The Arrythmias

8/8/2019 The Arrythmias

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Dr Mohamed A. FathiDr Mohamed A. Fathi

Cardiology specialist andCardiology specialist andTutorTutor

GMCHRCGMCHRC


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What is Arrhythmia??What is Arrhythmia??

Definition of Arrhythmia:Definition of Arrhythmia:

It is abnormalIt is abnormal Origin, Rate,Origin, Rate,

Rhythm, Conduct velocity andRhythm, Conduct velocity andsequencesequence of heart activation.of heart activation.


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Anatomy of the conducting system


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Pathogenesis and InducementPathogenesis and Inducement

of Arrhythmiaof Arrhythmia Some physical conditionSome physical condition

Pathological heart diseasePathological heart disease

Other system diseaseOther system disease Electrolyte disturbance andElectrolyte disturbance and

acidacid--base imbalancebase imbalance

Physical and chemical factors orPhysical and chemical factors ortoxicosistoxicosis


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Mechanism of Arrhythmia

Mechanism of Arrhythmia

Abnormal heart pulseAbnormal heart pulseformationformation

1.1. Sinus pulseSinus pulse2.2. Ectopic pulseEctopic pulse3.3. Triggered activityTriggered activity

Abnormal heart pulseAbnormal heart pulseconductionconduction

1.1. ReentryReentry2.2. Conduct blockConduct block


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Classification of ArrhythmiaClassification of Arrhythmia Abnormal heart pulseAbnormal heart pulse

formationformation1.1. Sinus arrhythmiaSinus arrhythmia2.2. Atrial arrhythmiaAtrial arrhythmia

3.3. Atrioventricular junctionalAtrioventricular junctionalarrhythmiaarrhythmia

4.4. Ventricular arrhythmiaVentricular arrhythmia

Abnormal heart pulseAbnormal heart pulse

conductionconduction1.1. SinusSinus--atrial blockatrial block2.2. IntraIntra--atrial blockatrial block3.3. AtrioAtrio--ventricular blockventricular block

4.4. IntraIntra--ventricular blockventricular block


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Diagnosis of ArrhythmiaDiagnosis of Arrhythmia

Medical historyMedical history

Physical examinationPhysical examination

Laboratory testLaboratory test


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Sinus ArrhythmiaSinus Arrhythmia


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Sinus ArrhythmiaSinus Arrhythmia


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Sinus tachycardiaSinus tachycardia Sinus rate > 100 beats/minSinus rate > 100 beats/min

(100(100--180)180)

Causes:Causes:1.1. Some physical condition:Some physical condition:

exercise, anxiety, exciting,exercise, anxiety, exciting,

alcohol, coffeealcohol, coffee2.2. Some disease: fever,Some disease: fever,

hyperthyroidism, anemia,hyperthyroidism, anemia,

myocarditismyocarditis


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Sinus tachycardiaSinus tachycardia


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SinusSinus BradycardiaBradycardia Sinus rate < 60 beats/minSinus rate < 60 beats/min

Normal variant in many normal andNormal variant in many normal andolder peopleolder people

Causes:Causes: Trained athletes, during sleep,Trained athletes, during sleep,drugs (drugs (--blockerblocker) , Hypothyriodism,) , Hypothyriodism,CAD or SSSCAD or SSS

Symptoms:Symptoms:

1.1. Most patients have no symptoms.Most patients have no symptoms.

2.2. Severe bradycardia may causeSevere bradycardia may causedizziness, fatigue, palpitation, evendizziness, fatigue, palpitation, even

syncope.syncope.


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SinusSinus BradycardiaBradycardia


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Sinoatrial exit block (SAB)Sinoatrial exit block (SAB)

SAB: Sinus pulse was blocked soSAB: Sinus pulse was blocked soit couldnt active the atrium.it couldnt active the atrium.

Causes: CAD, Myopathy,Causes: CAD, Myopathy,Myocarditis, digitalis toxicity, etMyocarditis, digitalis toxicity, etal.al.

