aritmia jantung-fk ump
TRANSCRIPT
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ARITMIA JANTUNG
Dr. dr. Taufik Indrajaya, SpPD, KKV, FINASIM
Divisi Kardiologi Departemen Penyakit Dalam
FK UNSRI / RSMH Palembang
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Tingkat Kemampuan
Tingkat Kemampuan 1
Mengenali dan menempatkan gambaran-2 klinik
sesuai penyakit ketika membaca literatur
Tingkat Kemampuan 2 Membuat diagnosis klinik berdasarkan PF dan
pemeriksaan tambahan. Mampu merujuk
secepatnya
Tingkat Kemampuan 3 3a : (2) dan memutuskan dan memberi terapi
pendahuluan, merujuk kasus bukan emergensi
3b: (3a), merujuk kasus emergensi.
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Level of Ability: 2 up to 3 B
Further reading:
1. Hursts: The Heart.
2. Harrissons. Principles of Internal
Medicine
3. Buku Ilmu Penyakit Dalam PAPDI 4. Buku Ajar Kardiologi FK UI
5. Internet, Others.
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A gooD baSic KnOwlEdge
of the heart and cardiac function
is Essentialin order
toUnderstand
the 12 lead ECG
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Anatomy
http://www.bartleby.com/107/illus499.htmlhttp://www.bartleby.com/107/illus499.htmlhttp://butler.cc.tut.fi/~malmivuo/bem/bembook/06/06x/0603x.htm -
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Cardiovascular system works ..
http://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.htmlhttp://www.mercksharpdohme.com/disease/heart/coronary_health/anatomy/cardio01.html -
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CARDIAC OUTPUT = STROKE VOLUMEx HEART RATE
Autoregulation
(Frank-Starling Law of the Heart)
Contractility
Sympathetic
Nervous System
Parasympathetic
Nervous System
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Cardiac Cycle
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Electrophysiology of The Heart
The different waveforms for each of the specialized cells.
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Schematic representation of Normal ECG
http://upload.wikimedia.org/wikipedia/en/9/9e/SinusRhythmLabels.svg -
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C P R
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TOPIK
1. Manifestasi klinik2. Penyebab aritmia
3. Kertas rekaman EKG
4. Lima jenis dasar aritmia
5. Aritmia asal sinus
6. Irama ektopik
7. Irama re-entrant
8. Empat Pertanyaan9. Artimia Supraventrikuler
10. Aritmia Ventrikel
11. Aritmia Supraventrikuler vs Ventrikuler.
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Dis- /Arrhythmias :
Disorders of the regular rhythmic beating of theheart.
Common2.2 million Americans are living with
AF (one type of rhythm problem). Can occur in a healthyheart and be of minimal
consequence.
Also may indicate a serious problemand lead to
heart disease, stroke or sudden cardiac death. The goal: ultimately reduce disability and death
from heart disease and stroke.
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Signs or Symptoms
May not cause any signs or symptoms.
A fluttering in your chest
A racing heartbeat
A slow heartbeat
Chest pain
Shortness of breath
Lightheadedness
Dizziness
Fainting (syncope) or near fainting
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Causes
Common: heart disease, high BP, DM,smoking, excessive alcohol or caffeine,drug abuse, stress
Scarringmost commonly, from aprevious heart attack disrupt theinitiation or conduction of electricalimpulses.
In a healthy person with a normal, healthyheart, a sustained arrhythmia to developcaused by outside trigger: an electricalshock or the use of illicit drugs.
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Causes ..
1. HHypoxia:Pulmonary disorders.
2. IIschemia and Irritability:
myocardial infarctions; angina,
myocarditis.
3. S
Sympathetic Stimulation:hyperthyroidism, congestive heart
failure, nervousness, exercise).
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Causes
DDrugs:Many drugs can causearrhythmias.
EElectrolyte Disturbances:
Hypokalemia, imbalances of calcium andmagnesium.
BBradycardia:to predispose to
arrhythmias ~ the sick sinus syndrome. SStretch:congestive heart failure and
valvular disease can cause arrhythmias.
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Any pre-existing structural heart condition
can lead to arrhythmia development due to:
Inadequate blood supply.
It can alter the ability of heart tissue includingthe cells that conduct electrical impulses to
function properly.
Damage or death of heart tissue.
This can affect the way electrical impulses spread
in the heart.
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These pre-existing heart conditions may
include:
Coronary artery disease (CAD).
Cardiomyopathy.
Valvular heart diseases.
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Kertas Rekaman EKG
A typical rhythm strip
It can be as short or as long as you need
to decipher the rhythm.
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ECG Paper
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A systematic and complete approach
Check the patient details - correctly labelled? What is the rate?
Is this sinus rhythm? If not, what is going on?
What is the mean frontal plane QRS axis?
Are the P wavesnormal (look at II and V1) What is the PR interval?
Are the QRS complexesnormal?
Are the ST segmentsnormal, depressed orelevated?
Are the T wavesnormal? What is the QTinterval?
Are there abnormal U waves?
http://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htmhttp://www.anaesthetist.com/icu/organs/heart/ecg/index.htm -
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Heart Rate ( Regular Rhytm )
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Heart Rate ( Irregular Rhytm ) ..
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Principles of Rhythm Analysis
The standard 12-lead ECG and Rhythm
strips are the most easily accessible tools
for the diagnosis of a cardiac rhythm
disturbance.
Recognition of the P-waveand QRS
morphologyand their relative timing may
be the only information needed to
diagnose the arrhytmia correctly.
