Sinus versus nonsinus tachycardia in the emergency department: Importance of age and heart rate

Background

The emergency department diagnosis of sinus versus nonsinus tachycardia is an important clinical challenge. The objective of this study was to identify subjects with a high prevalence of nonsinus tachycardia.

Methods

Heart rate and cardiac rhythm were prospective reviewed in 500 consecutive patients with heart rate ≥ 100 beats/min in a busy emergency department. A predictive model based on age and heart rate was then developed to identify the probability of nonsinus tachycardia.

Results

As age and heart rate increased, nonsinus tachycardias became more frequent. The probability of nonsinus tachycardia in a subject ≥ 71 years with heart rate ≥ 141 beats/minute was 93%, compared to only three percent in a subject ≤ 50 years with heart rate 100–120 beats/minute. A simple point score system based on age and heart rate helps predict the probability of sinus tachycardia versus nonsinus tachycardia.

Conclusion

Nonsinus tachycardia is significantly more common than sinus tachycardia in elderly patients in the emergency department. The diagnosis of sinus tachycardia becomes much less likely as age and heart rate increase.     

Fetal arrhythmias: Diagnosis and management

This article reviews important features for improving the diagnosis and management of fetal arrhythmias. The normal fetal heart rate ranges between 110 and 160 beats per minute. A fetal heart rate is considered abnormal if the heart rate is beyond the normal ranges or the rhythm is irregular. The rate, duration, and origin of the rhythm and degree of irregularity usually determine the potential for hemodynamic consequences. Most of the fetal rhythm disturbances are the result of premature atrial contractions (PACs) and are of little clinical significance. Other arrhythmias include tachyarrhythmias (heart rate in excess of 160 beats/min) such as atrioventricular (AV) reentry tachycardia, atrial flutter, and ventricular tachycardia, and bradyarrhythmias (heart rate <110 beats/min) such as sinus node dysfunction, complete heart block (CHB) and long QT syndrome (which is associated with sinus bradycardia and pseudo-heart block).     

Atrial Pacing to Control Heart Rate and Rhythm in Acute Cardiac Conditions

Increasing the heart rate by a bedside atrial pacing technique was successfully utilized to treat serious cardiac arrhythmia or failure in 13 patients. Nine of these had ventricular arrhythmia refractory to drugs. Seven had evidence of sinus node depression or disease since their sinus pacemaker was below 70 beats per minute under decompensated conditions. In five, coronary artery disease was associated with the bradycardia and in two, digitalis toxicity was related to depression of the intrinsic pacemaker rate. Two patients in the coronary group required implantation of a permanent demand ventricular pacemaker. Hemodynamic studies were performed in seven patients. Only one patient had no increase in cardiac output with pacing rates above his resting rate. The other six patients showed an increase in cardiac output from 22 to 81% at paced rates between 70 and 125/minute. The duration of pacing ranged from one hour to 14 days and averaged five days.     

Heart rate, body temperature and physical activity are variously affected during insulin treatment in alloxan-induced type 1 diabetic rat

Diabetes mellitus is associated with a variety of cardiovascular complications including impaired cardiac muscle function. The effects of insulin treatment on heart rate, body temperature and physical activity in the alloxan (ALX)-induced diabetic rat were investigated using in vivo biotelemetry techniques. The electrocardiogram, physical activity and body temperature were recorded in vivo with a biotelemetry system for 10 days before ALX treatment, for 20 days following administration of ALX (120 mg/kg) and thereafter, for 15 days whilst rats received daily insulin. Heart rate declined rapidly after administration of ALX. Pre-ALX heart rate was 321+/-9 beats per minute, falling to 285+/-12 beats per minute 15-20 days after ALX and recovering to 331+/-10 beats per minute 5-10 days after commencement of insulin. Heart rate variability declined and PQ, QRS and QT intervals were prolonged after administration of ALX. Physical activity and body temperature declined after administration of ALX. Pre-ALX body temperature was 37.6+/-0.1 °C, falling to 37.3+/-0.1 °C 15-20 days after ALX and recovering to 37.8+/-0.1 °C 5-10 days after commencement insulin. ALX-induced diabetes is associated with disturbances in heart rhythm, physical activity and body temperature that are variously affected during insulin treatment.     

