心电图教学课件：ECG-Arrhythmia -

Arrhythmias张晓丹心脏传导系统图心电信号传递的三站第一站：窦房结第二站：房室结第三站：浦肯野纤维与心室肌细胞心房束支心室ElectrophysiologyAutomaticityExcitabilityAbsoluterefractoryperiodEffectiverefractoryperiodRalativerefractoryperiodConductivity房室结最慢（20～200mm/s)，普氏最快（4000mm/s)心律失常概述

定义：心脏激动的起源异常（Abnormalorigin）或/和传导异常（Abnormalconduction）

分类：目前多按形成原因分类ClassificationAbnormalorigin----sinusarrhythmia----ectopicrhythm:passivity—escapeactivity—prematurecontraction—tachycardia—flutterandfibrillationAbnormalconduction----physiologicalblock:----pathologicalblock:S-AB;A-VB;LBBB;RBBB----accessorypathway:pre-excitationsyndrome

产生机制（1）折返激动（reentry）（2）触发活动(triggeredactivity)（3）异位起搏点兴奋性增高(ectopicpacemakerexcitabilityrise)常规心电图的波形组成和测量示意图

SINUSRHYTHMAND

SINUSARRHYTHMIAS

Sinusrhythmfeatures:(1)EveryPwaveisfollowingbyaQRScomplex;

(2)PwaveisuprightinleadI,II,aVF,V4-V6,inverseinaVR;(3)

P-Rinterval≥0.12sec;(4)

Normalrateis60-100beats/min*正常窦性心律示例*

SinusTachycardia(1)

Sinusrhythm,rate>100bpm

TheR-Rinterval(ortheP-Pinterval)<0.60sec.(2)

P-RandQ-Tintervalareshorterthanusual(3)

S-Tsegmentisslightdepression,Twavesmaybeflattened

Factorsassociatedwithsinustachycardia(1)PhysiologicExerciseStrongemotionAnxietystates(2)PathologicFeverHemorrhage（出血）Anemia（贫血）

MyocarditisHyperthyroidism（甲亢）SinusBradycardia(1)

Sinusrhythm(2)

Heartrate<60bpm(R-RintervalorP-Pinterval>1.0sec)Factorsassociatedwithsinusbradycardia(1)Physiologic

LaborersandtrainedathletesEmotionalstatesleadingtosyncope（晕厥）(2)Pathologic

-blockerHypothyroidismSinusarrhythmia

SinusrhythmandPRinterval,DifferenceofP--Pinterval>0.12sec

inthesamelead

SinusarrestThePwavemissedforashorttime

SickSinusSyndrome(SSS)(1)

Sinusbradycardia(HR<50/min);(2)

SinusarrestorSAblock;(3)

Tachycardia:Atrialtachycardia,

AtrialFlutter,

Atrialfibrillation;(4)AVblock.Conditionsassociatedwithsinoatrialnode

dysfunction

AgeIdiopathicfibrosis(特发性纤维化)Ischaemia,includingmyocardialinfarctionHighvagaltone（迷走N张力增高）

Myocarditis（心肌炎）Digoxintoxicity（洋地黄中毒）Prematurecontractions期前收缩（早搏）定义：

起源于窦房结以外的异位起搏点提前发出的激动产生机制：

（1）折返激动（reentry）（2）触发活动(triggeredactivity)（3）异位起搏点兴奋性增高(ectopicpacemakerexcitabilityrise)期前收缩术语联律间期(couplinginterval)代偿间歇(compensatorypause)插入性期前收缩（间位性期前收缩）单源性期前收缩多源性期前收缩频发性期前收缩*室性早搏-二联律**房性早搏—二联律*

1.PrematureVentricularContraction(1)Ventricularcomplex(QRS)isnotprecededbyaprematureP'wave.(2)PrematureQRScomplexisthewiderandthebizarre,DurationofQRS>0.12sec.TwaveindirectionisoppositetoQRScomplex.(3)Completecompensatorypause

bigeminytrigeminy2.PrematureAtrialContractions

(1)TheprematureP'wavediffersincontourfromthenormalPwaveinthesamelead.(2)TheP'-Rinterval>0.12s.(3)Theremaybeanoncompensatorypause.