Symptoms: dizziness, fatigue,Symptoms: dizziness, fatigue,syncopesyncope

Therapy is same to SSSTherapy is same to SSS


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Divided into three types: Type I,Divided into three types: Type I,II, IIIII, III

Only type II SAB can beOnly type II SAB can berecognized by EKG.recognized by EKG.


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Sinus Arrest orSinusSinus Arrest orSinus

Standsti

llStandsti

ll

Sinus arrest or standstill isSinus arrest or standstill isrecognized by a pause in therecognized by a pause in thesinus rhythm.sinus rhythm.

Causes:Causes: myocardial ischemia,myocardial ischemia,hypoxia, hyperkalemia, higherhypoxia, hyperkalemia, higherintracranial pressure, sinus nodeintracranial pressure, sinus node

degeneration and some drugsdegeneration and some drugs(digitalis,(digitalis, --blocks)blocks)..

Symptoms:Symptoms: dizziness, amaurosis,dizziness, amaurosis,

syncopesyncope


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Sinus Arrest orSinusSinus Arrest orSinus

Standsti

llStandsti

ll


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Sick Sinus Syndrome (SSS)Sick Sinus Syndrome (SSS)

SSS: The function of sinus node wasSSS: The function of sinus node wasdegenerated. SSS encompasses bothdegenerated. SSS encompasses bothdisordered SA node automaticitydisordered SA node automaticity

andS

A conduction.andS

A conduction. Causes: CAD, SAN degeneration,Causes: CAD, SAN degeneration,

myopathy, connective tissue disease,myopathy, connective tissue disease,metabolic disease, tumor, traumametabolic disease, tumor, trauma

and congenital disease.and congenital disease. With marked sinus bradycardia,With marked sinus bradycardia,

sinus arrest, sinus exit block orsinus arrest, sinus exit block orjunctional escape rhythmsjunctional escape rhythms

BradycardiaBradycardia--tachycardia syndrometachycardia syndrome


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Therapy:Therapy:

1.1. Treat the etiologyTreat the etiology

2.2. Treat with drugs: antiTreat with drugs: anti--bradycardia agents, the effectbradycardia agents, the effectof drug therapy is not good.of drug therapy is not good.

3.3. Artificial cardiac pacing.Artificial cardiac pacing.


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Atrial arrhythmiaAtrial arrhythmia


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Premature contractionsPremature contractions Common arrhythmiaCommon arrhythmia

The termsThe terms premature beat","premature beat","premature contraction","premature contraction","premature systole", orpremature systole", or extraextrasystolesystole indicate that theindicate that the

atria ,AV junction, or ventricleatria ,AV junction, or ventricleare stimulated prematurely.are stimulated prematurely.


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Atrial premature contractionsAtrial premature contractions

(APCs)(APCs)1).A premature P wave is present .It1).A premature P wave is present .It

may be superimposed on themay be superimposed on thepreceding T wave because it ispreceding T wave because it ispremature. The premature P wave ispremature. The premature P wave is

usually followed by a QRS complexusually followed by a QRS complexand a T wave. Occasionally, it is notand a T wave. Occasionally, it is notfollowed by a QRS complex and a Tfollowed by a QRS complex and a Twave .(blocked atrial premature beat).wave .(blocked atrial premature beat).2).The QRS and T waves that follow2).The QRS and T waves that follow

the premature P waves usuallythe premature P waves usuallyresemble the other QRS and T wavesresemble the other QRS and T wavesin the lead.in the lead.


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(APCs)(APCs) 3).The P3).The P--R interval of the atrialR interval of the atrial

premature beat is usually longer thanpremature beat is usually longer thanthe normal PR intervals in the ECG.the normal PR intervals in the ECG.4).An atrial premature beat is often4).An atrial premature beat is often

followed by a noncompensatory pause.followed by a noncompensatory pause.5).The ventricular complex is usually5).The ventricular complex is usuallynormal but may be aberrant in from ifnormal but may be aberrant in from ifthe premature atrial beat coincidesthe premature atrial beat coincideswith the refractory phase of thewith the refractory phase of the

previous ventricular beat .Theprevious ventricular beat .Theaberrant QRS is called aberrantaberrant QRS is called aberrantconduction.conduction.


