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Pathological Arrhythmias/ Tachyarrhythmias

caused by:

� 1.Ectopic focus:

✁ Extrasystole or premature beat. If discharge is occasional.

Can be:

✁ Atrial Extrasystole

✂ Vevtricular Extrasystole

✄ ✄ ✄ ☎ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ☎ ✡ ☛ ✟

✄ �✁ 2.Cardiac Arrhythmia

Caused by

✂ Ectopic focus discharging repetitively & rate is higher than SAN

☎ Circus movement

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Circus movement

� 1. Wave of excitation continue to travel indefinitely in myocardium

✁ 2. Retrograde conduction due to transient block in bundle of HIS

✁ 3. Wolff-Parkinson-White Syndrome

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

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CARDIAC ARRHYTHMIAS

ATRIAL VENTRICULAR

FLUTTER

EXTRASYSTOLE

FIBRILLATION

FLUTTER

FIBRILLATION

HR 220

HR 200-350

HR 300-500

EXTRASYSTOLE

V. Tachycardia

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

Atrial arrhythmias

Following

� Atrial extrasystole ✄ atrial premature cont. are frequently present in healthy persons

✁ Paraoxysmal atrial Tachycardia

� Atrial flutter

✁ Atrial fibrillation

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� Pulse deficit

✁ Definition - A deficit of pulse in relation to heart rate is called pulse deficit.

✂ Causes :

Premature contraction

Atrial fibrillation

✄ ✄ ✄ ☎ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ☎ ✡ ☛ ✟

Premature contration

� During premature contraction, heart contracts ahead of time & if ventricles are not filled properly stroke volume decreases & in such cond. pulse wave passing to periphery may be so weak that it is not felt at the radial artery.

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Atrial fibrillation

� Irregular adequate filling of ventricles results in pulse deficit

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Atrial Flutter

SAW TOOTHED ECG

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

Atrial Fibrillation

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

Ventricular Arrhythmias

� Ventricular tachycardia✄ Broad, bizarre QRS complex

✁ Ventricular Flutter, Ventricular Fibrillation ✂ Clinically ventricular asystole

☎ ☎ ☎ ✆ ✝ ✞ ✟ ✠ ✡ ✟ ☛ ✝ ✆ ☛ ☞ ✠

Ventricular Tachycardia

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Fibrillatory waves

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

Paroxysmal Tachycardia

� Is a bout of tachycardia which begins & ends suddenly (paroxysm= a sudden outburst)

✁ A bout can last for several minutes

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

1.Paroxysmal Atrial (atrial rate= 160-220/ min) Tachycardia

2.Atrioventricular junctional Tachycardia (atrial rate= 120-200/ min)

3.Ventricular Tachycardia (ventricular rate= 140-220/ min)

Paroxysmal supraventricular Tachycardia includes Atrial & Junctional Tachycardia

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

Myocardial Ischemia

� Myocardial ischaemia -Is interruption in blood supply of heart.

✁ Irreversible changes & death of muscle cells

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ECG changes in MI

� Defect in infarcted Ecg changes in

Cells over lying leads

1.Rapid Repolarization ST seg elevation

✄ ✁ ✂ ☎ ✆ ✝ ☎ ✞ ✟ ☎ ✠ ✡ ☛ ☞ ✌ ✌

3.Delayed Depolarization ✍

✎ ✎ ✎ ✏ ✑ ✒ ✓ ✔ ✕ ✓ ✖ ✑ ✏ ✖ ✗ ✔

ECG findings in MI

Findings in ant. Infarct:

Time Changes Leads

� Hrs aft. Inf. ST ele. I,aVL & V3-6

ST dep. II,III& aVF

� Hrs to days Q wave I,aVL,&V5-6

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

✄ ✄� Weeks ---- Q wave & QS complex persists

ST seg. becomes isoelectric

T wave inverted

✁ Late years -- QS complex persists, T wave normal

✂ ✂ ✂ ☎ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ☎ ✡ ☛ ✟

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ECG✄ Ionic Changes

Hyperkalemia (✁ K+)-Dangerous & lethal

� Tall & peaked T wave

� Prolongation of QRS complex

� Paralysis of atria

� Vent. Arrhythmias

✂ RMP decreases

☎ ☎ ☎ ✆ ✝ ✞ ✟ ✠ ✡ ✟ ☛ ✝ ✆ ☛ ☞ ✠

ECG in hypokalemia

� Hypokalemia (☎ K+)-less dangerous

✁ PR interval prolonged

✁ U wave prominent

✁ T wave invertion in chest leads

✂ ✂ ✂ ✄ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ✄ ✡ ☛ ✟

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hypercalcemia

Hypercalcemia (✁ Ca++)

