心律失常英文版文档课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Cardiac Arrhythmia,心律失常英文版文档课件,1,INTRODUCTION,Arrthythmia:,abnormalities of cardiac rhythm and conduction,Arrthythmias can be lethal (sudden cardiac death ) , symptomatic ( syncope , near syncope dizziness , or palpitations ) , or asymptomatic .,INTRODUCTION,2,Property of cardiac elctrophysiology,Excitability,Automaticity,Conductivity,Property of cardiac elctrophys,3,Excitability,Electrical activity which takes place when myocardial cell is stimulated,Electrical activity of single myocardial cell is called action potential(AP),ExcitabilityElectrical activit,4,Excitability,Composition and features of AP,There are five phase,（,0,、,1,、,2,、,3,、,4,）,Electrophysiological phenomena during AP,Refractory period,Absolute, Effective, Relative,ExcitabilityComposition and fe,5,Conductivity,Electrical impulse can conduct in myocardial tissue bidirectionally,Normal conduction pathway,：,sinus nodeintranode bundle atrioventricula node and intraatrial bundleHis bundleright and left bundle branch(including left anterosuperior and posteroinferior)Purkinje fibermyocardium,ConductivityElectrical impulse,6,automaticity,Property of spontaneously discharging cells(spotaneous AP, diastolic depolarization),Automaticity increases from high to low as follows:,Physiological status,：,SN,、,AVN,、,HIS,、,Purkinje,pathological,：,diseased myocardial and conductive tissue, etc.,automaticityProperty of sponta,7,Property of normal rhythm,Impulse from SN,Heart rate is within 60,100/min,Regular rhythm,，,P interval,，,QRS complex duration,Frontal axis within -30,90,It is considered as arrhythmia if any item above is not matched,Property of normal rhythmImpul,8,心律失常英文版文档课件,9,Classification of cardiac arrhythmias,Classified on property of electrical activity,Abnormality of impulse and conduction,Classified on heart rate, rapid or slow,Rapid or slow arrhythmias,Classified on clinical manifestation, mild or sever,Fatal or nonfatal,High risk or low risk,Classification of cardiac arrh,10,Mechanisms of arrhythmogenesis,Reentry,Conduction inconsistency of anatomy or physiology,Single directional conduction blocking,Delayed conduction,Initial blocking area recovers excitability,Mechanisms of arrhythmogenesis,11,心律失常英文版文档课件,12,Mechanisms of arrhythmogenesis,Increased automaticity,Endogenous or exogenous catecholamine increasing,Abnormality of acid, electrolyte balance,Ischemia, hypoxia,Mechanical stretch,drugs,Disturbance of nerve,Mechanisms of arrhythmogenesis,13,Mechanisms of arrhythmogenesis,Triggered activity,Depolarizing oscillations of membrane voltage induced by abnormal inward Na+ during earlier or later reporlarization, ie, After depolarization,Early depolarization,Delayed depolarization,Mechanisms of arrhythmogenesis,14,Category of Arrthythmia,Abnormalities of impulses generating,Abnormalities of impulses conduction,Category of ArrthythmiaAbnorm,15,Abnormalities of impulses generating,Sinus arrthythmias:,sinus bradycardia,sinus tachycardia,sinus arrest,Abnormalities of impulses gene,16,Abnormalities of impulses generating,Ectopic rhythm:,1.Passive abnormalrhythm: escape beat, escape rhythm,(atrial, AV junctional, ventricular),2.Initiative ectopic rhythm:,premature beat(atrial, AV junctional, ventricular),paroxysmal tachycardia(atrial, AV junctional,ventricular),atrial flutter, atrial fibrillation,ventricular flutter, ventricular fibrillation,Abnormalities of impulses gene,17,Abnormalities of impulses conduction,2.pathologic: sinoatrial block, intra-atrial block, atrial ventricular block, bundle branch block, intraventricular block.,3.abnormal