Jiaqi Zhao
Department of Cardiology, Affiliated
Hospital of
Ji ning Medical College, Ji ning
Part 1.Overview
Cardiac Arrhythmia :abnormalities of cardiac
impulse(frequency 频率、 rhythm 节律、 the
origin 起源部位、 conduction velocity 传导速度
and order of excitement 激动次序 of cardiac
impulse )。
分类( Classification ):Disorders of
impulse formation (冲动形成异常) and/or
Abnormalities of impulse
conduction( 冲动传导异常 ) 。
一、 Disorders of impulse formation or automaticity
complex tachycardias
Reentry
Sinus brady. P P P P
→ Sinus arrest
→ V. escape P
rhythm
Failure of V.
escape
rhythm
→ Asystole
Tachycardia-Bradycardia
(Form of “Sick Sinus”) Syndrome
Atrial
Flutter
Presenting Features
– May be asymptomatic
– Vagally mediated AF
Commoner at night; when having a large meal
– Alcohol binges
Atrial Fibrillation Epidemiology
Affects 2 to 4% of population
Increases to 5 to 10 % of patients over 80
Associated with 2-fold increased risk of
death
Risk of thromboembolism is approximately
5% per year but may be as high as 20% in
high risk groups not anticoagulated
Atrial Fibrillation
Associated conditions
– Thyrotoxicosis
– Hypertension
– Heart failure
– Valve disease
Drugs
– Adenosine
– Digoxin
Miscellaneous
– Chest infection/ Surgery/ Cholecystitis etc
Mechanism of Atrial
Fibrillation
Multiple reentrant wavelets moving between right
and left atrium
May be initiated by rapidly firing automatic foci
found commonly in pulmonary veins, SVC, and
coronary sinus.
Factors that shorten atrial refractoriness and slow
conduction velocity perpetuate atrial fibrillation
Factors that lengthen atrial refractoriness
(antiarrhythmic drugs ) aid in termination
Atrial Fibrillation
Symptoms
– Tend to be due to the ventricular response as opposed to
AF
Exceptions
– Mitral stenosis
– Pulmonary hypertension
– Palpitations
– Increased heart rate
– Lethargy
– Dyspnoea
– Cardiac chest pain
– Features of TIA/ Stroke
Acute Management of Atrial
Fibrillation
Focuses on Rate control
Patient with atrial fibrillation may undergo DC
cardioversion or pharmacologic conversion if less
than 48 hours duration or following TEE on
Heparin without evidence of left atrial thrombus.
Following cardioversion the patient should be kept
anticoagulated for 4 weeks with goal INR of 2 to 3
until atrial function normalizes. ( warfarin )
Management of Atrial Fibrillation
Aimed at symptom relief by rate and
rhythm control
Aimed at reducing risk of
thromboembolism by anticoagulation
Preventing tachycardia mediated
cardiomyopathy (a progressive, reversible
rate-induced form of LV dysfunction)
Acute Management of Atrial
Fibrillation
50% of patients with paroxysmal atrial
fibrillation will spontaneously convert within
24 hours
Digoxin used heavily in the past for
prevention and conversion of atrial fibrillation
is ineffective at either and may be
profibrillatory as it decreases the atrial
refractory period
Acute Management of Atrial
Fibrillation
Rate control may be attained with calcium channel
blockers or beta blockers in patients with normal
L.V. function.
Calcium channel blockers may be used cautiously in
patients with depressed LV function but are
associated with increased mortality in the long term.
Beta blockers should be avoided in acutely
decompensated CHF patients with atrial fibrillation
Atrial Fibrillation and
Depressed L.V. Function
Digoxin and amiodarone may be of effective in
patients with LV dysfunction and decompensated
congestive heart failure to slow ventricular
response.
