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Arrhythmia,Zhuwen-qing,Dep.OfCardiology,Zhong-ShanHospital,FuDanUniversity.Shanghai.China.,Conductionandanatomyofheart,Conductionsystem,StableSVTisgenerallywelltoleratedinpatientswithoutunderlyingheartdisease!?butmayleadtomyocardialischemiaorcongestiveheartfailureinpatientswithcoronarydisease,valvularabnormalities,andsystolicordiastolicmyocardialdysfunction.Ventriculartachycardia,iflasting1030secs,oftenresultsinhemodynamiccompromiseandismorelikelytodeteriorateintoventricularfibrillation.,RATEDifferentiationofSVTfromVA;Evaluationoftherapyinpatientswithaccessoryatrioventricularpathways;EvaluationoftheefficacyofpharmacotherapyinsurvivorsofsuddendeathorotherpatientswithsymptomaticorlifethreateningVT;Evaluationofpatientsforcatheterablationproceduresorantitachycardiadevices.,AutonomicTesting(TiltTableTesting)withrecurrentsyncopeornearSyncope,arrhythmiasarenocause.Thisisparticularlytruewhenthepatienthasnoevidenceofassociatedheartdiseasebyhistory,examination,ECG,ornoninvasivetesting.Syncopemaybeneurocardiogenicinorigin,mediatedbyexcessivevagalstimulationoranimbalancebetweensympatheticandparasympatheticautonomicactivity.,TECHNIQUESFOREVALUATINGRHYTHMDISTURBANCES,TECHNIQUESFOREVALUATINGRHYTHMDISTURBANCES,AutonomicTesting(TiltTableTesting),60-80,TECHNIQUESFOREVALUATINGRHYTHMDISTURBANCES,Antiarrhythmiadrug,Antiarrhythmicdrugshavelimitedefficacyandfrequentsideeffects.Theyareoftendividedintofourclasses.ClassIagentsblockmembranesodiumchannels.ThreesubclassesarefurtherdefinedbytheeffectofagentsonthePurkinjefiberactionpotentialClassladrugsslowtherateofriseoftheactionpotential(Vmax)andprolongitsduration,thusslowingconductionandincreasingrefractorineas.Classlbagentsshortenactionpotentialduration,theydonotaffectconductionorrefractoriness.ClassIcagentsprolongVmaxandslowrepolarization,thusslowingconductionandprolongingrefractoriness,butmoresothanclassladrugs,Antiarrhythmiadrug,ClassIIagents-beta-blockersDecreaseautomaticity,ProlongAVconduction,Prolongrefractoriness.,Antiarrhythmiadrug,ClassIIIagentsBlockpotassiumchannelsProlongrepolarization,wideningtheQRSandprolongingtheQTinterval.Decreaseautomaticityandconductionandprolongrefractoriness.,Antiarrhythmiadrug,ClassIVagents-slowcalciumchannelblockersDecreaseautomaticityandAtrioventricularconduction,Drugs,Antiarrhythmiadrug-Risk,TheriskofantiarrhythmicagentshasbeenhighlightedbytheCoronaryArrhythmiaSuppressionTrial(CAST).TwoclassIcagents(flecainide,encairfide)andaclamlaagent(moficizine)increasedmortalityratesinpatientswithasymptonlaticventricularectapyaftermyocardialinfarction.Therefore,theseagents(anyantiarrhythmicdrug)shouldnotbeusedexceptforlife-threateningventriculararrhythmiasandsymptomaticsupraventriculartachyarrhythmias.,RadiofrequencyAblation,AblationhasbecometheprimarymodalityoftherapyformanysymptomaticSVTIncludingAVNRTAVRT-involvingaccessorypathways,paroxysmalatrialtachycardia,inappropriatesinustachycardia,junctionaltachycardia,Manylaboratorieshaveachievedreasonablesuccessratesinpreventingatrialflutterwithrediofrequencytechniques,andexperiencewithatrialfibrillationisaccumlatingaswell.,RadiofrequencyAblation,CatheterablationofVAhasprovedmoredifficult.ThreespecilicformsofVAprovedtobeamenabletoradiofrequeneyablation.bundlebranchreentry,VToriginatinginrightventricuiaroutflowtract,VToriginatingintheleftsideoftheinterventricularseptum.OtherformsofVT,maybeamenabletoablation,butexperiencethusfarislimited.,RadiofrequencyAblation,Inaddition,someproceduresinvolvetransseptalorretrogradeleftventricularcatheterization,withtheattendantpotentialcomplicationsofaorticperforation,damagetotheheartvalves,orleft-sidedemboli.Theseproceduresaregenerallysafe,thoughthereisalowincidenceofperforationoftheatriaorrightventriclethatresultsinpericardialtamponadeandsufficientdamagetotheatriovantricularnodetorequirepermanentcardiacpacing.,AVRTablation,AVNRTAblation,Atrialtachycardia-ablation,Atrialfibrillationaccountsfor1/3ofallpatientdischargeswitharrhythmiaasprincipaldiagnosis.,2%VF,Datasource:BailyD.JAmCollCardiol.1992;19(3):41A.,34%AtrialFibrillation,18%Unspecified,6%PSVT,6%PVCs,4%AtrialFlutter,9%SSS,8%ConductionDisease,3%SCD,10%VT,SUPRAVENTRICULARARRHYTHMIASsinusbradycardia,CausesofSlowRhythms:HypoxiaHyperkalemiaAcuteMIHeartDiseaseIncreasedparasympathetictoneDrugeffectsfromnarcotics,benzodiazepines,digoxin,betablockers,propranolol,orcalciumchannelblockers,SinusBradycardia,DecreaseintherateofatrialdepolarizationRhythmisregularRate100beats/minPwave,PRinterval,andQRScomplexareallnormal,SinusTachycardia,Treatment:AlleviatetheunderlyingcauseinappropriatesinustachycardiathatmaybeverysymptomaticorleadtoLVcontractiledysfunction.Radiofrequeneymodificationofthesinusnodehasmitigatedthisproblem,ATRIALPREMATUREBEATS,APBoccurbeforethenextsinusnodeimpulseorareentry_circuitisestablished.Pwaveusuallydiffersfromthepatientsnormal.R-Rcyclelengthisusuallyunchangedoronlyslightlyprolonged.prematurebeatsoccurinnormalheartsandareneverasufficientbasisheartdisease.Speedingoftheheartratebyanymeansusuallyabolishesmostprematurebeats.EarlyAPBmaycauseaberrantQRScomplexesormaybenonconductedtotheventriclesbecausethelatterarestillrefractory.,VariabilityofVentricularEctopywithAge,Effectofageonprobability(%)ofhavingmorethanagivennumberofPVCsper24hoursinsubjectswithnormalhearts.,10-29,30-39,40-49,50-59,60-69,DatafromKostisJB.Circulation.1981;63(6):1353.,Age,VENTRICULARBEATS,DistinctioncanbeverydifficultinpatientswithawideQRS;itisimportantbecauseofthedifferingprognosticandtherapeuticimplicationsofeachtype.ventricularoriginincludeatrioventriculardissociation;aQRSdurationexceeding0.14s;captureorfusionbeats(infrequent);leftaxisdeviatinnwithrightbundlebranchblockmorphology;monophasic(R)orbiphasic(qR,QR.,orRS)complexesinV1,;and(6)aqRorQScomplexinV6.,VENTRICULARBEATS,SupraventricularoriginisfavoreclbyatriphasicQRScomplex,especiallyiftherewasinitialnegativityinleadsIandV6;ventricularratesexcceeding170/min;QRSdurationlongerthan0.12sbutnotlongerthan0.14s:thepresenceofpreexcitationsyndrome.,Asingleirritablefocuswithintheventriclefiresprematurelygivingrisetoanectopicbeat.QRSiswideIfeveryotherbeatisPVCventricularbigeminyIfeverythirdbeatisaPVCventriculartrigeminyIfeveryfourthbeatisPVCventricularquadrigeminyAPVCthatfallsontheTwaveprecipitatesVTorVF,VENTRICULARBEATS,VENTRICULARBEATS,Treatment:PVCswhichneedtobetreatedare:MultifocalOccurincoupletsFallonoraftertheTwaveThatoccurgreaterthan6perminute,PrematureVentricularContraction,TreatmentContinued:InthesettingofanacuteMI,PVCsneedtobeaggressivelytreatedwithnitroglycerine,aspirin,morphineandoxygen.LidocaineisthedrugofchoicetodiminishPVCs,butdoeslittletotheunderlyingpathology.,SUPRAVENTRICULARTACHYCARDIA,thecommonestparoxysmaltachycardiaandoftenoccursinpatientswithoutstructuralheartdisease