3.Prematurejunctionalcontraction

(1)Aprematurenormal-appearingQRScomplex.(2)ThejunctionalPwave(P’)maybeappearbefore,in,andaftertheQRS.(3)Usuallyacompletecompensatorypause.

Tachycardia机制:异位起搏点兴奋性增高(ectopicpacemakerexcitabilityrise)或折返激动（reentry）引起快速异位心律1)Paroxysmalsupraventriculartachycardia2)VentricularTachycardiaParoxysmalsupraventriculartachycardiaAnytachyarrhythmiaarisingfromtheatriaortheatrioventricularjunctionisasupraventriculartachycardia.thetermsupraventriculartachycardiaisreservedforatrial

tachycardiasandarrhythmiasarisingfromtheregionoftheatrioventricularjunctionThemostcommonjunctional

tachycardias

atrioventricular

nodalre­entranttachycardia(AVNRT)DualA-Vnodalpathwaysatrioventricularre­entranttachycardia(AVRT)accessorypathway1.Paroxysmalsupraventriculartachycardia(PSVT)a.Heartratebetween160–250bpm.b.ApreciselyregularrhythmwithnormalQRS.atrioventricular

nodalre­entranttachycardia(AVNRT)发生机理：re­entrantRequires:1)Twoconductingpathways2)Unidirectionalblockinone3)Slowconductionintheother4)

re­entrycircuit

2.VentricularTachycardiaa)

Therateis140200/minandtherhythmisveryslightlyirregular.b)

QRScomplexisthewiderandthebizarre,DurationofQRS>0.12sec.c)

PwavedissociatedfromQRS（房室分离）;TherateofPwaveislessthanTherateofQRSd)

Ventricularcapture(心室夺获);e)

Fusionbeatsarepresent（室性融合波）.*室性心动过速伴房室分离*3.

NonparoxysmalTachycardiaNonparoxysmal

junctionalTachycardia,Theheartrateis70130/min

NonparoxysmalventricularTachycardia.Theheartrateis60100/min

4.

Torsdedepointes

FlutterandFibrillation

1.AtrialFlutter(1)

AbsenceofnormalPwaves;(2)

Pwavesreplacedbysaw-toothflutterwave(Fwaves);(3)

FlutterwavesseenbestinleadsII,III,aVF;(4)

Fwavesalwaysuniforminsize,shapeandfrequencyandabsenceofisoelectriclinebetweenFwaves;(5)

Regularatrialrhythmwitharateof240-350/min;(6)Ventricularresponseof1:1,2:1,3:1,4:1orhigher*心房扑动*2.AtrialFibrillation(1)

AbsenceofclearPwaves;(2)

Pwavesreplacedbyfwaves;(3)

fwaves:irregularinsize,shape,bestseeninleadV1;(4)

Rateoffwavesis350-600/min;(5)

Irregularlyirregularventricularrate;(6)

Generally,durationofQRScomplex<0.12sec;*心房颤动*AtrialFibrillationAtrialFibrillationisthemostcommonsustainedarrhythmia.bymultiplere­entrantcircuitsor“wavelets”ofactivationsweepingaroundtheatrialmyocardiumCausesofatrialfibrillation

IschaemicheartdiseaseHypertensiveheartdiseaseRheumaticheartdiseaseThyrotoxicosisAlcoholmisuse(acuteorchronic)Cardiomyopathy(dilatedorhypertrophic)SicksinussyndromePost­cardiacsurgeryChronicpulmonarydiseaseVentricularFlutterand

VentricularfibrillationVentricularflutter:

ItisimpossibletoseparatetheQRScomplexesfromtheSTsegmentandtheTwaves

Ventricularfibrillation:TheECGshowsfineorcoarsewavesthatarerapid,andirregularinsize,shape,andwidth.ConductionDisturbances传导异常传导障碍意外传导捷径传导病理性传导阻滞生理性干扰脱节心脏传导阻滞