Digoxin alone is rarely effective when the patient
is sympathetically drive
Avoid high dose digoxin with amiodarone as
digoxin levels increase 2-fold with amiodarone
Chronic Management of Atrial
Fibrillation
Patientswith atrial fibrillation, paroxysmal or
sustained should be anticoagulated if any of the
following risk factors for stroke are present:
– diabetes – hypertension
– valvular disease – congestive heart failure
– hyperthyroidism – age greater than 65
– Prior CVA
Chronic Management of Atrial
Fibrillation
Rate control with Maintenance of sinus
calcium channel is similar with class I
blockers, beta blockers and class III drugs
or combination with approaching 50%
digoxin.
recurrence at 1 year
Digoxin may be used in
Recurrence of atrial
bed bound patients but is
easily overcome with fibrillation 80% at 1
sympathetic stimulation. year without treatment
Chronic management of Atrial
Fibrillation
ClassIII agents may have Class IC agents safe in
improved efficacy absence of structural
– Amiodarone heart disease.
pulmonary toxicity
Few side effects
thyroid
NSR AVNRT
AVNRT
AVNRT
五 . 预激综合征
Wolf-Parkinson-White Syndrome
Second electrical connection
exists between the atria and
ventricles (accessory
pathway)
– Resemble atrial tissue
– Results in
a short PR
Delta wave (pre-excitation)
Family history
– Higher prevalence in the children; especially if
multiple accessory pathways
Examination
– Frequently normal
Clinical findings
May be asymptomatic
About 1.8% of the patients take place tachycardia
– 80%AVRT
– 15%-30% Atrial fibrillation
– 5% Atrial flutter
AVRT Antegradely
( Wide QRS)
Retrogradely 95%
Common cause of
narrow complex
Tachycardias
Clinical findings
Sudden onset/ offset( 突发突止)
Patient may feel an ectopic beat to initiate the
arrhythmia
Vagal maneuvres (刺激迷走 N ) to terminate the
arrhythmia
Anxiety/ breathless/ palpitations
– Syncope (due to high rate or due to transient asystole at
termination)
Sudden death /HF due to atrial fibrillation with
rapid ventricular conduction
WPW syndrome ECG
Accelerated AV conduction PR <120 msec
Prolonged QRS > 120 msec
Abnormal slurred upstroke of QRS ( delta
wave)
ST-T
Abnormal depolarization and repolarization
may lead to pseudoinfarction pattern
2 type : A and B
PR interval is short Rate = 100 bpm
(80 to 90 msec)
QRS is wide
(over 120 msec)
PR interval is short
(80 to 90 msec)
预激综合征合并房颤
[ 治疗 ]
预激本身不需治疗,
并发心动过速且发作频繁伴有明显症
状者,应给予治疗。方法:药物、导
管消融术、外科手术。
若发作正向房室折返性心动过
速,可参照房室结折返性心动过速处
理。
[治疗] 预激综合征患者发作房扑
与房颤时伴有晕厥或低血压,应立即施
行电复律。不能用西地兰、异搏定静推
经导管消融治疗预激综合征并
PSVT 应列为首选。
适应症:
1. 发作频繁者;
2. 并房颤或扑动,心室率极快者。
Part 5 Ventricular Arrhythmia
一 . 室性期前收缩( premature ventricular
beats ),是一种最常见的心律失常。
[ 病因 ] 正常人与各种心脏病患者均可发生室
性期前收缩。
心电图特点 :
①
提前出现的宽大畸形的 QRS 波,其
前无 P 波 ;
② ST 、 T 与主波方向相反 ;
③ 代偿间歇完全。
Compensatory (代偿间期)
[ 心电图检查 ]
1. 配对间期:室性期前收缩与其前面的窦性
搏动之间期。
2. 二联律是指每个窦性搏动后跟随一个室性
期前收缩;
3. 三联律是每两个正常搏动后出现一个室性
期前收缩。
4. 成对室性期前收缩:连续发生两个。
5. 连续三个或以上称室性心动过速。
[ 心电图检查 ]
6. 同一导联内,形态相同者为单形性
;不同者称多形或多源性期前收缩。
7. 间位性室早 : 室早恰巧插入两个窦
性搏动之间 , 不产生室早后停顿。
8. 室性并行心律 :
1) 配对间期不恒定 ;
2) 长短间期之间有最小公倍数 ;
3) 可产生室性融合波。
PVC Bigeminy (二联律)
PVC Couplet (成对)
Interpolated PVC( 间位)
PVC with R-on-T
PVC Triplet (室速)
[ 治疗 ]
如无明显症状,不必使用药物。
如症状明显,治疗以消除症状为目
的。药物宜选择 β 受体阻滞剂。
A 42 year old smoker presents to the ED with
palpitations. His blood pressure is 100/60. The
following rhythm strip is obtained . What is the next
appropriate step?
