Aritmia Jantung-fk Ump

8/10/2019 Aritmia Jantung-fk Ump

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ARITMIA JANTUNG

Dr. dr. Taufik Indrajaya, SpPD, KKV, FINASIM

Divisi Kardiologi Departemen Penyakit Dalam

FK UNSRI / RSMH Palembang


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Tingkat Kemampuan

Tingkat Kemampuan 1

Mengenali dan menempatkan gambaran-2 klinik

sesuai penyakit ketika membaca literatur

Tingkat Kemampuan 2 Membuat diagnosis klinik berdasarkan PF dan

pemeriksaan tambahan. Mampu merujuk

secepatnya

Tingkat Kemampuan 3 3a : (2) dan memutuskan dan memberi terapi

pendahuluan, merujuk kasus bukan emergensi

3b: (3a), merujuk kasus emergensi.


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Level of Ability: 2 up to 3 B

Further reading:

1. Hursts: The Heart.

2. Harrissons. Principles of Internal

Medicine

3. Buku Ilmu Penyakit Dalam PAPDI 4. Buku Ajar Kardiologi FK UI

5. Internet, Others.


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A gooD baSic KnOwlEdge

of the heart and cardiac function

is Essentialin order

toUnderstand

the 12 lead ECG


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Anatomy
http://www.bartleby.com/107/illus499.htmlhttp://www.bartleby.com/107/illus499.htmlhttp://butler.cc.tut.fi/~malmivuo/bem/bembook/06/06x/0603x.htm


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Cardiovascular system works ..
http://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.html


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CARDIAC OUTPUT = STROKE VOLUMEx HEART RATE

Autoregulation

(Frank-Starling Law of the Heart)

Contractility

Sympathetic

Nervous System

Parasympathetic

Nervous System


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Cardiac Cycle


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Electrophysiology of The Heart

The different waveforms for each of the specialized cells.
http://butler.cc.tut.fi/~malmivuo/bem/bembook/06/06x/conducti/0607a.htm


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Schematic representation of Normal ECG
http://upload.wikimedia.org/wikipedia/en/9/9e/SinusRhythmLabels.svg


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C P R


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TOPIK

1. Manifestasi klinik2. Penyebab aritmia

3. Kertas rekaman EKG

4. Lima jenis dasar aritmia

5. Aritmia asal sinus

6. Irama ektopik

7. Irama re-entrant

8. Empat Pertanyaan9. Artimia Supraventrikuler

10. Aritmia Ventrikel

11. Aritmia Supraventrikuler vs Ventrikuler.


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Dis- /Arrhythmias :

Disorders of the regular rhythmic beating of theheart.

Common2.2 million Americans are living with

AF (one type of rhythm problem). Can occur in a healthyheart and be of minimal

consequence.

Also may indicate a serious problemand lead to

heart disease, stroke or sudden cardiac death. The goal: ultimately reduce disability and death

from heart disease and stroke.


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Signs or Symptoms

May not cause any signs or symptoms.

A fluttering in your chest

A racing heartbeat

A slow heartbeat

Chest pain

Shortness of breath

Lightheadedness

Dizziness

Fainting (syncope) or near fainting


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Causes

Common: heart disease, high BP, DM,smoking, excessive alcohol or caffeine,drug abuse, stress

Scarringmost commonly, from aprevious heart attack disrupt theinitiation or conduction of electricalimpulses.

In a healthy person with a normal, healthyheart, a sustained arrhythmia to developcaused by outside trigger: an electricalshock or the use of illicit drugs.


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Causes ..

1. HHypoxia:Pulmonary disorders.

2. IIschemia and Irritability:

myocardial infarctions; angina,

myocarditis.

3. S

Sympathetic Stimulation:hyperthyroidism, congestive heart

failure, nervousness, exercise).


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Causes

DDrugs:Many drugs can causearrhythmias.

EElectrolyte Disturbances:

Hypokalemia, imbalances of calcium andmagnesium.

BBradycardia:to predispose to

arrhythmias ~ the sick sinus syndrome. SStretch:congestive heart failure and

valvular disease can cause arrhythmias.


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Any pre-existing structural heart condition

can lead to arrhythmia development due to:

Inadequate blood supply.

It can alter the ability of heart tissue includingthe cells that conduct electrical impulses to

function properly.

Damage or death of heart tissue.

This can affect the way electrical impulses spread

in the heart.


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These pre-existing heart conditions may

include:

Coronary artery disease (CAD).