Atrial Rate And Rhythm Abnormalities In A Patient With Hyperkalemia

A 67 year old man presented with a serum potassium of 7.7 mEq/L and slow atrial flutter with variable A-V block and peaked T waves. Initial treatment for hyperkalemia was followed by an increase in the atrial flutter rate to 300 beats per minute. After hemodialysis the rhythm converted to sinus.     

Interactions of respiration and the bradycardia of submersion in harbor seals.

Six harbor seals with percutaneous tracheostomies were artificially ventilated while immersed. Changes in the oxygen content of the inspired gas and in the minute-volume altered the magnitude of the bradycardia observed after the animal had been submerged for 30 s. The average heart rate in five seals changed from 16.7 (S.D. = 4.4) beats per minute during artificial ventilation with N2, to 58.7 (S.D. = 10.4) beats per minute while breathing air, but this cardiac chronotropic effect of oxygen was blocked by addition of 7% CO2 to the inspired gas. Ventilatory minute-volumes above approximately 3 litres/min caused cardiac acceleration in a manner related to ventilation; below this, changes in heart rate were inconsistent. While being artificially ventilated with air, the average heart rate in five seals changed from 16.5 beats per minute to 73.4 beats per minute as ventilation was increased from 0 to greater than 8 litres/min. These experiments demonstrate that O2, CO2, and ventilatory minute-volume have significant effects upon the heart rate of seals under water and suggest the presence of chemoreceptor-mediated effects on heart rate during submersion.     

Coronary venous flow and O2 saturation during transitional phases between various cardiac rates.

The instantaneous and continuous interrelationship between coronary blood flow and coronary venous O2 saturation was determined during transient periods following abrupt rate change in the electrically paced canine heart. Through a catheter in the coronary sinus, O2 saturation was continuously monitored using a fibreoptics technique, and venous flow was measured with an electromagnetic flowmeter. Various patterns of change in flow and O2 saturation were observed depending both on the absolute values of the cardiac rates as well as on the relative difference between them during changes from one rate to another. Whereas elevation of coronary flow was monophasic when the magnitude of heart rate change was below 75 beats per minute, a drop in flow was observed preceeding its elevation when the difference was greater. At high rates further increase in rate caused either no alteration or led to a monophasic drop in flow during the transitional period. Changes in O2 saturation were observed only when heart rate difference exceeded 60 beats per minute. Between 60-90 beats per minute O2 saturation remained steady except during the transient rate elevation, ending in a lower steady state O2 saturation. The results indicate that both O2 saturation and coronary flow change with heart rate initially because of mechanical consequence of the increased rate on the myocardium, and later according to its new metabolic needs also manifested by changed O2 extraction.     

Variations in heart rate and rhythm of harbor seal pups during rehabilitation

Heart rate and rhythm is regulated by the autonomic nervous system, which matures during the first months of life. Little is known about heart rate and rhythm development and potential arrhythmias in seal pups during rehabilitation in seal centers. Using an iPhone ECG device, 1 min ECGs were obtained from harbor seal pups admitted to a seal rehabilitation facility. ECGs were taken from 55 seals after admission, 53 seals after 14 d, and 52 seals prior to release. From 24 seal pups additional ECGs were taken daily for the first week of rehabilitation. At admission sinus rhythm with a median heart rate of 148 complexes per minute was detected, prior to release sinus bradycardia or sinus arrhythmia with a median heart rate of 104 complexes minute was present. P wave morphology was highly variable and single supra‐ and ventricular premature complexes were recorded in individual animals. The first 14 d were characterized by highly variable heart rates and rhythms, including episodes of sinus tachycardia and 2nd degree atrioventricular blocks. The reduction in heart rates and development of a regular heart rhythm during rehabilitation suggest adaptation to the unfamiliar environment, resolution of disease, and/or maturation of the autonomic nervous system.     

