循环系统内科学心律失常-英文教学课件：arrhythmia-0.ppt

1、ARRHYTHMIAEdited by Yingmin Chen Definition of Arrhythmia: The Origin, Rate, Rhythm, Conduct velocity and sequence of heart activation are abnormally. Anatomy of the conducting systemPathogenesis and Inducement of Arrhythmia Some physical conditionPathological heart diseaseOther system disease Elect

2、rolyte disturbance and acid-base imbalancePhysical and chemical factors or toxicosisMechanism of ArrhythmiaAbnormal heart pulse formation1. Sinus pulse2. Ectopic pulse3. Triggered activityAbnormal heart pulse conduction1. Reentry2. Conduct blockClassification of ArrhythmiaAbnormal heart pulse format

3、ion1. Sinus arrhythmia2. Atrial arrhythmia3. Atrioventricular junctional arrhythmia4. Ventricular arrhythmia Abnormal heart pulse conduction1. Sinus-atrial block2. Intra-atrial block3. Atrio-ventricular block4. Intra-ventricular blockAbnormal heart pulse formation and conductionDiagnosis of Arrhythm

4、ia Medical history Physical examination Laboratory testTherapy Principal Pathogenesis therapy Stop the arrhythmia immediately if the hemodynamic was unstable Individual therapyAnti-arrhythmia Agents Anti-tachycardia agents Anti-bradycardia agentsAnti-tachycardia agentsModified Vaugham Williams class

5、ification1. I class: Natrium channel blocker2. II class: -receptor blocker3. III class: Potassium channel blocker4. IV class: Calcium channel blocker5. Others: Adenosine, DigitalAnti-bradycardia agents1. -adrenic receptor activator2. M-cholinergic receptor blocker3. Non-specific activatorClinical us

6、ageAnti-tachycardia agents: Ia class: Less use in clinic1. Guinidine2. Procainamide3. Disopyramide: Side effect: like M-cholinergic receptor blocker Anti-tachycardia agents: Ib class: Perfect to ventricular tachyarrhythmia1. Lidocaine 2. MexiletineAnti-tachycardia agents: Ic class: Can be used in ve

7、ntricular and/or supra-ventricular tachycardia and extrasystole. 1. Moricizine 2. Propafenone Anti-tachycardia agents:II class: -receptor blocker1. Propranolol: Non-selective2. Metoprolol: Selective 1-receptor blocker, Perfect to hypertension and coronary artery disease patients associated with tach

8、yarrhythmia. Anti-tachycardia agents: III class: Potassium channel blocker, extend-spectrum anti-arrhythmia agent. Amioarone: Perfect to coronary artery disease and heart failure patients Sotalol: Has -blocker effect BretyliumAnti-tachycardia agents:IV class: be used in supraventricular tachycardia1

9、. Verapamil2. DiltiazemOthers: Adenosine: be used in supraventricular tachycardiaAnti-bradycardia agents Isoprenaline Epinephrine Atropine AminophyllineProarrhythmia effect of antiarrhythmia agents Ia, Ic class: Prolong QT interval, will cause VT or VF in coronary artery disease and heart failure pa

10、tients III class: Like Ia, Ic class agents II, IV class: BradycardiaNon-drug therapy Cardioversion: For tachycardia especially hemodynamic unstable patient Radiofrequency catheter ablation (RFCA): For those tachycardia patients (SVT, VT, AF, AFL) Artificial cardiac pacing: For bradycardia, heart fai

11、lure and malignant ventricular arrhythmia patients.Sinus ArrhythmiaSinus tachycardia Sinus rate 100 beats/min (100-180)Causes:1. Some physical condition: exercise, anxiety, exciting, alcohol, coffee2. Some disease: fever, hyperthyroidism, anemia, myocarditis 3. Some drugs: Atropine, Isoprenaline Nee

12、dnt therapySinus BradycardiaSinus rate 3s3. Type II SAB4. Nonsinus tachyarrhythmia ( SVT, AF or Af).5. SNRT 1530ms, SNRTc 525ms6. Instinct heart rate 110ms. Paroxysmal tachycardiaTherapy: AVNRT & orthodromic AVRT1. Increase vagal tone: carotid sinus massage, Valsalva maneuver.if no successful, 2. Dr

13、ug: verapamil, adrenosine, propafenone3. DC shockAntidromic AVRT:1. Should not use verapamil, digitalis, and stimulate the vagal nerve.2. Drug: propafenone, sotalol, amiodarone RFCAPre-excitation syndrome(W-P-W syndrome)There are several type of accessory pathway1. Kent: adjacent atrial and ventricu

14、lar 2. James: adjacent atrial and his bundle3. Mahaim: adjacent lower part of the AVN and ventricularUsually no structure heart disease, occur in any age individualWPW syndrome Manifestation: Palpitation, syncope, dizziness Arrhythmia: 80% tachycardia is AVRT, 15-30% is AFi, 5% is AF, May induce ven

15、tricular fibrillationWPW syndromeTherapy:1. Pharmacologic therapy: orthodrome AVRT or associated AF, AFi, may use Ic and III class agents. 2. Antidromic AVRT cant use digoxin and verapamil.3. DC shock: WPW with SVT, AF or Afi produce agina, syncope and hypotension4. RFCAVentricular arrhythmia Ventri