pathway conduction:,preexcitation syndrome,Abnormalities of impulses cond,18,Sinus Arrhythmia,心律失常英文版文档课件,19,1.Normal sinus rhythm,the P wave appear regularly,the P wave is upright in lead I, II, AVF, V4-V6,and negative in lead AVR,P-R interval exceed 120ms.,1.Normal sinus rhythm,20,.,.,21,2.Sinus Tachycardia,ECG Sinus Tachycardia is defined as a heart rate faster than 100 beats / min with sinus rhythm, frequency between 100-150bpm. P wave have a normal contour and appear before each QRS complex with a stable P-R interval,.,2.Sinus TachycardiaECG Sinus T,22,Sinus Tachycardia,Causes: it occurs with fever , exercise , emotion , pain ,anemia , heart failure , shock , thyrotoxicosis , or in response to many drugs . Alcohol ,tea, caffeine and alcohol withdrawal are common causes of sinus tachycardia.,Sinus TachycardiaCauses: it oc,23,3.Sinus bradycardia,ECG: sinus rhythm ECG, heart rate slower than 60 beats /min .,3.Sinus bradycardiaECG: sinus,24,Sinus bradycardia,Causes:,Physiological:,young adults, atheletes, during sleep.,Pathological:,hypothermia, raised intracranial pressure, AMI affecting the SA node, drugs(e.g. beta-blockers), fibrosis of SA node.,Sinus bradycardiaCauses:,25,4.Sinus arrhythmia,Sinus arrhythmia is characterized by a variation in sinus cycle length during which the maximum sinus cycle length minus minimum sinus cycle length exceeds 120ms .,4.Sinus arrhythmia Sinus arrhy,26,Sinus arrhythmia is a cyclic increase in normal heart rate with inspiration and decrease with expiration . It results from reflex changes in vagal influence on the normal pacemaker,Sinus arrhythmia is a cyclic i,27,5.Sinus arrest,ECG,: PP interval elongates abruptly, basically at sinus bradycardia, which is not common multiples of basic PP interval,Escape beat or rhythm is common seen,5.Sinus arrestECG: PP interva,28,心律失常英文版文档课件,29,6.Sick sinus syndrome sss,Etiology,Intrinsic,：,sinus node itself is involved, e.g. ischemia, regressive degeneration, infiltration of other cells or tissues,Extrinsic,：,high vagal tone, hyperkalemia, antiarrhythmics,most frequent etiology are regressive degeneration and CHD,6.Sick sinus syndrome sssEtio,30,Sick Sinus Syndrome,ECG:,persistent marked sinus bradycardia(50bpm);,sinus arrest , sinoatrial block;,sinoatrial block and atrialventricular block exist at the same time; No escape beats appear after sinus arrest,bradycardia-tachycardia syndrome(sinus bradycardia, atrial tachycardia, atrial flutter, atrial fibrillation alternatively),Sick Sinus SyndromeECG:,31,Sick Sinus Syndrome,Sick Sinus Syndrome,32,心律失常英文版文档课件,33,Premature Contraction,Concept: originated in the sinoatrial node other than the issue of ectopic pacemaker excitement in advance, also known as premature .,Mechanisms: reentry excited; triggered activity; ectopic pacemaker increased excitability .,Site: atrial, atrioventricular junction, ventricular,Premature ContractionConcept:,34,Coupling interval,Interval from ectopic beat to pre-normal beat,Atrial premature contraction: beginning of ectopic P wave to pre-normal P wave,Ventricular premature contraction: beginning of ectopic QRS wave to pre-normal QRS wave,Coupling intervalInterval from,35,心律失常英文版文档课件,36,Compensatory pause,the sum of the pre- and postextrasystolic PP/RR,intervals (the long interval after ectopic instead of sinus),Compensatory pausethe sum of,37,Inserted premature contraction,premature beat Insert between two adjacent normal sinus beat,Without compensatory pause,Inserted premature contraction,38,Uniformed premature contraction,the same ectopic pacemaker,the same coupling interval and formation,Uniformed premature