Transcript 心律失常arrhythmia

Cardiac Arrhythmia
--Bradycardic Arrhythmia
Hu Gangying
Department of Cardiology
Renmin Hospital of Wuhan University
Education
Aims and Requirements
Master
Etiology
Manifestation
Diagnosis
Therapeutic Principles
Aims and Requirements
To be familiar with
The electrocardiogram character
Diagnosis of arrhythmia
To understand
The mechanism of arrhythmia
Components of conduction
system (in order)
 Sinus atria nodal
 Internodal bunch
 Atria ventricular nodal
 His bunch
 Left and right bundle
 Purkinje fibers
General discription
• Anatomy of cardiac conduction system
浦肯野氏纤维
心脏传导系统示意图
Blood supply
Sinus Node
• 10 to 20 mm long, 2 to 3 mm wide
• lies at the junction of the superior vena
cava and right atrium
• The artery supplying from the right (55 to
60 % or the left circumflex (40 to 45%
coronary artery
Sinus Node
• Nodal cells, also called “P cells” and thought
to be the source of normal impulse formation
• TRANSITIONAL CELLS: Also known as “T cells”
may provide the only functional pathway for
distribution of the sinus impulse formed in the
nodal cells to the rest of the atrial
myocardium
INTERNODAL AND
INTRAATRIAL CONDUCTION
• Impulses travel from the
sinus to the AV node through
three intraatrial pathways
• The anterior internodal
pathway , also called the
Bachmann bundle
• The middle internodal tract
• The posterior internodal tract
AV NODE
• The normal AV
junction area
can be divided
into 3 distinct
regions
THE BUNDLE OF HIS
• Connects with the distal part of
the compact AV node,
perforates the central fibrous
body, and continues through
the annulus fibrosis, where it is
called the nonbranching portion
as it penetrates the
membranous septum
• Branches from the anterior and
posterior descending coronary
arteries supply the bundle of
His
• Bundle of his – bundle branches
THE BUNDLE BRANCHES
• Including the left
bundle branch and the
right bundle branch
• Left bundle branch
including
anterosuperior fascicle
and posteroinferior
fascicle
PURKINJE FIBERS
• Connect with the ends of
the bundle branches to
form interweaving
networks on the
endocardial surface of
both ventricles
Impulse conduction
SA
LA
RA
CS
TV
AV
MV
LV
RV
R
Q
PR nterval
ST Segment
S
Innervation of cardiac
conducton system
• Vagus (-)
• Sympathetics (+)
CLASSIFICATION OF
ARRHYTHMOGENESIS
 Disorders of impulse formation
 Disorders of impulse conduction
Disorders of Impulse
Formation
 SINUS NODAL DISTURBANCES
– Sinus tachycardia
– Sinus bradycardia
– Sinus arrhythmia
– Sinus arrest
Disorders of Impulse
Formation
 ECTOPIC RHYTHM
– Passive ectopic rhythm
 Escape beats
 Escape beats rhythm
– Active ectopic rhythm

Premature beat

Paroxysmal tachycardia

Atrial flutter, atrial fibrillation

Ventricular flutter, ventricular fibrillation
Disorders of impulse
conduction
• Physical: interferece and dissociation
• Pathological:
– Sinoatrial block
– Intraatrial block
– AV block
– Bundle branch or fasciclular block
• Accessory AV pathway: preexcitation
syndrome (W-P-W)
MECHANISMS OF
ARRHYTHMOGENESIS
Disorders of impulse formation
Abnormality of autorhythmicity
Triggered Activity
Disorders of impulse conduction
Reentry
Automaticity
Normal Sinus Rhythm
Increase phase 4 => increase HR
Hyperpolarization => slower HR
Triggered Activity
• Leakage of positive ions into the cardiac cell
creating a bump of afterdepolarization (AD)
• Might generate another action potential.
