ARRHYTHMIA

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ARRHYTHMIA

‘ a change in a heart’s normal electrical conduction system can result in an arrhythmia or irregular heartbeat’

an arrhythmia can be an abnormally slow heartbeat or an abnormally fast heartbeat

In some cases it can be fatal . .

a.d.a.m

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E K GE K G• Definisi : Grafik Aksi Potensial Kontraksi otot

Cyclus (1 Sistole+ 1 Diastole)

• Sistem Konduksi : – SA : Pace Maker 70 - 80 x/m

– AV : 50 - 60 x/m– HIST : 30 - 40 x/m

• Depolarisasi• Repolarisasi• Polarisasi

• P - R int : 0,12 - 0,20”• QRS Compl : 0,10”• QT int : 0,40 - 0,42”• Gel P : < 0,11”

POT : <8,2 mm 1500

Menghitung HR : Jarak R-R

SA

AV - AN - N - NH

RBB

HIST

LPHB

LAHB

P

R

TU

C S

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SA nodeSA nodeSumber impuls Sumber impuls normal/ alamiah , normal/ alamiah , 60 – 10060 – 100 x/mx/m

AV nodeAV nodeBisa mengeluarkan Bisa mengeluarkan impuls 40-50x/menitimpuls 40-50x/menit

Berkas HisBerkas HisSerabut PurkinjeSerabut Purkinje

VentrikelVentrikelBisa mengeluarkan Bisa mengeluarkan impuls 30 x/mimpuls 30 x/m

definisi Aritmia…

Irama yang bukan dari SA node Irama yang tidak teratur, sekalipun

berasal dari SA node Frekuensi kurang dari 60x/menit (sinus

bradikardia) atau lebih dari 100x/menit (sinus takikardia)

Terdapatnya hambatan impuls supra atau infra ventrikular

Buku ajar IPD FK UI

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SA node merupakan fokus irama jantung yang paling dominan, sehingga pada umumnya irama jantung adalah irama sinus.

Bila SA node tidak lagi mendominasi fokus lain, maka irama jantung akan ditentukan oleh fokus lain.

Fokus irama jantung ini menjadi dasar klasifikasi aritmia.

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Mekanisme timbulnya aritmia Pengaruh persarafan autonom (simpatis dan

parasimpatis) yang berpengaruh terhadap HR SA node mengalami depresi sehingga fokus

irama jantung diambil alih fokus lain Fokus yang lebih aktif dari SA node dan

mengontrol irama jantung Nodus SA menghasilkan impuls, tapi tidak dapat

keluar (sinus arrest) atau mengalami hambatan dalam perjalanannya keluar SA node (SA block)

Terjadi hambatan perjalanan impuls sesudah keluar SA node (atrium, bundle of His, ventrikel, dll)

Buku ajar IPD FK UI

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Disturbances in automaticity : bertambah cepat atau bertambah lambatnya suatu daerah otomatisiti. Misal di sinus node, AV node, abnormal beats/ depolarisasi dari atrium, AV junction, ventrikel, dll.

Disturbances in conduction : konduksi terlalu cepat (WPW) atau terlalu lambat (blok AV).

Combinations of altered automaticity and conduction.

CAUSE OF CARDIAC ARRHYTHMIAS :

Disturbance of Rate and Rhythm1. Sinus arrhytmia, bradycardia, and

tachycardia2. Atrial Premature Beats ( Atrial Extrasystoles )3. Paroxysmal Supraventricular Tachycardia4. Supraventricular Tachycardias due to

accesory AV pathways ( Preexcitation Syndromes )

5. Atrial Fibrillation6. Atrial flutter7. Multifocal ( Chaotic ) Atrial Tachycardias8. AV Junctional Rhythm

Normal Sinus Rhythms

Each impulse starts in the sinus node and travels across the atria, down the AV node, and through the ventricles, following the same track, moving at the same speed.

As a result, P waves will appear at regular intervals. Each P wave will be followed at identical intervals by QRS complexes and T waves. Every beat will look exactly like every other beat

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Sinus Arrhythmia

Sinus arrhythmia. All the beats are identical and the intervals are normal, but the space between beats varies as the heart speeds and slows with breathing. This is a normal phenomenon.

The pulse will probably speed up as you inhale and slow as you exhale

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PSVT :PSVT :

-due to re-entry mechanism-due to re-entry mechanism-narrow QRS complex-narrow QRS complex-regular-regular-retrograde atrial depolarisation-retrograde atrial depolarisation-P wave ?-P wave ?

Important Note:

Supraventricular tachycardias don't necessarily mean heart disease: they frequently occur in patients with otherwise normal hearts, and they never threaten life. Ventricular tachycardias of the common type almost always indicate heart disease and they indicate an urgent need for careful and thorough study.