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(APCs)(APCs)


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(APCs)(APCs) Causes:Causes: rheumatic heart disease,rheumatic heart disease,

CAD, hypertension, hyperthyroidism,CAD, hypertension, hyperthyroidism,

hypokalemiahypokalemia Symptoms:Symptoms: many patients have nomany patients have no

symptom, some have palpitation,symptom, some have palpitation,chest incomfortable.chest incomfortable.

Therapy:Therapy: Neednt therapy in theNeednt therapy in thepatients without heart disease. Canpatients without heart disease. Canbe treated withbe treated with --blocker,blocker,propafenone, moricizine or verapamil.propafenone, moricizine or verapamil.


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Atrial tachycardiaAtrial tachycardia

ClassifyClassify by automatic atrialby automatic atrialtachycardia (AAT); intratachycardia (AAT); intra--atrialatrial

reentrant atrial tachycardia (IART);reentrant atrial tachycardia (IART);chaotic atrial tachycardia (CAT).chaotic atrial tachycardia (CAT).

Etiology: atrial enlargement, MI;Etiology: atrial enlargement, MI;

chronic obstructive pulmonarychronic obstructive pulmonarydisease; drinking; metabolicdisease; drinking; metabolicdisturbance; digitalis toxicity;disturbance; digitalis toxicity;

electrolytic disturbance.electrolytic disturbance.


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Atrial tachycardiaAtrial tachycardia

May occur transient; intermittent;May occur transient; intermittent;or persistent.or persistent.

Symptoms: palpitation; chestSymptoms: palpitation; chestuncomfortable, tachycardia mayuncomfortable, tachycardia mayinduce myopathy.induce myopathy.

Auscultation: the first heart soundAuscultation: the first heart soundis variableis variable


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IntraIntra--atrial reentry tachycardiaatrial reentry tachycardia

(IART)(IART) ECG characters:ECG characters:

1.1. Atrial rate is around 130Atrial rate is around 130--150bpm;150bpm;

2.2. P wave is different from sinus PP wave is different from sinus Pwave;wave;

3.3. PP--R intervalR interval 0.12 0.12

4.4. Often appear type I or type II, 2:1Often appear type I or type II, 2:1AV block;AV block;

5.5. EP study: atrial program pacingEP study: atrial program pacing

can induce and terminatecan induce and terminate


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Automatic atrial tachycardiaAutomatic atrial tachycardia

(AAT)(AAT) ECG characters:ECG characters:

1.1. Atrial rate is around 100Atrial rate is around 100--

200bpm;200bpm;2.2. Warmup phenomenaWarmup phenomena

3.3. P wave is different from sinus PP wave is different from sinus Pwave;wave;

4.4. PP--R intervalR interval 0.12 0.12

5.5. Often appear type I or type II,Often appear type I or type II,2:1 AV block;2:1 AV block;

6.6. EP study: Atrial program pacingEP study: Atrial program pacing


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Chaotic atrial tachycardia (CAT)Chaotic atrial tachycardia (CAT) Also termed Multifocal atrialAlso termed Multifocal atrial

tachycardia.tachycardia. Always occurs in COPD or CHF,Always occurs in COPD or CHF, Have a high inHave a high in--hospital mortalityhospital mortality

( 25( 25--56%). Death is caused by the56%). Death is caused by theseverity of the underlying disease.severity of the underlying disease. ECG characters:ECG characters:1.1. Atrial rate is around 100Atrial rate is around 100--130bpm;130bpm;2.2. The morphologies P wave are moreThe morphologies P wave are more

than 3 types.than 3 types.3.3. PP--P, PP, P--R and RR and R--R interval areR interval are

different.different.4.4. Will progress to af in half the casesWill progress to af in half the cases5.5. EP study: Atrial program pacing cantEP study: Atrial program pacing cant


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TherapyTherapy

IRAT:IRAT: Esophageal PulsationEsophageal PulsationModulation, RFCA, Ic and IV classModulation, RFCA, Ic and IV class

antianti--tachycardia agentstachycardia agents AAT: Digoxin, IV, II, Ia and IIIAAT: Digoxin, IV, II, Ia and III

class anticlass anti--tachycardia agents;tachycardia agents;RFCARFCA

CAT: treat the underlying disease,CAT: treat the underlying disease,verapamil or amiodarone.verapamil or amiodarone.

Associated with SSS: ImplantAssociated with SSS: Implantaceace--maker.maker.


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Atrial flutterAtrial flutter

Etiology:Etiology:

1.1. It can occur in patients withIt can occur in patients withnormal atrial or withnormal atrial or withabnormal atrial.abnormal atrial.

2.2. It is seen in rheumatic heartIt is seen in rheumatic heartdisease (mitral or tricuspiddisease (mitral or tricuspid

valve disease), CAD,valve disease), CAD,hypertension,hypertension,hyperthyroidism, congenitalhyperthyroidism, congenitalheart disease, COPD.heart disease, COPD.

3.3. Related to enlargement ofRelated to enlargement of


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Symptoms:Symptoms: depend on underlyingdepend on underlyingdisease, ventricular rate, thedisease, ventricular rate, thepatient is at rest or is exertingpatient is at rest or is exerting

With rapid ventricular rate:With rapid ventricular rate:palpitation, dizziness, shortnesspalpitation, dizziness, shortnessof breath, weakness, faintness,of breath, weakness, faintness,

syncope, may develop anginasyncope, may develop anginaand CHF.and CHF.


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Therapy:Therapy:

1.1. Treat the underlying diseaseTreat the underlying disease

2.2. To restore sinus rhythm:To restore sinus rhythm:Cardioversion,Cardioversion, EsophagealEsophagealPulsation Modulation, RFCA,Pulsation Modulation, RFCA,Drug (III, Ia, Ic class).Drug (III, Ia, Ic class).

3.3. Control the ventricular rate:Control the ventricular rate:digitalis. CCB,digitalis. CCB, --blockblock

4.4. AnticoagulationAnticoagulation


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Atrial fibrillationAtrial fibrillation

Subdivided into three types:S

ubdivided into three types:paroxysmal, persistent,paroxysmal, persistent,permanent.permanent.

Etiology:Etiology:

1.1. Morbidity rate increase in olderMorbidity rate increase in olderpatientspatients

2.2. Etiology just like atrial flutterEtiology just like atrial flutter

3.3. IdiopathicIdiopathic Mechanism:Mechanism:

1.1. Multiple wavelet reMultiple wavelet re--entry;entry;

2.2. Rapid firing focus in pulmonaryRapid firing focus in pulmonary


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Manifestation:Manifestation:

Affected by underlying diseases,Affected by underlying diseases,ventricular rate and heart function.ventricular rate and heart function.

May develop embolism in left atrial.May develop embolism in left atrial.Have high incidence of stroke.Have high incidence of stroke.

The heart rate, S1 and rhythm isThe heart rate, S1 and rhythm isirregularly irregularirregularly irregular

If the heart rhythm is regular, shouldIf the heart rhythm is regular, shouldconsider about (1) restore sinus rhythm;consider about (1) restore sinus rhythm;(2) AF with constant the ratio of AV(2) AF with constant the ratio of AVconduction; (3) junctional or ventricularconduction; (3) junctional or ventricular

tachycardia; (4) slower ventricular ratetachycardia; (4) slower ventricular rate


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Therapy:Therapy:1.1. Treat the underlying diseaseTreat the underlying disease2.2. Restore sinus rhythm: Drug,Restore sinus rhythm: Drug,

Cardioversion, RFCA, MazeCardioversion, RFCA, Mazesurgerysurgery

3.3. Rate control:Rate control: digitalis. CCB,digitalis. CCB, --blockblock

4.4. Antithrombotic therapy:Antithrombotic therapy:Aspirine, WarfarinAspirine, Warfarin


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Atrioventricular JunctionalAtrioventricular Junctional

arrhythmiaarrhythmia


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Atrioventricular junctionalAtrioventricular junctional

premature contractionspremature contractions

Etiology and manifestation is likeEtiology and manifestation is likeAPCsAPCs

Therapy the underlying diseaseTherapy the underlying disease

Neednt antiNeednt anti--arrhythmia therapy.arrhythmia therapy.