Early
Delayed
Triggered Activity
• Ischemia-repurfusion
• Digitalis intoxication
• Lower kalii
Tachyarrhythmias
• Automaticity
• Triggered Activity
• Reentry
a


b

a

b
A
B
Diagnosis of Arrhythmia
• History
• Physical Examination
• ECG
• Holter ECG
• Treadmill ECG
• Transesophageal ECG
• Clinical Electrophysiological Study
HISTORY
• Careful collection
• Patient’s discription of palpitation
• Try to get follow:
– Exit and type of arrhythmia
– Causition : cigarette, alcohol, coffee and mental
pressure
– Frenqunce of arrhythmia
– Impact of Arrhythmia on patient
– Reaction of arrhythmia to medicine and nondrug thereapy such as posture, breath, excise
Physical Examination
• Rate
• Rhythm
• heart sound
• Reaction to massage of coratid sinus
ELECTROCARDIOGRAM (ECG)
• Most important non-invasive method
• 12 LEADS recording
• Lead II or V1 for analysis of P WAVE
• Rhythm and rate of atrium or ventricle?
• PR interval: fixed or change at time?
• Shape of P wave and QRS complex?
• Relationship of P wave and QRS complex?
Holter ECG Monitering
• Continue recording of ECG for 24
hours
• Whether palpitation or syncope is
related to arrhythmia?
• Whether arrhythmia or ischemia
is related to daily activities?
• To evaluate the effect of antiarrhythmic drugs
• To evaluate the effect and
function of pacemaker or ICD
Event recorder
• Portable
• Implantable
Exercise ECG
• Treadmill test
• Normal patient may have arrhythmia
during or after excise
• Sensitivity and specificity of Exercise ECG
Transesophageal ECG
• Left atrium close to esophageal
• Transesophageal atrial pacing and recording
• Diagnosis of W-P-W or DAVNP
• To induce and terminate tachycardia:
terminate the tachycardia (PSVT)
• evaluate the effects of some AAD
• Diagnosis of sick sinus syndrome
Clinical Electrophysiological Study
• Transvenious insertion of several
electrodes to multiposition of the heart
• High right atrium, His bundle, Apex of right
ventricle, coronary sinus
• Programmed stimulus
Clinical Electrophysiological Study
• Diagnosis
• Treatment
• Prognosis
• Indication
– Determination of the function of Sinus node
– Atrial ventricular block or intra-ventricular block
– Tachycardia
– Unknown syncopy
心律失常
心电图的导联系统
The Standard ECG
• 常规十二导联体系（Einthoven 体系）
• 标准肢体导联Ⅰ、Ⅱ、Ⅲ
• 加压单极肢体导联 aVR、aVL 、aVF
Einthoven system
Standard limb leads Ⅰ、Ⅱ、Ⅲ
Augmented unipolar leads aVR、aVL 、aVF
胸前导联V1~V6
Unipolar precordial leads V1~V6
V1: th胸骨右缘第四肋间
V1: right 4 intercostal space
V2：胸骨左缘第四肋间
V2: left 4th intercostal space
V4：左胸骨中线与第五肋间交接处
V3: halfway
between V2 and V4
V4: leftV3：V2与V3之间
5th intercostal space, mid-clavicular line
V5：左腋前线V4水平处
V5: horizontal
to V4, anterior axillary line
V6：左腋中线V4水平处
V6: horizontal
to V5, mid-axillary line
心电图的测量
Measurement of ECG