contractio,39,Multiformed premature contraction,more than two forms appear in the same lead,the different coupling interval and formation,Multiformed premature contract,40,Frequent premature contraction,Bigeminy :,1normal+1,premature,3,Trigeminy:,2normal+1 premature,1normal+2 premature,Frequent premature contraction,41,1.Preamature ventricular contraction,Ventricular premature contraction are characterized by wide(QRS,0.12s), bizarre QRS complexes,Premature QRS complex with no preceding related P wave,the T wave is opposite in direction to the major deflection of the QRS.,fully compensatory pause,1.Preamature ventricular contr,42,preamature ventricular contraction,There is a fully compensatory pause (i.e. the interval between conducted sinus beats that bracket the VPC equals two basic RR intervals.) .- Most commonly,VPCs are not conducted retrogradely to the atrium to reset the sinoatrial node. Thus they result in a fully compensatory pause,preamature ventricular contrac,43,心律失常英文版文档课件,44,心律失常英文版文档课件,45,VPCs may uniformed or multiformed,VPCs may uniformed or multif,46,Inserted VPCs,Inserted VPCs,47,2.Preamature atrial contraction, A premature P wave ,the contour of the P wave usually differs from the patient s normal complex ., followed by a prolonged PR interval (0.12s)., there is a less than fully compensatory pause .( the sum of the pre- and postextrasystolic PP intervals is less than the sum of two sinus PP intervals.),2.Preamature atrial contractio,48,atrial extrasystoles with,prolonged PR interval,atrial extrasystoles with prol,49,nonconducted atrial extrasystoles,nonconducted atrial extrasysto,50,QRS duration 0.,slurring(delta wave) on the upstroke of the QRS,Interval from ectopic beat to pre-normal beat,Sick Sinus Syndrome,Radiofrequace can cure them,pathologic:,Type A preexcitation syndrome,Thus they result in a fully compensatory pause,nonparoxysmal ventricular tachycardia range from 60-100bpm.,atrial extrasystoles with wide QRS,Depolarizing oscillations of membrane voltage induced by abnormal inward Na+ during earlier or later reporlarization, ie, After depolarization,Palpation is mainstream of symptom,secondary ST-T wave changes that are generally opposite to the major delta and QRS vectors.,(2) Second-degree AVB,Type A preexcitation syndrome,The escape rhythm may arise from junctional area, in which case its rate will tipically be 40-60bpm, or it may arise from ventricular area with a rate of 20-40bpm.,Conductivity,(2) Second-degree AVB,atrial extrasystoles with wide QRS,QRS duration 0.atrial extrasy,51,3.preamature junctional contraction,Premature retrograde P wave,P waves inverted in leads ,III,and aVF,P wave may be observed after the QRS complex or before the QRS complex,or may not seen,，,normal-appearing QRS complexes,Most of them with complete compensatory pause,3.preamature junctional contra,52,心律失常英文版文档课件,53,心律失常英文版文档课件,54,Ectopic tachycardia,Excitability,Automaticity,Reentry,Include atrial,junctional,ventricular,Ectopic tachycardiaExcitabilit,55,1.Paroxysmal Supraventricular,Tachycardia(PSVT),1.The heart rate may be 160250 beats /min (usually 160220beats /min )and is perfectly regular .,2.Usually sudden onset and offset.,1.Paroxysmal Supraventricular,56,3.The P wave usually differs in contour from sinus beats ,may occur just before just after , or within the QRS.,4.QRS complexes are narrow. (or wide QRS-there is aberrant conduction),3.The P wave usually differs i,57,心律失常英文版文档课件,58,Mechanism of paroxysmal supraventricular tachycardia,AV node reentry is majority of mechanism,Mechanism of paroxysmal suprav,59,ECG of AVNRT,Tachycardia of narrowing