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1、心律失常（Cardiac Arrhythmia),Dr.Wei Meng,MD,FACCDepartment of cardiology,affiliated 6th peoples hospital,Shanghai Jiao Tong University,心律失常（Cardiac Arrhythmia),Mechanism of arrhythmia,Property of cardiac elctrophysiology兴奋性（Excitability)自律性(automaticity)传导性(Conductivity),Mechanism of arrhythmiaPropert,E
2、xcitability,Excitability indicates that myocardial cell has electrical activity when it is stimulatedElectrical activity of single myocardial cell is called action potential(AP)Electrical activity of whole heart makes ECG,ExcitabilityExcitability indic,0,-60,-90,+20,Threshold voltage,mv,0,1,2,3,4,AR
3、P,ERP,RRP,Super-conductive period,ARP:Absolute Refractory period;ERP:Effective Refractory period;RRP:Relative Refractory period,0-60-90+20Threshold voltagemv0,Conductivity,Electrical impulse can conduct in myocardial tissue bidirectionallyNormal conduction pathway：sinus nodeintranode bundle atrioven
4、tricula node and intraatrial bundleHis bundleright and left bundle branch(including left anterosuperior and posteroinferior)Purkinje fibermyocardium,ConductivityElectrical impulse,automaticity,Cells spontaneously discharging(spontaneous AP,diastolic depolarization)Automaticity increases from high to
5、 low as follows:Physiological status：SN、AVN、HIS、Purkinjepathological：diseased myocardial and conductive tissue,etc.,automaticityCells spontaneousl,Property of normal rhythm,Impulse from SNHeart rate is within 60100/minRegular rhythm，PP interval0.12sPR interval is between 0.120.20s，QRS complex durati
6、on0.10sFrontal axis within-30110It is considered as arrhythmia if any item above is not matched,Property of normal rhythmImpul,内科学课件07-心律失常-8年制,Mechanisms of arrhythmogenesis,Enhanced automaticity Triggered activityAutomatic cells diminish or malfunction,Dysfunction of conductive tissuesReentry,Mech
7、anisms of arrhythmogenesis,Mechanisms of arrhythmogenesis(1),Enhanced automaticity Endogenous or exogenous catecholamine increasingAbnormality of acid,basic,electrolyte balance Ischemia,hypoxia Mechanical stretch drugsDisturbance of nerve and liquid modulation,Mechanisms of arrhythmogenesis,Mechanis
8、ms of arrhythmogenesis(2),Triggered activityDepolarizing oscillations of membrane voltage induced by abnormal inward Na+current(one or more preceding AP)during earlier or later reporlarization,ie,After depolarizationEarly depolarizationDelayed depolarization,Mechanisms of arrhythmogenesis,内科学课件07-心律
9、失常-8年制,Mechanisms of arrhythmogenesis(3),Automatic cells diminish or malfunction,such as sick sinus syndromeDysfunction of conductive tissues,such as sinoatrial block,atrioventricular block or bundle branch block as well as abnormal pathway,Mechanisms of arrhythmogenesis,Mechanisms of arrhythmogenes
10、is(4),Reentryprerequisite of reentry Conduction inconsistency of anatomy or physiology Single directional conduction blockingDelayed conductionInitial blocking area recovers excitability(reentry cycle length great than refractory period of the blocking),Mechanisms of arrhythmogenesis,内科学课件07-心律失常-8年
11、制,Classification of cardiac arrhythmias,Classified on property of electrical activityAbnormality of impulse and conductionClassified on heart rate,rapid or slowRapid or slow arrhythmiasClassified on clinical manifestation,mild or severFatal or nonfatalHigh risk or low riskClassified on origin of arr
12、hythmias,Classification of cardiac arrh,Method of diagnosing arrhythmia and its evaluation,Symptom Caused by abnormal contractile：palpitation,discomfort,beating stop,etc.Induced by cardiac output decreasing：chest compressing and pain,dizziness,presyncope,syncope,short of breathlessFactors related to