Atrioventricular Block Subsequent to Intraoperative Device Closure Atrial Septal Defect with Transthoracic Minimal Invasion; A Rare and Serious Complication

Objectives

Atrioventricular block (AVB) is a infrequent and serious complication after percutaneous ASD closure. In this study, we report on the incidence of AVB associated with intraoperative device closure of the ASD with transthoracic minimal invasion, and the outcomes of this complication in our center.

Methods

Between May 2006 and January 2011, a total of 213 secundum-type ASD patients were accepted in our hospital for intraoperative and transthoracic device closure with a domestic occluder. All patients were assessed by real-time transthoracic echocardiography (TTE) and electrocardiograph (ECG).

Results

All patients were occluded successfully under this approach. Immediate postprocedure third-degree AVB was observed in two patients. Since heart rates were in the range of about 50 to 55 beats per minute, no intervention was needed except for close observation for one patient. Another patient who recovered sinus rhythm intermittently during the operation was fitted with a temporary pacemaker. Approximately one week following glucocorticoid treatment, the AVB resolved spontaneously in these two patients. Mobitz type II AVB occurred in three patients during the procedure. Two patients developed post-operative cardiac arrest and were rescued successfully with cardiopulmonary resuscitation. One other patient changed to Mobitz type I AVB after three days. During the follow-up period, which ranged from six months to five years, no further occurrence of AVB was found.

Conclusions

Intraoperative and transthoracic device closure of secundum ASDs with domestic occluder resulted in excellent closure rate. AVB is an infrequent but serious complication during and after device closure of a secundum ASD. AVB is a complication that warrants greater attention and long-term follow-up.     

瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤患者的疗效及对血清细胞因子的影响

目的:分析瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤患者的疗效及对血清细胞因子的影响。方法:将80例心脏瓣膜病并发房颤患者依据简单随机法分为对照组和观察组,每组40例。对照组采用心脏瓣膜置换术治疗,观察组采用心脏瓣膜置换术同期射频消融改良迷宫术治疗,比较两组窦性心律转复情况,手术情况,手术前后心功能、血清金属蛋白酶组织抑制因子-1(TIMP-1)、基质金属蛋白酶-1(MMP-1)和基质金属蛋白酶-9(MMP-9)水平的变化以及术后并发症的发生情况。结果:观察组术后当天、术后1月、术后3月及术后6月的窦性心律转复率均显著高于对照组(P0.05),体外循环时间、主动脉阻断时间及术后24 h引流量均明显多于对照组(P0.05)。两组呼吸机使用时间和监护室时间比较差异无统计学意义(P0.05)。术后6个月,两组左室舒张末期内径、左室收缩末期内径、血清MMP-1和MMP-9水平均较术前显著下降,且观察组以上指标明显低于对照组;两组LVEF及血清TIMP-1水平较术前显著上升,且观察组以上指标均显著高于对照组(P0.05)。两组术后均无严重并发症发生。结论:瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤安全有效,早期窦性心律的转复率高,且可改善患者血清TIMP-1、MMP-1、MMP-9水平。     

Indications for Treatment of Complete Atrioventricular Dissociation

For purposes of correct treatment it is important to recognize that patients with complete atrioventricular dissociation fall into three groups: Group I—established third-degree heart block with and without Stokes-Adams attacks; Group II—periodic third-degree heart block with and without Stokes-Adams attacks; Group III—established third-degree heart block with cardiac failure. Most patients in Group I present no technical problems when a pacemaker is implanted. In Group II it is advisable to insert a temporary intracardiac catheter electrode and maintain a rate of 60 to 64 during the periods of third-degree heart block. Sudden reversion, in this group, from sinus rhythm can be fatal. Group III patients will often require a pacemaker set in excess of 74 beats until they are free of cardiac failure. Fifteen of 20 patients with complete atrioventricular dissociation showed marked functional improvement after insertion of a pacemaker. The development, in our laboratory, of a 4″ portable pacemaker impulse detector has been invaluable in locating the cause of failure in an implanted pacemaker.     

