医学课件心律失常3

2024/9/101LianjunGaoM.D.PH.DThefirstaffiliatedhospitalofDalianMedicalUniversityCardiacArrhythmias2024/9/102IntroductionNormalcardiacactivation SN internodeltract Pwave AVN HisRBB LBB

PurkinjefiberQRScomplex2024/9/103--Rate/rhythm/origination/

velocity/sequenceNormalHR：SR、Moderaterate、RegularrhythmArrhythmia

：Anyrhythmotherthananormalsinusrhythm

>100bpm、<60bpm、irregularSNAVNConceptofarrhythmiaIntroductionSinusnode--NaturalpacemakerAVnode--Nextpacemaker2024/9/104Pathogenesisofarrhythmiafunctional(non-pathological)--EPabnormalities--withoutheartdiseasepathological--EPabnormalities--withheartdiseaseNormalheart(valvularheartdisease)(coronaryarterydisease)(cardiomyopaty)(myocarditis)(hypertensiveheartdisease)(non-cardiaccause)Introduction2024/9/105MechanismofarrhythmiaDisordersofimpulseformation

Abnormalautomaticity--SN,AVN,conductionsystem,AorV

Triggeredactivity--A,V,His-purkinjesystemAbnormalitiesofimpulseconduction

Reentry--slowconduction,excitability,unidirectionalblock

Velocityabnormality--delayorblockcausedbyprolongedRP

Pathwayabnormality--AVaccessorypathwaySNAVNLBBRBBAVIntroduction2024/9/106Reentry--unidirectionalblock,slowconduction,excitabilityMechanismofarrhythmiaIntroductionSANAVNLBBRBBAVAppropriatedelaytoallowrepeatdepolarization7ClinicalfeaturesofarrhythmiaHarmlessorlife-threateningdependingonthetypeofthearrhythmiasandtheunderlyingheartdisease早搏APC室速VT室颤VF室上速PSVTIntroduction**Asymptomatic、Papitation、Fatique、Dizziness、Nearsyncope、Syncope、Heartfailure、Hypotension、Suddendeath8Classification

ofarrhythmiaTachyarrhythmias --SNT --Prematurebeats(A,AVN,V) --Tachycardia(A,AVN,V) --

Flutterandfibrillation(A,V) --

W-P-WsyndromBradyarrhythmias --SSSsicksinussyndrome --escapebeats(A,AVN,V) --conductionblockS-A、A-V、VIntroductionSNAAVNLBBRBBLARVRALV9MethodsfordiagnosingarrhythmiasHistory:symptoms,Modeofonsetandoffset,accompaniedsymptomPhysicalexamination:raterhythmElectrocardiogram:12leads、longIIlead、obviousPwaveAmbulatoryECG:24hrs、48hrs-1weekTransesophagealECG:diagnosisandmanagmentElectrophysiologicstudy

:goldenstandard6methodsIntroduction10

12leadsandlongtracingrecordMethodsfordiagnosingarrhythmiasIntroductionLRNF11AAVVAVAVTransesophagealelectrogramandpacingAPwaveidentificationisthefirststepMethodsfordiagnosingarrhythmiasIntroduction12AmbulatorymonitoringorHoltermonitoring-24h,48h,72h…PVCBlockedPwaveMethodsfordiagnosingarrhythmiasIntroduction13DiagnosingthesyncopeofunknownreasonbyHoltermonitoringAF14.5ｓSinusarrestIntroduction2024/9/1014IntracardiacstimulationMethodsfordiagnosingarrhythmiasIntroductionElectrophysiologicstudy(EPS)Intracardiacrecoredings2024/9/1015MethodsfordiagnosingarrhythmiasECG/DCG/transesophagealECGArrhythmiasaredeterminedbyfourbasicaspects4aspectsIntroductionRateofPwaveandQRScomplexRegularityofPwaveandQRScomplex