2 、应选择毒副反应较少的药物。
3 、单一药物治疗无效时,可联合应用 。
4 、抗心律失常药物亦可与埋藏式心室起搏
装置合用,治疗复发性心动过速。
三、根治 外科手术、导管消融术等亦
可成功应用于选择性病例。
Therapy for Ventricular
Tachycardia
Clinical condition of patient
– Unstable requires DC cardioversion
– Stable may be treated with Drugs or Cardioversion
Presence or absence of Left ventricular
dysfunction determines choice of pharmacologic
therapy
– Amiodarone 150 mg I.V. over 10 minutes may be RX
of choice maximum 1200gm/24 hours recommendation
一 . 加速性心室自主节
律
二、尖端扭转性室速 尖端扭转是多形性
室速的一个特殊类型。频率 200~250 次 / 分,振幅与波
峰呈周期性改变。 QT 间期通常超过 0.5s , U 波明显。
可进展为心室颤动和猝死。
本型室速的病因可为先天性、电解质紊乱、应用Ⅰ
A 或某些Ⅰ C 类药物、颅内病变及心动过缓等。
治疗:应努力寻找和去除导致 QT 间期延长的病
变和停用有关药物。首先给予静脉注射镁盐,异丙肾上
腺素或阿托品亦可应用。先天性长 QT 间期综合征应选
用 β 受体阻滞剂。
Torsades de Pointes
Polymorphic VT associated with long QT
– increased risk if QTC 500 msec or greater QT > 600
msec.
Frequently initiated after pause
Usually Iatrogenic (医源性)
– Hypokalemia,Hypomagnesemia, Drugs, combination
May be congenital (先天性)
– LQT1, LQT2,LQT3
Classic Torsades de Pointes
Polymorphic VT
“Node” (“point”)
心室扑动呈正弦波,波幅大而规
则, 频率 150~300 次 / 分。
心室颤动
心室颤动的波形、振幅与频率均极不
规则,无法识别 QRS 波群、 ST 段与
T 波。
Ventricular Tachycardia
Flutter and Fibrillation
Needs a
Cardioverter
(essentially
a small
Requires a shock to
small shock needed Low blood pressure
CARDIOVERTER ventricles)
Needs a
Defibrillator
Requires a
(essentially
DEFIBRILLATOR
large shock needed a large
No blood pressure
shock to
ventricles)
谢谢
第六节 心脏传导阻滞
Part 6 Heart Block
First Degree: Prolonged conduction time
Second Degree: Intermittent non-conduction
Third Degree: Persistent non-conduction
房室传导阻滞
房室传导阻滞( atrioventricular block ,
AVB )又称房室阻滞,是指房室交界区脱离了
生理不应期后,心房冲动传导延迟或不能传导
至心室。
[ 病因 ] 正常人或运动员可发生文氏型房
室阻滞(莫氏Ⅰ型),与迷走神经张力增高有关。
其他导致房室传导阻滞的病变有:急性心肌梗
死、冠状动脉痉挛、病毒性心肌炎、电解质紊
乱、心脏手术药物中毒等。
一 .AV Heart Block
There are three types of AV heart block:
1. First-degree AV block– the PR interval is uniformly prolonged
beyond 0.2 second.
