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GANGGUAN IRAMA

JANTUNG

Definition of arrhythmia
Cardiac arrhythmia is an
abnormality of the heart rhythm
Bradycardia heart rate slow
(<60 beats/min)
Tachycardia heart rate fast
(>100 beats/min)

GANGGUAN IRAMA
JANTUNG
Aritmia jantung merupakan istilah
kolektif untuk semua gangguan
irama jantung di luar irama sinus yg
normal.
Gangguan terjadi pada saat
pembentukan impuls,hantaran
maupun kombinasi keduanya.
Sering menimbulkan rasa cemas
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The Electrical System

GANGGUAN IRAMA
JANTUNG
Gangguan yg tergolong ringan,menimbulkan
berbagai keluhan(denyut jantung terasa
berat,dada bergetar,denyut berhenti).
Tidak jarang,aritmia yg berat,tidak
menimbulkan keluhan.
Penelitian sebelumnya,dilaporkan adanya
kematian mendadak,ternyata di sebabkan
oleh fibrilasi ventrikel,yg sebelumnya hanya
merpakan ekstra sistol yg tidak terkendali.
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GANGGUAN IRAMA
JANTUNG
Aritmia dapat terjadi pada orang
sehat,segala umur.
Aritmia ekstra sistole ventrikel merupakan
aritmia yg dijumpai pada orang sehat dan
sakit.
Pada waktu olah raga dilaporkan pada33%
laki laki,dan 15% pada wanita.
Pembicaraan disini di tekankan pada
strategi praktis penanggulangan,selain
Atrium, aritmia ventrikel,yg merupakan
jenis aritmia yg terbanyak dijumpai
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DIAGNOSIS ARITMIA
Riwayat penyakit,fisik diagnostik,px EKG
Mudah ditegakkan.
Merencanakan strategi
penanggulangan,cukup sulit.
Evaluasi yg tidak lengkap,mengalami
kegagalan untuk mengenal penyakit dasar
yg menimbulkan aritmia,yg sebenarnya
dapat diobati.Atau sebaliknya penderita
diberikan pengobatan berlebihan yg
sebenarnya tidak perlu
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Cardiac Cycle

P Wave-Atrial Depolarization
PR Segment-Indicative of the delay in the AV node
PR Interval-Refers to all electrical activity in the heart before
the impulse reaches the ventricles
Q Wave-First negative deflection after the P wave but before the
R wave
R Wave-First positive deflection following the P wave
S Wave-First negative deflection after the R wave
QRS Complex-Signifies ventricual depolarization
T Wave-Indicates ventricular repolarization (Note: Atrial
repolarization wave is buried in the QRS complex).

Normal Sinus Rhythm


Sinus node is the pacemaker, firing at a regular rate of 60 - 100
bpm. Each beat is conducted normally through to the ventricles
Regularity: regular
Rate: 60-100 beats per minute
P Wave: uniform shape; one P wave for each QRS
PRI: .12-.20 seconds and constant
QRS: .04 to .1 seconds

Sinus Bradycardia

Sinus node is the pacemaker, firing regularly at a rate of less than 60 times per
minute. Each impulse is conducted normally through to the ventricles
Regularity: The R-R intervals are constant; Rhythm is regular
Rate: Atrial and Ventricular rates are equal; heart rate less than 60
P Wave: Uniform P wave in front of every QRS
PRI: PRI is between .12 -.20 and constant

QRS: QRS is less than .12

10

Sinus Tachycardia
Sinus node is the pacemaker, firing regularly at a rate of greater
than 100 times per minute. Each impulse is conducted normally
through to the ventricles .
Regularity: The R-R intervals are constant; Rhythm is regular
Rate: Atrial and Ventricular rates are equal; heart rate greater
than 100
P Wave: Uniform P wave in front of every QRS
PRI: PRI is between .12 -.20 and constant
QRS:QRS is than .12

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Atrial Flutter
A single irritable focus within the atria issues an impulse that is
conducted in a rapid, repetitive fashion. To protect the ventricles
from receiving too many impulses, the AV node blocks some of
the impulses from being conducted through to the ventricles.
Regularity: Atrial rhythm is regular. Ventricular rhythm will be
regular if the AV node conducts impulses through in a consistent
pattern. If the pattern varies, the ventricular rate will be irregular
Rate: Atrial rate is between 250-350 beats per minute.
Ventricular rate will depend on the ratio of impulses conducted
through to the ventricles.