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Atrial Fibrillation :Atrial Fibrillation :

- from multiple area of re-entry within atria- from multiple area of re-entry within atria- or from multiple ectopic foci- or from multiple ectopic foci- irregular, narrow QRS complex- irregular, narrow QRS complex- very rapid atrial electrical activity (400-700- very rapid atrial electrical activity (400-700 x/min).x/min).- no uniform atrial depolarisation- no uniform atrial depolarisation

Atrial fibrillation with a rapid ventricular response (average about 200 beats). When the heart is beating this rapidly it can't fill enough between beats to pump efficiently. Congestive heart failure is the result.

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Atrial Flutter :Atrial Flutter :

-The result of a re-entry circuit within the atriaThe result of a re-entry circuit within the atria-irregular / regular QRS rateirregular / regular QRS rate-Narrow QRS complexNarrow QRS complex-Rapid P waves (300x/min), “sawtooth” Rapid P waves (300x/min), “sawtooth”

Atrial flutter with 2:1 conduction from the atria to the ventricles. The atrial rate is 300 bpm and the ventricular rate is 150bpm the most common pattern of atrial flutter.

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Junctional rhythm:Junctional rhythm:

- AV junction can function as a pace - AV junction can function as a pace maker (40-60 x/min).maker (40-60 x/min).

- due to the failure of sinus node to initiate - due to the failure of sinus node to initiate timed impulse or conduction problem.timed impulse or conduction problem.

- normal-looking QRS.- normal-looking QRS.- retrograde P wave.- retrograde P wave.- P wave may precede, coincide with, or - P wave may precede, coincide with, or

follow the QRSfollow the QRS

Extrasystoles

Everyone has them. You feel your heart skip a beat; there's an odd pause and you wonder if your heart is going to start again. What happens is that one of the ectopic pacemakers becomes irritable and fires early, when it isn't needed. The ectopic beat cuts into a normal sinus rhythm like this:

“ beat   beat   beat   beatBEAT   beat”

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18V E S

SR

shows premature beats arising in the ventricles. Note the characteristic wide, bizarre shape of the whole QRST complex compared to the shape of the normal sinus beats.

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SR SR SR SRSR SR

VES VES

Sinus rhythm with Sinus rhythm with multifocal VESmultifocal VES

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SINUS RHYTHM WITH VES SINUS RHYTHM WITH VES COUPLETCOUPLET

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SINUS RHYTHM WITH VES, R SINUS RHYTHM WITH VES, R ON TON T

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VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA•Frekuensi 120-300x/menit•Tidak ada gelombang P•Komplek QRS lebar atau lebih dari normal•Hantaran : Berasal dari ventrikel, dengan kemungkinan hantaran retrograde ke jaringan penyambung dan atrium.•Irama : Biasanya regular, tetapi dapat ireguler.

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TORSADE DE TORSADE DE POINTESPOINTES

A rapid ectopic ventricular rhythm starts after the fourth beat. The wide complexes change direction completely, from straight up to straight down and back again, like a ballerina twisting sur les pointes (on the points) of her ballet shoes. This is a dangerous variation of ventricular tachycardia and can lead to sudden cardiac death.

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VENTRICULAR VENTRICULAR FIBRILLATIONFIBRILLATION

When the ventricles fibrillate, no blood is pumped out of the heart and the victim falls instantly unconscious. The changes of death start within minutes.

Onset of ventricular fibrillation, interrupting a normal sinus rhythm. A single ventricular ectopic beat acts as the trigger, and the ventricles go into the irregular, rapid twitching recorded in the ECG

26 Prolonged PR interval

11stst DEGREE AV DEGREE AV BLOCKBLOCK

The activating impulse may take longer than normal to reach the ventricles. Instead of 0.20 second, the PR may stretch out to 0.24, 0.28, or even to extreme lengths such as 0.60 second (Fig. 12-19). In other words, in this kind of atrioventricular block, every activating impulse does reach the ventricles it just takes longer than normal doing it. This is first-degree heart block.

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Missing QRSMissing QRS Missing QRSMissing QRS

22ndnd DEGREE AV BLOCK, DEGREE AV BLOCK, TYPE 1 TYPE 1

Some of the waves may reach the ventricles, while others are completely blocked and never get there. This is called second-degree heart block

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22ndnd DEGREE AV BLOCK, DEGREE AV BLOCK, TYPE 2TYPE 2

Missing QRSMissing QRS

Complete heart block in the AV node. The narrow QRS complexes mean that the bundle branch system is functioning normally. The P waves are wandering through the tracing with no relationship to the QRS complexes. Life is maintained by an ectopic focus in the AV node.

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PP PP PP PP PP PP PP

QRSQRS QRSQRS QRSQRS

TOTAL AV BLOCK / 3TOTAL AV BLOCK / 3rdrd DEGREE DEGREE AV BLOCKAV BLOCK

Complete heart block in the AV node. The narrow QRS complexes mean that the bundle branch system is functioning normally. The P waves are wandering through the tracing with no relationship to the QRS complexes. Life is maintained by an ectopic focus in the AV node.