13、 symptom:medications,diet,emotion,infection,etc.,Method of diagnosing arrhythmi,Method of diagnosing arrhythmia and its evaluation,SignChanging of rhythm:slow or fast,regular or irregularIntensity of heart sound：S1 muffle or loud，cannon soundRelation between carotid vein wave pulse and heart rate,an
14、d changing of blood pressure,Method of diagnosing arrhythmi,Method of diagnosing arrhythmia and its evaluation,ElectrocardiogramMost valuable:evaluating arrhythmia type,property,prognosis,etc.Dynamic Electrocardiogram(Holter)Most valuable:assessing arrhythmia type,numbers,distribution,property,progn
15、osis.Evaluating clinical significance,effects of treatment,etc.,Method of diagnosing arrhythmi,Method of diagnosing arrhythmia and its evaluation,Esophagus electrocardiogramDifferentiating SVT from VT，understanding mechanism of SVT.Semi-invasive.,Method of diagnosing arrhythmi,Method of diagnosing a
16、rrhythmia and its evaluation,Electrophysiologic study(EPS)Classical way of researching arrhytnmias.InvasiveAssessing function of SNSinus node recovery time,SNRTSinoatrial conduction time,SACTAssessing AV conduction Analyzing mechanisim of tachyarrhythmiasEvaluating unknown syncope,Method of diagnosi
17、ng arrhythmi,Method of diagnosing arrhythmia and its evaluation,Exercise ElectrocardiogramSuitable for some of arrhythmias,such as VTOthers Average signal technique，such as late potential(LP),QT dispersion,T wave alteration used for evaluating prognosis of ventricular arrhythmia,Method of diagnosing
18、 arrhythmi,Specific arrhythmias,Rapid arrhythmias Premature contractionAtrial,junctional,ventricularTachyarrhythmias Sinus,atrial,supraventricular,junctional,ventricular,atrial flutter and fibrellationBradyarrhythmiasDisease of sinus,AV node or bundle branch,Specific arrhythmiasRapid arr,Specific ar
19、rhythmias,Two syndromes Preexciting syndromeRelated with rapid arrhythmiasSick sinus syndrome(SSS)Related with slow arrhythmias,Specific arrhythmiasTwo syndr,sinus arrhythmias,sinus arrhythmias,Sick sinus syndrome,Features of ECG(1)Serious persistent bradycardia(often 50bpm)Brady-tachy syndrone,recu
20、rrent episode of both bradyarrhythmia and supraventricular tachycardia(AF,AFL,SVT)under basis of bradyarrhythmia,there is often long asystole after rapid arrhythmias stop,which can cause syncope or presyncope,Sick sinus syndromeFeatures of,Sick sinus syndrome,Features of ECG(2)Frequent sinus arrest
21、or exit block with slow HRBoth of sinoatrial and AV node are diseased escape interval 2s,or slow and persistent AFAFL,or slow escape rhythm,Sick sinus syndromeFeatures of,Sick sinus syndrome,Etiology Intrinsic：sinus node itself is involved,e.g.ischemia,regressive degeneration,infiltration of other c
22、ells or tissues Extrinsic：high vagal tone,hyperkalemia,antiarrhythmics most frequent etiology are regressive degeneration and CHD,Sick sinus syndromeEtiology,Sick sinus syndrome,Symptoms Ischemia of brain,heart,kidneyAdams-Stokes syndromeDiagnosis Typical ECG patternsSymptoms is related with ECG cha
23、ngingsHolter,provoking test,treadmill and finally electrophysiological study for the suspected.Holter is most valuable,Sick sinus syndromeSymptoms,Sinus standstill,Features PP interval elongates abruptly,basically at sinus bradycardia,which is not common multiples of basic PP intervalEscape beat or
24、rhythm is common seenSymptoms is depend on duration of standstill Symptomatic treatment,pacemaker is ultimate choice,Sinus standstillFeatures,内科学课件07-心律失常-8年制,sinoatrial block,Classification of ECGFirst degree SAB cant be seen on ECGThird degree SAB cant be differentiated from sinus standstillSecond
25、 degree SAB is divided into two subtype,i.e.type I and type II second degree SAB Symptoms and therapy are same as sinus standstill,sinoatrial blockClassification,Type I Second degree SAB,Features of ECGPP interval progressively shortens until next P wave fails to occurThe long PP interval that norma