A patient with dizziness,tachycardia and a DDDR pacemaker

An 84-year-old female patient presented to the coronary care unit with dizziness. A DDD-R minute ventilation sensor pacemaker had been implanted eight years previously. The ECG showed an atrial and ventricular paced rhythm of 140 beats/min. After disconnecting the patient from the cardiac monitor the pacemaker rate dropped gradually to 90 beats/min. The cardiac rhythm monitoring system applies low-amplitude electrical pulses in order to measure respiration rate by transthoracic impedance (TTI) measurement. The minute ventilation pacemaker sensor is driven by the same TTI measurement for rate response. Inappropriate interference between these two systems caused a sensor-driven high pacemaker rate. The dizziness was not related to the sensor-driven high rate.     

Auscultation of Foetal Heart Rate: an Assessment of its Error and Significance

Auscultation of foetal heart rate was shown to be subject to three types of error: a random error, an error biased towards normality when the heart rate is fast or slow, and an error based on the inability to count the heart rate during contractions. In spite of these limitations a clinically observed foetal heart rate of more than 160 beats per minute was shown to be associated with significantly lower Apgar scores at birth. In contrast, a steady foetal heart rate of 100–120 beats per minute was not.     

Circadian variation of abnormal heart beats in an elderly population and their relation to sudden cardiac death.

The relationships between the circadian variation of abnormal heart beats and the circadian variation in sudden cardiac death warrant further discussion for the high correlations demonstrated here are difficult to ignore. In the healthy group abnormal beats showed a high correlation of their circadian variation with that of sudden cardiac death which is independent of heart rate. As a result the conclusion that the relationship of the circadian variations of abnormal heart beats and sudden cardiac death is merely dependent on a mutual dependence on activity is not supported here. The present data illustrates a strong association between arrhythmias and sudden cardiac death. The relationship of sudden cardiac death with abnormal heart beats demonstrated here, however, cannot confirm a causal role of the latter on the former for both may be responding to circadian variations of some underlying mechanism such as ischemia. Additionally the population studied here, although relatively comparable in terms of living conditions and other significant factors, was not strictly age-matched with those from the sudden cardiac death study warranting further caution in interpreting the association demonstrated here. The results from the unhealthy group, although somewhat limited, indicate that cardiovascular morbidity may alter the relationship of sudden cardiac death and abnormal heart beats. Such a result could be explained by the presence of other forms of heart disease which could be responsible for sudden cardiac death in the unhealthy group. An interesting question to ask concerning the data presented above is whether or not significant circadian variations in in the frequency of abnormal heart beats could have been demonstrated when exogenous factors such as meal times and activity were altered. The data on in hospital sudden cardiac death indicates that the circadian variation in sudden cardiac death is significantly altered by the radical changes in routine which accompany hospitalization. If the relationship between the circadian variation of sudden cardiac death and abnormal heart beats is as strong as the results presented here indicate, it is likely that the alteration of such exogenous factors would also change the circadian variation of abnormal heart beats. The results of the present study indicate that both the circadian variation in abnormal heart beats, and its relationship to sudden cardiac death, warrant further study.     