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Nonparoxysmal AV junctionalNonparoxysmal AV junctional

tachycardiatachycardia Mechanism:Mechanism: relate to hyperrelate to hyper--

automaticity or trigger activityautomaticity or trigger activityof AV junctional tissueof AV junctional tissue

Etiology:Etiology: digitalis toxicity;digitalis toxicity;inferior MI; myocarditis; acuteinferior MI; myocarditis; acuterheumatic fever andrheumatic fever and

postoperation of valve diseasepostoperation of valve disease ECG:ECG: the heart rate ranges 70the heart rate ranges 70--

150 bpm or more, regular,150 bpm or more, regular,normal QRS complex, maynormal QRS complex, mayoccur AV dissociation andoccur AV dissociation and


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Nonparoxysmal AV junctionalNonparoxysmal AV junctional

tachycardiatachycardia

Therapy:Therapy:

Treat underlying disease;Treat underlying disease;

stopping digoxin, administerstopping digoxin, administerpotassium, lidocaine,potassium, lidocaine,phenytoin or propranolol.phenytoin or propranolol.

Not for DC shockNot for DC shock

It can disappearIt can disappearspontaneously. If had goodspontaneously. If had goodtolerance, not require therapy.tolerance, not require therapy.


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Paroxysmal tachycardiaParoxysmal tachycardia

Most PSVT (paroxysmalMost PSVT (paroxysmalsupraventricular tachycardia) is due tosupraventricular tachycardia) is due toreentrant mechanism.reentrant mechanism.

The incidence of PSVT is higher inThe incidence of PSVT is higher inAVNRT (atrioventricular node reentryAVNRT (atrioventricular node reentrytachycardia) and AVRT (atioventriculartachycardia) and AVRT (atioventricular

reentry tachycardia), the mostreentry tachycardia), the mostcommon is AVNRT (90%)common is AVNRT (90%)

Occur in any age individuals, usuallyOccur in any age individuals, usuallyno structure heart disease.no structure heart disease.


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Manifestation:Manifestation: Occur and terminal abruptly.Occur and terminal abruptly.

Palpitation, dizziness,Palpitation, dizziness,syncope, angina, heartsyncope, angina, heartfailure and shock.failure and shock.

The sever degree of theThe sever degree of thesymptom is related tosymptom is related toventricular rate,ventricular rate,persistent duration andpersistent duration andunderl in diseaseunderl in disease


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ECG characteristic of AVNRTECG characteristic of AVNRT

1.1. Heart rate is 150Heart rate is 150--250 bpm,250 bpm,regularregular

2.2. QRS complex is often normal,QRS complex is often normal,wide QRS complex is withwide QRS complex is withaberrant conductionaberrant conduction

3.3. Negative P wave in II III aVF,Negative P wave in II III aVF,buried into or following by theburied into or following by theQRS complex.QRS complex.

4.4. AVN jump phenomenaAVN jump phenomena


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ECG characteristic of AVRTECG characteristic of AVRT

1.1. Heart rate is 150Heart rate is 150--250 bpm,250 bpm,

regularregular2.2. In orthodromic AVRT, the QRSIn orthodromic AVRT, the QRS

complex is often normal, widecomplex is often normal, wideQRS complex is with antidromicQRS complex is with antidromic