.Attacksbeginandendabruptlyandmaylastafew,secondstoseveralhoursorlonger.Hrmaybe140-240/mia(usually160-220/min)andisperfectlyregular(despiteexerciseorchangeinposition).Pwaveusuallydiffersincontourfromshinsbeats.Asymptomatic,butsomeexperiencemildchestpainorshormessofbreath,especiallywhenepisodesareprolonged,evenintheabsenceofassociatedcardiacabnormalities.PSVTmayresultfromdigitalistoxicityandtheniscommonlyassociatedwithatrioventricularblock.,SVT,SVT,SVT-Care,AMechanicalMeasures:Avarietyofmethodshavebeenusedtointerruptattacks,andpatientsmaylearntoperformthesethemselves.TheseincludeValsalvasmaneuver,stretchingthearmsandbody,loweringtheheadbetweentheknees,coughing,andbreathholding.,SVT-treatment,B.DrugTherapy:Iffail,rapidlyintravenousagentswillterminatemorethan90%ofepisodes,Intravenousadenosine(orATP)hasaverybriefdurationofactionandminimalnegativeinotropieactivity,A6-mgbolusisadministered.Ifnoresponseisobservedafter10minutes,asecondandthird12-mgbolusshodldbegiven.Sincethehalf-lifeofadenosineislessthan10seconds,drugmustbegivenrapidly(in12secondsfromaperipheralintravenousline).Adenosineisverywelltolerated,butnearly20%-flushing,andsomepatientsexperienceseverechestdiscomfort.,SVTCare,CalciumchannelblockersalsorapidlyinduceatrioventricularblockandbreakmostepisodesofreentrySVT.IVverapamilmaybegivenasa2.5mg-bolus,followedbyadditionaldosesof2.5to5mgevery1-3minutesuptoatotalof20mgifbloodpressureandrhythmarestable.Iftherecurs,furtherdosescanbegiven,SVT-Care,Cardioversion:Ifthepatientishemodynamicallystableorifadenosineandvempamilarecontraindicatedorineffective,synchronizedelectricalcardioversion(beginningat100J)isalmostuniversallysuccessful.Ifdigitalistoxicityispresentorstronglysuspected,asinthecaseofparoxysmaltachycardiawithblock.electricalcardioversionshouldbeavoided.,PreventionofAttacks,A.RadiofrsquencyAblation:SafetyandLessrecurrentB.Drugs:Verapamil、Propafenone、Amiodarone,PreexcitationSyndromes,Wolff-ParkinsonWhitesyndrome.Directconnectionsbetweentheatriaandventricle(Kentbundles);Lown-Ganong-Levinesyndrome:shortPRintervalandnormalQRSmorphologyMahaimfibers:whollyorpartlywithinthenode,PreexcitationSyndromes,AVRT-WPW,Pathwaysoccurin0.1-0.3%.20-30%ofpatientswithtachyarrhythmiashaveatrialfibrillationorflutter!PatientswithRRintervalslessthan220msareathighestrisk.DigoxinSayNO!verapamilandbetablockersmaydecreaseAPrefractorinessandincreaseventricularresponseandshouldbeavoidedinatrialfibrillationwithaccessorypathwaysTreatment.,WPW,AVRTWPWCare,Radiofrequencycatheterablation;PharmacologicTherapy.,Atrialfibrillation,Atrialfibrillationisthecommonestchronicarrhythmia.Itoccursinrheumaticheartdisease,dilatedcardiomyopatliy,ASD,hypertension,mitralvalveprolapse,andhypertrophiccardiomyopathyaswellasinpatientswithnoapparentcardiacdisease.itmaybetheinitialpresentingsigninthyrotoxicosis.Atrialfibrillationoftenappearsparoxysmallybeforebecomingtheestablishedrhythm.,Atrialfibrillation,Atrialrateis350-600/min,butmostimpulsesareblockedattheatrioventricularnode.Diagnosis:ECG,Atrialfibrillation,Acutemanagementearlycardieversion-2448hsayNoOradequatelyanticoagulatedfor3-4weeksIVbeta-blockersorverapamilordiltiazem,digoxin,oracombinationoftheseapproaches.,Atrialfibrillation,TreatmentofChronicAtrialFibrillationTheproblemsposedbychronicAfareprimarilytwo:symptomsrelatedtothearrhythmiasandtheincreasedriskofthromhoemboliephenomena.Drug:anticoagulationorcontrolHrAblation