Geological cycles

Abstract

Deep body temperature (DBT) and heart rate (HR) circadian rhythms were determined by radiotelemetry in 4 mares kept under controlled light and temperature conditions. Ovulations were determined by rectal palpation of their ovaries. Mean DBT values ranged from 35.85 ± .04 to 37.22 ± .02°C The circadian range of oscillation was extremely low, approximately 0.5° C, with time of maximum temperature occurring midway through the dark period. Mean HR values ranged from 36.4 ± 1.7 to 53.0 ±3.6 beats per min. The circadian range of oscillation was also low, less than 15 beats per min with time of maximum HR occurring approximately at the time of lights off. The HR circacadian rhythm peaked before the DBT circadian rhythm by 3 to 8 hrs. Ovulation did not appear to consistently affect DBT and HR circadian rhythms or their phase relationships.     

Hemodynamic effects of pacing-induced tachycardia in valvular aortic stenosis.

The hemodynamic effects of tachycardia were studied in 13 patients with valvular aortic stenosis. Observations were made during sinus rhythm (average heart rate 80 beats/min) and two periods (P1 and P2) when atrial pacing increased the heart rate to 109 and 131 beats/min respectively. The cardiac index did not change, but the left ventricular stroke work index fell from 61.8 to 39.5 g X m/m2 (p less than 0.001) as the heart rate increased. The left ventricular end-diastolic pressure averaged 18 mm Hg during sinus rhythm and fell to about 11.5 mm Hg at P1 and P2 (p less than 0.001). The brachial arterial systolic pressure did not change during pacing, but the left ventricular systolic pressure fell from 208 mm Hg to 201 mm Hg during P1 (p less than 0.05) and 193 mm Hg during P2 (p less than 0.001). The mean systolic aortic valve gradient averaged 64 mm Hg during sinus rhythm and fell to 51 mm Hg during P2 (p less than 0.001), and the peak aortic valve gradient fell from 82 to 69 mm Hg during P2 (p less than 0.001). The left ventricular ejection time fraction increased from 26.9% during sinus rhythm to 31.9% during P1 (p less than 0.05) and 34.7% during P2 (p less than 0.005). Because of the prolonged left ventricular ejection time fraction and smaller stroke volume, a smaller pressure gradient developed across the stenosed valve at higher heart rates. The pacing test was of little value in assessing left ventricular function and thus is not useful during invasive investigations of valvular aortic stenosis.     

Features of the Application of Heart Rhythm Variability Analysis in Cardiologic Patients

Conflicting aspects of the clinical application of the heart rhythm variability (HRV) analysis in cardiovascular patients were critically analyzed. It was found that, in cardiovascular patients, the HRV pattern depended on not only mediators of autonomic nervous system but the electrophysiological state of myocardium and cardiac conduction as well. To make the HRV analysis more informative, the integral estimation method was substantiated, which allowed us to carry out the HRV analysis based on the main objective parameter of the rhythm pacing system, i.e., the heart beats, for both sinus and ectopic rhythms. The specific heart rhythm functions, namely scatter and concentration, were discovered. The scatter function was tested using the standard deviation of distribution of the RR-intervals (SDNN, SDNN-i, and SDANN-i), X, TINN, and TIRR. The rMSSD, Amo, and triangular indexes were physiologically treated as the sinus node capacity for the rhythmconcentration. The diagnostic and prognostic importance of the integral method is discussed, which may be used as a supplementary method when interpreting the results of the HRV analysis in cardiovascular patients.     

The effect of NADP+ on cardiomyocyte electrophysiological properties of C57BL/6 and mdx mice

