内科学心律失常课件

,CARDIACARRHYTHMIAEditedbyXUJIN/chenying-minDepartmentofCardiologyRenjiHospital,THEGENERALITY,DefinitionofArrhythmia:TheOrigin,Rate,Rhythm,Conductvelocityandsequenceofheartactivationareabnormally,窦房结结间束房间束房室结房室束或叫希氏束左、右束支浦顷野氏纤维,ANATOMYOFTHEHEART,PathogenesisandInducementofArrhythmia,SomephysicalconditionPathologicalheartdiseaseOthersystemdiseaseElectrolytedisturbanceandacid-baseimbalancePhysicalandchemicalfactorsortoxicosis,MechanismofArrhythmia,AbnormalheartpulseformationSinuspulseEctopicpulseTriggeredactivityAbnormalheartpulseconductionReentryConductblock,MechanismofArrhythmia,AbnormalheartpulseformationSinuspulseEctopicpulseTriggeredactivity,自律性窦房结60100次/min房室结附近4060次/min浦氏纤维2040次/min,MechanismofArrhythmia,AbnormalheartpulseformationSinuspulseEctopicpulseTriggeredactivity,MechanismofArrhythmia,AbnormalheartpulseformationSinuspulseEctopicpulseTriggeredactivity,细胞膜电位100beats/min(100-180)Causes:Somephysicalcondition:exercise,anxiety,exciting,alcohol,coffeeSomedisease:fever,hyperthyroidism,anemia,myocarditisSomedrugs:Atropine,IsoprenalineNeednttherapy,窦性心律，心率136次/分,SinusBradycardia,Sinusrate2.0s.24hHolter:24hsinusbeat：2.0-2.5sEPSTUDY:SNRT1530ms,SNRTc525msInstinctheartrate0.12s继发性ST-T改变未见P波或P波与QRS波无关有时可见心室夺获和心室融合彼,Ventriculartachycardia,心电图特点举例HR160bpmQRS宽大畸形ST-T异常未见P波,Ventriculartachycardia,MonomorphicVT:100-250bpm,occurandterminateabruptly,regular,心电图特点举例室房分离,Ventriculartachycardia,MonomorphicVT:100-250bpm,occurandterminateabruptly,regular,心电图特点举例,心室融合波,心室夺获,Ventriculartachycardia,MonomorphicVT:100-250bpm,occurandterminateabruptly,regular,心电图特点举例,短阵室速,多形性室速,Ventriculartachycardia,Sanguinetti:1997,P,T,QRS,QT,QT,antiarrhythmiadrugproarrhythmia,凡延长QT间期的AAD都有致TDP作用？,RonT,Acceleratedidioventricularrhythm:RelatedtoincreaseautomatictoneEtiology:Oftenoccurinorganicheartdisease,especiallyAMIreperfusionperiods,heartoperation,myocarditis,digitalistoxicityECGcharacteristics:arunsof3-10ventricularbeats,rateof60-110bpm,tachycardiaisacapableofwarmupandclosedown,oftenseenAVdissociation,fusionorcapturebeats,Ventriculartachycardia,非阵发性室性心动过速：心室率60次/分，室房分离,Brugada分步鉴别诊断室速与宽QRS波形室上速,Manifestation:NonsustainedVTwithnosymptomSustainedVT:withsymptomandunstablehemodynamic,patientmayfeelpalpitation,shortofbreathness,presyncope,syncope,angina,hypotensionandshock.TreatmentofVT1.Treatunderlyingdisease2.Cardioversion:HemodynamicunstableVT(hypotension,shock,angina,CHF)orhemodynamicstablebutdrugwasnoeffect3.Pharmacologicaltherapy:-blockers,lidocainoramiodarone4.RFCA,ICDorsurgicaltherapy,Ventriculartachycardia,Acceleratedidioventricularrhythm:usuallynosymptom,neednttherapy.AtropineincreasedsinusrhythmTdp:Treatunderlyingdisease,Magnesiumiv,atropineorisoprenaline,-blockorpacemakerforlongQTpatienttemporarypacemaker,TherapyofSpecialtypeVT,室扑心电图特点,无正常QRS-T波群代之以连续快速且相对规则的正弦波频率200250次/分,室颤的心电图特点无正常QRS-T波群代之以大小不等、极不规则的低小颤动波频率200500次/分,Ventricularflutterandfibrillation,Ventricularflutterandfibrillation,Etiology:Oftenoccurinsevereorganicheartdisease:AMI,ischemiaheartdiseaseProarrhythmia(especiallyproducelongQTandTdp),electrolytedisturbanceAnaesthesia,lightningstrike,electricshock,heartoperation,Manifestation:Unconsciousness,twitch,nobloodpressureandpulse,goingtodieTherapy:ItsafatalarrhythmiaCardio-PulmonaryResuscitate(CPR)ICD,Cardiacconductionblock,Cardiacconductionblock,Blockposition:Sinoatrial;intra-atrial;atrioventricular;intra-ventricularBlockdegreeTypeI:prolongtheconductivetimeTypeII:partialblockTypeIII:completeblock,AtrioventricularBlock,AVblockisadelayorfailureintransmissionofthecardiacimpulsefromatriumtoventricle.Etiology:Atheroscleroticheartdisease;myocarditis;rheumaticfever;cardiomyopathy;drugtoxicity;electrolytedisturbance,collagendisease,levsdisease.,First-degreeAVblock:First-degreeAVblockarea1:1relationshipbetweenPwavesandQRScomplexesbutwithaP-Rintervalof0.20s.BlockmayoccurinanypartofAVjunctionalsystem.EitherinAVnodeorinHis-bundle.MostcommonblockisinAVnode.UsingHis-bundleelectrocardiogramrecordcanmakediagnosis.,AtrioventricularBlock,TypeISecond-degreeAVblock:TypeISecond-degreeAVblockischaracterizedbyWenckebachperiodicityinwhichtheP-RintervalgraduallyprolongsuntilaPwavefailstoconducttotheventricles,aftertheblockedPwaveconductionthenresumes,theP-Rintervalofthisnextconductedbeatshorten.,AtrioventricularBlock,TypeISecond-degreeAVblock:BlockmayoccurinanypartofAVjunctionalsystem.WithnormalQRScomplexinsurfaceECG;usuallyblockinAVnode.WithBBB-QRScomplexinsurfaceECG;blockinAVnodeorinHis-bundle.TypeISecond-degreeAVblockmayprogresstothethird-degreeAVblock,butitsrareseen.,AtrioventricularBlock,TypeIIsecond-degreeAVblockTypeIIsecond-degreeAVblockischaracterizedbysuddenfailureofoneorseveralconsecutivePwavestoconducttotheventricleswithoutprogressivelengtheningoftheP-RintervalpriortotheblockedPwave.AVblockischaracterizedbyafixedratioofPwavestoQRScomplexes,2:1,3:1,4:1,thisisusuallyreferredtoas“advanced”or“high-grade”second-degreeblock.,AtrioventricularBlock,TypeIIsecond-degreeAVblockTypeIIsecond-degreeAVblockwithwideQRScomplexisblockedinHis-purkinjesystems.IfitwithnormalQRScomplex,mayblockinAVnode.2:1AVblockcanbeeithertypeIortypeIIsecond-degreeAVblock,withnormalQRScomplexisoftenTypeIsecond-degreeAVblock,withBBBQRScomplexusuallyneedforEPstudytodefinition.,AtrioventricularBlock,Third-degreeorcompleteAVblockThird-degreeorcompleteAVblockistotalabsenceofconductionbetweenatriaandventricles.ThereisAVdissociation,theventricularratebeingslowerthantheatrialrateandbeinggovernedbyasubsidiarysub-AVnodalpacemaker.AregularventricularrateinthepresenceofatrialfibrillationshouldheightenonessuspicionofcompleteAVblock.,AtrioventricularBlock,Third-degreeorcompleteAVblockInthenormalQRScomplexwithventricularrateisaround4060bpm,BlockisintheHis-bundleandsub-Hisbundle.IntheabnormalwideQRScomplexwithventricularrateislessthan40bpm,blockisinthedistalofintraventricularsystems.EPstudycanmakedecision.,AtrioventricularBlock,Manifestations:First-degreeAVblock:almostnosymptoms;SeconddegreeAVblock:palpitation,fatigueThirddegreeAVblock:Dizziness,agina,heartfailure,lightheadedness,andsyncopemaycausebyslowheartrate,Adams-StokesSyndromemayoccursinsevercase.Firstheartsoundvariesinintensity,willappearboomingfirstsoundTreatment:IorIIdegreeAVblockneedntantibradycardiaagenttherapyIIdegreeIItypeandIIIdegreeAVblockneedantibradycardiaagenttherapyImplantPaceMaker,AtrioventricularBlock,IntraventricularBlock,Intraventricularconductionsystem:RightbundlebranchLeftbundlebranchLeftanteriorfascicularLeftposteriorfascicular,Rightbundlebranchblock:,IntraventricularBlock,Leftbundlebranchblock:,IntraventricularBlock,LBBissubdividedintoleftanteriorfascicularblockandleftposteriorfascicularblock,LAHblockismoreoftenthanLPHblock.RBBB;LBBB;LAH;LPH;LBBB+RBBB;RBBB+LAH;RBBB+LPH.,IntraventricularBlock,Etiology:Myocarditis,valvedisease,cardiomyopathy,CAD,hypertension,pulmonaryhe