (5): 1649–59. doi : 10.1161/01.cir.83.5.1649. PMID 2022022. Baerman JM, Morady F, DiCarlo LA, de Buitleir M (January 1987).[en.wikipedia.org]
Staphylococcus Aureus
  • A 58-year-old woman with previous mitral and tricuspid valve replacement and permanent pacemaker implantation suffered from recurrent fever and Staphylococcus aureus bacteremia.[ncbi.nlm.nih.gov]
Ventricular Bigeminy
  • In this paper, we propose a new method for detection and classification of shockable ventricular arrhythmia (VT/VF) and non-shockable ventricular arrhythmia (normal sinus rhythm, ventricular bigeminy, ventricular ectopic beats, and ventricular escape[ncbi.nlm.nih.gov]
  • . - ventricular bigeminy is the occurrence of a PVC every other beat, trigeminy is every third beat, quadrigeminy every fourth beat. The main point with these types is that the PVC’s are more frequent in these circumstances.[heartpoint.com]
  • Example 5 R on T phenomenon: There is sinus rhythm with frequent PVCs in a pattern of ventricular bigeminy. The QT interval is markedly prolonged (at least 600ms), with each PVC falling on the preceding T wave ( ‘R on T’ phenomenon).[lifeinthefastlane.com]
  • The term “ventricular bigeminy” refers to alternating normal sinus and premature ventricular complexes. Three or more successive premature ventricular complexes are arbitrarily defined as ventricular tachycardia.[aafp.org]
  • bigeminy " PVCs that occur at intervals of 2 normal beats to 1 PVC are termed "PVCs in trigeminy" Three premature ventricular grouped together is termed a "run of PVCs" in general, runs lasting longer than three beats with an increased heart rate are[en.wikipedia.org]
T Wave Alternans
  • Catecholamine provoked microvoltage T wave alternans in genotyped long QT syndrome. Pacing & Clinical Electrophysiology. 2003;26(8):1660–7. Google Scholar 104. Nemec J, Hejlik JB, Shen WK, Ackerman MJ.[doi.org]
  • […] the ECG, syncope, and sudden death as a result of ventricular tachyarrhythmias. 1 2 3 4 Other repolarization abnormalities identified in the syndrome include increased QT-interval dispersion on the 12-lead ECG, 5 6 7 abnormal ST-T–wave morphology, 8 9 T-wave[doi.org]
  • During provocation, epinephrine infusion should be stopped if systolic blood pressure rises above 200 mm Hg, there is an increase in premature ventricular contractions or nonsustained ventricular tachycardia or polymorphic VT occurs, T-wave alternans[doi.org]
Electrocardiogram Change
  • If the VA occur during or less than 10 seconds after injection and some typical electrocardiogram changes (such as bradycardia, QT interval prolongation, T-wave amplitude, rotation of QRS axis, and PR prolongation) are simultaneously observed before the[revespcardiol.org]

Treatment
  • After discontinuing the HCQ, the QT interval was shorter and the patient recovered after treatment with lidocaine and isoproterenol.[ncbi.nlm.nih.gov]
  • We suggest that this treatment should be seriously considered in those patients with SSc and malignant ventricular arrhythmias unresponsive to drug therapy.[ncbi.nlm.nih.gov]
  • After 2-month treatment with octreotide, a long-acting somatostatin analogue, levels of both hormones were decreased.[ncbi.nlm.nih.gov]
  • We observed late onset in vivo repolarization instability after ibandronate treatment.[ncbi.nlm.nih.gov]
  • The quinidine treatment for the SCN5A R222Q mutation can be life saving for patients.[ncbi.nlm.nih.gov]

Prognosis
  • We evaluate the clinical and electrocardiographic characteristics of these patients as well as their prognosis.[ncbi.nlm.nih.gov]
  • Abstract The prognosis of systemic sclerosis (SSc) is poor, and a significant number of patients suffer sudden death, probably related to malignant ventricular arrhythmias for which there is no reliable drug treatment.[ncbi.nlm.nih.gov]
  • Although the prognosis for the majority of patients without apparent coronary arterial lesion is excellent, regular follow up must be performed on patients with a history of KD.[ncbi.nlm.nih.gov]
  • The prognosis in the case of an infant is uniformly poor; though cases surviving surgery have been reported recently [3–6] . We report a 2-month-old infant undergoing surgical treatment for Uhl's anomaly with critical ventricular arrhythmia.[academic.oup.com]
  • Annual International Conference of the IEEE Engineering in Medicine and Biology IEEE , (2010) . 978-1-4244-4123-5 978-1-4244-4124-2 Thomas Ho Chee Tat and Chen Xiang Using tele-medical electrocardiography monitoring and analysis for a more immediate prognosis[dx.doi.org]