We have studied the influence of NADP⁺ on routine electrocardiography (ECG) in 6-month-old C57BL/6 and mdx mice. The animals were anesthetized by ether before ECG recording. ECG registration was carried out at a speed of 100 mm/s. The first ECG recording was made before intraperitoneal NADP⁺ injection in a dose of 13 or 80 mg/kg. The second ECG recording was made 10 min after NADP⁺ injection. Anesthesia was then terminated. The mice were occasionally anesthetized 45–60 min later, and the third ECG was recorded 1 h after injection of NADP⁺. ECG recording was carried out at a speed of 100 mm/s in standard leads I, II, and III and unipolar leads AvR, AvL, and AvF. Values of standard ECG characteristics, such as the P wave and the intervals PQ, QT, RR, and the QRS complex, were measured in milliseconds in standard lead II. We did not observe any differences between ECG magnitudes of 2- to 3-month-old C57BL/6 and mdx mice during trial experiments. Mice of both strains had a sinus rhythm in their heart rate. The QRS complex in mdx mice had a tendency to be larger than in C57BL/6 mice. Heart rates fluctuated between 722 ± 22 and 681 ± 21 beats per minute. The effect of NADP⁺ was studied in 6-month-old male mice. The increase in the RR interval and the decline in heart rate from 697 ± 21 to 461 ± 23 and 491 ± 28 beats per min for C57BL/6 mice (p < 0.01) and from 722 ± 28 beats per minute to 454 ± 31 beats per min for mdx mice were registered 10 min after NADP⁺ injection at a dose of 80 mg/kg. The increase in the RR interval can be explained by an increase in the QT interval. A statistically significant reduction in the QT interval leading to a diminished RR interval was observed in mdx mice 1 h after NADP⁺ injection. NADP⁺ at a dose of 13 mg/kg did not significantly change the ECG properties in mdx mice. ECG of mdx mice was characterized by negative repolarization of the T wave in 37% of all leads. The amount of leads with negative T-wave repolarization decreased up to 3% 1 h after NADP⁺ injection in dose of 80 mg/kg. The results have shown that cytomembranes of ventricular cardiac myocytes and the degree of oxidative stress are the main targets of the action of NADP⁺ in C57BL/6 and mdx mouse hearts.     

Cholinergic and adrenergic tone on the heart of the Antarctic dragonfish, Gymnodraco acuticeps, living at sub-zero temperatures

Heart rate and ventral aortic blood pressures were recorded from the Antarctic dragonfish,Gymnodraco acuticeps, a member of the family Bathydraconidae. At −1.0 °C, the resting heart rate was 17.4 beats per minute and the ventral aortic pressure was 3.4 kPa. Cholinergic and adrenergic tone on the heart was determined by administration of the muscarine and ß-adrenoreceptor antagonists, atropine and sotalol, respectively. Neither antagonist influenced ventral aorta blood pressure; however, injection of atropine resulted in a significant increase in heart rate, and sotalol a decrease in heart rate. The cholinergic tone accounted for 30% of intrinsic heart rate and the adrenergic tone 26% of intrinsic heart rate. Comparison of these cardiac data with those for other teleosts from a wide range of thermal environments revealed no significant correlation for either cholinergic or adrenergic tone with body temperature (i.e. thermal independence); however, the resting and intrinsic heart rate of teleosts were strongly correlated with temperature.     

经颈静脉途径制备Beagle犬心脏记忆模型

目的经颈静脉途径应用心室起搏的方法制备心脏记忆犬模型。方法 8只普通级成年健康Beagle犬经腹腔麻醉后,Seldinger’s法穿刺颈外静脉成功后送入心内膜起搏电极,将电极头端固定于右室心尖部,近端连接于脉冲发生器。起搏频率设置较犬窦性心律时的基础心率快15%,保证起搏器连续起搏。结果连续起搏1周后所有动物均成功制备为心脏记忆模型。建模后犬的心率、呼吸、体重与建模前比较,无明显改变;所有模型组犬起搏前心电图均为窦性心律,起搏1周后出现心脏T波记忆,在下壁导联以及胸前导联均出现T波倒置,停止起搏后,心脏T波记忆逐渐消失;模型组犬与正常组犬心肌病理相比,无明显改变。结论经颈静脉途径应用心室起搏法建立心脏记忆犬模型的方法,具有手术简单,创伤小,诱发方式与临床相似等优点,为深入展开心脏记忆的机制研究奠定基础。