� Enhances myocardial contractility

� Heart stops in systole

(Clinically this level is not reached)

Hypocalcemia (☎ ✂ ✄ ++)

✆ ST seg. prolonged

✝ ✝ ✝ ✞ ✟ ✠ ✡ ☛ ☞ ✡ ✌ ✟ ✞ ✌ ✍ ☛

Effect of Sodium

� Sodium level has little effect

✁ ☎ ✂ ✄ +----Low voltage ECG

✆ ✆ ✆ ✝ ✞ ✟ ✠ ✡ ☛ ✠ ☞ ✞ ✝ ☞ ✌ ✡

ECG: Uses

� Detection of HR

✁ Ectopic focus

✁ Heart block

✁ MI

✁ Axis deviation

� Electrolyte imbalance

✁ Research

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

ECG limitation

� False negative

✁ False positive

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

HIS

Ele

ctro

gra

m

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� Cardiac Cycle

Includes various changes in heart from beat to beat

✁ Mechanical changes/cardiodynamics

✁ Electrical changes

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Events during cardiac Cycle

� Atria & ven. are two separate units connected by conducting tissue only Main events are

Atrial contraction

Atrial relaxation

Ventricular contraction

Ventricular relaxation

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Atrial cycle

� Total duration of one cycle is 0.8 sec (HR 75/mit)

✁ Atrial cycle

Atrial systole-------0.1 sec

Atrial diastole------0.7 sec

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Ventricular Diastole

� Diastole----0.5 sec

Protodiastolic phase---------0.04 sec

Isovolumic relaxation--------0.08 sec

First rapid filling--------------0.10 sec

Slow filling/ diastasis--------0.18 sec

Last rapid filling--------------0.10 sec

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Changes during cardiac cycle

Mechanical changes

� Valvular changes

� Pressure changes in

✁ Atria

✁ Ventricles &

✁ Aorta

� Volume changes in ventricles

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

sI HS AVC

SLV OPEN

II HS SLV Cl.PD 0.04 Sec

IMC 0.05 Sec

III HS AVO

IV HS

Diastasis 0.18

IMR 0.08 Sec

Last Rapid Filling 0.1 Sec

Max Ej. 0.1

Red. Ej. 0.15 Sec

First R.F.

0.10 Sec

Sec

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

I HS AVC

SLV OPEN

II HS SLV Cl.PD 0.04 Sec

IMC 0.05 Sec

III HS AVO

IV HS

Diastasis 0.18

IMR 0.08 Sec

Last Rapid Filling 0.1 Sec

Max Ej. 0.1

Red. Ej. 0.15 Sec

First R.F.

0.10 Sec

Sec

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

I HS AVC

SLV OPEN

II HS SLV Cl.PD 0.04 Sec

IMC 0.05 Sec

III HS AVO

IV HS

Diastasis 0.18

IMR 0.08 Sec

Last Rapid Filling 0.1 Sec

Max Ej. 0.1

Red. Ej. 0.15 Sec

First R.F.

0.10 Sec

Sec

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I heart Sound

Produced

EDV=135 ml

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Ventricular cycle - systole

Ventricular cycle

� Systole---------0.3 sec

Isometric/isovolumic contraction- 0.05sec

Rapid/maximum ejection---------- 0.10 sec

Reduced ejection-------------------- 0.15 sec

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Changes are in

� AV valve (atrioventricular)

Mitral (bicuspid)

Tricuspid

� Semilunar valves

Aortic

Pulmonary

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

� Heart sounds

✁ Heart Sounds✄ total 4 types I, II, III,& IV

✂ I & II heard by stethoscope

✂ III & IV picked by phonocardiography

✂ Period between I & II--Systolic period

✂ Period between II & I☎ Diastolic period

✆ ✆ ✆ ✝ ✞ ✟ ✠ ✡ ☛ ✠ ☞ ✞ ✝ ☞ ✌ ✡

I & II Heart Sounds

SYSTOlic DIASTOLIC PERIOD

ECG

� � � ✁ ✂ ✄ ☎ ✆ ✝ ☎ ✞ ✂ ✁ ✞ ✟ ✆

� I H.S.