2. Second-degree AV block– there are two subtypes:
A. wenckebach (Mobitz type 1) AV block-increasing prolongation
of the PR interval occurs until a P wave is blocked and not followed
by a QRS complex.
B. mobitz type II AV block– a series of P waves occurs without
QRS complex; The conducted P waves have the same PR interval.
3. Third-degree (c omplete) AV block– this shows the following:
A. the atrial and ventricles beat independently because stimuli
cannot pass through the AV junction.
B. the atrial rate is faster than the ventricular rate.
C. the PR interval constantly changes
Mobitz I (Wenckebach) the PR progressively lengthens
with one P wave for every QRS until a beat is dropped.
Usually the block is above His bundle.
Mobitz II the PR is constant but with occasional dropped
beats. This is a more serious arrhythmia because the injury is
probably in fast conducting tissue below the His bundle which
is not under vagal control.
Mobitz II - 2nd degree block
Complete AV heart block. Since there is no
conduction down the AV node pathway atria and
ventricles beat regularly but at different rates.
Summary
The (relatively) good:
Mobitz I AV block, or
Wenckebach block The bad:
Mobitz II AV block, and...
The ugly:
Complete heart block
[ 治疗 ]
应针对不同的病因进行治疗。
Ⅰ0AVB 与Ⅱ 0Ⅰ 型 AVB 室率不太慢者,无需接
受治疗。
Ⅱ0Ⅱ 型 AVB 与Ⅲ 0AVB 如室率显著缓慢,伴
有血流动力学障碍,甚至 Adams-Stokes 综合征发
作者,应给予治疗。
[ 治疗 ]
阿托品( 0.5~2.0mg ,静脉注射)适用于
阻滞位于房室结的患者。异丙肾上腺素
( 1~4ug/min 静脉滴注)适用于任何部位的房室
传导阻滞。以上药物使用超过数天,往往效果不
佳且易发生严重的不良反应。因此,对于症状明
显、室率缓慢者,应及早给予临时性或永久性心
脏起搏治疗。
二 . 室内传导阻滞
室内传导阻滞( intraventricular block )
又称室内阻滞,是指希氏束分叉以下部位的传
导阻滞。
右束支阻滞较为常见。左束支常发生于
充血性心力衰竭、急性心肌梗死、急性感染、
风心病、冠心病等。单支、双支阻滞通常无临
床症状。完全性三分支阻滞的临床表现与完全
性房室阻滞相同。
Right Bundle Branch Block Left Bundle Branch Block
(RBBB) (LBBB)
VAT ≥ 0.07 s
右束支阻滞( right bundle branch block )
1. QRS 时限达 0.12s 或以上 ; 2.V1 导联呈 rsR’ , R’ 波粗钝 ;
3.V5 、 V6 导联呈 qRS , S 波宽阔。 4.T 波与 QRS 波主波方向相