26、l regular PP interval,Type I Second degree SABFeatur,内科学课件07-心律失常-8年制,Type secondary degree SAB,Features of ECGP wave is lost abruptly,followed by long pauseThe duration of the pause takes the form of 2:1,3:1 AV conductionEscape beat or rhythm can been seen,Type secondary degree SABFea,内科学课件07-心律失常-
27、8年制,Sinus tachycardia,Clinical featuresVery common.Etiology including sympathetic execitation,excise,avtive infection,blood loss,hypoxia,heart failure,etc.Palpitation or chest discomfort are often complained Etiological treatment,Sinus tachycardiaClinical feat,Atrial arrhythmias,Atrial arrhythmias,P
28、remature atrial contraction,Features of ECGPremature P wave followed by near normal QRS complexQRS complex is similar to it from sinus node with incomplete compensatory pause Sometimes,PR interval is prolonged,Premature P wave not conduct to the ventricles,or aberration in ventricle,full compensator
29、y pause can be seen,Premature atrial contractionFe,内科学课件07-心律失常-8年制,Premature atrial contraction,Clinical features Common seen,provoked by variety of factors,e.g.infection,inflammation,ischemia,tobacco,alcohol etc.it is more common in the elderlySymptom is related to prolonged compensatory pause,inc
30、reased contraction,frequent PAC and sensitivity of patientsOn auscultation,irregular beating,longer interval,increased S1Treatment aim for etiology except obvious symptom antiarrhythmics can be given,Premature atrial contractionCl,Automatic atrial tachycardia,Features Less common.Most have underlyin
31、g diseases,HR is around 130 bpm,200 bpm less seenP wave is not as same as sinus one,PR interval changing with slightly irregular rhythmAV block with different ratio can be seen“Warm-up”can be seen at its initial attackEtiological or symptomatic treatment,RF also plays a role,Automatic atrial tachyca
32、rdiaFe,chaotic atrial tachycardia,Features Rare,most having basic diseaseHR is between 100-130 bpm,at lest two kind P wave can be seenPR and PP interval are changing,P not conducting sometimes,isoelectrical line between PP interval can be seen,precursor of atrial fibrillationEtiological or symptomat
33、ic treatment，antiarrhythmics with caution,chaotic atrial tachycardiaFeat,Atrial flutter(AFL),Features of ECGP wave disappears,substituted by regular saw-like F wave with its rate between 220350 bpmVentricular response(AV ratio)is usually 2:1,sometimes 4:1 or irregularStimulation of vagus nerve or ex
34、ercise may decrease or increase AV ratio with multipleUsually AFL is due to reantry around tricuspid ring,and tend to become AF,Atrial flutter(AFL)Features of,内科学课件07-心律失常-8年制,Atrial flutter(AFL),Clinical featuresHR is usually around 150 bpm which represents AV ratio is 2:1，may having underlying dis
35、easesTiny and rapid jugular pulses can be seen with its rate beyond 300 bpmSimilar manifestation to it in atrial fibrillation(AF)Rate or rhythm control depends on clinical presentation,Atrial flutter(AFL)Clinical f,Atrial fibrillation(AF),Features of ECGNo P wave,replaced by rapid,chaotic and tiny a
36、trial waves with its rate of 350600 bpmVentricle response is irregularly due to AV delay,irregular rates with normal QRS complex,but individual QRS complex may slightly different,Atrial fibrillation(AF)Feature,内科学课件07-心律失常-8年制,Etiologies of atrial arrhythmias,CardiacDegeneration,ischemic,myocarditis
37、,enhanced load due to variety of heart diseases,hypertension,post CABG,preexciting syndrome,lone AFNon cardiacAlcohol abuse,hyper-or hypothyroidism,alteration of vagal or sympathetic tone,COPD,pulmonary embolism,diabetes,sepsis,Etiologies of atrial arrhythmi,Atrial fibrillation,Clinical featuresComm
