心律失常总论课件

心律失常总论心律失常总论心律失常总论1四川大学华西医院四川大学华西医院22024/6/242024/6/24OutlineArrhythmia is any of a 2四川大学四川大学华华西医院西医院32024/6/242024/6/24DefinitionThe Origin,Rate,Rh3四川大学四川大学华华西医院西医院42024/6/242024/6/24Arrythmia related Cardioanatom42024/6/242024/6/24四川大学华西医院四川大学华西医院5Cardiac Conduction SystemSAN 5四川大学华西医院四川大学华西医院62024/6/242024/6/24Pacing conduction system四川大学华西62024/6/242024/6/24四川大学华西医院四川大学华西医院7Pathogenesis and Inducement o72024/6/242024/6/24四川大学华西医院四川大学华西医院8Mechanism of ArrhythmiaAbnorma8 Phase 1Phase 1快速复极初期：钾离子外流快速复极初期：钾离子外流 Phase 0Phase 0 快速或上升快速或上升钠离子内流入进入细胞进行除钠离子内流入进入细胞进行除极极 Phase 2 Phase 2 平台期平台期:持续的钠离子内流和持续的钠离子内流和缓慢钙离子内流和钾离子外流缓慢钙离子内流和钾离子外流 Phase 3 Phase 3 快速复极末期快速复极末期:钾离子钾离子外流外流 Phase 4 Phase 4 静息期静息期5 5 PhasesPhases心肌细胞的动作电位心肌细胞的动作电位Phase 1Phase 0 Phase 2 Phase触发机制后电位产生于动作电位的第3相（早期）或第4相（晚期）可触发心律失常2024/6/242024/6/24四川大学华西医院四川大学华西医院10Abnormal heart pulse formation102024/6/242024/6/24四川大学华西医院四川大学华西医院11Automaticity Heart cells other112024/6/242024/6/24四川大学华西医院四川大学华西医院12Triggered activity is like a 12四川大学四川大学华华西医院西医院132024/6/242024/6/24Abnormal heart pulse conductio13Fast Conduction PathSlow RecoverySlow Conduction PathFast RecoveryReentry RequiresElectrical ImpulseCardiac Conduction Tissue1.2 distinct pathways that come together at beginning and end to form a loop.2.A unidirectional block in one of those pathways.3.Slow conduction in the unblocked pathway.2024/6/24四川大学华西医院14Fast Conduction PathSlow Condu14Fast Conduction PathSlow RecoverySlow Conduction PathFast RecoveryThe“Re-Entry”Mechanism of Ectopic Beats&RhythmsElectrical ImpulseCardiac Conduction TissueTissues with these type of circuits may exist:in microscopic size in the SA node,AV node,or any type of heart tissue in a“macroscopic”structure such as an accessory pathway in WPW2024/6/24四川大学华西医院15Fast Conduction PathSlow Condu15Fast Conduction PathSlow RecoverySlow Conduction PathFast RecoveryPremature Beat ImpulseCardiac Conduction Tissue1.An arrhythmia is triggered by a premature beat 2.The beat cannot gain entry into the fast conducting pathway because of its long refractory period and therefore travels down the slow conducting pathway only Repolarizing Tissue(long refractory period)The“Re-Entry”Mechanism of Ectopic Beats&Rhythms2024/6/24四川大学华西医院16Fast Conduction PathSlow Condu163.The wave of excitation from the premature beat arrives at the distal end of the fast conducting pathway,which has now recovered and therefore travels retrogradely(backwards)up the fast pathway Fast Conduction PathSlow RecoverySlow Conduction PathFast RecoveryCardiac Conduction TissueThe“Re-Entry”Mechanism of Ectopic Beats&Rhythms2024/6/24四川大学华西医院173.The wave of excitation fro174.On arriving at the top of the fast pathway it finds the slow pathway has recovered and therefore the wave of excitation re-enters the pathway and continues in a circular movement.This creates the re-entry circuitFast Conduction PathSlow RecoverySlow Conduction PathFast RecoveryCardiac Conduction TissueThe“Re-Entry”Mechanism of Ectopic Beats&Rhythms2024/6/24四川大学华西医院184.On arriving at the top of 18Atrial Re-entry atrial tachycardia atrial fibrillation atrial flutterAtrio-Ventricular Re-entry Wolf Parkinson White supraventricular tachycardiaVentricular Re-entry ventricular tachycardiaAtrio-Ventricular Nodal Re-entry supraventricular tachycardiaRe-entry Circuits as Ectopic Foci and Arrhythmia Generators2024/6/24四川大学华西医院19Atrial Re-entryAtrio-Ventricul19bRADYCARDIASA slow rhythm(less than 60 beats/min)May be caused by a slowed signal from the SAN,a pause in the normal activity of the SAN,or by blocking