QRS,P wave is inverted,in avF,RP interval,70 ms,P wave in QRS end,AV node reentry is majority of mechanism,ECG of AVNRT,60,Mechanism of paroxysmal supraventricular tachycardia,AV reentry is majority of mechanism,Mechanism of paroxysmal suprav,61,ECG of AVRT,Tachycardia of narrowing QRS,P wave is inverted,in avF,RP interval 70 ms,P wave in ST segment,AV reentry (bypass retrograde)is majority of mechanism,ECG of AVRT,62,Supraventricular paroxysmal tachycardia,Most without organic heart disease, common seen,Attack with sudden initiation and termination, maintaining short for minutes or long for hours. Palpation is mainstream of symptom,Hypotension,Good reaction to treatment, e.g. vagal maneuvers, antiarrhythmics. Radiofrequace can cure them,Supraventricular paroxysmal ta,63,2.Ventricular Tachycardia,（,VT,）,Three or more consecutive ventricular premature beats .,wide(QRS,0.12s), bizarre QRS complexes, the T wave is opposite in direction to the major deflection of the QRS .,The usual rate is 140200 beats /min and is moderately regular but less so than atrial tachycardia .,2.Ventricular Tachycardia（VT）T,64,suddenly onset;,capture beatswhere a P wave is followed by a normal QRS.,fusion beats.,occasionally find P wave,but frequency of P is less than QRS,no ralationship between P and QRS wave.,suddenly onset;,65,心律失常英文版文档课件,66,Features of VT,Often with organic diseases, inducing hemodynamics deterioration causing remarkable symptoms,Both sustained and non-sustained VT seen in clinical,It should be stopped as soon as possible(with antiarrhythmics or DC cardioversion),Varapamil, adenosine, -blocker are effective for some specific VT,Features of VT,67,3.Nonparoxysmal Tachycardia,The onset of nonparoxysmal tachycardia is usually gradual, with a warm-up period prior to stabilization of the rate.,nonparoxysmal junctional tachycardia range from 70-130bpm,nonparoxysmal ventricular tachycardia range from 60-100bpm.,3.Nonparoxysmal Tachycardia,68,Mechanism of nonparoxysmal tachycardia,Include: supraventricular,ventricular,Mechanism:,excitability and automaticity,of,ectopic pace point,Often with organic diseases,Mechanism of nonparoxysmal tac,69,4.Torsade de pointes(TDP),ECG of TDP,A forms of ventricular tachycardia in which QRS morphology twists around the baseline , may occur spontaneously,4.Torsade de pointes(TDP)ECG o,70,心律失常英文版文档课件,71,Features,Congenital (recurrent syncope, deafness, long QT, i.e long QT syndrome),Acquired (drugs e.g. quinidine, electrolyte disturbance-hypokalemia or hypomagnesemia., high degree AVB, etc.), at least 80% is acquired in clinical,Long QT is common,TDP, most of it, terminating spontaneously,Features,72,Flutter and Fibrillation,Ectopic frequency exceed tachycadial frequency,Formation of the ring movement,Multiple micro-reentrant,Flutter and FibrillationEct,73,1.Atrial flutter,1.Atrial flutter,74,ECG of Atrial flutter,1.Regular sawtooth atrial flutter wave (F wave), appears in lead II, III, AVF, rates of 250350 beats/min;,2 transmission of every second ,third , or fourth impulse through the atrioventricular node to the,ventricles.ventricular response (AV ratio) is usually 2:1, sometimes 4:1 or irregular,.,3.narrow QRS complex.