Cardiomyopathy.

Valvular heart diseases.


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Kertas Rekaman EKG

A typical rhythm strip

It can be as short or as long as you need

to decipher the rhythm.


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ECG Paper


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A systematic and complete approach

Check the patient details - correctly labelled? What is the rate?

Is this sinus rhythm? If not, what is going on?

What is the mean frontal plane QRS axis?

Are the P wavesnormal (look at II and V1) What is the PR interval?

Are the QRS complexesnormal?

Are the ST segmentsnormal, depressed orelevated?

Are the T wavesnormal? What is the QTinterval?

Are there abnormal U waves?
http://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htm


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Heart Rate ( Regular Rhytm )


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Heart Rate ( Irregular Rhytm ) ..


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Principles of Rhythm Analysis

The standard 12-lead ECG and Rhythm

strips are the most easily accessible tools

for the diagnosis of a cardiac rhythm

disturbance.

Recognition of the P-waveand QRS

morphologyand their relative timing may

be the only information needed to

diagnose the arrhytmia correctly.


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The Five Basic Types of Arrhytmias

The heart is capable of only five basic types ofrhythm disturbances:

1. Arrhythmias of sinus origin.

2. Ectopic rhythms: focus other than the sinus.3. Re-entrant arrhytmias.

4. Conduction blocks (another chapter).

5. Preexcitation syndromes ~ accessoryconduction pathways that bypass the normal

ones, providing an electrical shortcut, or short

circuit : WPW (another chapter).


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(A) Sinus tachycardia.

(B) Sinus bradycardia.

Aritmia Asal Sinus


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Sinus arrhythmia. The heart rate

accelerates with inspiration and slows with

expiration.

Sinus arrhythmia.

The heart rate accelerates with inspiration and slows with expiration


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Sinus arrest occurs after the fourth beat.

The fifth beat, restoring electrical activity to theheart, is a junctional escape beat. Note the

absence of a P wave before this last beat.


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Non Sinus Pacemakers


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Junctional escape. The first two beats are normal sinus beats with a normal P

wave preceding each QRS complex.

There is then a long pause followed by a series of threejunctional escape beats occurring at a rate of 40 to 45 beats

per minute.

(A) N l i


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(A) Normal sinusrhythm.

(B) Sinus arrest.

The sinus nodefalls silent. Nocurrent isgenerated

The EKG showsno electricalactivity.

(C) Sinus exit block.

The sinus nodecontinues to fire,but the wave ofdepolarizationfails to exit thesinus node intothe atrialmyocardium.

EKG shows noelectrical activity.


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Irama Ektopik

(A) Normally, the sinus node drives the heart.

(B) e.g.,the AV junction


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Irama Re-entrant

(1) Normally,pathwaysAand B(any two adjacentregions of cardiacfunction) conductcurrent equallywell.

(2) Here, however,

conduction throughpathway Bistemporarily slowed.Current passingdownAcan then

turn back andconduct in aretrograde fashionthrough B.

(3) The reentry loop is

established.


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Normal sinus rhythm and

The Four Questions answered.


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The Four Questions

1. Are normal P waves present ?

2. Are the QRS complexes narrow or

wide ?3. What is the relationship between the

P waves and the QRS ?

4. Is the rhythm regular or irregular ?

A it i S t ik l


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(A) The third beat is an atrial premature beat.

(B) The fourth beat is ajunctional premature beat. Thereis no P wave preceding the premature QRS complex.

Aritmia Supraventrikuler


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The third beat is an atrial premature beat.

The P wave is shaped differently from the other,somewhat unusual-looking P waves, and thebeat is clearly premature.


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(A)A junctional premature beat. .

(B)The third beat is a junctional escape beat

PSVT in 3 different


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PSVT in 3 different

Patients :

A~ simultaneous

activation of the atriaand ventricles; theretrograde P wavesare lost in the QRScomplexes.

B~ a SVT mimicking amore serious rhythmcalled VT.

C here,retrograde Pwaves can be seen.

D ~Pseudo-Rconfigurationin leadV1 representing theretrograde P waves(arrows) of PSVT.

(E) The AV node isusually the site of thereentrant circuit thatcauses the arrhythmia.

RegularP waves are retrograde if

visible

Rate 150-250 bpm

Carotid massage slows or

terminates

PSVTIts onset is sudden,

Initiated by a premature

supraventricular beat,

its termination is just as

abrupt.