of the electrical impulse on its way from the atria to the ventricles(AV block or heart block)May also be present in the normally functioning heart of endurance athletes or other well-conditioned persons2024/6/24四川大学华西医院20bRADYCARDIASA slow rhythm(les20四川大学四川大学华华西医院西医院212024/6/242024/6/24MECHANISM OF BRADYCARDIAS窦房结自律21四川大学华西医院四川大学华西医院222024/6/242024/6/24Classification of ArrhythmiaAt22四川大学四川大学华华西医院西医院232024/6/242024/6/24Diagnosis of ArrhythmiaMedical23四川大学华西医院四川大学华西医院242024/6/242024/6/24四川大学华西医院242023/8/11242024/6/242024/6/24四川大学华西医院四川大学华西医院252023/8/11四川大学华西医院25252024/6/242024/6/24四川大学华西医院四川大学华西医院262023/8/11四川大学华西医院26262024/6/242024/6/24四川大学华西医院四川大学华西医院27ELECTROCARDIOGRAM“5”steps app27YESNOCHAOTIC FLAT LINEWIDENARROWPEAVFAsystoleVT2024/6/242024/6/24四川大学华西医院四川大学华西医院28Step 1:Is there a“QRS”(No 28YESNOVARYCONSTANTMORPHOLOGYRATE220 to 350AFJUNCTIONALInvertedRR IntervalJUNCTIONALAtrial Flutter2024/6/242024/6/24四川大学华西医院四川大学华西医院29Step 2:Is there a“P”WaveYES292024/6/242024/6/24四川大学华西医院四川大学华西医院302023/8/11四川大学华西医院30302024/6/242024/6/24四川大学华西医院四川大学华西医院312023/8/11四川大学华西医院31312024/6/242024/6/24四川大学华西医院四川大学华西医院32Step 3:What is the relationsh32 0.2Io AVBConstant?YesIIo AVB type 2NoRR intervalYesIIIoAVBNoType1 IIoPR intervalPR intervalHEART BLOCKn“P”=n“QRS”?NoYesConstant?2024/6/242024/6/24四川大学华西医院四川大学华西医院33 0.2Io AVBConstant332024/6/242024/6/24四川大学华西医院四川大学华西医院341st Degree block(AV Nodal Del342024/6/242024/6/24四川大学华西医院四川大学华西医院352023/8/11四川大学华西医院35352024/6/242024/6/24四川大学华西医院四川大学华西医院362023/8/11四川大学华西医院36362024/6/242024/6/24四川大学华西医院四川大学华西医院37Event Monitors Holter monitori372024/6/242024/6/24四川大学华西医院四川大学华西医院38Exercise testing Symptoms only382024/6/242024/6/24四川大学华西医院四川大学华西医院39Signal Averaged ECGUsed only i392024/6/242024/6/24四川大学华西医院四川大学华西医院40Electrophysiologic Testing Ca40四川大学华西医院四川大学华西医院412024/6/242024/6/24ManagementPhysical maneuvers,412024/6/242024/6/24四川大学华西医院四川大学华西医院42Therapy PrincipalPathogenesis 42四川大学华西医院四川大学华西医院432024/6/242024/6/24Physical maneuvers(vagal mane432024/6/242024/6/24四川大学华西医院四川大学华西医院44Anti-arrhythmia AgentsAnti-tac442024/6/242024/6/24四川大学华西医院四川大学华西医院45Anti-tachycardia agentsModifie45 Phase 1Phase 1快速复极初期：钾离子外流快速复极初期：钾离子外流 Phase 0Phase 0 快速或上升快速或上升钠离子内流入进入细胞进行除钠离子内流入进入细胞进行除极极 Phase 2 Phase 2 平台期平台期:持续的钠离子内流和持续的钠离子内流和缓慢钙离子内流和钾离子外流缓慢钙离子内流和钾离子外流 Phase 3 Phase 3 快速复极末期快速复极末期:钾离子钾离子外流外流 Phase 4 Phase 4 静息期静息期5 5 PhasesPhases心肌细胞的动作电位心肌细胞的动作电位Phase 1Phase 0 Phase 2 Phase类类别别 亚亚 类类 电电 生生 理理 效效 应应 代代 表表 制制 剂剂 新新 制制 剂剂 传导传导速度速度 不应不应期期 Ap时时限限 a a 多多 奎尼丁奎尼丁AjmalineAjmaline、PirmenolPirmenol、AprindinAprindinb b/利多卡因利多卡因MaxiletineMaxiletine、TocainideTocainidec c EncainideEncainidePropafenonePropafenone、FlecainideFlecainide、LorcainideLorcainide、EthmozideEthmozide 心得安心得安=胺碘酮胺碘酮SotablSotabl 异搏定异搏定硫氮唑酮硫氮唑酮BepridiBepridi四川大学四川大学华华西医院西医院47其它药物包括：洋地黄类(临床上称之为第五类)以及新斯的明、甲氧胺、氯化钾、硫酸镁、ATP等抗缓慢心律失常的药物，包括：拟交感胺类、阿托品类、碱性药物等 2024/6/242024/6/24Classification of AADs类别 亚 类 电472024/6/242024/6/24四川大学华西医院四川大学华西医院48Clinical usage:Ia classGuinid482024/6/242024/6/24四川大学华西医院四川大学华西医院49Clinical usage:Ib classLidoca492024/6/242024/6/24四川大学华西医院四川大学华西医院50Clinical usage:Ic classMorici502024/6/242024/6/24四川大学华西医院四川大学华西医院51Clinical usage:II classPropra512024/6/242024/6/24四川大学华西医院四川大学华西医院52Clinical usage:III classAmioa522024/6/242024/6/24四川大学华西医院四川大学华西医院53Clinical usage:IV class and O532024/6/242024/6/24四川大学华西医院四川大学华西医院54Anti-bradycardia agents-adren542024/6/242024/6/24四川大学华西医院四川大学华西医院55Proarrhythmia effect of antiar552024/6/242024/6/24四川大学华西医院四川大学华西医院56Non-drug therapyCardioversion:56四川大学四川大学华华西医院西医院57Q&A2024/6/242024/6/24四川大学华西医院57Q&A2023/8/1157