医、技学院(华盛顿医疗手册培训-心律失常)课件

CardiacArrhythmiasJunJiangDepartmentofCardiologyCardiacArrhythmiasJunJiang1CardiacArrhythmiasJunJiangCa医、技学院(华盛顿医疗手册培训-心律失常)课件2医、技学院(华盛顿医疗手册培训-心律失常)课件2医、技学院(华盛顿医疗手册培训-心律失常)课件3医、技学院(华盛顿医疗手册培训-心律失常)课件3MechanismsofArrhythmogenesisMechanismsofArrhythmogenesis4MechanismsofArrhythmogenesisTACHYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrateexceeds100beatsperminute(bpm).ClassificationNarrow-ComplexTachyarrhythmia(QRS<120milliseconds):Wide-ComplexTachyarrhythmia(QRS≥120milliseconds):TACHYARRHYTHMIASDefinition5TACHYARRHYTHMIASDefinitionTACAtrialRe-entryatrialtachycardiaatrialfibrillationatrialflutterAtrio-VentricularRe-entryWolfParkinsonWhitesupraventriculartachycardiaVentricularRe-entryventriculartachycardiaAtrio-VentricularNodalRe-entrysupraventriculartachycardiaRe-entryCircuitsasEctopicFociandArrhythmiaGeneratorsAtrialRe-entryAtrio-Ventricul6AtrialRe-entryAtrio-VentriculHistoryPalpitations(suddenonsetortermination)Dyspnea,angina,lightheadednessorsyncopeanddecreasedlevelofconsciousnessBaselinesymptomsthatreflectpoorLVfunctiondyspneaonexertionOrthopneaparoxysmalnocturnaldyspnealowerextremityswellingHistoryoforganicheartdiseaseorendocrinopathyHistoryoffamilialorcongenitalcausesofarrhythmiashypertrophiccardiomyopathy(HCM)congenitallongQTsyndromeMedications:Criticaltoobtainacompletelist,includingover-the-counterandherbalmedicationsHistory7HistoryHistory7PhysicalExaminationSignsofclinicalstabilityorinstabilityvitalsignsmentalstatusperipheralperfusionFindingsoforganicheartdiseaseJVPpulmonaryralesperipheraledemaCardiacborderS3gallopmurmurPalpatethepulseandassessforrateandregularity.“Cannon”AwavesIfirregular,thensuggestiveofunderlyingAVdissociationandclueforVTIfregularin1:1ratiowithperipheralpulse,thensuggestiveofAVNRT,AVRT,orajunctionaltachycardiaPhysicalExamination8PhysicalExaminationPhysicalEDiagnosticTestingLaboratoriesSerumelectrolytescompletebloodcount(CBC)thyroidfunctiontestsatoxicologyscreenElectrocardiographyImagingChestradiographEchocardiogramCT,MRI,CAGContinuousambulatoryECGmonitoringIn-hospitaltelemetrymonitoringEventrecordersExerciseECGElectrophysiologystudy(EPS)DiagnosticTesting9DiagnosticTestingDiagnosticTTreatmentTreatment10TreatmentTreatment10

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RhythmsfromtheSinusNodeNormalSinusRhythm(NSR)

SinusTachycardia:HR>100b/mCauses:Withdrawalofvagultone&Sympatheticstimulation(exercise,pain,orfight)Fever&inflammationHypovolemiaAnemaiHypoxiaHeartFailureorCardiogenicShock(bothrepresenthypoperfusionstates)HeartAttack(myocardialinfarctionorextensionofinfarction)Drugs(alcohol,nicotine,caffeine)TherapytargetedattreatmentofunderlyingpathophysiologicprocessRhythmsfromtheSinusNodeNor12RhythmsfromtheSinusNodeNorSupraventricularTachyarrhythmiasParoxysmalsupraventriculartachycardi(PSVT)PrevalenceandincidenceofPSVTare2.25per1,000AVNRT(60%)AVRT(30%)AtrialfibrillationAFisthemostcommonnarrow-complextachycardiaseenintheinpatientsettingAtrialflutterAFlcanoftenaccompanyAFandisdiagnosedone-tenthasoftenasAFbutistwiceasprevalentasthePSVTsAtrialtachycardiafarlesscommonJunctionaltachycardiaSinoatrialnodalreentranttachycardia(SANRT)SupraventricularTachyarrhythm13SupraventricularTachyarrhythmTREATMENTAcutetreatmentofsymptomaticSVTshouldfollowtheACLSprotocolasbeforeAVnodalblockingagentsortechniquesManySVTscanbeterminatedAF,AFl,andsomeatrialtachycardiaswillpersistwithaslowingoftheventricularrateCorrectionofelectrolyteabnormalities(K+andMg+)UnderlyingetiologyChronictreatmentshouldbeaimedateitherpreventionofrecurrenceorpreventionofthecomplicationsRadiofrequencyablation(RFA)Successratesfrom85%to95%Comparedtoantiarrhythmictherapy,RFAimprovesqualityoflifeandismorecost-effectiveinthelongtermTREATMENT14TREATMENTTREATMENT1415AVNRTP’inleadI,II,V1-V315AVNRTP’inleadI,II,V1-V31515AVNRTP’inleadI,II,V1-V31AVRTAVRT16AVRTAVRT16WPW-A4WPW-A417WPW-A4WPW-A417WPW-BWPW-B18WPW-BWPW-B18AtrialFibrillationClassificationFirstoccurrence.Thespontaneousconversionrateis>60%ParoxysmalAF:<7daysandusually<48hoursinduration.PersistentAF:>7daysindurationorrequirecardioversionPermanentAF

MedicalmanagementRatecontrolofAFdiltiazem,verapamilβ-adrenergicblockersdigoxinPreventionofthromboembolicevents

RhythmcontrolPharmacologiccontrolElectricalcardioversionNonpharmacologicmethodsofrhythmcontrolincludecatheterorsurgicalablationAtrialFibrillation19AtrialFibrillationAtrialFibrClassificationofAnti-arrhythmicsClassificationofAnti-arrhyth20ClassificationofAnti-arrhyth医、技学院(华盛顿医疗手册培训-心律失常)课件21医、技学院(华盛顿医疗手册培训-心律失常)课件21StrokeRiskinPatientsWithNonvalvularAFStrokeRiskinPatientsWithN22StrokeRiskinPatientsWithN23AFwithWPW23AFwithWPW2323AFwithWPW23AFwithWPW23医、技学院(华盛顿医疗手册培训-心律失常)课件24医、技学院(华盛顿医疗手册培训-心律失常)课件24医、技学院(华盛顿医疗手册培训-心律失常)课件25医、技学院(华盛顿医疗手册培训-心律失常)课件25thereisnopwave,indicatingthatitdidnotoriginateanywhereintheatria,butsincetheQRScomplexisstillthinandnormallooking,wecanconcludethatthebeatoriginatedsomewhereneartheAVjunction.Thebeatisthereforecalleda"junctional"ora“nodal”beatJunctionalEscapeBeatQRSisslightlydifferentbutstillnarrow,indicatingthatconductionthroughtheventricleisrelativelynormalRecognizingandNamingBeats&Rhythmsthereisnopwave,indicating26thereisnopwave,indicatingVentricularTachyarrhythmiasGENERALPRINCIPLESVentriculartachyarrhythmiasshouldbeinitiallyapproachedwiththeassumptionthattheywillhaveamalignantcourseuntilprovenotherwiseCharacterizationofthearrhythmiainvolveshemodynamicstabilityDurationMorphologythepresenceorlackofunderlyingstructuralheartdiseaseUltimately,thischaracterizationwillaidindeterminingthepatient'sriskforsuddencardiacarrestandneedfordeviceorablation-basedtherapyVentricularTachyarrhythmias27VentricularTachyarrhythmiasVeDefinitionofVentricularTachyarrhythmiasNonsustainedVTThreeormoreconsecutiveventricularcomplexes(>100bpm)thatterminatesspontaneouslywithin30secondswithoutsignificanthemodynamicconsequencesorneedforinterventionSustainedmonomorphicVTTachycardiacomposedofventricularcomplexesofasingleQRSmorphologythatlastslongerthan30secondsorrequirescardioversionduetohemodynamiccompromise.PolymorphicVTischaracterizedbyanever-changingQRSmorphologyTdPistypicallyprecededbyaprolongedQTintervalinsinusrhythmPolymorphicVTisusuallyassociatedwithhemodynamiccollapseorinstabilityVFisassociatedwithdisorganizedmechanicalcontraction,hemodynamiccollapse,andsuddendeathSCDisdefinedasthedeaththatoccurswithin1houroftheonsetofsymptomsIntheUnitedStates,350,000casesofSCDoccurannuallyDefinitionofVentricularTach28DefinitionofVentricularTach医、技学院(华盛顿医疗手册培训-心律失常)课件29医、技学院(华盛顿医疗手册培训-心律失常)课件29医、技学院(华盛顿医疗手册培训-心律失常)课件30医、技学院(华盛顿医疗手册培训-心律失常)课件30医、技学院(华盛顿医疗手册培训-心律失常)课件31医、技学院(华盛顿医疗手册培训-心律失常)课件31EtiologyVTassociatedwithstructuralheartdiseaseActiveischemiaorhistoryofinfarctNonischemiccardiomyopathyInfiltrativecardiomyopathies(sarcoid,hemochromatosis,amyloid)AdultswithpriorrepairofcongenitalheartdiseaseArrhythmogenicrightventriculardysplasiaorcardiomyopathyBundlebranchreentryVTVTintheabsenceofstructuralheartdiseaseInheritedionchannelopathies(Brugada,longQTsyndromes)CatecholaminergicpolymorphicVTIdiopathicVT(VOT)Etiology32EtiologyEtiology32BrugadacriteriaBrugadacriteria33BrugadacriteriaBrugadacriteRecognizingandNamingBeats&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.RecognizingandNamingBeats&34RecognizingandNamingBeats&医、技学院(华盛顿医疗手册培训-心律失常)课件35医、技学院(华盛顿医疗手册培训-心律失常)课件35医、技学院(华盛顿医疗手册培训-心律失常)课件36医、技学院(华盛顿医疗手册培训-心律失常)课件36TREATMENTDifferentiationofSVTwithaberrancyfromVTonthebasisofanalysisofthesurfaceECGiscriticalinthedeterminationofappropriateacuteandchronictherapyImmediateunsynchronizedDCcardioversionistheprimarytherapyforpulselessVTandVFNonpharmacologictherapyICDsRadiofrequencycatheterablationMedicationsVFthatisresistanttoexternaldefibrillationrequirestheadditionofIVantiarrhythmicagents.IVamiodaroneappearstobemoreeffectiveinincreasingsurvivalofVFwhenusedinconjunctionwithdefibrillationChronicantiarrhythmicdrugtherapyisindicatedforthetreatmentofrecurrentsymptomaticventriculararrhythmiasTREATMENT37TREATMENTTREATMENT37医、技学院(华盛顿医疗手册培训-心律失常)课件38医、技学院(华盛顿医疗手册培训-心律失常)课件38LAORAOLAORAO39LAORAOLAORAO39BRADYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrate<60bpmCausesofBradycardiaIntrinsicCongenitaldiseaseIdiopathicdegeneration(aging)InfarctionorischemiaCardiomyopathyInfiltrativedisease:sarcoidosis,amyloidosisCollagenvasculardiseasesSurgicaltraumaInfectiousdiseaseExtrinsicAutonomicallymediated(NeurocardiogenicsyncopeCarotidsinushypersensitivity)Increasedvagaltone:coughing,vomiting,micturition,defecation,intubationDrugs:β-blockers,calciumchannelblockers,digoxin,antiarrhythmicagentsHypothyroidismHypothermiaNeurologicdisorders:increasedintracranialpressureElectrolyteimbalances:hyperkalemia,hypermagnesemiaHypercarbia/obstructivesleepapneaSepsisBRADYARRHYTHMIASDefinition40BRADYARRHYTHMIASDefinitionBRADIAGNOSISSTABLE:Isthepatienthemodynamicallyunstable?SYMPTOMS:Doesthepatienthavesymptomsanddothesymptomscorrelatewiththebradycardia?SHORT-TERM:Arethecircumstancessurroundingthearrhythmiareversibleortransient?SOURCE:Whereintheconductionsystemisthedysfunction?Hasthebradyarrhythmiabeencapturedonelectrocardiographicmonitoring?SCHEDULEAPACEMAKER:DoesthepatientrequireaPPM?DIAGNOSIS41DIAGNOSISDIAGNOSIS41

SinusBradycardia:HR<60b/mCauses:Increasedvagultone,decreasedsympatheticoutput,(endurancetraining)HypothyroidismHeartAttack(commonininferiorwallinfarction)Vasovagulsyncope(peoplepassingoutwhentheygettheirblooddrawn)Depression

SickSinusSyndrome:Failureoftheheart’spacemakingcapabilitiesCauses:Idiopathic(nocausecanbefound)Cardiomyopathy(diseaseandmalformationofthecardiacmuscle)ImplicationsandAssociationsAssociatedwithTachycardia/BradycardiaarrhythmiasIsoftenfollowedbyanectopic“escapebeat”oranectopic“rhythm”SinusBradycardia:HR<60b42SinusBradycardia:HR<60b医、技学院(华盛顿医疗手册培训-心律失常)课件43医、技学院(华盛顿医疗手册培训-心律失常)课件43医、技学院(华盛顿医疗手册培训-心律失常)课件44医、技学院(华盛顿医疗手册培训-心律失常)课件44医、技学院(华盛顿医疗手册培训-心律失常)课件45医、技学院(华盛顿医疗手册培训-心律失常)课件45医、技学院(华盛顿医疗手册培训-心律失常)课件46医、技学院(华盛顿医疗手册培训-心律失常)课件46医、技学院(华盛顿医疗手册培训-心律失常)课件47医、技学院(华盛顿医疗手册培训-心律失常)课件47医、技学院(华盛顿医疗手册培训-心律失常)课件48医、技学院(华盛顿医疗手册培训-心律失常)课件48医、技学院(华盛顿医疗手册培训-心律失常)课件49医、技学院(华盛顿医疗手册培训-心律失常)课件49医、技学院(华盛顿医疗手册培训-心律失常)课件50医、技学院(华盛顿医疗手册培训-心律失常)课件50医、技学院(华盛顿医疗手册培训-心律失常)课件51医、技学院(华盛顿医疗手册培训-心律失常)课件51医、技学院(华盛顿医疗手册培训-心律失常)课件52医、技学院(华盛顿医疗手册培训-心律失常)课件52actuallya"retrogradep-wavemaysometimesbeseenontherighthandsideofbeatsthatoriginateintheventricles,indicatingthatdepolarizationhasspreadbackupthroughtheatriafromtheventriclesQRSiswideandmuchdifferent("bizarre")lookingthanthenormalbeats.Thisindicatesthatthebeatoriginatedsomewhereintheventriclesandconsequently,conductionthroughtheventriclesdidnottakeplacethroughnormalpathways.Itisthereforecalleda“ventricular”beatVentricularEscapeBeatthereisnopwave,indicatingthatthebeatdidnotoriginateanywhereintheatriaRecognizingandNamingBeats&Rhythmsactuallya"retrogradep-wave53actuallya"retrogradep-waveTHANKSTHANKS54THANKSTHANKS54CardiacArrhythmiasJunJiangDepartmentofCardiologyCardiacArrhythmiasJunJiang55CardiacArrhythmiasJunJiangCa医、技学院(华盛顿医疗手册培训-心律失常)课件56医、技学院(华盛顿医疗手册培训-心律失常)课件56医、技学院(华盛顿医疗手册培训-心律