反。不完全右束支阻滞的图形与上述相似,但 QRS 时限小于 0.12s
Right Bundle Branch Block
(RBBB)
左束支阻滞( left bundle branch
block )
QRS 时限达 0.12s 或以上。 V5 、 V6 导联 R 波宽大
,顶部有切迹或粗钝,其前方无 q 波。 V1 、 V2 导联
呈宽阔的 QS 波或 rS 波形。 T 波与 QRS 波主波方向相
反。不完全左束支阻滞的图形与上述相似,但 QRS 时限
Left Bundle Branch Block
左前分支传导阻滞
左后分支传导阻滞
[ 治疗 ] 慢性束支阻滞患者如无症状,
无需接受治疗。双支与不完全性三分支阻滞有可
能进展为完全性房室阻滞,但是是否一定发生以
及何时发生均难以预料,不必常规施行预防性起
搏器治疗。急性前壁心肌梗死发生双分支、三分
支阻滞,或慢性双分支、三分支阻滞,伴有
Adams-Stokes 综合征发作者,则应及早考虑心
脏起搏器治疗。
第七节 抗心律失常药物的分类
I 类 延迟快速 Na+ 通道
Ia 抑制 0 相除极速度 , 减慢传导 , 延长复极作
用明显,延长动作电位时程 奎尼丁
Ib 轻度抑制 0 相除极速度 , 缩短动作电位时程
利多卡因
Ic 明显抑制 0 相除极速度 , 不影响动作电位时程
心律平
II 类 抑制交感神经 (β 阻断作用 ) 倍他乐克
III 类 延长复极时间 ( 复极延长作用 ) 胺碘酮
IV 类 钙拮抗剂 ( 钙拮抗作用 ) 异搏定
第八节心律失常的手术治疗
一、心脏起搏治疗
起搏器的功能及类型
起搏器命名代码
第一位 第二位 第三位 第四位 第五位
起搏心腔 感知心腔 感知后反应方式 程控功能 其他
O 无 O 无 O 无 略
A 心房 A 心房 I 抑制 R 频率调整
V 心室 V 心室 T 触发
D 心房 + 心室 D 心房 + 心室 D 双重( I+T )
S 心房或心室 S 心房或心室
起搏器的功能及类型
起搏器种
类
根据应用的方式分 根据电极导线植入部位分
: :
•临时心脏起搏 •单腔起搏器
•植入式心脏起搏 •双腔起搏器
•三腔起搏器
植入永久性心脏起搏器的适应证( 1 )
•伴有临床症状的任何水平的完全或高度
房室
传导阻滞。
•伴有症状的束支 - 分支水平阻滞,间歇性
第
二度 Ⅱ型房室传导阻滞。
•病态窦房结综合征或房室传导阻滞,有
明显
植入永久性心脏起搏器的适应证( 2 )
• 治疗心律失常或其他疾病所必需的药物,如
引起有症状的心动过缓时,应该植入起搏器
。
• 反复发生的颈动脉窦性晕厥和血管迷走性晕
厥,以心脏反应为主者。
• 药物治疗效果不满意的顽固性心力衰竭(可
行
心脏再同步起搏治疗)。
Cardiac Resynchronization
Therapy
(心脏再同步治疗)
二、心脏电复律
cardioversion
定义
心脏电复律是在短时间内向心
脏通以高压强电流,使心肌瞬间同
时除极,消除异位性快速心律失常
,使之转复为窦性心律的方法。亦
称为心脏电除颤。
• 心室颤动和扑动:是电复律的绝对指征
。
• 心房颤动和扑动伴血流动力学障碍者。
• 药物及其他方法治疗无效或有严重血流
动力学障碍的阵发性室上性心动过速、
室性心动过速、预激综合征伴快速心律
失常者。
• 病史多年,心脏(尤其是左心房)明显增大
及心房内有新鲜血栓形成或近 3 个月有栓塞
史。
• 伴高度或完全性房室传导阻滞的心房颤动或
扑动。
• 伴病态窦房结综合征的异位性快速心律失常
。
• 有洋地黄中毒、低钾血症时,暂不宜电复律
。
电复律种类
直流电非同步电除颤
用于心室颤动、心室扑
动
直流电同步电复律
除心室颤动以外的快速型心律失
常
电复律能量选择
室颤 200 ~ 360J
房颤 100 ~ 150J
室上速 100 ~
150J 室速 100 ~ 200J
房扑 50 ~ 100J
第八节心律失常的介入治疗
三、心导管射频消融
术
radio frequency catheter ablation , RFCA
是治疗心律失常的一种导管治
疗技术。射频消融仪通过导管头端
的电极释放射频电能,在导管头端
与局部的心肌内膜之间电能转化为
热能,达到一定温度( 46 ~
90℃ )后,使特定的局部心肌细胞
脱水、变形、坏死,自律性和传导
性能均发生改变,从而使心律失常
得以根治。
For the Ladies!!!
Um, and guys…
if your into that.