AVRTAVRT

3.3. Retrograde P wave, RRetrograde P wave, R--P>110ms.P>110ms.


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Therapy:Therapy: AVNRT & orthodromic AVRTAVNRT & orthodromic AVRT1.1. Increase vagal tone: carotid sinusIncrease vagal tone: carotid sinus

massage, Valsalva maneuver.if nomassage, Valsalva maneuver.if nosuccessful,successful,2.2. Drug: verapamil, adrenosine,Drug: verapamil, adrenosine,

propafenonepropafenone3.3. DC shockDC shock Antidromic AVRT:Antidromic AVRT:1.1. Should not use verapamil, digitalis,Should not use verapamil, digitalis,

and stimulate the vagal nerve.and stimulate the vagal nerve.2.2. Drug: propafenone, sotalol,Drug: propafenone, sotalol,

amiodaroneamiodarone


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PrePre--excitation syndromeexcitation syndrome

(W(W--PP--W syndrome)W syndrome) There are several type ofThere are several type of

accessory pathwayaccessory pathway

1.1. Kent: adjacent atrial andKent: adjacent atrial andventricularventricular

2.2. James: adjacent atrial and hisJames: adjacent atrial and hisbundlebundle

3.3. Mahaim: adjacent lower partMahaim: adjacent lower partof the AVN and ventricularof the AVN and ventricular

Usually no structure heartUsually no structure heart


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WPW syndromeWPW syndrome


Palpitation, syncope,Palpitation, syncope,

dizzinessdizziness Arrhythmia: 80%Arrhythmia: 80%

tachycardia is AVRT, 15tachycardia is AVRT, 15--30%30%

is AFi, 5% is AF,is AFi, 5% is AF, May induce ventricularMay induce ventricular

fibrillationfibrillation


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WPW syndromeWPW syndrome

Therapy:Therapy:

1.1. Pharmacologic therapy:Pharmacologic therapy:orthodrome AVRT or associatedorthodrome AVRT or associated

AF, AFi, may use Ic and IIIAF, AFi, may use Ic and IIIclass agents.class agents.

2.2. Antidromic AVRT cant useAntidromic AVRT cant use

digoxin and verapamil.digoxin and verapamil.3.3. DC shock: WPW with SVT, AFDC shock: WPW with SVT, AF

or Afi produce agina, syncopeor Afi produce agina, syncopeand hypotensionand hypotension

4.4. RFCARFCA


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Ventricular arrhythmiaVentricular arrhythmia


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Ventricular PrematureVentricular Premature

Contractions (VP

Cs)

Contractions (VP

Cs)

Etiology:Etiology:

1.1. Occur in normal personOccur in normal person

2.2. Myocarditis, CAD, valve heartMyocarditis, CAD, valve heartdisease, hyperthyroidism, Drugdisease, hyperthyroidism, Drugtoxicity (digoxin, quinidine andtoxicity (digoxin, quinidine andantianti--anxiety drug)anxiety drug)

3.3. electrolyte disturbance, anxiety,electrolyte disturbance, anxiety,drinking,drinking, coffeecoffee


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VPCsVPCs


1.1. palpitationpalpitation

2.2. dizzinessdizziness3.3. syncopesyncope

4.4. loss of the second heartloss of the second heart

soundsound


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PVCsPVCs

Therapy:Therapy: treat underlying disease,treat underlying disease,antiarrhythmiaantiarrhythmia

No structure heart disease:No structure heart disease:

1.1. Asymptom: no therapyAsymptom: no therapy

2.2. Symptom caused by PVCs: antianxietySymptom caused by PVCs: antianxietyagents,agents, --blocker and mexiletine toblocker and mexiletine torelief the symptom.relief the symptom.

With structure heart disease (CAD,With structure heart disease (CAD,HBP):HBP):

1.1. Treat the underlying diseasTreat the underlying diseas

2.2. --blocker, amiodaroneblocker, amiodarone

3.3. Class I especially class Ic agentsClass I especially class Ic agents


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Ventricular tachycardiaVentricular tachycardia

Etiology: often in organic heartEtiology: often in organic heartdiseasedisease

CAD, MI, DCM, HCM, HF,CAD, MI, DCM, HCM, HF,

long QT syndromelong QT syndrome

Brugada syndromeBrugada syndrome

Sustained VT (>30s),S

ustained VT (>30s),Nonsustained VTNonsustained VT

Monomorphic VT, Polymorphic VTMonomorphic VT, Polymorphic VT


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Torsades de points (Tdp):Torsades de points (Tdp): A specialA specialtype of polymorphic VT,type of polymorphic VT,