First heart sound

Mechanism of generation:

✁ Vibrations of closing valve

✁ Turbulance of blood

✁ Vibrations of ventricular wall

Two components Mitral & Tricuspid

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Characteristics I HS

Are:

� Prolonged & soft-----Lubb

� Duration-------0.15 sec

� Frequency ---25---45 Hz

Auscultation- Best heard in Mitral & Tricuspid areas

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Auscultation- I HS

� Mitral Area (near apex beat)-Lt. V ICS

slightly inside the mid clavicular line

✁ Tricuspid Area -Lt V ICS near sternal border

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Significance

� Marks beginning of systole

✁ Duration & intensity indicates condition of myocardium & A-V valves.

✁ Proper closure of A-V valves

✁ Coincides with R wave of ECG

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Abnormalities of I HS

� Faint sound-

✁ Weak myocardium

✁ PR interval prolonged

✂ Calcific mitral stenosis

✁ Mitral incompetence

✄ Intense sound-

✂ more force of contraction

☎ ☎ ☎ ✆ ✝ ✞ ✟ ✠ ✡ ✟ ☛ ✝ ✆ ☛ ☞ ✠

� Intense sound (loud) -

✁ more force of contraction

✁ Mitral stenosis

✂ Short PR interval

✄ ✄ ✄ ☎ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ☎ ✡ ☛ ✟

� Splitting of Mitral & Tricuspid by 10 to 30 ms. is normal

✁ Split sound---- bundle branch block.

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

II HS

Mechanism of generation;

� Closure of semilunar valves

� Oscillation of Aortic & Pulmonary walls

� Oscillation of blood column in Aorta & Pulmonary artery

✁ ✁ ✁ ✂ ✄ ☎ ✆ ✝ ✞ ✆ ✟ ✄ ✂ ✟ ✠ ✝

Auscultation-II HS

� ✁ ✂ ✄ ✂ ☎ ✆ ✝ ✄ ✞ ✟ ✆ ✞ ☎ ✟ ✠ ✡ ✞ ☛ ✝ ☞ ✌ ✍ ✎ ✏

✑ Duration------0.12 sec

✑ Frequency----50 Hz.

Auscultation✒ Best at Aortic & Pulmonary

Areas

✓ Aortic Area--Rt. II ICS near the sternum

✑ Pulm. Area✔ Lt. II ICS near the sternum

✕ ✕ ✕ ✖ ✗ ✘ ✙ ✚ ✛ ✙ ✜ ✗ ✖ ✜ ✢ ✚

Splitting of -II HS

� It has two components Aortic & Pulmonary

Normal splitting

✁ During inspiration-----0.04 sec

✁ During expiration------0.02 sec

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Signifance -II HS

� Marks end of systole & beginning of diastole

✁ Clear sound indicates perfect closure of semilunar valves & there is no (incompetence)

� Coincides with end of T wave of ECG

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Applied aspects

� Intensified if Aortic or pulmonary press.

Is high

✁ Splitting in Bundle branch block

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

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III HS

� Mechanism- Vibrations of ventricular wall caused by rapidly entering blood

✁ Characteristics- Short, soft & low pitched

Duration- 0.1 sec

✁ Auscultation- Normally not heard with stethoscope, can be recorded

� Appears between T & P waves of ECG

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

IV HS

� Mechanism- Vibration caused by last rapid filling

✁ Characteristic- Short & low pitched

✁ Duration- 0.03 sec

✁ Recorded by phonocardiography

✁ Falls between end of P wave & onset of Q wave

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

Phonocardiogram

� A microphone is applied to precordium

✁ Sounds are amplified & recorded by oscillograph

✁ The record is called phonocardiogram

✂ ✂ ✂ ✄ ☎ ✆ ✝ ✞ ✟ ✝ ✠ ☎ ✄ ✠ ✡ ✞

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� Murmurs

✁ Definition- are abnormal heart sounds produced during cardiac cycle

✂ Type of murmur Abnormality

✂ Systolic - Aortic/pulmonary Stenosis

Mitral/Tricuspid Insuffi.

✂ Diastolic - Aortic/Pulmonary Insuffi. Mitral/Tricuspid Stenosis

✄ ✄ ✄ ☎ ✆ ✝ ✞ ✟ ✠ ✞ ✡ ✆ ☎ ✡ ☛ ✟

Ca

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