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Prof. Hardi Darmawan, MD, MPH&TM.,FRSTM
Department of Physiology & Biophysic
ARRHYTHMIA
Definition of Arrhythmia:The Origin, Rate, Rhythm, Conduct
velocity and sequence of heart
activation are abnormally.
2
Arrhythmia
ARRHYTHMIA VARIATION IN NORMAL RHYTHM
DYSRHYTHMIA ABNORMAL, DISTURBED RHYTHM
RESULTS FROM IMPULSE
FORMATION DISTURBANCE OR
CONDUCTION DISTURBANCE
3
AXIOM
ALL RHYTHM INTERPERTATION MUST
BE CORRELATED WITH SIGNS &
SYMPTOMS AND PATIENT
CONDITION
TREAT THE PATIENT,
NOT THE MONITOR4
Impulse formation
(site of impulse origin)
SA Node
AV Node
Ventricle
Ectopic
Premature Beat
Dysrhythmia
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Anatomy of the conducting system
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Normal Sinus Rhythm NORMAL SINUS RHYTHM IS PRODUCED BY
THE SA NODE
P WAVE FOLLOWS QRS COMPLEX IN A PREDICTABLE RELATIONSHIP
ALL P WAVES LOOK ALIKE, ALL QRS COMPLEXES ARE NARROW
R R INTERVAL IS REGULAR
RATE: 60 100 bpm
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Normal Sinus Rhythm
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Normal Sinus Rhythm
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Sinus / Atrial dysrhythmia
ORIGINATE FROM SA NODE OR ATRIA
(ABOVE VENTRICLES)
CONDUCTION WITH VENTRICLE IS UNDISTURBED
USUALLY BENIGN & SYMPTOMATIC
RHYTHM MAY BE IRREGULAR
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SINUS TACHYCARDIA SINUS BRADYCARDIAATRIAL FIBRILLATIONATRIAL FLUTTER Premature atrial contractions Paroxysmal atrial tachycardia Supraventricular Tachycardia
Sinus / Atrial dysrhythmia
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Dysrhythmia
Bradycardia / Tachycardia
Flutter / Fibrillation
Heart blocks
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Pathogenesis and Inducement of Arrhythmia
Some physical condition
Pathological heart disease
Other system disease
Electrolyte disturbance and acid-base imbalance
Physical and chemical factors or toxicosis
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Occurrence/Incidence
80 % of patient AMI
50 % of anesthetized patient
25 % of digitalis patient
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Etiology Physiological
Pathological:Valvular heart disease.Ischemic heart disease.Hypertensive heart diseases.Congenital heart disease.Cardiomyopathies.Carditis.RV dysplasia.Drug related.Pericarditis. Pulmonary diseases.Others.
Mechanism of Arrhythmia
Abnormal heart pulse formation1. Sinus pulse2. Ectopic pulse3. Triggered activity
Abnormal heart pulse conduction1. Reentry2. Conduct block
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Classification of Arrhythmia
Abnormal heart pulse formation1. Sinus arrhythmia2. Atrial arrhythmia3. Atrioventricular junctional arrhythmia4. Ventricular arrhythmia
Abnormal heart pulse conduction1. Sinus-atrial block2. Intra-atrial block3. Atrio-ventricular block4. Intra-ventricular block
Abnormal heart pulse formation and conduction17
Classification of Arrhythmia
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1. Characteristics: a. flutter very rapid but regular contractions b. tachycardia increased rate c. bradycardia decreased rate d. fibrillation disorganized contractile activity
2. Sites involved: a. ventricular b. atrial c. sinus d. AV node e. Supraventricular (atrial myocardium or AV node)
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Common Arrhythmias
Atrial
AF
A Flutter
Paroxs. SVT AVNRT
AVRT (WPW)
Multifocal atrial tachycardia
Ventricular
VT
VF
Torsades
Bradyarrhytmia
Medication
AV block
SSS
Ventricular fibrillation
Basic Rhythm Strip Interpretation
1. Determine the rate. Does the atrial rate equal the ventricular rate.
2. Is the rhythm regular/irregular?
3. Find the P wave. Is there a P wave for every QRS?
4. Determine the PRI (Normal 0.12-0.20 sec)
5. Find the QRS (Normal
Diagnosis of Arrhythmia
Medical history
Physical examination
Laboratory test
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Therapy Principal
Pathogenesis therapy
Stop the arrhythmia immediately if the hemodynamic was unstable
Individual therapy Personalized Medicine
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Arrhythmia Assessment ECG
24h Holter monitor
Echocardiogram
Stress test
Coronary angiography
Electrophysiology study
Arrhythmia Presentation Palpitation.
Dizziness.
Chest Pain.
Dyspnea.
Fainting.
Sudden cardiac death.
Strategy of Antiarrhythmic Agents
Suppression of dysrhythmias
A. Alter automaticityi. decrease slope of Phase 4
depolarizationii. increase the threshold potentialiii. decrease resting (maximum
diastolic) potential
B. Alter conduction velocityi. mainly via decrease rate of
rise of Phase 0 upstrokeii. decrease Phase 4 slopeiii. decrease membrane restingpotential and responsiveness
C. Alter the refractory periodi. increase Phase 2 plateau
ii. increase Phase 3 repolarization
iii. increase action potential duration
antiarrhythmic agents:
There are five main classes in the Vaughan
Williams classification of antiarrhythmic agents:
1.Class I agents interfere with the sodium (Na+)
channel.
2.Class II agents are anti-sympathetic nervous
system agents. Most agents in this class are beta
blockers.
3.Class III agents affect potassium (K+) efflux.
4.Class IV agents affect calcium channels and the
AV node.
5.Class V agents work by other or unknown
mechanisms
Anti-arrhythmia Agents
Anti-tachycardia agents
Anti-bradycardia agents
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Anti-tachycardia agents
Modified Vaugham Williams classification
1. I class: Natrium channel blocker
2. II class: -receptor blocker
3. III class: Potassium channel blocker
4. IV class: Calcium channel blocker
5. Others: Adenosine, Digital
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Anti-bradycardia agents
1. -adrenic receptor activator
2. M-cholinergic receptor blocker
3. Non-specific activator
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