ConfigurationofPwaveandQRScomplex

RelationshipofPwaveandQRScomplexVTPSVT2024/9/1016

Antiarrhythmicdrugs8

mg302024/9/1017

ClasssIsodiumchannelblocker

ⅠAquinidine,Procainamide

ⅠBLidocain ⅠCpropafenoneClasssII-blocker

ClasssIIIpotasiumchannelblocker

Amiodarone,Sotalol

ClasssIVcalciumchannelblocker

Verapamil,diltiazemAntiarrhythmicdrugs

AntiarrhythmicdrugsfortachyarrhythmiasThreesubclassesAfPSVTvfVT2024/9/1018AntiarrhythmicdrugsAntiarrhythmicdrugsforbradyarrhythmiasIIIIII5.7s4.8s31bpmBeta-adrenergicagonists

isoprenaline

atropine

aminophylline2024/9/1019Nonpharmocologicaltherapy2024/9/1020NonpharmocologicaltherapyCardioversionandDefibrillation

RF

CatheterablationPacemakerimplantationCardiacsurgery2024/9/1021NonpharmocologicaltherapyCardioversionandDefibrillationPrinciple:depolarizationsimultaneouslyType：SynchronizedDCcardioversion —tachycardia/AF/Af/PSVT/VTnon-synchronizedDC(cardioversionordefibrillation)

Vf/VF（emergency）

ThroughthoracicIntra-thoracic

Intra-cardiacdefibrillatorSuccessrate:>95%Contraindication：intracardiacthrombus/bradycardia/overdosageofdigitalisComplication：arrhythmias/myocardialdamage/skinburn/thrombosis2024/9/1022

Nonpharmocologicaltherapy

RF

Catheterablation

2024/9/1023

Nonpharmocologicaltherapy

Radiofrequency

CatheterablationRFcatheterPSVT,WPW,AT,AF,AF,VT2024/9/1024NonpharmocologicaltherapyPacemakerimplantationpacermaker：bradycardia：SSS,AVBICD：VT/Vf2024/9/1025NonpharmocologicaltherapyCardiacsurgery2024/9/1026P-QRS-TsequenceP-R:0.12-0.20ssinusP(II,III,aVFupright.aVRdownward)narrowQRSHeartrate60-100bpmNormalsinusrhythm2024/9/1027SinusNoderhythmNormalSinusRhythmP-QRS-Tsequence

P-R0.12-0.20s

SinusP--II,III,aVFupright.aVRdownward

NarrowQRS

HR60-100bpm2024/9/1028ECG:Sinusrhythm,HR>100bpm,usuallywithgradualonsetandoffsetEtiology:DifferentphysiologicorpathophysiologiccausesTherapy:Treattheunderlyingdisease,eliminateprecipitatingcauses,-blockadeSinusTachycardia2024/9/1029SinusbradycardiaECG:Sinusrhythm,HR<60bpmEtiology:Normalyoungadults,athletes,increas-edvagaltone,SSS,inferiorAMITherapy:asymptomatic--notreatment,symptomatic--Pacemakerimplantation2024/9/1030ECG:

DisappearanceofPwaveproducesalongP-PintervalwithnorelationshiptothebasicP-Pinterval,thelongP-Pintervalusuallyisterminatedbyescapebeatsorrhythm.Clinicalfeatures:

Dizziness,blackness,syncope.Etiology:

Increasedvagaltone,SSS,theeffectsofmedicationTherapy:

sameassinusbradycardiaSinusarrest2024/9/1031SinoatrialblockSeconddegreeSAB--MobitzI(Wenckebach)P-PcycleprogressivelyshorteruntilapauseNoPwaveorQRSduringthepausePauselessthantwiceoftheprecedingP-P2024/9/1032SinoatrialblockSeconddegreeMobitzIIP-PcycleconstantbeforeapauseNoPwaveorQRSduringthepausePausemeasuredtwoormoretimesofP-P2024/9/1033SSScanbecharacterizedasabnormalitiesofautomaticityorconduction,orboth.Sicksinussyndrome2024/9/1034EtiologyofSicksinussyndromeIdiopathic(degenerative)IschemicInfiltrative:Amyloid,SclerodermaInflammatory:Rhuematicfever,PericarditisCardiomyopathy(dilated)CollagenvasculardiseaseSurgicaltraumaFamilial(genetic)CongenitalDruginduced2024/9/1035SicksinussyndromeEtiology:Thecauseisuncertainbuthasbeenattributedtoautoimmuneprocess.IschemicheartdiseaseisrarelyacauseofSSS.Degenerationofthesinusnodeandpossiblyalsoitsnervousconnectionsarethemajorcauses,especiallyinagedpatients.2024/9/1036Clinicalmanifestaion:

sinusbradycardia,sinusarrest,sinoatrialblock+escape,atrialtachycardia,flutter,orfibrillation(brady-tachycardiasyndrome)AVB？Sicksinussyndrome2024/9/1037SicksinussyndromeSupplementoryexaminations:SNRT>2000ms,CSNRT>550ms,HolterECG:TotalHR<80,000beats/24hrMeanheartrate<55bpmAtropinetest：HR<90bpmExercisetest：HR<100bpm2024/9/1038SicksinussyndromeComplications:

AVB--8.5%,in3~10yearsAtrialfibrillation:Afmayoccurin>50%Systemicembolism:15.2%inunpacedpatients,1.3%inpatientsofsimilaragewithoutSSSCongestiveheartfailure2024/9/1039Etiology:

NormalpeopleorstructuralheartdiseaseSymptom:

PalpitationECG:

PrematureP’-QRS-T;ThemorphologyofP’waveisdifferentfromthesinusone;P’-R>0.12s;NarroworaberratedQRS;NoncompensatorypauseTherapy:Treat

underlyingdisease,sedative,

-blockadeAtrialprematurebeats2024/9/1040aVRV1IIAtrialprematurebeats2024/9/1041ECG:

RegularP’-QRS-T;

P’aberratedornotvisual; P’-R>0.12s,R-P’>P’-R; NarroworaberratedQRS;

HR:150-200bpm;

morethanthreedifferentmorphologiesofP’

wave andP’-Rintervalswith

chaoticatrial tachycardiaAtrialtachycardia2024/9/1042Therapy:

Treatunderlyingdisease; verapamil, propafenone, Amidarone.

RadiofrequencycatheterablationAtrialtachycardia2024/9/1043Atrialtachycardia2024/9/1044Therapy:

Treatunderlyingdisease;Termination--propafenone,amiodarone, cardioversion, transesophagealpacing, DCconversion;Controlventricularrate--digitalis, verapamil,diltiazem,-blockade;PreventionAFLreoccurrence– Amiodarone,Propafenone,AtrialflutterRFablation2024/9/1045Atrialflutter:ECGPwavereplacedbysawtooth-likeFwave,nobaselinebetweenFwaves;FwavenegativeinII,III,aVF,V1(typeI);NarooworaberratedQRS;Fwaverate:250-350bpm;Regularorirregularventricularratedepend-ingAVconduction,usually2:1,3:1,4:1AVconduction.2024/9/1046Atrialflutter:ECG2024/9/1047AtrialFibrillationPwavesdisappearandreplacedbyfwaves;Rateoffwave350-600bpm;NarroworaberratedQRS;RhythmofQRS:totallyirregular.2024/9/1048RateofQRSdependingonAVconduction,usuallybetween100-160bpm.InhighdegreeAVB,therateofQRSisslowandtherhythmmayberegular.AtrialFibrillation2024/9/1049Etiology:

Structuralheartdisease,postcardiacsurgery,lungdisease,normalpeople.Pathogenesis:

Multi-micro-reentryandectopicfocidriving.Updating…Clinicalmanifestations:

Palpitations,breathless-ness,heartfailure,systemicembolismAtrialFibrillation2024/9/1050Therapy

Treatunderlyingdisease;TerminationAmiodarone,propafenone,DCcardioversionControlventricularratedigitalis,verapamil,-blockade,ablationofAVconduction+PMimplantation;PreventionAFreoccurrenceAmiodarone,propafenone,surgury,RFablationAnticoagulation--Aspirine,WafarineAtrialFibrillation2024/9/1051Classification:

Acuteatrialfibrillation:within24-48hours.Paroxysmalatrialfibrillation:7days.Permanentatrialfibrillation:atrialfibrillationhastobeterminatedbydifferentinterventionalmeansandsinusrhythmcanbemaintained.Persistentatrialfibrillation:morethan7daysAtrialFibrillation2024/9/1052ParoxysmalSupraVentricularTachycardia(PSVT)TOPIC2024/9/1053NarrowsenseAtrial-VentricularNodalReentryTachycardia(AVNRT)Atrial-VentricularReentryTachycardia(AVRT)2024/9/1054Etiology:

“Nostructural”heartdiseaseAVNdualpathways(congenitaloracquired)AVNodalReentrantTachycardia(AVNRT)2024/9/1055

SlowconductionRecoveryoftheexcitabilitybeforethearriveofnextimpulseUnidirectionalconductionblockSlowpathway:slowconductionvelocity,shortrefractoryperiodFastpathway:fastconductionvelocity,longrefractoryperiodAVNodalReentrantTachycardia(AVNRT)2024/9/1056Clinicalmanifestation:

OnsetandterminateabruptlyItmayterminateduringdeepinspirationorValsava maneuverpalpitations,breathlessness,syncope,dizziness, anginapectoris,occasionallyheartfailureAVnodalreentranttachycardia

(AVNRT)2024/9/1057RegularQRS,HR:150-250bpm,R-P’<70ms,usuallyretrogradeP’waveisnotvisual.AVNRT

2024/9/1058Clinicalmanifestation:

ParoxysmalAVRT,onsetandterminateabruptly,itmayterminateduringdeepinspirationorValsavamaneuver.ParoxysmalAforAF.

palpitations,breathlessness,hypotension,syncope,suddencardiacdeathPreexcitationsyndrome---AVRT2024/9/1059Sinusrhythm:P-R<0.12s;wave,wideQRS;SecondaryST-Tchanges.AVRTECG2024/9/1060Therapy:

Termination—Increasevagaltone,ATP,verapamil,digitalis,transesophagealpacingPrevention--verapamil,propafenone,amiodaroneCure--RFablationPreexcitationsyndrome---AVRT2024/9/1061Pwavesdisappearandreplacedbyfwave;TotallyirregularR-Rinterval,rapidQRSrate(200-300bpm);ChangingbizarreQRSanddifferentamplitude PreexcitationSyndrome+Af

2024/9/1062Therapy:

AmiodaronePropafenoneContraindicators:verapamil,digitalis,lidocaineIfthepatientbloodpressureisloworventricularfibrillationoccurs,emergentDCcardioversionissuggestedPreexcitationsyndrome+Af2024/9/1063VentricularArrhythmias2024/9/1064Etiology:

Normalpeople,structuralheartdisease,medicationeffectsSymptoms:

Palpitations,syncopePrematureventricularbeats2024/9/1065ECG:

PrematureQRSwithwidedurationandabnormalpattern;NoprecedingrelatedPwave;SecondaryST-Tchanges;Constantcouplinginterval;completecompensatorypause Prematureventricularbeats2024/9/1066Definition:

Threeormorecontinuousprematureventricularbeatsconstituteventriculartachycardia.Itisoneofthepotentiallife-threateningarrhythmias.Mechanism:

Highectopicventricularautomaticity,reentry,triggeredactivityVentriculartachycardia2024/9/1067Etiology:

Normalpeople(idiopathicVT),structuralheartdisease(CHD,MI,cardiomyopathy),medicationeffectsSymptoms:

DependingonthedurationandrateofVTandtheleftventricularfunction.Palpitations,breathlessness,syncope,hypotension,death.Sometimes,itdegeneratesintoventricularfibrillation.Ventriculartachycardia2024/9/1068VentriculartachycardiaWide,bizarreQRS(slightmorphologychanging),secondaryST-Tchanges;HR:100-250bpm,relativeregular;AVdissociation,fusionandcapturebeatmayappear;durationofsustainedVT>30s,nonsustainedVT<30s.2024/9/1069Ventriculartachycardia:ECGPPPPPPPPPP2024/9/1070TerminationandpreventionofidiopathicVT: verapamil, propafenone; ItcanbecuredbyRFCAPathologicVT: Termination--Lidocaine,Amiodarone, propafenone,DCcardioversion; Prevention--Amiodarone,-blockade, ICD,RFCA?TherapyofVentriculartachycardia2024/9/1071Mechanism:Notclear,Possiblyduetomultifocalincreasedautomaticity,itmaybeonespecifictypeofpolymorphicVTEtiology:Electrolyteimbalance(hypokalemia),Drugtoxicity(quinidine,sotalol),completeAVB.(CongenitallongQTinterval)Symptomes:Breathlessness,hypotension,syncope.Itfrequentlydegeneratesintoventricularfibrillation.RapidsustaineduniformVTcanalsodegeneratesintoVf,usuallyfollowingastageofpolymorphicVT.ThisisafairlycommonmechanismofsuddencardiacdeathrecordedbyHoltermonitor.Ventriculartachycardia:Torsadedespointes2024/9/1072ECG:

RapidHR:200-250bpm;LongQ-Tinterval(>0.5s),Uwave;TheamplitudeandpeakofQRSkeepchanging;Initiation:acquiredform--bradycardiadependent,(congenitalform--adrenergicdependent)Therapy:Magnesiumsulfate,isoproterenol,pacingVentriculartachycardia:Torsadedespointes硫酸镁2024/9/1073Etiology:Myocardiumischemia,W-P-W+Af,TdesPSymptom:

DegeneratesintoVf,lossofconsciousness,convulsion,death.Theheartstopscontractingeffectively.ECG:

P-QRS-Twavesdisappearandreplacedbysinewavewithlargeamplitude,HR150-300bpmVentricularflutter2024/9/1074VentricularflutterTherapy:

DCcardioversionandcardiopulmonaryresuscitation2024/9/1075Ventricularflutter2024/9/1076VentricularfibrillationEtiology:Myocardiumischemia,WPW+Af,Symptom:

Disappearanceofheartsoundandpulsationofgreatartery,BP:0,lossofconsciousness,convulsion,death,sincetheheartstopscontractingeffectively.2024/9/1077VentricularfibrillationECG:

P-QRS-Twavesdisappearandreplacedbycoarseanderraticconfigurationsorbyasmall,virtuallyflatline,HR250-500bpm.Noatrialactivityispresent2024/9/1078Therapy:DCcardioversionandcardiopulmonaryresuscitation;Ventricularfibrillation2024/9/1079ImplantableCardioverterDefibrillatorPrimaryprevention:VTinpatientwithpost-MIandcardiomyopathyBrugadasyndrome,LongQTsyndrome,ShortQTsyndromeSecondarypreventionPatientsurvivedfromcardiacsuddendeath2024/9/1080ImplantableCardioverterDefibrillator2024/9/1081Case2024/9/1082Cardiacconductionblock2024/9/1083Locationofblock: Sinoatrialblock, intraatrialblock,AVblock, intraventricularblock(LBBB,RBBB,LAFB,LPFB)Theblockdegree:

Firstdegree--longconductiontime Seconddegree--longconductiontimeand/orpartofthe conductionisblock(MobitzIandII) Thirddegree--alltheconductionisblockClassification2024/9/1084Normalpeople,structuralheartdisease,drugtoxicity,electrolyteimbalance,degenerationoftheconductionsystemEtiology

SymptomsAsymptomatic,palpitation,pulsedeficit,weakness,dizziness,blurvision,presyncope,syncope(Adams-Stokes’syndrome)朦2024/9/1085Atropine,isoproterenol,ArtificialPacemakerTherapy

2024/9/1086Artificialcardiacpacing:Physiologicalpacing2024/9/1087FirstdegreeAVBP-R>0.20s;regularnarrowQRSwaves;mostoftheblocklocationisintheAVnode NosignificantclinicalimplicationAtrioventricularblockP2024/9/1088Atrioven