Etiology:Etiology:

1.1. congenital (Long QT),congenital (Long QT),2.2. electrolyte disturbance,electrolyte disturbance,

3.3. antiarrhythmia drug proarrhythmiaantiarrhythmia drug proarrhythmia(IA or IC),(IA or IC),

4.4. antianxiety drug,antianxiety drug,

5.5. brain disease,brain disease,

6.6. bradycardiabradycardia


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Accelerated idioventricularAccelerated idioventricularrhythm:rhythm:

1.1. Related to increase automaticRelated to increase automatictonetone

2.2. EtiologyEtiology: Often occur in organic: Often occur in organicheart disease, especially AMIheart disease, especially AMI

reperfusion periods, heartreperfusion periods, heartoperation, myocarditis, digitalisoperation, myocarditis, digitalistoxicitytoxicity


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VTVT


1.1. Nonsustained VT with noNonsustained VT with nosymptomsymptom

2.2. Sustained VT : with symptomSustained VT : with symptomand unstable hemodynamic,and unstable hemodynamic,patient may feel palpitation,patient may feel palpitation,

short of breathness,short of breathness,presyncope, syncope, angina,presyncope, syncope, angina,hypotension and shock.hypotension and shock.


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VTVT

ECG characteristics:ECG characteristics:

1.1. Monomorphic VT: 100Monomorphic VT: 100--250 bpm, occur250 bpm, occurand terminate abruptly,regularand terminate abruptly,regular

2.2. Accelerated idioventricular rhythm: aAccelerated idioventricular rhythm: aruns of 3runs of 3--10 ventricular beats, rate of10 ventricular beats, rate of6060--110 bpm, tachycardia is a capable110 bpm, tachycardia is a capableof warm up and close down, oftenof warm up and close down, oftenseen AV dissociation, fusion or captureseen AV dissociation, fusion or capturebeatsbeats

3.3. Tdp: rotation of the QRS axis aroundTdp: rotation of the QRS axis around

the baseline, the rate from 160the baseline, the rate from 160--280280


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Treatment of VTTreatment of VT

1.1. Treat underlying diseaseTreat underlying disease

2.2. Cardioversion: HemodynamicCardioversion: Hemodynamicunstable VT (hypotension,unstable VT (hypotension,shock, angina, CHF) orshock, angina, CHF) orhemodynamic stable but drughemodynamic stable but drugwas no effectwas no effect

3.3. Pharmacological therapy:Pharmacological therapy: --blockers,blockers, lidocain orlidocain oramiodaroneamiodarone

4.4. RFCA, ICD or surgical therapyRFCA, ICD or surgical therapy


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Therapy ofSpecial type VTTherapy ofSpecial type VT

Accelerated idioventricularAccelerated idioventricularrhythm:rhythm:

usually no symptom, needntusually no symptom, neednttherapy.therapy.

Atropine increased sinus rhythmAtropine increased sinus rhythm

Tdp:Tdp:

1.1. Treat underlying disease,Treat underlying disease,

2.2. Magnesium iv, atropine orMagnesium iv, atropine orisoprenaline,isoprenaline, --block orblock or

acemaker for lon T atientacemaker for lon T atient


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Ventricular flutter and fibrillationVentricular flutter and fibrillation

Often occur in severe organicOften occur in severe organicheart disease: AMI, ischemiaheart disease: AMI, ischemia

heart diseaseheart disease Proarrhythmia (especiallyProarrhythmia (especially

produce long QT and Tdp),produce long QT and Tdp),

electrolyte disturbanceelectrolyte disturbance Anaesthesia, lightning strike,Anaesthesia, lightning strike,

electric shock, heart operationelectric shock, heart operation

Its a fatal arrhythmiaIts a fatal arrhythmia


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Ventricular flutter and fibrillationVentricular flutter and fibrillation


