ARRHYTHMIA

Eko AntonoDivision of Cardiovascular

Department of Internal MedicineDr. Hasan Sadikin Hospital

Diagrammatic representation of mechanism of reentry

Blood supply of the AV conduction system

The resting membrane potential and the action potential of an ordinary working cell from the ventricular myocardium

Schematic representation of pacemaker cell action potential

Schematic representation of ventricular myocardial working cell action potential

Action potentials recorded from isolated pacemaker cells immersed in a saline bath and firing at their own inherent

discharge rates

Action potentials from different myocardial cells

TERMINOLOGY

ETIOLOGY

SIGNS AND SYMPTOMS

SINUS RHYTHM

Relation of an electrocardiogram to the anatomy of the cardiac conduction system

Sinus bradycardia.

Sinus tachycardia

SUPRAVENTRICULAR ARRHYTHMIAS

Non-compen-satory

postextrasystolic pause

Short coupling interval in

supra-ventricular

extra-systole

Supraven-tricular

extrasystole

Atrial flutter with high-grade AV block.

Atrial flutter. The atrial rate is 250 beats per minute, and the rhythm is regular. Every other flutter wave is conducted to

ventricles (2:1 block), resulting in regular ventricular rhythm at a rate of 125 beats per minute

Atrial flutter with variable AV block.

The different appearances of the flutter line in atrial flutter

Fig 5.21 (hal 141 & 142)

Atrial flutter with an AV conduction ratio (AV-CR) at sleep and rest of 6 : 1

or 4 : 1 decreasing to 1 : 1 with slight exercise

Atrial fibrillation with controlled ventricular response.

Atrial fibrillation with rapid ventricular response

Atrial fibrillation (A) untreated and (B) after digitalis

VENTRICULAR ARRHYTHMIAS

Premature ventricular complex

Unifocal premature ventricular complexes. Note occurrence of wide, premature QRS complexes. Interval

between preceding normal QRS and PVC (coupling interval) remains constant, and morphology remains the

same

Multiformed premature ventricular complexes. Note variation in morphology and in coupling interval of PVCs

Premature ventricular complex with fully compensatory pause

Ventricular bigeminy. Note that every other betas is PVC. Both coupling interval and morphology remain constant;

hence they are unifocal

Pairs of premature ventricular complexes

R-on-T phenomenon. Multiple PVCs are present. Mulitple PVCs are present. On right, a PVC falls on downslope of T

wave, precipitating ventricular fibrillation

The QRST complex in ventricular arrhythmia

The apprearance of the QRST complex in ventricular

extrasystole

Regular appearanc

e of extrasystol

e

Lown’s criteria (1975) for a

grading system of “warning

arrhythmias” in AMI

Precipitation of ventricular tachycardia by late-cycle PVC. Note brief salvo of ventricular tachycardia that is initiated

by PVC occurring well beyond T wave

Ventricular tachycardia

Ventricular tachycardia and the diagnostic significance of ventricular extrasystole

Toardes de pointes

Torsade de pontes ventricular tachycrdial in third degree AV block

Coarse ventricular fibrillation

Fine ventricular fibrillation (“coarse” asystole)

Onset of ventricular fibrillation in the first hours of an acute myocardial infarction

Arrhythmogenic right

ventricular dysplasia. A 6-

year-old boy with fainting

spells

Ventricular asystole

CONDUCTION DISTURBANCES

First-degree AV block. The PR interval is prolonged to 0.31 second

Second-degree AV block type I

Second-degree AV block type II.

Third-degree AV block occuring at level of AV node.

Third-degree AV block occuring at ventricular level

Review of cardiac

arrhythmias (1) :

Arrhythmias with extopic

impulse formation

Review of cardiac

arrhythmias (2) :

Arrhythmias with

disturbances in impulse

conduction

BATAS AKHIR SLIDE

P wave polarity and pacemaker

site in atrial and AV junctional

arrhythmia

Extra-systole in

singles (A) and in pairs of couplets

(B) and brief

attacks of tachycardia

l (C)

third-degree AV block with ventricular asystole

Premature junctional complexes

Junctional excape complexes

Paroxysmal supraventricular tachycardial (PSVT)

Atrial tachycardia with block

Survival rates are estimates of probability of survival to hospital discharge for patients with witnessed collapse and with ventricular fibrillation as initial rhythm