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The carotid sinus

contains baroreceptors

that influence vagal

input to the heart,primarily affecting the

sinus node and AV

node.

Stimulation of the rightcarotidbaroreceptorsprimarily stimulatessinus node vagal input.

Stimulation of the leftcarotidbaroreceptors ismore likely to affect thevagal input to the AVnode


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An episode of PSVT is broken almost at once bycarotid massage.

The new rhythm is a sinus bradycardia with arate of 50 beats per minute.


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Atrial flutter.

Carotid massage increases the block from 3:1 to

5:1.

Regular, saw toothed

2:1, 3:1, 4:1 etc block

Atrial rate 250-350 bpm

Ventricular rate , 1/3,

etc of atrial rate

Carotid massage:

increases block !!


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Atrial fibrillation

Another example of atrial fibrillation. In the absence ofa clearly fibrillating baseline, the only clue that thisrhythm is atrial fibrillation is the irregularly irregular

appearance of the QRS complexes.

Irreguler

Undulating baseline

Atrial rate 350-500 bpm

Ventricular rate : variable

Carotid massage: may slow ventricular rate !!


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Paroxysmal Atrial Tachycardia.

P waves are not always visible, but here they can be seen easily.

Notice the varying distance between the P waves and the ensuingQRS complexes; this reflects a varying conduction delay betweenthe atria and ventricles that often accompanies PAT.

Regular

Rate 100-200 bpm

Characteristic warm up period in automatic form

Carotid massage :no effect, or only mild slowing


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Aritmia Ventrikel

(A) A premature ventricular contraction.

(B) Bigeminy. PVCs and sinus beatsalternate in a 1:1 fashion.


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(A)Beats 1 and 4 are sinus in origin. The otherthree beats are PVCs (multiform).

(B)A PVC falls on the T wave of the second sinusbeat, initiating a run of VT.


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Ventricular tachycardia.

The rate is about 200 bpm.

A run of three or more

consecutive PVCs

Rate 120-200 bpm

Unlike PSVT, may be

slightly irregular


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Ventricular tachycardia degenerates into

ventricular fibrillation( VF ).

No true QRS complexes

No cardiac output

Need CPR and DC

B i h th


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Accelerated idioventricular rhythm.

There are no P waves, the QRS complexes are

wide, and the rate is about 75 beats per minute.

Benign rhythm

Regular

50-100 bpm

< 50 bpm called Idioventricular rhytm


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Torsades de pointes.

The QRS complexes seem to spin around thebaseline, changing their axis and amplitude

= Twisting of the Point

In pt with Prolong QT interval

Congenital or electrolit imbalance


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SUMMARY : Ventr icu lar A rrhy thm ias


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Rules of Malignancyfor PVCs :

1. Frequent PVCs

2. Consecutive PVCs3. Multiform PVCs

4. R-on-T phenomenon

5. Any PVC occurring during an AMI(or in any patient with underlying

heart disease)


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The heart rate of a 72-year-old woman isrescued from VT by a shock delivered by

an implantable cardioverter-defibrillator.

P ibl it f d ti bl k


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Possible sites for conduction block


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Sinoatrial (SA) block

Sinus rhythm for three beats, then a 'sinus pause' P waves arrowed

The expected P wave is not seen, but the SA node must

have been depolarized because the next P wave

appears at the predicted time


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Any rhythm other than sinus rhythm is

called an 'arrhythmia'.

The term 'dysrhythmia' - which means

essentially the same thing

Properly speaking,

conduction disorders are not

arrhythmias.


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RBBB


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RBBB

Sinus rhythm with a normal PR interval

RSR1 pattern in V1

The dominant R wave is characteristic of RBBB, and does not

indicate RV hypertrophy

Wide and slurred S wave in V6


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LBBB

Sinus rhythm

Broad QRS complexes with notch in the R wave in I, VL, V5, V6

Inverted T waves are associated with bundle branch block, and

have no other significance.


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ECG Interpretation

A mystery?

An enigma?

Confusing?

Difficult?
http://www.spiritandkitsch.com/img/mona.jpg


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ECG INTERPRETATION

If the normal

ECG is knowntheninterpretation

of abnormalsbecomeseasier


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Summary

This Module introduced you to:

Abnormal ECG : ARRHYTMIA

Dont worry too much right now about

trying to remember all the details.

Youll focus more on advanced ECG

interpretation inyour clinical years !!
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Thanks forattention
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Aritmia Jantung-fk Ump

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