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Atrial Flutter
P Wave: When the atria flutter they produce a series of well
defined P waves. When seen together, these "Flutter"
waves have a sawtooth appearance.
PRI (PR INTERVAL): Because of the unusual "Flutter"
configuration of the P wave and the proximity of the wave to
the QRS comples, it is often impossible to determine a PRI
in the arrhythmia. Therefore, the PRI is not measured in
Atrial Flutter.
QRS: QRS is less than .12 seconds; measurement can be
difficult if one or more flutter waves is concealed within the
QRS complex.

13

Atrial Fibrillation

The atria are so irritable that a multitude of foci initiate impulses,


causing the atria to depolarize repeatedly in a fibrillatory manner. The
AV node blocks most of the impulses, allowing only a limited number
through to the ventricles.

Regularity: Atrial rhythm is unmeasurable; all atrial activity is chaotic.


The ventricular rhythm is grossly irregular, having no pattern to its
irregularity.

Rate: Atrial rate cannot be measured because it is so chaotic; research


indicates that it exceeds 350 beats per minute. The ventricular rate is
significantly slower because the AV node blocks most of the impulses.
If the ventricular rate is below 100 beats per minute, the rhythm is said
to be "controlled"; if it is over 100 bpm, it is considered to have a "rapid
ventricular response."

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Atrial Fibrillation
P Wave: In this arrhythmia
the atria are not depolarizing
in an effective way; instead,
they are fibrillating. Thus, no
P wave is produced. All atrial
activity is depicted as
"fibrillatory" waves, or
grossly chaotic undulations
of the baseline.
PRI: Since no P waves are
visible, no PRI can be
measured.
QRS: QRS is less than .12
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Lone Atrial Fibrillation

Absence of identifiable cardiovascular, pulmonary, or


associated systemic
disease

Approximately 0.8 - 2.0% of patients with atrial fibrillation


(Framingham Study)1

In one series of patients undergoing electrical


cardioversion, 10% had lone AF.2

1 Brand
2 Van

FN. JAMA. 1985;254(24):3449-3453.


Gelder IC. Am J Cardiol. 1991;68:41-46.

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Symptoms and Signs Atrial Fi


brillation
Palpitations

Presyncope
Fatigue

Chest

pain
Dyspnea
Syncope

Signs:
Irregularly irregular pulse
Raised JVP/Absent a Waves
Cardiomegaly
RA dilatation
Valvular disease
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Control of Ventricular Rate in


Atrial Fibrillation

Digoxin

Calcium channel blockers


Verapamil, diltiazem

Beta blockers

18

Medication for Rate Control in Atrial


Fibrillation
Agent

Action

Digoxin

Cardiac

Immediate
IV dose

0.5 mg +

Oral
maintenance
therapy

Avoid use in

0.125-0.5 mg/day; WPW, HCM

glycoside 0.25 mg in 4-6 h + renal


0.25 mg in 4-6 h
Diltiazem Calcium
channel
blocker

20 mg (or 25-35 120-360 mg/day; WPW, constipation,


mg/kg) over 2 min hepatic
peripheral edema,
+ 2nd bolus
CHF
allowed after
20 min + 5, 10,
15 mg/h infusion

Verapamil Calcium
channel

5-10 mg every
120-240 mg/day; Same as diltiazem,
30 min or 5 mg/h hepatic
risks with CHF
Adapted from Blackshear JL. Mayo Clin Proc. 1996;71:150-160.
blocker
possibly greater 19

Medication for Rate Control in Atrial


Fibrillation
Agent

Action

Immediate
IV dose

Oral
maintenance
therapy

Avoid use in

Propranolol

-blocker

0.5-1.0 mg every
5 min up to 5 mg
total

40-320 mg/day;
hepatic

Bronchospastic
lung disease,
CHF

Metaprolol

-blocker

5 mg every 5 min
up to 15 mg total

50-200 mg/day;
hepatic

Same as
propranolol

Esmolol

-blocker

0.5 mg/kg/min
load over 1 min
+ 0.05-0.3 mg/
kg/min

None

Same as
propranolol

Adapted from Blackshear JL. Mayo Clin Proc. 1996;71:150-160.