38、on with aging as well as those with underlying diseases Symptomatic severity depends on HR,AF duration,underlying heart diseaseTend to embolism because of thrombosis in atriaMay have long cardiac arrest after paroxysmal AF stops,Atrial fibrillation Clinical f,Atrial fibrillation,Clinical featuresWit
39、h stethoscope,palpating artery pulse and watching jugular pulse,near all most of AF can be diagnosed with confidenceAmphasisng prevention embolismRate or rhythm control depends on clinical presentation,Atrial fibrillationClinical fe,AF Classification based on features of episode:,New classificationF
40、irst-detected episodeRecurrent paroxysmal(self-terminating,7 d)permanentOld classification paroxysmal,persistent and permanent AF,AF Classification based on fea,Junctional arrhythmias,Junctional arrhythmias,Junctional premature contraction,Features of ECGPremature retrograde P wave(may not seen)The
41、P usually in front of QRS complex(may follows QRS one),PR0.10s，RP0.20sMost of them with complete compensatory pause,QRS complex normal or in aberration,Junctional premature contracti,Junctional premature contraction,Clinical features Rather common.Most occurred with organic heart diseaseSimilar find
42、ings to atrial one on auscultationSymptom is similar to that of atrial onesTreatment is not necessary unless obvious symptom,Junctional premature contracti,内科学课件07-心律失常-8年制,Nonparoxysmal junctional tachycardia,Features Less common.Most have underlying diseases,digitalis side effect Attack gradually,
43、AV dissociation common,QRS complex usually normalHR between 70-130 bpm,hemodynamics relatively changing less Eiological treatment,antiarrhythmics is not recommended,Nonparoxysmal junctional tachy,Supraventricular paroxysmal(AV nodal reantrant)tachycardia,Features of ECGHR between 160250bpm,absolute
44、regular,QRS complex narrowing(exception of aberration)Occasionally,retrograde P wave seenReentry(AV node,AV)is majority of mechanism,Supraventricular paroxysmal(A,Supraventricular paroxysmal tachycardia,Clinical featuresMost without organic heart disease,common seenAttack with sudden initiation and
45、termination,maintaining short for minutes or long for hours.Palpation is mainstream of symptomHypotension,collapse is far less than VT Good reaction to treatment,e.g.vagal maneuvers,antiarrhythmics.Radiofrequace is best way for radical cure,Supraventricular paroxysmal ta,内科学课件07-心律失常-8年制,Pre-excitat
46、ion or Wolf-Parkinson-white(WPW)syndrome,Features of ECGPR interval 0.12 s or normal,wave in onset of QRS complex which result in widened QRS complex followed by secondary ST-TchangePR interval is 0.12 s，but QRS complex is normal(short PR syndrome or LGL(lown-Ganong-Levine syndrome),Pre-excitation o
47、r Wolf-Parkins,内科学课件07-心律失常-8年制,Features of Preexcitation syndrome,P-R=0.12s,wave Secondary ST-T change STV often seen,Features of Preexcitation sy,内科学课件07-心律失常-8年制,内科学课件07-心律失常-8年制,内科学课件07-心律失常-8年制,Preexcitation syndrome,Clnical featuresPart of patients have onset of SVT,AF,AFL,its mechanism is ree
48、ntryThere are several types of preexcitation,e.g.persist,intermittent,latent,concealedIt is predisposed to sudden death if refractory period of accessory pathway is 270msTherapy is as same as it in STV,but digitalis,varapamil,-blocker are forbidden in AF attack,Preexcitation syndromeClnical,Ventricu
49、lar arrhythmias,Ventricular arrhythmias,Ventricular premature contraction,Features of ECGPremature QRS complex with no preceding related P wave QRS complex is bizarre in shape with full compensatory pause(insert one exception)AV dissociation can be seen,Ventricular premature contract,Ventricular pre
50、mature contraction,Clinical featuresMost common.Seen at organic heart diseases,some of it in AMI or myocardiopathy can induce fatal arrhythmiaSimilar features to other premature complex on auscultation.Palpitation is a common complainTreatment regimen on basis of clinical manifestation,Ventricular p