:pacemakeretc.Surgeon,AtrialFlutter,AFislesscommonthanfibrillation.COPDorwithrheumaticorCHD,CHF,ASD,orsurgicallyrepairedcongenitalheartdisease.Atrialratesof250-350/rain,withtransmissionofevery2:1/3:1/4:1atrioventricularnodetotheventricles.,ATRIALFLUTTER,Chronicatrialflutterisoftenadifficultmanagementproblem,ratecontrolisdifficult.Drug:anticoagulationorcontrolHrAblation:pacemakeretc.Surgeon,ATRIALFLUTTER,DiagramofAtrialFlutterCircuitWithinRightAtrium,CosioFG.AmJCardiol.1993;71:705-709.,Inferiorvenacava-tricuspidvalveisthmus,ATRIALTACHYCARDIA,ThisisarhythmcharacterizedbyvaryingP-wavemorphology(bydefinition,threeororefoci)andmarkedlyirregularPPintervals.Therateisusuallybetween100and140/min,andatrieventricularblockisunusualMostpatientshavesevereassociatedCOPD.Treatmentoftheunderlyingconditionisthemosteffectiveapproach;verapamil,240-480mgdailyindivideddoses,isalsoofvalueinsamepatients.,ATRIALTACHYCARDIA,ATRIALTACHYCARDIA,ATRIOVENTRICULARTIONALRHYTHM,Theatrial-nodaljunctionorthenodal-Hisbundlejunctionsmayassumepacemakeractivityfortheheart,usuallyatarateof4060/min.Patientswithmyocarditis,CHD,anddigitalistoxicityaswellasinindividualswithnormalhearts.Diagnosis:ECG/monitoring,butitcanbesuspectedifIhejugularvenouspulseshowscannonawaves.NonparoxysmaljunctionaltachyeardiaresultsfromdigitalistoxicityorischemiaandisassociatedwithanarrowQRScomplexandarateusuallylessthan120-130/min.Consideredbenignwhenitoccursinacutemyocardialinfarction,buttheischemiamayalsocauseVTandVf.,VENTRICULARARRHYTHMIAS-ENTRICULARPREMATUREBEAT,VentricularPrematurebeatsarecharacterizedbywideQRScomplexesthatdifferinmorphologyfromthepatientsnormalbeats.TheyareusuallynotprecededbyaPwave,althoughretrogradeventriculoatrialConductionmayoccur.,VENTRICULARARRHYTHMIAS-VENTRICULARPREMATUREBEAT,VENTRICULARARRHYTHMIAS-VENTRICULARPREMATUREBEAT,Diagnosis:ECG/AmbulatorymonitoringTreatment:Drugs/AblationIfnoassociatedcardiacdiseaseispresentandasymptomatic,notherapyisindicated.mayexacerbateseriousarrhythmiasin520%ofpatients.Therefore,toavoidusingclassIorIIIantiarrhythmicagentsinpatientswithoutsymptoms.,VENTRICULARARRHYTHMIAS-VENTRICULARTACHYCARDIA,VTisdefinedasthreeormoreconsecutiveventricularprematurebeats.Theusualrateis160-140/mmandismoderatelyregularbutlesssothanatrialtachycardia.Diagnosis:ECG/Monitor/EPS,VENTRICULARARRHYTHMIAS-VT,VTcauseshypotension,heartfailure,ormyocardialischemia,synchronizedDCcardioversionwith100-360Jshouldbeperformedimmediately.PatientisstableIVlidocaine/procainamide/amiodarone.VTaimbeterminatedandPreventrecurrent.,Ventriculartachycardia,VENTRICULARARRHYTHMIAS-VT,SustainedVTDrugsAblationAICDSurgeon,VENTRICULARARRHYTHMIAS-VT,NonsustainedVT(NSVT)definedasrunsofthreeormorebeatslastinglessthan30seconds.ICDwillimproveprognosis.Betterprognosissuggeststhatbeta-blockersshouldbethefirstlineoftherapy.Althoughtherearenodefinitivedatawithamiodarone.Otherantiarrhythmicagentsshouldgenerallybeavoidedbecausctheirproarrhythmicriskappearstooutweighallybenefit,eveninpatientswithinduciblearrhythmiasthataresuccessfullysuppressedintheelectrophysiologylaboratory.,VENTRICULARFIBRILLATION,ThecausativerhythminmostCasesisventricularfibrillation,whichisusuallyprecededbyveutriculartachycardiaexceptinthesettingofacuteisehemiaorinfarction.Diagnosis:?!Treatment:Drugs/AICD!?,VentricularFlutterorfibrillation,ConductionDisturbance-Sicksin
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