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Ventricular Arrhythmia

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Ventricular Tachycardia

An irritable focus in the ventricles fires regularly at a rate of 150-250


beats per minute to override higher sites for control of the heart.
Regularity: This rhythm is usually regular, although it can be slightly
irregular.
Rate: Atrial rate cannot be determined. The ventricular rate range is
150-250 beats per minute. If the rate is below 150 bpm, it is considered
a slow VT. If the rate exceeds 250 bpm, its called Ventricular Flutter.
P Wave: None of the QRS complexes will be preceded by P waves;
you may see dissociated P waves intermittently across the strip.
PRI: Since the rhythm originates in the ventricles, there will be no PRI.
QRS: The QRS complexes will be wide and bizarre, measuring at least
.12 seconds. It is often difficult to differentiate between the QRS and
the T wave.

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Ventricular Fibrillation
Multiple foci in the ventricles become irritable and generate
uncoordinated, chaotic impulses that cause the heart to fibrillate
rather than contract.
Regularity: There are no waves or complexes that can be
analyzed to determine regularity. The baseline is totally chaotic.
Rate: The rate cannot be determined since there are no
discernible waves or complexes to measure.
P Wave: There are no discernible P waves.
PRI: There is no PRI.
QRS: There are no discernible QRS complexes.

Discrnble: dpt dnlai

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PENANGGULANGAN ARITMIA
VENTRIKEL

1.KELUHAN: ada keluhan atau tidak


2.ETIOLOGI: apa penyakit dasarnya
3.NILAI PROGNOSTIK: baik atau buruk
4.PENGOBATAN: perlu atau tidak

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25

KELUHAN PENDERITA

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DIAGNOSIS TAHAP AWAL

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DIAGNOSIS TAHAP LANJUT

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NILAI PROGNOSTIK ARITMIA


VENTRIKEL

Arti klinis aritmia ventrikel


tergantung pada
A.Penyebabnya:mempunyai nilai
prognostik sendiri
B.Frekuensi dan kompleksitasnya

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1.KLASIFIKASI ARITMIA
VENTRIKEL

A.Denyut ventrikel prematur : bbrp


kategori.(ekstra sistole),menurut
berat rngannya dibagi bbrp kategori.
B.Takhikardi Ventrikel tdk tetap
C.Takhikardi Ventrikel tetap

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A.Denyut Ventrikel Prematur

Ekstra sistole ventrikel,kompleks


Ventrikel prematur.
Aritmia ini ,menurut berat ringannya
di bagi lagi atas beberapa kategori
Secara umum ekstra sistole yg
sering terjadi,tetapi tidak
berlandaskan penyakit jantung
tertentu,prognosis nya baik dan
resiko mati mendadak kecil
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KLASIFIKASI ARITMIA VENTRIKEL


Denyut ventrikel prematur,menurut berat ringannya dibagi:

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B.TAKIKARDI VENTRIKEL(TV)
TIDAK MENETAP
Disebut takikardi ventrikel tdk menetap apabila dijumpai
3 atau lebih eksta sistole ventrikel(EVS) berturut
turut(denyut nadi lebih dari 100/mnt).
Dibedakan atas:
A. TV paroksismal(mono/poli morfik)dg atau tanpa
keluhan.
B. TV monomorfik repetitif:episode TV berulang dg
konfigurasi QRS uniform terjadi sepanjang hari dan
kopleks QRS normal diantara serangan.
Prognosis penderita dg TV jenis ini tergantung pd
kelainan dan fugsi miokard.

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C.TAKIKARDI VENTRIKEL TETAP


Disebut tetap,bila TV terjadi selama 15
hingga 30 detik atau TV minimal 100 ESV.
Umumnya hampir simtomatik,pada PJK
terasa nyeri dada

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2.PEMBAGIAN BERDASAR Hirarki


Frekuensi dan Bentuk

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PENYAKIT JANTUNG YG
MENJADI LANDASAN

1.Penyakit jantung koroner


2.Kardiomiopati Kongestif
3.Kardiomiopati Hipertropik
4.Prolaps Katup Mitral

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1.Penyakit Jantung Koroner


ESV pada IMA sangat sering dijumpai da
resiko TV dan FV primer.
Resiko lebih tinggi pd permulaan infark
dan menurun setelah 12 hingga 24 jam
Hal ini penting untk merawat penderita yg
di duga mengalami IMA di perawatan
intensif secara dini.