心脏传导阻滞病因器质性损害迷走N张力高药物性作用心脏传导阻滞

按发生部位分类窦房阻滞房内阻滞房室阻滞室内阻滞心脏传导阻滞按阻滞程度分类一度阻滞二度阻滞三度阻滞心脏传导阻滞按发生情况分类永久性暂时性交替性渐进性窦房阻滞(sinoatrialblock)二度二型窦房阻滞窦性停搏房内阻滞(intra-atrialblock)以不完全阻滞常见上房间束阻滞常见，与左房大相鉴别AtrioventricularconductionblockAtrioventricularconductioncanbedelayed,intermittentlyblocked,orcompletelyblocked—classifiedcorrespondinglyasfirst,second,orthirddegreeblock.1.FirstDegreeA-VBlockProlongedP-Rinterval:

P-Rinterval>0.20sec.inadults(varieswithheartrate)

2.SecondDegreeA-VBlock(1)MobitztypeI(Wenckebachphenomenon).ThepatternisaprogressiveprolongationoftheP-Rintervaluntilabeatisdropped.ThefirstbeatafterthepausehastheshortestP-Rinterval,whichmayormaynotbenormal.(2)MobitztypeIIThePRintervalisconstantuntilabeatisdroppedHighdegreeatrioventricularblock,whichoccurswhenaQRScomplexisseenonlyaftereverythree,four,ormorePwaves,mayprogresstocompletethirddegreeatrioventricularblock.Thereisafixednumericalrelationshipbetweenatrialandventricularimpulses,whichmaybe2:1(2atrialbeatstooneventricularbeat)or3:1or4:1.ThirdDegreeA-VBlock

(Completeheartblock)(1)Theatrialandtheventricularrhythmsareabsolutely,independentofoneanother.(ThereisnorelationshipofPtoQRS.)(2)atrialrate>ventricularrate.QRSreater.CausesofatrioventricularconductionblockMyocardialischaemiaorinfarctionDegenerationoftheHis­PurkinjesystemInfection—forexample,Lymedisease,diphtheria(白喉)Immunologicaldisorders—forexample,systemiclupus

erythematosus（系统性红斑狼疮）SurgeryCongenitaldisorders束支与分支传导阻滞一、右束支传导阻滞（rightbundlebranchblock,RBBB)二、左束支传导阻滞（leftbundlebranchblock,LBBB)三、左前分支传导阻滞(leftanteriorfascicularblock)四、左后分支传导阻滞(leftposteriorfascicularblock)4.CompleteRightBundleBranchBlock

(1)rsR’pattern(Mpattern)inV1orV2;(2)QRS≥0.12sec.(3)WideandslurredSwaveinleadsI,V5andV6.(4)RpeaktimeinV1>0.05s(5)ST-TchangesinleadsV1andV2.CompleteRightBundleBranchBlock5.CompleteLeftBundleBranchBlock(1)Leftaxisdeviation.(2)Awide,slurredRinI,avL,V5,V6.

(3)QRS≥0.12sec.(4)TheQRSinV1,V2maybeQSorrStype.(5)qwavedisappearinI,V5,V6.(6)RpeaktimeinV5,V6>0.06s(7)ST-Tchanges.CompleteLeftBundleBranchBlock左前分支阻滞

leftanteriorfascicularblock电轴显著左偏＞-45°具有肯定价值Ⅱ，Ⅲ，avF导联呈rS型,SIII＞SII

Ⅰ,avL导联呈qR型，且RavL＞RⅠQRS时间轻度增宽，<0.12sST-T一般正常*左前分支阻滞*左后分支阻滞

leftposteriorfascicularblockQRS波群右偏，在120°以上Ⅰ、aVL呈rS型Ⅲ、aVF导联呈qR型，q<0.025s,RIII>RIIQRS波群时间正常或轻度延长<0.12s诊断还需排除其它电轴右偏的情况如右室肥厚肺气肿正常小儿等WPW综合征-经典型