• 走纸速度 25mm/s
• 标准电压 1mV =10mm
• 每小格 1mm=0.04s
Paper speed 25mm/s
Standard voltage 1mV=10mm
Each square 1mm=0.04s
ECG各波段的组成
•
• P波 心房的除极过程
• P-R段心房复极及房室结、
希氏束的活动
•
• P-R间期 P波与P-R段的合
并
•
QRS 波群心室的除极
过程
ST段和T波心室的缓
慢和快速复极
U波
平均心电轴
•
•
•
•
通常指额面心室除极过程的平均电势
正常范围 –300~900
心电轴左偏 – 300~– 900
心电轴右偏 900~1800
心电轴的目测法判断
 背对背，向左偏
 尖对尖，向右偏
正常心电图特点
Characteristics of Normal ECG
P波的特征
(Charactaristic of P wave)
 意义 代表从右房到左房的心电
活动
 形态 呈钝圆形，有时呈双峰
 时间
<0.12s
Activation of right and left
atria
Shape—being rounded
Duration <0.12s
P波的特征
(Charactaristic o f P wave)
方向 Ⅰ、Ⅱ、aVF、V4-V6直立， aVR 倒置
振幅 肢体导联<0.25mv, 胸导联<0.2mv
P-R间期(PR interval )
• 代表心房除极到心室除极
• 正常范围0.12s--0.20s
QRS 波群(QRS complex)
 意义
QRS波群代表心
室的除极时间
 形态
QRS (QRS
complexes)波群 胸前导
联自右向左 R 波逐渐增
高， S 波逐渐减小，
R/S 比值逐渐增高
Bradycardic
Arrhythmia
Sinus Bradycardia
Etiology
physiological
the young, athelete, sleeping
pathological
cerebral disease, severe hypoxia, hypothermia,
hypothyroidism, jaundice
Medicine ( amiodarone, -blocker, CCB, digoxin)
heart disease: acute myocadial infartion (inferior
wall)
Clinical manifestations
 vertigo (眩晕), dizziness(头晕)
 near-syncope, syncope
 Dyspnea(呼吸困难), fatigue, weakness
 palpitation, discomfort
 ECG features:
sinus rhythm
an upright P wave
a normal P-R interval
heart rate<60/min
窦性心动过缓
Managements
 No symptom: no treatment
 Symptom:
Atropine
Isoproterenol
Pacemaker
Sinus arrest
•
•
•
•
•
•
•
Etiology
Vagus tone increase
Hypersensitive carotid sinus syndrome
AMI
Degeneration(退化) of sinus node
Cerebral accident
Digoxin
Ach
ECG features
• P-P interval prolong
• No times among short p-p and long p-p
• Hypostatic potential pacemaker control
ventricle
Sinus Arrest-窦性停搏
Manifestation
症状(symptoms)：
眩晕(vertigo)、黑朦(near-syncope)晕厥
（syncope)或死亡(death)
 management
Same as sinus bradycardia
Sinoatrial block
 Rarely
 Etiology: CAD,HISS,心肌炎,Familial sinus
disease, SN damage, Digoxin/Quiedin
 ECG：二度:可见莫氏I型（文氏现象）或II型
阻滞; 一、三度不能诊断
（P-P间期依次逐渐缩短直至发生一次P波漏脱）
Sinoatrial conduct
block-窦房传导阻滞
Sinoatrial Exit Block
• A pause resulting from absence of the
normally expected P wave
• The duration of the pause is a multiple of
the basic P-P interval
（P-P间期相等间隙发生一次P波漏脱）
Manifestation
症状(symptoms)
眩晕(vertigo)、乏力(fatigue) 、黑朦
(near-syncope)晕厥（syncope)
management
Same as sinus bradycardia
病态窦房结综合征
(Sick sinus syndrome , SSS)
是由窦房结病变导致功能减退，
产生多种心律失常的综合表现
病 因 (Etiology)
 Oxygen deficit and ischemia of
sinus atria nodal
 Fibrosis、degeneration
 Myocarditis (心肌病)
 Vagotonia
 Drug
Clinical Manifestation
症状(symptom)：心、脑等
脏器灌注不足的症状:
眩晕(vertigo)、黑朦(nearsyncope)晕厥（syncope)胸痛
(chest pain)或死亡(death)
体征（physical examination)
low heart rate， S1 ↓
Sick Sinus Syndrome
• ECG
–
–
–
–
Sinus bradycardia (<40bpm)
Sinus arrest and Sinoatrial block (>3s)
Sinus arrest or AV-block