Unconsciousness, twitch, noUnconsciousness, twitch, noblood pressure and pulse, goingblood pressure and pulse, goingto dieto die

Therapy:Therapy:

1.1. CardioCardio--Pulmonary ResuscitatePulmonary Resuscitate(CPR)(CPR)

2.2. ICDICD


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Cardiac conduction blockCardiac conduction block

Block position:Block position:

Sinoatrial; intraSinoatrial; intra--atrial;atrial;atrioventricular; intraatrioventricular; intra--ventricularventricular

Block degreeBlock degree

1.1. Type I: prolong the conductiveType I: prolong the conductivetimetime

2.2. Type II: partial blockType II: partial block

3.3. Type III: complete blockType III: complete block


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Atrioventricular BlockAtrioventricular Block

AV block is a delay or failure inAV block is a delay or failure intransmission of the cardiactransmission of the cardiacimpulse from atrium to ventricle.impulse from atrium to ventricle.

Etiology:Etiology:

Atherosclerotic heart disease;Atherosclerotic heart disease;myocarditis; rheumatic fever;myocarditis; rheumatic fever;cardiomyopathy; drug toxicity;cardiomyopathy; drug toxicity;electrolyte disturbance, collagenelectrolyte disturbance, collagendisease, levs disease.disease, levs disease.


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AV BlockAV Block

AV block is divided into threeAV block is divided into threecategories:categories:

1.1. FirstFirst--degree AV blockdegree AV block

2.2. SecondSecond--degree AV block:degree AV block:further subdivided into type Ifurther subdivided into type I

and type IIand type II3.3. ThirdThird--degree AV block:degree AV block:

complete blockcomplete block


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AV BlockAV Block

Manifestations:Manifestations:

FirstFirst--degree AV block: almost nodegree AV block: almost nosymptoms;symptoms;

Second degree AV block: palpitation,Second degree AV block: palpitation,fatiguefatigue

Third degree AV block: Dizziness,Third degree AV block: Dizziness,

agina, heart failure,agina, heart failure,lightheadedness, and syncope maylightheadedness, and syncope maycause by slow heart rate, Adamscause by slow heart rate, Adams--S

tokesS

yndrome may occurs inS

tokesS

yndrome may occurs in


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AV BlockAV Block

Treatment:Treatment:

1.1. I or II degree AV blockI or II degree AV block

neednt antibradycardianeednt antibradycardiaagent therapyagent therapy

2.2. II degree II type and IIIII degree II type and III

degree AV block needdegree AV block needantibradycardia agentantibradycardia agenttherapytherapy

3.3. Implant Pace MakerImplant Pace Maker


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Intraventricular BlockIntraventricular Block

Intraventricular conductionIntraventricular conductionsystem:system:

1.1. Right bundle branchRight bundle branch

2.2. Left bundle branchLeft bundle branch

3.3. Left anterior fascicularLeft anterior fascicular

4.4. Left posterior fascicularLeft posterior fascicular


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Etiology:Etiology:

Myocarditis, valve disease,Myocarditis, valve disease,cardiomyopathy, CAD,cardiomyopathy, CAD,

hypertension, pulmonary hearthypertension, pulmonary heartdisease, drug toxicity, Lenegredisease, drug toxicity, Lenegredisease, Levs disease et al.disease, Levs disease et al.


Single fascicular or bifascicularSingle fascicular or bifascicularblock is asymptom; triblock is asymptom; tri--fascicularfascicularblock may have dizziness;block may have dizziness;

palpitation, syncope and Adamspalpitation, syncope and Adams--


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Therapy:Therapy:

1.1. Treat underlying diseaseTreat underlying disease

2.2. If the patient is asymptom; noIf the patient is asymptom; notreat,treat,

3.3. bifascicular block andbifascicular block andincomplete trifascicular blockincomplete trifascicular block

may progress to complete block,may progress to complete block,may need implant pace maker ifmay need implant pace maker ifthe patient with syncopethe patient with syncope

The Arrythmias

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