37

Atherothrombosis: a Generalized
and Progressive Process
Normal
Normal
Normal

FattyStreak Fibrous
Fatty

streak

plaque

Atherosclerotic
plaque

Plaque
rupture/
fissure &
thrombosis

Unstable
angina
MI

}ACS

Ischemic
stroke/TIA
Clinically silent
Stable angina
Intermittent claudication

Critical leg
ischemia
Cardiovascular
death

Increasing age
ACS, acute coronary syndrome; TIA, transient ischemic
attack

38

2.KARDIO MIOPATI KONGESTIF


ESV derajad tiggi sering dijumpai terutama
bila disertai dg payah jantung.
Aritmia ini meninggikanresio mati
mendadak

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Cardiomyopathy

Dilated/Congestive
Nursing Review, 2001
40 of 48

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3.KARDIO MIOPATI
HIPERTROFIK

TV yg menetap,merupakan faktor resiko


mati mendadak pada kelainan ini.

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Functional Classification
Dilated

(Congestive, DCM, IDC)

Ventricular dilation, hypokinetic left ventricle, and


systolic dysfunction

Hypertrophic

Inappropriate myocardial hypertrophy, with or without


left ventricular obstruction

Restrictive

(IHSS, HCM, HOCM, ASH)

(Infiltrative)

Abnormal ventricular filling with diastolic dysfunction

Arrhthymogenic

42 of 48

Right Ventricular (ARVD)

Fibroadipose replacement of right ventricle

42

4.Prolaps Katup Mitral


Walau jarang,dapat terjadi TV yg
menetap dan dapat mati mendadak

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Valves of the Heart

44

Management(Pengobatan)Vaughan Williams classification


of antiarrhythmic drugs

Class I: block sodium channels


Ia (quinidine, procainamide,
disopyramide)
Ib (lignocaine)
Ic (flecainide)
Class II: -adrenoceptor
antagonists (atenolol, sotalol)
Class III: prolong action
potential and prolong refractory
period (suppress re-entrant
rhythms) (amiodarone, sotalol)
Class IV: Calcium channel
antagonists. Impair impulse
propagation in nodal and
damaged areas (verapamil)

Phase 1

IV
Phase 2

0 mV
Phase 0

-80mV

III
Phase 3

Phase 4

II

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PENGOBATAN

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DASAR PENGOBATAN ARITMIA


VENTRIKEL

Paradoks tentang resiko pro aritmia yg mungkin lebih berbahaya dari


pada aritmianya sendiri ikut menambah konflik antara perlu dan
urgensipengobatan aritmia ini.
Pengobatan hendknya secara individual,tidak ada pedoman yg berlaku
untuk semua kasus.
Prinsip ada 2 alasan unt mengobati,
A.Keluhan yg mengganggu pola hidup

B.Denyut ventrikel prematur derajad tinggi yg mempunyai nilai


prognostik.

Penderita tanpa kelainan organik:bila keluhan menetap,meskipun


telah diyakini,bahwa tidak ada gangguan jantung berat.hendaknya
diobati dg obat yg paling ringan.

Penghambat reseptor beta dosis kecil dianjurkan sg pilihan pertama


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DASAR PENGOBATAN ARITMIA


VENTRIKEL
Payah jantung kongesti berat:apapun
sebabnya,umumnya disertai ESV derajat
tinggi,dg resiko mati mendadak.
Amiodaron mrpakan obat efektif.
Pada penelitian pengobatan ACE inhibitor
menunjukkan hasil yg bagus bagi payah
jantungnya sendiri dan ekstra sistole
ventrikuler.

48

Summary

Anti-arrhythmic drugs are classified by their


effect on the cardiac action potential
Not all drugs fit this classification
In clinical practice treatment of arrhythmias is
determined by the type of arrhythmia (SVT,
VT) and clinical condition of the patient
Anti-arrhythmic drugs are efficacious but may
have serious adverse effects
Not all arrhythmias are treated with drug
therapy alone
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Eff:mnjur

THE END
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JAUHILAH TABIAT MEROKOK


SEKIRANYA
ANDA MENYAYANGI
DIRI DAN KELUARGA ANDA

TER MA KAS H
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