(unless there is coexistent bundle branch block),ECG of Atrial flutter1.Regula,75,心律失常英文版文档课件,76,Features of AFL,HR is usually around 150 bpm which represents AV ratio is 2:1,，,may having underlying diseases,Tiny and rapid jugular pulses can be seen with its rate beyond 300 bpm,Treatment,Features of AFL,77,Impure flutter(flutter-fibrillation),occurring at a rate faster than pure flutter,shows variability in the contour of the flutter waves and can represent dissimilar atrial rhythms.,Impure flutter(flutter-fibrill,78,2.Atrial fibrillation(AF),Features of ECG,No P wave, replaced by rapid, chaotic and tiny atrial beating with its rate in 350,600 bpm,Ventricle response is irregularly with normal QRS complex, but individual QRS complex may slightly different,ventricular response ranges 100-160bpm,can be slower or faster,.,2.Atrial fibrillation(AF)Feat,79,心律失常英文版文档课件,80,心律失常英文版文档课件,81,Features of AF,Very common with underlying diseases in majority cases.,There are characteristics of three “P” in clinical, i.e. paroxysmal, persistent and permanent AF,Symptoms severity depends on whether HR is too fast , or AF duration too long, or underlying heart disease too severe,Features of AFVery common wit,82,Difference between AF with mission and ventricular premature beat,Initial vector,QRS deformation characteristics,Coupling interval,Difference between AF with mis,83,3.Ventricular flutter,Ventricular flutter usually appears as a sine wave with a rate between 150 and 250 beats/min, without QRS-T waves.,3.Ventricular flutter,84,4.ventricular fibrillation,Ventricular fibrillation(VF) is recognized by grossly irregular undulations of varying amplitudes, contours, and rates.,200 and 500 beats/min, without QRS-T waves.,4.ventricular fibrillationVent,85,CONDUCTION DISTURBANCES,2.pathologic:,Site,Degree,Occurrence,3.abnormal pathway conduction:,preexcitation syndrome,CONDUCTION DISTURBANCES,86,1.Sinoatrial block (,SA block),1.Sinoatrial block (SA block,87,Sinoatrial block (,SA block),Classification of ECG,First degree SAB cant be seen on ECG,Third degree SAB cant be differentiated from sinus arrest,Second degree SAB is divided into two subtype, i.e. type I and type II second degree SAB,Symptoms and therapy are same as sinus arrest,Sinoatrial block (SA block)C,88,Type I Second degree SAB,Features of ECG,PP interval progressively shortens prior to the pause,PP interval before the pause it after the PP interval,The duration of the pause is 0.20s (old man 0.22s) with all atrial impulses conducted,.,(1)First-degree AVBPR interval,97,(2) Second-degree,AVB,Second-degree,AVB,Second-degree AVB,(2) Second-degree AVBSecond-de,98,type second degree AVB,Mobitz type ,Wenchebach block,the P wave appear regularly, the atrioventricular conduction time(PR interval) progressively lengthens , before the blocked QRS beat; Then PR interval shorten again and progressively lengthens, going round and round-,Wenckebach phenomenon,type second degree AVBMobit,99,Features of ECG,Progressive PR interval prolongation occurs, resulting in a nonconduction P wave( the pause), the duration of the pause is two basic RR cycles,RR interval progressively shortens,First PR interval after the pause is shortest, AV conduction ratios usually are 3:2 or 4:3,Features of ECG,100,心律失常英文版文档课件,101,心律失常英文版文档课件,102,Second-degree AVB,Mobitz type,Second-degree AVBMobitz type,103,Features of ECG,PR interval is usually normal and no change,P wave do not conduct suddenly or periodically, making the long pause,The long pause is multiples of basic cycles,Features of ECG,104,心律失常英文版文档课件,105,(3)Third-degree atrioventricular block,shows P wave and the R waves are independent from each other , P wave and the R waves are regular , but no supraventricular impulses are conducted to the ventricles. The atrial rate is always faster than the ventricular rate. The escape rhythm may arise from junctional area, in which case its rate will tipically be 40-60bpm, or it may arise from ventricular area with a rate of 20-40bpm.,(3)Third-degree atrioventricul,106,心律失常英文版文档课件,107,心