Bradycardia-tachycardia symdrome (AFL, AF,
AT)
心电图检查
(包括动态心电图检查)
 显著的窦缓，心率＜50次／分
 窦房阻滞，窦性停搏，并逸搏，逸搏
心律
 慢－快综合征
 全传导系统阻滞
电生理检查及其他检查
(electrophysiological test)
心电生理
窦房结恢复时间（sinoatrial nodal recovery time)
正常时，SNRT不应超过2000ms,
CSNRT不超过525ms。
窦房传导时间(sinoatrial conductive time)
SACT正常值不超过147ms
电生理检查及其他检查
(electrophysiological test)
• Other examination
– Intrinsic heart rate mesurement
Injection of prololol and atropine to
block the innervation of heart
正常值=118.1 ━ (0.75x年龄)
诊 断
(diagnosis)
根据病史、体征、心电图、动态心电图、
食管或心内电生理等可明确诊断
History, feature, ECG, Holter,
electrophysiology
Sick Sinus Syndrome
• Treatment
– Asymptomatic: follow up without treatment
– Symptomatic: pacemaker implantation
– Bradycardia-tachycardia: pacemaker +AAD
HEART BLOCK
• Decrease or block of impulse
conduction can occur at any site:
– Between sinus node and atrium (SA block)
– Within the atria (intra atrial block)
– Between atria and ventricles (AV block)
– Within the ventricles (intraventricular
block)
房室传导阻滞
(atrio ventricular block)
发生部位
– 房室结
– 希氏束
– 心室内左右或三束支
意义
– 部位越低，危险性越
大
• Location
• AVN
• His bundle
• bundle
branches and
their fascicles
• Significant
• more low,
more dangerous
房室传导阻滞
（atrioventricular block, AVB）
Etiology
•
•
•
•
•
•
•
•
High vagus tone
AMI /Spasm of coronary artery
Myocarditis、Cardiamyopathy
Congenital heart diseases
Primary hypertension
Surgery or RFCA
Disorder of electrolyte
Diffuse fibrosis of the conduction system
(Lenergre disease)
• medicine damage
AV BLOCK
• First degree AVB：usually asymptomatic
• Second degree ：palpitation
• Third degree：differently depends on the
heart rate
眩晕(vertigo)、黑朦(near-syncope)晕厥（syncope)
或死亡(death)
ECG features
• First degree block
P/QRS 1:1 P-R>0.20
• Second degree block
Mobitz typeⅠ: P-R interval progressively
longer, then dropped
Mobitz type Ⅱ: P-R interval constant
sudden dropped
• Third degree block : P/QRS≠1
房室传导阻滞（I、II度）
 I度AVB P－R＞0.20 S，每个P波后均有相关的QRS波
 II度AVB
 II度I型AVB，又称文氏型，P－R间期逐渐延长，直至P
波受阻，其后QRS波脱漏，R－R间期逐渐缩短，包含
受阻P波的R－R间期小于窦性PP两倍
 莫氏II型：心房冲动突然阻滞，但PR间期不变；P波后
QRS波按固定比例脱漏
I 度房室传导阻滞 1st Degree AV Block
• P-R间期延长，> 0.20
• 每个P波后有QRS波群
• 与年龄、心率有关
PR interval > 0.20 sec;
P waves conduct to the ventricles
II 度房室传导阻滞 2nd Degree AV Block
II 度房室传导阻滞 2nd Degree AV Block
III度AVB心电图
全部心房冲动均不能传至心室
 P波与QRS波完全无关联
心房率快于心室率，P－P＜R－R
QRS波形态取决于阻滞部位
完全性房室传导阻滞
Management
• Ablated cause
• First degree and Mobitz Ⅰ
need not treatment
• Third degree and Mobitz Ⅱ
pace
治 疗
 除去诱因及病因
 I度及II度I型AVB无需治疗
 II度II型及III度AVB为持续性时，
若药物不能纠治时原则上均需植
入心脏起搏器
临时起搏器
temporary pacemaker
植入性起搏器
implantable pacemaker
室内传导阻滞
（intraventricular block）
室内传导阻滞亦称
束支或分支阻滞
Etiology：similar as AVB
束支传导阻滞
Classification of
Intraventricular block
• A. Bundle Branch Block
1. Right bundle branch block
a. Complete
b. Incomplete
