Prof. Hardi Darmawan, MD, MPH&TM.,FRSTM

Department of Physiology & Biophysic

ARRHYTHMIA

Definition of Arrhythmia:The Origin, Rate, Rhythm, Conduct

velocity and sequence of heart

activation are abnormally.

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Arrhythmia

ARRHYTHMIA VARIATION IN NORMAL RHYTHM

DYSRHYTHMIA ABNORMAL, DISTURBED RHYTHM

RESULTS FROM IMPULSE

FORMATION DISTURBANCE OR

CONDUCTION DISTURBANCE

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AXIOM

ALL RHYTHM INTERPERTATION MUST

BE CORRELATED WITH SIGNS &

SYMPTOMS AND PATIENT

CONDITION

TREAT THE PATIENT,

NOT THE MONITOR4

Impulse formation

(site of impulse origin)

SA Node

AV Node

Ventricle

Ectopic

Premature Beat

Dysrhythmia

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Anatomy of the conducting system

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Normal Sinus Rhythm NORMAL SINUS RHYTHM IS PRODUCED BY

THE SA NODE

P WAVE FOLLOWS QRS COMPLEX IN A PREDICTABLE RELATIONSHIP

ALL P WAVES LOOK ALIKE, ALL QRS COMPLEXES ARE NARROW

R R INTERVAL IS REGULAR

RATE: 60 100 bpm

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Normal Sinus Rhythm

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Normal Sinus Rhythm

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Sinus / Atrial dysrhythmia

ORIGINATE FROM SA NODE OR ATRIA

(ABOVE VENTRICLES)

CONDUCTION WITH VENTRICLE IS UNDISTURBED

USUALLY BENIGN & SYMPTOMATIC

RHYTHM MAY BE IRREGULAR

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SINUS TACHYCARDIA SINUS BRADYCARDIAATRIAL FIBRILLATIONATRIAL FLUTTER Premature atrial contractions Paroxysmal atrial tachycardia Supraventricular Tachycardia

Sinus / Atrial dysrhythmia

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Dysrhythmia

Bradycardia / Tachycardia

Flutter / Fibrillation

Heart blocks

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Pathogenesis and Inducement of Arrhythmia

Some physical condition

Pathological heart disease

Other system disease

Electrolyte disturbance and acid-base imbalance

Physical and chemical factors or toxicosis

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Occurrence/Incidence

80 % of patient AMI

50 % of anesthetized patient

25 % of digitalis patient

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Etiology Physiological

Pathological:Valvular heart disease.Ischemic heart disease.Hypertensive heart diseases.Congenital heart disease.Cardiomyopathies.Carditis.RV dysplasia.Drug related.Pericarditis. Pulmonary diseases.Others.

Mechanism of Arrhythmia

Abnormal heart pulse formation1. Sinus pulse2. Ectopic pulse3. Triggered activity

Abnormal heart pulse conduction1. Reentry2. Conduct block

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Classification of Arrhythmia

Abnormal heart pulse formation1. Sinus arrhythmia2. Atrial arrhythmia3. Atrioventricular junctional arrhythmia4. Ventricular arrhythmia

Abnormal heart pulse conduction1. Sinus-atrial block2. Intra-atrial block3. Atrio-ventricular block4. Intra-ventricular block

Abnormal heart pulse formation and conduction17

Classification of Arrhythmia

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1. Characteristics: a. flutter very rapid but regular contractions b. tachycardia increased rate c. bradycardia decreased rate d. fibrillation disorganized contractile activity

2. Sites involved: a. ventricular b. atrial c. sinus d. AV node e. Supraventricular (atrial myocardium or AV node)

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Common Arrhythmias

Atrial

AF

A Flutter

Paroxs. SVT AVNRT

AVRT (WPW)

Multifocal atrial tachycardia

Ventricular

VT

VF

Torsades

Bradyarrhytmia

Medication

AV block

SSS

Ventricular fibrillation

Basic Rhythm Strip Interpretation

1. Determine the rate. Does the atrial rate equal the ventricular rate.

2. Is the rhythm regular/irregular?

3. Find the P wave. Is there a P wave for every QRS?

4. Determine the PRI (Normal 0.12-0.20 sec)

5. Find the QRS (Normal

Diagnosis of Arrhythmia

Medical history

Physical examination

Laboratory test

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Therapy Principal

Pathogenesis therapy

Stop the arrhythmia immediately if the hemodynamic was unstable

Individual therapy Personalized Medicine

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Arrhythmia Assessment ECG

24h Holter monitor

Echocardiogram

Stress test

Coronary angiography

Electrophysiology study

Arrhythmia Presentation Palpitation.

Dizziness.

Chest Pain.

Dyspnea.

Fainting.

Sudden cardiac death.

Strategy of Antiarrhythmic Agents

Suppression of dysrhythmias

A. Alter automaticityi. decrease slope of Phase 4

depolarizationii. increase the threshold potentialiii. decrease resting (maximum

diastolic) potential

B. Alter conduction velocityi. mainly via decrease rate of

rise of Phase 0 upstrokeii. decrease Phase 4 slopeiii. decrease membrane restingpotential and responsiveness

C. Alter the refractory periodi. increase Phase 2 plateau

ii. increase Phase 3 repolarization

iii. increase action potential duration

antiarrhythmic agents:

There are five main classes in the Vaughan

Williams classification of antiarrhythmic agents:

1.Class I agents interfere with the sodium (Na+)

channel.

2.Class II agents are anti-sympathetic nervous

system agents. Most agents in this class are beta

blockers.

3.Class III agents affect potassium (K+) efflux.

4.Class IV agents affect calcium channels and the

AV node.

5.Class V agents work by other or unknown

mechanisms

Anti-arrhythmia Agents

Anti-tachycardia agents

Anti-bradycardia agents

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Anti-tachycardia agents

Modified Vaugham Williams classification

1. I class: Natrium channel blocker

2. II class: -receptor blocker

3. III class: Potassium channel blocker

4. IV class: Calcium channel blocker

5. Others: Adenosine, Digital

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Anti-bradycardia agents

1. -adrenic receptor activator

2. M-cholinergic receptor blocker

3. Non-specific activator

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