医、技学院(华盛顿医疗手册培训心律失常)

CardiacArrhythmiasJunJiangDepartmentofCardiologyMechanismsofArrhythmogenesisTACHYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrateexceeds100beatsperminute(bpm).ClassificationNarrow-ComplexTachyarrhythmia(QRS<120milliseconds):Wide-ComplexTachyarrhythmia(QRS≥120milliseconds):AtrialRe-entryatrialtachycardiaatrialfibrillationatrialflutterAtrio-VentricularRe-entryWolfParkinsonWhite

supraventriculartachycardiaVentricularRe-entryventriculartachycardiaAtrio-VentricularNodalRe-entry

supraventriculartachycardiaRe-entryCircuitsasEctopicFociandArrhythmiaGeneratorsHistoryPalpitations(suddenonsetortermination)Dyspnea,angina,lightheadednessorsyncopeanddecreasedlevelofconsciousnessBaselinesymptomsthatreflectpoorLVfunctiondyspneaonexertionOrthopneaparoxysmalnocturnaldyspnealowerextremityswellingHistoryoforganicheartdiseaseorendocrinopathyHistoryoffamilialorcongenitalcausesofarrhythmiashypertrophiccardiomyopathy(HCM)congenitallongQTsyndromeMedications:Criticaltoobtainacompletelist,includingover-the-counterandherbalmedicationsPhysicalExaminationSignsofclinicalstabilityorinstabilityvitalsignsmentalstatusperipheralperfusionFindingsoforganicheartdiseaseJVPpulmonaryralesperipheraledemaCardiacborderS3gallopmurmurPalpatethepulseandassessforrateandregularity.“Cannon”AwavesIfirregular,thensuggestiveofunderlyingAVdissociationandclueforVTIfregularin1:1ratiowithperipheralpulse,thensuggestiveofAVNRT,AVRT,orajunctionaltachycardiaDiagnosticTestingLaboratoriesSerumelectrolytescompletebloodcount(CBC)thyroidfunctiontestsatoxicologyscreenElectrocardiographyImagingChestradiographEchocardiogramCT,MRI,CAGContinuousambulatoryECGmonitoringIn-hospitaltelemetrymonitoringEventrecordersExerciseECGElectrophysiologystudy(EPS)Treatment

RhythmsfromtheSinusNodeNormalSinusRhythm(NSR)

SinusTachycardia:HR>100b/mCauses:Withdrawalofvagultone&Sympatheticstimulation(exercise,pain,orfight)Fever&inflammation

Hypovolemia

AnemaiHypoxiaHeartFailureorCardiogenicShock(bothrepresenthypoperfusionstates)HeartAttack(myocardialinfarctionorextensionofinfarction)Drugs(alcohol,nicotine,caffeine)

TherapytargetedattreatmentofunderlyingpathophysiologicprocessSupraventricularTachyarrhythmiasParoxysmalsupraventriculartachycardi(PSVT)PrevalenceandincidenceofPSVTare2.25per1,000AVNRT(60%)AVRT(30%)AtrialfibrillationAFisthemostcommonnarrow-complextachycardiaseenintheinpatientsettingAtrialflutterAFlcanoftenaccompanyAFandisdiagnosedone-tenthasoftenasAFbutistwiceasprevalentasthePSVTsAtrialtachycardiafarlesscommonJunctionaltachycardiaSinoatrialnodalreentranttachycardia(SANRT)TREATMENTAcutetreatmentofsymptomaticSVTshouldfollowtheACLSprotocolasbeforeAVnodalblockingagentsortechniquesManySVTscanbeterminatedAF,AFl,andsomeatrialtachycardiaswillpersistwithaslowingoftheventricularrateCorrectionofelectrolyteabnormalities(K+andMg+)UnderlyingetiologyChronictreatmentshouldbeaimedateitherpreventionofrecurrenceorpreventionofthecomplicationsRadiofrequencyablation(RFA)Successratesfrom85%to95%Comparedtoantiarrhythmictherapy,RFAimprovesqualityoflifeandismorecost-effectiveinthelongterm15AVNRTP’inleadI,II,V1-V3AVRTWPW-A4WPW-BAtrialFibrillationClassificationFirstoccurrence.Thespontaneousconversionrateis>60%ParoxysmalAF:<7daysandusually<48hoursinduration.PersistentAF:>7daysindurationorrequirecardioversionPermanentAF

MedicalmanagementRatecontrolofAFdiltiazem,verapamilβ-adrenergicblockersdigoxinPreventionofthromboembolicevents