2. Left bundle branch block
a. Complete
b. Incomplete
Classification of
Intraventricular defects
• B. Peripheral Left Ventricular
conduction Defects:
1. Left anterior fascicular block
2. Left posterior fascicular block
3. etc
Classification of
Intraventricular defects
• C. Bilateral Bundle Branch Block
1. Right bundle branch block with left
anterior fascicular block
2. Right bundle branch block with left
posterior fascicular block
3. Right or left bundle branch block with
prolonged AV conduction(P-R>0.20)
4. Altering right and left bundle branch
block
• D. Trifascicular Block
Right bundle branch block
• Etiology
Rheumatic heart disease
Hypertensive heart disease
Coronary artery disease
Cardiomyopathy
Congenital heart disease
normal individuals
Right bundle branch block
• Incidence
a fairly common finding
not diagnostic of heart disease
ECG features
完全性右束支传导阻滞
① QRS 波群时限≥0.12s
② V1、V2呈rsR’或M型，R波粗钝；
③ I、V5、V6导联呈qRS，S波宽阔
④ 继发性ST-T改变
不完全性右束支传导阻滞
QRS波群时限QRS<0.12s
CRBBB
EKG:QRS时限0．12s或以上；V1呈rsR’, R’波粗钝
V5、V6导联qRS, S波宽阔；T波与主波方向相反
Left bundle branch block
Etiology and incidence
 Heart failure、AMI
 Hypertensive heart disease
 Rheumatic heart disease
 Coronary artery disease
 Drug
 rarely seen in normal heart
ECG features
完全性左束支传导阻滞 CLBBB
•
QRS 波群时限≥0.12s
•
V1、V2呈rS型或QS型；
•
V5、V6 q波消失，R宽大、切迹
•
继发性ST-T改变
不完全性左束支传导阻滞 NCLBBB
QRS 波群时限<0.12s
CLBBB
ECG:QRS时限0.12s或以上；V5、V6导联R波宽大,顶部切
迹或粗钝, V1、V2呈宽QS波或rS波粗钝； V5、V6导联T
波与主波方向相反
Fascicular Block
左前分支阻滞（LAFB）
电轴左偏-45度～-90度
I、aVL呈qR型
II、III、aVF呈rS型
QRS时限小于0.12s
左前分支传导阻滞
left anterior fascicular block
电轴左偏
II、III、aVF呈rS
I，aVL呈qR
SIII>SII RaVL>RI
QRS时限不超过0.11s
Fascicle Block
左后分支阻滞（LPFB）
•
•
•
•
•
电轴右偏，以超过120°为可靠
I、aVL呈rS
II、III、aVF呈qR
RIII>RII
QRS时限<0.12s
左后分支传导阻滞
left posterior fascicular block
电轴右偏
I、aVL呈rS
II、III、aVF呈qR
RIII>RII
QRS时限<0.12s
CRBBB+LAFB
Managements
 除去病因及诱因
 慢性单侧束阻滞若无症状无需治疗
 双分支及不完全性三分支阻滞不需
常规预防性起搏器治疗
Managements
急性前壁心梗并双束支、三分支阻
滞或慢性双分支及不完全性三分支阻滞
伴有晕厥或Adams-Stroke综合征发作者，
则应及早考虑心脏起搏器治疗
填空题
2000ms
SNRT不应超过-------------,
525ms
CSNRT不超过--------,
SACT正常值不超过
147ms
-----------
SSS的ＥＫＧ 持速而显著的窦缓、窦性停搏与窦房阻滞、
特点：
双结病变、慢－快综合征
SSS有症状时，需植入人工心脏起搏器
宽大R
rsR’ or M
RBBB 的V1导联QRS波呈------------------- LBBB 的V6导联QRS波呈-------ＬＡＦＢ心电图特点是： 电轴左偏， I，aVL呈qR， II、III、aVF呈rS，
SIII>SII ， RaVL>RI，QRS时限不超过0.12s
ＬＰＦＢ心电图特点是： 电轴右偏，I、aVL呈rS，II、III、aVF
呈qR，RIII>RII，QRS时限〈0.12s
II度II型及III度AVB为持续性时，若药物不能纠治时原
植入心脏起搏器
则上均需-------------------------------
名词解释
• Sick sinus syndrome
请给出下列心电图的完整诊断
SIII>SII RaVL<RI
请给出下列心电图的诊断
思考题
•
•
•
•
•
•
SSS的临床表现有哪些？
SSS如何诊断？
SSS如何治疗？
SSS心电图有何表现？
第一度、第二度、第三度房室传导阻滞的
心电图特征是什么？
SSS及AVB的起搏器指征分别是什么？
①what’s the clinic manifestation of
bradyarrhythmia?
②how to diagnose the bradyarrhythmia?
③how to treat the bradyarrhythmia?
④what’s the electrocardiogram character
of bradyarrhythmia?