Etiology
  • Ventricular arrhythmia originating from outflow tract diverticulum is even rarer and its etiology, epidemiology and proper treatment still remain controversial.[ncbi.nlm.nih.gov]
  • The patient underwent a successfully surgical repair by semitotal resection of the right ventricle free wall, tricuspid annuloplasty, and one and one-half ventricular repair. 1 Introduction Uhl's anomaly, a very rare anomaly with unknown etiology, is[academic.oup.com]
  • Incidence and presumed etiology of ventricular fibrillation during coronary angioplasty. Am J Cardiol . 1991;67:769-70. Medline 9 . Murdock DK, Euler DE, Becker DM, Murdock JD, Scanlon PJ, Gunnar RM.[revespcardiol.org]
  • Etiology The physiopathology of this type of VT is unknown but it has been suggested that microscopic tumors such as myocardial hamartomas, also known as histiocytoid cardiomyopathy (see this term), are responsible.[orpha.net]
  • This arrhythmia may be either of congenital etiology or may occur after cardiac surgery. Sudden death is uncommon in children with arrhythmias but when it occurs, is frequently caused by ventricular arrhythmias.[af-ablation.org]

Epidemiology
  • - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary[ncbi.nlm.nih.gov]
  • Ventricular arrhythmia originating from outflow tract diverticulum is even rarer and its etiology, epidemiology and proper treatment still remain controversial.[ncbi.nlm.nih.gov]
  • Definitions, epidemiology and future perspectives for the prevention of sudden cardiac death 3.1 Epidemiology of sudden cardiac death 3.2 Indications for autopsy and molecular autopsy in sudden death victims 3.3 Risk prediction of sudden cardiac death[escardio.org]
  • Rafik Tadros, Anh-Tuan Ton, Céline Fiset and Stanley Nattel , Sex Differences in Cardiac Electrophysiology and Clinical Arrhythmias: Epidemiology, Therapeutics, and Mechanisms , Canadian Journal of Cardiology , 30 , 7 , (783) , (2014) .[doi.org]
Sex distribution
Age distribution

Pathophysiology
  • The pathophysiology of arrhythmias in this population is complex and seems to be related to structural cardiac abnormalities caused by CKD, associated with several triggers, such as water and electrolyte disorders, hormonal conditions, arrhythmogenic[ncbi.nlm.nih.gov]
  • RATIONALE: Disruption in subcellular targeting of Ca(2 ) signaling complexes secondary to changes in cardiac myocyte structure may contribute to the pathophysiology of a variety of cardiac diseases, including heart failure (HF) and certain arrhythmias[ncbi.nlm.nih.gov]
  • Therefore, future therapies must aim to target the underlying pathophysiology that contributes to the generation of ventricular arrhythmia.[ncbi.nlm.nih.gov]
  • Kass , Molecular Pathophysiology of Congenital Long QT Syndrome , Physiological Reviews , 97 , 1 , (89) , (2017) . Amara Greer-Short, Sharon A. George, Steven Poelzing and Seth H.[doi.org]
  • Pathogenesis Pathophysiology Pedigree analysis suggests autosomal recessive mode of inheritance, although proportion of affected kittens is greater than expected. Failure of ectodermal (hypotrichosis) and entodermal (thymic aplasia) development.[vetstream.com]

Prevention
  • METHODS: In this study, 93 patients who received ICDs for secondary prevention, had an LVEF of 45%, and underwent echocardiographic follow-up assessment after receiving an ICD were enrolled.[ncbi.nlm.nih.gov]
  • All patients with VA storm should be considered for transfer to an experienced high-volume tertiary centre for evaluation and treatment to prevent further recurrence of VA storm. Published by the BMJ Publishing Group Limited.[ncbi.nlm.nih.gov]
  • The abnormal autonomic state has been shown to be a strong prognostic marker of increased mortality and propensity to lethal arrhythmias, for which there is no effective prevention.[ncbi.nlm.nih.gov]
  • METHODS AND RESULTS: 90 ischaemic cardiomyopathy patients with primary prevention ICDs were recruited. 35 had received appropriate therapy from the ICD for potentially-fatal VA while the remaining 55 patients had not.[ncbi.nlm.nih.gov]
  • Conduction disturbances are frequently observed, and may necessitate pacemaker implantation to prevent sudden death.[ncbi.nlm.nih.gov]

References

Article

  1. Prystowsky EN, Padanilam BJ, Joshi S, Fogel RI. Ventricular Arrhythmias in the Absence of Structural Heart Disease. J Am Coll Cardiol. 2012;59(20):1733-1744.
  2. Roberts-Thomson KC1, Lau DH, Sanders P. The diagnosis and management of ventricular arrhythmias. Nat Rev Cardiol. 2011;8(6):311-321.
  3. Hebbar AK, Hueston WJ. Management of common arrhythmias: Part II. Ventricular arrhythmias and arrhythmias in special populations. Am Fam Physician. 2002;65(12):2491-2496.
  4. Pedersen CT, Kay GN, Kalman J, Borggrefe M, Della-Bella P, Dickfeld T, et al. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace. 2014;16(9):1257-1283.
  5. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.

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Last updated: 2019-06-28 10:44