16、cular Premature Contractions (VPCs)Etiology:1. Occur in normal person2. Myocarditis, CAD, valve heart disease, hyperthyroidism, Drug toxicity (digoxin, quinidine and anti-anxiety drug)3. electrolyte disturbance, anxiety, drinking, coffeeVPCs Manifestation: 1. palpitation2. dizziness3. syncope 4. los

17、s of the second heart sound PVCsTherapy: treat underlying disease, antiarrhythmiaNo structure heart disease: 1.Asymptom: no therapy 2.Symptom caused by PVCs: antianxiety agents, -blocker and mexiletine to relief the symptom.With structure heart disease (CAD, HBP):1.Treat the underlying diseas2.-bloc

18、ker, amiodarone3.Class I especially class Ic agents should be avoided because of proarrhytmia and lack of benefit of prophylaxisVentricular tachycardia Etiology: often in organic heart disease CAD, MI, DCM, HCM, HF, long QT syndrome Brugada syndrome Sustained VT (30s), Nonsustained VT Monomorphic VT

19、, Polymorphic VTVentricular tachycardiaTorsades de points (Tdp): A special type of polymorphic VT, Etiology: 1. congenital (Long QT), 2. electrolyte disturbance, 3. antiarrhythmia drug proarrhythmia (IA or IC), 4. antianxiety drug, 5. brain disease, 6. bradycardiaVentricular tachycardiaAccelerated i

20、dioventricular rhythm:1. Related to increase automatic tone2. Etiology: Often occur in organic heart disease, especially AMI reperfusion periods, heart operation, myocarditis, digitalis toxicityVTManifestation: 1. Nonsustained VT with no symptom 2. Sustained VT : with symptom and unstable hemodynami

21、c, patient may feel palpitation, short of breathness, presyncope, syncope, angina, hypotension and shock.VTECG characteristics: 1. Monomorphic VT: 100-250 bpm, occur and terminate abruptly,regular 2. Accelerated idioventricular rhythm: a runs of 3-10 ventricular beats, rate of 60-110 bpm, tachycardi

22、a is a capable of warm up and close down, often seen AV dissociation, fusion or capture beats 3. Tdp: rotation of the QRS axis around the baseline, the rate from 160-280 bpm, QT interval prolonged 0.5s, marked U wave Treatment of VT1. Treat underlying disease2. Cardioversion: Hemodynamic unstable VT

23、 (hypotension, shock, angina, CHF) or hemodynamic stable but drug was no effect3. Pharmacological therapy: -blockers, lidocain or amiodarone4. RFCA, ICD or surgical therapy Therapy of Special type VTAccelerated idioventricular rhythm:usually no symptom, neednt therapy. Atropine increased sinus rhyth

24、mTdp:1. Treat underlying disease, 2. Magnesium iv, atropine or isoprenaline, -block or pacemaker for long QT patient3. temporary pacemakerVentricular flutter and fibrillation Often occur in severe organic heart disease: AMI, ischemia heart disease Proarrhythmia (especially produce long QT and Tdp),

25、electrolyte disturbance Anaesthesia, lightning strike, electric shock, heart operation Its a fatal arrhythmiaVentricular flutter and fibrillationManifestation: Unconsciousness, twitch, no blood pressure and pulse, going to dieTherapy:1. Cardio-Pulmonary Resuscitate (CPR)2. ICDCardiac conduction bloc

26、kBlock position: Sinoatrial; intra-atrial; atrioventricular; intra-ventricularBlock degree1. Type I: prolong the conductive time2. Type II: partial block3. Type III: complete block Atrioventricular Block AV block is a delay or failure in transmission of the cardiac impulse from atrium to ventricle.

27、Etiology: Atherosclerotic heart disease; myocarditis; rheumatic fever; cardiomyopathy; drug toxicity; electrolyte disturbance, collagen disease, levs disease.AV BlocklAV block is divided into three categories:1. First-degree AV block2. Second-degree AV block: further subdivided into type I and type

28、II3. Third-degree AV block: complete blockAV Block Manifestations: First-degree AV block: almost no symptoms; Second degree AV block: palpitation, fatigue Third degree AV block: Dizziness, agina, heart failure, lightheadedness, and syncope may cause by slow heart rate, Adams-Stokes Syndrome may occu

29、rs in sever case. First heart sound varies in intensity, will appear booming first soundAV BlockTreatment:1. I or II degree AV block neednt antibradycardia agent therapy2. II degree II type and III degree AV block need antibradycardia agent therapy3. Implant Pace MakerIntraventricular BlockIntravent

30、ricular conduction system: 1. Right bundle branch2. Left bundle branch3. Left anterior fascicular4. Left posterior fascicularIntraventricular Block Etiology: Myocarditis, valve disease, cardiomyopathy, CAD, hypertension, pulmonary heart disease, drug toxicity, Lenegre disease, Levs disease et al. Ma

31、nifestation: Single fascicular or bifascicular block is asymptom; tri-fascicular block may have dizziness; palpitation, syncope and Adams-stokes syndromeIntraventricular BlockTherapy:1. Treat underlying disease2. If the patient is asymptom; no treat,3. bifascicular block and incomplete trifascicular block may progress to complete block, may need implant pace maker if the patient with syncope