RhythmcontrolPharmacologiccontrolElectricalcardioversionNonpharmacologicmethodsofrhythmcontrolincludecatheterorsurgicalablationClassificationofAnti-arrhythmicsStrokeRiskinPatientsWithNonvalvularAF23AFwithWPWthereisnopwave,indicatingthatitdidnotoriginateanywhereintheatria,butsincetheQRScomplexisstillthinandnormallooking,wecanconcludethatthebeatoriginatedsomewhereneartheAVjunction.Thebeatisthereforecalleda"junctional"ora“nodal”beatJunctionalEscapeBeatQRSisslightlydifferentbutstillnarrow,indicatingthatconductionthroughtheventricleisrelativelynormalRecognizingandNamingBeats&RhythmsVentricularTachyarrhythmiasGENERALPRINCIPLESVentriculartachyarrhythmiasshouldbeinitiallyapproachedwiththeassumptionthattheywillhaveamalignantcourseuntilprovenotherwiseCharacterizationofthearrhythmiainvolveshemodynamicstabilityDurationMorphologythepresenceorlackofunderlyingstructuralheartdiseaseUltimately,thischaracterizationwillaidindeterminingthepatient'sriskforsuddencardiacarrestandneedfordeviceorablation-basedtherapyDefinitionofVentricularTachyarrhythmiasNonsustainedVTThreeormoreconsecutiveventricularcomplexes(>100bpm)thatterminatesspontaneouslywithin30secondswithoutsignificanthemodynamicconsequencesorneedforinterventionSustainedmonomorphicVTTachycardiacomposedofventricularcomplexesofasingleQRSmorphologythatlastslongerthan30secondsorrequirescardioversionduetohemodynamiccompromise.PolymorphicVTischaracterizedbyanever-changingQRSmorphologyTdPistypicallyprecededbyaprolongedQTintervalinsinusrhythmPolymorphicVTisusuallyassociatedwithhemodynamiccollapseorinstabilityVFisassociatedwithdisorganizedmechanicalcontraction,hemodynamiccollapse,andsuddendeathSCDisdefinedasthedeaththatoccurswithin1houroftheonsetofsymptomsIntheUnitedStates,350,000casesofSCDoccurannuallyEtiologyVTassociatedwithstructuralheartdiseaseActiveischemiaorhistoryofinfarctNonischemiccardiomyopathyInfiltrativecardiomyopathies(sarcoid,hemochromatosis,amyloid)AdultswithpriorrepairofcongenitalheartdiseaseArrhythmogenicrightventriculardysplasiaorcardiomyopathyBundlebranchreentryVTVTintheabsenceofstructuralheartdiseaseInheritedionchannelopathies(Brugada,longQTsyndromes)CatecholaminergicpolymorphicVTIdiopathicVT(VOT)BrugadacriteriaRecognizingandNamingBeats&RhythmsNotesonV-tach:CausesofV-tach

PriorMI,CAD,dilatedcardiomyopathy,oritmaybeidiopathic(noknowncause)TypicalV-tachpatient

MIwithcomplications&extensivenecrosis,EF<40%,dwallmotion,v-aneurysm)V-tachcomplexesarelikelytobesimilarandtherhythmregularIrregularV-Tachrhythmsmaybeduetoto:breakthroughofatrialconductionatriamay“capture”theentirebeatbeatanatrialbeatmay“merge”withanectopicventricularbeat(fusionbeat)Fusionbeat-notep-waveinfrontofPVCandthePVCisnarrowerthantheotherPVC’s–thisindicatesthebeatisaproductofboththesinusnodeandanectopicventricularfocusCapturebeat-notethatthecomplexisnarrowenoughtosuggestnormalventricularconduction.Thisindicatesthatanatrialimpulsehasmadeitthroughandconductionthroughtheventriclesisrelativelynormal.TREATMENTDifferentiationofSVTwithaberrancyfromVTonthebasisofanalysisofthesurfaceECGiscriticalinthedeterminationofappropriateacuteandchronictherapyImmediateunsynchronizedDCcardioversionistheprimarytherapyforpulselessVTandVFNonpharmacologictherapyICDsRadiofrequencycatheterablationMedicationsVFthatisresistanttoexternaldefibrillationrequirestheadditionofIVantiarrhythmicagents.IVamiodaroneappearstobemoreeffectiveinincreasingsurvivalofVFwhenusedinconjunctionwithdefibrillationChronicantiarrhythmicdrugtherapyisindicatedforthetreatmentofrecurrentsymptomaticventriculararrhythmiasLAORAOBRADYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrate<60bpmCausesofBradycardiaIntrinsicCongenitaldiseaseIdiopathicdegeneration(aging)InfarctionorischemiaCardiomyopathyInfiltrativedisease:sarcoidosis,amyloidosisCollagenvasculardiseasesSurgicaltraumaInfectiousdiseaseExtrinsicAutonomicallymediated(NeurocardiogenicsyncopeCarotidsinushypersensitivity)Increasedvagaltone:coughing,vomiting,micturition,defecation,intubationDrugs:β-blockers,calciumchannelblockers,digoxin,antiarrhythmicagentsHypothyroidismHypothermiaNeurologicdisorders:increasedintracranialpressureElectrolyteimbalances:hyperkalemia,hypermagnesemiaHypercarbia/obstructivesleepapneaSepsisDIAGNOSISSTABLE:Isthepatienthemodynamicallyunstable?SYMPTOMS:Doesthepatienthavesymptomsanddothesymptomscorrelatewiththebradycardia?SHORT-TERM:Arethecircumstancessurroundingthearrhythmiareversibleortransient?SOURCE:Whereintheconductionsystemisthedysfunction?Hasthebradyarrhythmiabeencapturedonelectrocardiographicmonitoring?SCHEDULEAPACEMAKER:DoesthepatientrequireaPPM?

SinusBradycardia:HR<60b/mCauses:Increasedvagultone,decreasedsympatheticoutput,(endurancetraining)HypothyroidismHeartAttack(commonininferiorwallinfarc