失常)课件57医、技学院(华盛顿医疗手册培训-心律失常)课件57MechanismsofArrhythmogenesisMechanismsofArrhythmogenesis58MechanismsofArrhythmogenesisTACHYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrateexceeds100beatsperminute(bpm).ClassificationNarrow-ComplexTachyarrhythmia(QRS<120milliseconds):Wide-ComplexTachyarrhythmia(QRS≥120milliseconds):TACHYARRHYTHMIASDefinition59TACHYARRHYTHMIASDefinitionTACAtrialRe-entryatrialtachycardiaatrialfibrillationatrialflutterAtrio-VentricularRe-entryWolfParkinsonWhitesupraventriculartachycardiaVentricularRe-entryventriculartachycardiaAtrio-VentricularNodalRe-entrysupraventriculartachycardiaRe-entryCircuitsasEctopicFociandArrhythmiaGeneratorsAtrialRe-entryAtrio-Ventricul60AtrialRe-entryAtrio-VentriculHistoryPalpitations(suddenonsetortermination)Dyspnea,angina,lightheadednessorsyncopeanddecreasedlevelofconsciousnessBaselinesymptomsthatreflectpoorLVfunctiondyspneaonexertionOrthopneaparoxysmalnocturnaldyspnealowerextremityswellingHistoryoforganicheartdiseaseorendocrinopathyHistoryoffamilialorcongenitalcausesofarrhythmiashypertrophiccardiomyopathy(HCM)congenitallongQTsyndromeMedications:Criticaltoobtainacompletelist,includingover-the-counterandherbalmedicationsHistory61HistoryHistory61PhysicalExaminationSignsofclinicalstabilityorinstabilityvitalsignsmentalstatusperipheralperfusionFindingsoforganicheartdiseaseJVPpulmonaryralesperipheraledemaCardiacborderS3gallopmurmurPalpatethepulseandassessforrateandregularity.“Cannon”AwavesIfirregular,thensuggestiveofunderlyingAVdissociationandclueforVTIfregularin1:1ratiowithperipheralpulse,thensuggestiveofAVNRT,AVRT,orajunctionaltachycardiaPhysicalExamination62PhysicalExaminationPhysicalEDiagnosticTestingLaboratoriesSerumelectrolytescompletebloodcount(CBC)thyroidfunctiontestsatoxicologyscreenElectrocardiographyImagingChestradiographEchocardiogramCT,MRI,CAGContinuousambulatoryECGmonitoringIn-hospitaltelemetrymonitoringEventrecordersExerciseECGElectrophysiologystudy(EPS)DiagnosticTesting63DiagnosticTestingDiagnosticTTreatmentTreatment64TreatmentTreatment64

65

RhythmsfromtheSinusNodeNormalSinusRhythm(NSR)

SinusTachycardia:HR>100b/mCauses:Withdrawalofvagultone&Sympatheticstimulation(exercise,pain,orfight)Fever&inflammationHypovolemiaAnemaiHypoxiaHeartFailureorCardiogenicShock(bothrepresenthypoperfusionstates)HeartAttack(myocardialinfarctionorextensionofinfarction)Drugs(alcohol,nicotine,caffeine)TherapytargetedattreatmentofunderlyingpathophysiologicprocessRhythmsfromtheSinusNodeNor66RhythmsfromtheSinusNodeNorSupraventricularTachyarrhythmiasParoxysmalsupraventriculartachycardi(PSVT)PrevalenceandincidenceofPSVTare2.25per1,000AVNRT(60%)AVRT(30%)AtrialfibrillationAFisthemostcommonnarrow-complextachycardiaseenintheinpatientsettingAtrialflutterAFlcanoftenaccompanyAFandisdiagnosedone-tenthasoftenasAFbutistwiceasprevalentasthePSVTsAtrialtachycardiafarlesscommonJunctionaltachycardiaSinoatrialnodalreentranttachycardia(SANRT)SupraventricularTachyarrhythm67SupraventricularTachyarrhythmTREATMENTAcutetreatmentofsymptomaticSVTshouldfollowtheACLSprotocolasbeforeAVnodalblockingagentsortechniquesManySVTscanbeterminatedAF,AFl,andsomeatrialtachycardiaswillpersistwithaslowingoftheventricularrateCorrectionofelectrolyteabnormalities(K+andMg+)UnderlyingetiologyChronictreatmentshouldbeaimedateitherpreventionofrecurrenceorpreventionofthecomplicationsRadiofrequencyablation(RFA)Successratesfrom85%to95%Comparedtoantiarrhythmictherapy,RFAimprovesqualityoflifeandismorecost-effectiveinthelongtermTREATMENT68TREATMENTTREATMENT6869AVNRTP’inleadI,II,V1-V315AVNRTP’inleadI,II,V1-V36969AVNRTP’inleadI,II,V1-V31AVRTAVRT70AVRTAVRT70WPW-A4WPW-A471WPW-A4WPW-A471WPW-BWPW-B72WPW-BWPW-B72AtrialFibrillationClassificationFirstoccurrence.Thespontaneousconversionrateis>60%ParoxysmalAF:<7daysandusually<48hoursinduration.PersistentAF:>7daysindurationorrequirecardioversionPermanentAF

MedicalmanagementRatecontrolofAFdiltiazem,verapamilβ-adrenergicblockersdigoxinPreventionofthromboembolicevents

RhythmcontrolPharmacologiccontrolElectricalcardioversionNonpharmacologicmethodsofrhythmcontrolincludecatheterorsurgicalablationAtrialFibrillation73AtrialFibrillationAtrialFibrClassificationofAnti-arrhythmicsClassificationofAnti-arrhyth74ClassificationofAnti-arrhyth医、技学院(华盛顿医疗手册培训-心律失常)课件75医、技学院(华盛顿医疗手册培训-心律失常)课件75StrokeRiskinPatientsWithNonvalvularAFStrokeRiskinPatientsWithN76StrokeRiskinPatientsWithN77AFwithWPW23AFwithWPW7777AFwithWPW23AFwithWPW77医、技学院(华盛顿医疗手册培训-心律失常)课件78医、技学院(华盛顿医疗手册培训-心律失常)课件78医、技学院(华盛顿医疗手册培训-心律失常)课件79医、技学院(华盛顿医疗手册培训-心律失常)课件79thereisnopwave,indicatingthatitdidnotoriginateanywhereintheatria,butsincetheQRScomplexisstillthinandnormallooking,wecanconcludethatthebeatoriginatedsomewhereneartheAVjunction.Thebeatisthereforecalleda"junctional"ora“nodal”beatJunctionalEscapeBeatQRSisslightlydifferentbutstillnarrow,indicatingthatconductionthroughtheventricleisrelativelynormalRecognizingandNamingBeats&Rhythmsthereisnopwave,indicating80thereisnopwave,indicatingVentricularTachyarrhythmiasGENERALPRINCIPLESVentriculartachyarrhythmiasshouldbeinitiallyapproachedwiththeassumptionthattheywillhaveamalignantcourseuntilprovenotherwiseCharacterizationofthearrhythmiainvolveshemodynamicstabilityDurationMorphologythepresenceorlackofunderlyingstructuralheartdiseaseUltimately,thischaracterizationwillaidindeterminingthepatient'sriskforsuddencardiacarrestandneedfordeviceorablation-basedtherapyVentricularTachyarrhythmias81VentricularTachyarrhythmiasVeDefinitionofVentricularTachyarrhythmiasNonsustainedVTThreeormoreconsecutiveventricularcomplexes(>100bpm)thatterminatesspontaneouslywithin30secondswithoutsignificanthemodynamicconsequencesorneedforinterventionSustainedmonomorphicVTTachycardiacomposedofventricularcomplexesofasingleQRSmorphologythatlastslongerthan30secondsorrequirescardioversionduetohemodynamiccompromise.PolymorphicVTischaracterizedbyanever-changingQRSmorphologyTdPistypicallyprecededbyaprolongedQTintervalinsinusrhythmPolymorphicVTisusuallyassociatedwithhemodynamiccollapseorinstabilityVFisassociatedwithdisorganizedmechanicalcontraction,hemodynamiccollapse,andsuddendeathSCDisdefinedasthedeaththatoccurswithin1houroftheonsetofsymptomsIntheUnitedStates,350,000casesofSCDoccurannuallyDefinitionofVentricularTach82DefinitionofVentricularTach医、技学院(华盛顿医疗手册培训-心律失常)课件83医、技学院(华盛顿医疗手册培训-心律失常)课件83医、技学院(华盛顿医疗手册培训-心律失常)课件84医、技学院(华盛顿医疗手册培训-心律失常)课件84医、技学院(华盛顿医疗手册培训-心律失常)课件85医、技学院(华盛顿医疗手册培训-心律失常)课件85EtiologyVTassociatedwithstructuralheartdiseaseActiveischemiaorhistoryofinfarctNonischemiccardiomyopathyInfiltrativecardiomyopathies(sarcoid,hemochromatosis,amyloid)AdultswithpriorrepairofcongenitalheartdiseaseArrhythmogenicrightventriculardysplasiaorcardiomyopathyBundlebranchreentryVTVTintheabsenceofstructuralheartdiseaseInheritedionchannelopathies(Brugada,longQTsyndromes)CatecholaminergicpolymorphicVTIdiopathicVT(VOT)Etiology86EtiologyEtiology86BrugadacriteriaBrugadacriteria87BrugadacriteriaBrugadacriteRecognizingandNamingBeats&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.RecognizingandNamingBeats&88RecognizingandNamingBeats&医、技学院(华盛顿医疗手册培训-心律失常)课件89医、技学院(华盛顿医疗手册培训-心律失常)课件89医、技学院(华盛顿医疗手册培训-心律失常)课件90医、技学院(华盛顿医疗手册培训-心律失常)课件90TREATMENTDifferentiationofSVTwithaberrancyfromVTonthebasisofanalysisofthesurfaceECGiscriticalinthedeterminationofappropriateacuteandchronictherapyImmediateunsynchronizedDCcardioversionistheprimarytherapyforpulselessVTandVFNonpharmacologictherapyICDsRadiofrequencycatheterablationMedicationsVFthatisresistanttoexternaldefibrillationrequirestheadditionofIVantiarrhythmicagents.IVamiodaroneappearstobemoreeffectiveinincreasingsurvivalofVFwhenusedinconjunctionwithdefibrillationChronicantiarrhythmicdrugtherapyisindicatedforthetreatmentofrecurrentsymptomaticventriculararrhythmiasTREATMENT91TREATMENTTREATMENT91医、技学院(华盛顿医疗手册培训-心律失常)课件92医、技学院(华盛顿医疗手册培训-心律失常)课件92LAORAOLAORAO93LAORAOLAORAO93BRADYARRHYTHMIASDefinitionCardiacrhythmswhoseventricularrate<60bpmCausesofBradycardiaIntrinsicCongenitaldiseaseIdiopathicdegeneration(aging)InfarctionorischemiaCardiomyopathyInfiltrativedisease:sarcoidosis,amyloidosisCollagenvasculardiseasesSurgicaltraumaInfectiousdiseaseExtrinsicAutonomicallymediated(NeurocardiogenicsyncopeCarotidsinushypersensitivity)Increasedvagaltone:coughing,vomiting,micturition,defecation,intubationDrugs:β-blockers,calci