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The Five Basic Types of Arrhytmias
The heart is capable of only five basic types ofrhythm disturbances:
1. Arrhythmias of sinus origin.
2. Ectopic rhythms: focus other than the sinus.3. Re-entrant arrhytmias.
4. Conduction blocks (another chapter).
5. Preexcitation syndromes ~ accessoryconduction pathways that bypass the normal
ones, providing an electrical shortcut, or short
circuit : WPW (another chapter).
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(A) Sinus tachycardia.
(B) Sinus bradycardia.
Aritmia Asal Sinus
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Sinus arrhythmia. The heart rate
accelerates with inspiration and slows with
expiration.
Sinus arrhythmia.
The heart rate accelerates with inspiration and slows with expiration
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Sinus arrest occurs after the fourth beat.
The fifth beat, restoring electrical activity to theheart, is a junctional escape beat. Note the
absence of a P wave before this last beat.
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Non Sinus Pacemakers
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Junctional escape. The first two beats are normal sinus beats with a normal P
wave preceding each QRS complex.
There is then a long pause followed by a series of threejunctional escape beats occurring at a rate of 40 to 45 beats
per minute.
(A) N l i
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(A) Normal sinusrhythm.
(B) Sinus arrest.
The sinus nodefalls silent. Nocurrent isgenerated
The EKG showsno electricalactivity.
(C) Sinus exit block.
The sinus nodecontinues to fire,but the wave ofdepolarizationfails to exit thesinus node intothe atrialmyocardium.
EKG shows noelectrical activity.
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Irama Ektopik
(A) Normally, the sinus node drives the heart.
(B) e.g.,the AV junction
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Irama Re-entrant
(1) Normally,pathwaysAand B(any two adjacentregions of cardiacfunction) conductcurrent equallywell.
(2) Here, however,
conduction throughpathway Bistemporarily slowed.Current passingdownAcan then
turn back andconduct in aretrograde fashionthrough B.
(3) The reentry loop is
established.
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Normal sinus rhythm and
The Four Questions answered.
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The Four Questions
1. Are normal P waves present ?
2. Are the QRS complexes narrow or
wide ?3. What is the relationship between the
P waves and the QRS ?
4. Is the rhythm regular or irregular ?
A it i S t ik l
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(A) The third beat is an atrial premature beat.
(B) The fourth beat is ajunctional premature beat. Thereis no P wave preceding the premature QRS complex.
Aritmia Supraventrikuler
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The third beat is an atrial premature beat.
The P wave is shaped differently from the other,somewhat unusual-looking P waves, and thebeat is clearly premature.
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(A)A junctional premature beat. .
(B)The third beat is a junctional escape beat
PSVT in 3 different
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PSVT in 3 different
Patients :
A~ simultaneous
activation of the atriaand ventricles; theretrograde P wavesare lost in the QRScomplexes.
B~ a SVT mimicking amore serious rhythmcalled VT.
C here,retrograde Pwaves can be seen.
D ~Pseudo-Rconfigurationin leadV1 representing theretrograde P waves(arrows) of PSVT.
(E) The AV node isusually the site of thereentrant circuit thatcauses the arrhythmia.
RegularP waves are retrograde if
visible
Rate 150-250 bpm
Carotid massage slows or
terminates
PSVTIts onset is sudden,
Initiated by a premature
supraventricular beat,
its termination is just as
abrupt.
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The carotid sinus
contains baroreceptors
that influence vagal
input to the heart,primarily affecting the
sinus node and AV
node.
Stimulation of the rightcarotidbaroreceptorsprimarily stimulatessinus node vagal input.
Stimulation of the leftcarotidbaroreceptors ismore likely to affect thevagal input to the AVnode
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An episode of PSVT is broken almost at once bycarotid massage.
The new rhythm is a sinus bradycardia with arate of 50 beats per minute.
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Atrial flutter.
Carotid massage increases the block from 3:1 to
5:1.
Regular, saw toothed
2:1, 3:1, 4:1 etc block
Atrial rate 250-350 bpm
Ventricular rate , 1/3,
etc of atrial rate
Carotid massage:
increases block !!
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Atrial fibrillation
Another example of atrial fibrillation. In the absence ofa clearly fibrillating baseline, the only clue that thisrhythm is atrial fibrillation is the irregularly irregular
appearance of the QRS complexes.
Irreguler
Undulating baseline
Atrial rate 350-500 bpm
Ventricular rate : variable
Carotid massage: may slow ventricular rate !!
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Paroxysmal Atrial Tachycardia.
P waves are not always visible, but here they can be seen easily.
Notice the varying distance between the P waves and the ensuingQRS complexes; this reflects a varying conduction delay betweenthe atria and ventricles that often accompanies PAT.
Regular
Rate 100-200 bpm
Characteristic warm up period in automatic form
Carotid massage :no effect, or only mild slowing
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Aritmia Ventrikel
(A) A premature ventricular contraction.
(B) Bigeminy. PVCs and sinus beatsalternate in a 1:1 fashion.
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(A)Beats 1 and 4 are sinus in origin. The otherthree beats are PVCs (multiform).
(B)A PVC falls on the T wave of the second sinusbeat, initiating a run of VT.
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Ventricular tachycardia.
The rate is about 200 bpm.
A run of three or more
consecutive PVCs
Rate 120-200 bpm
Unlike PSVT, may be
slightly irregular
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Ventricular tachycardia degenerates into
ventricular fibrillation( VF ).
No true QRS complexes
No cardiac output
Need CPR and DC
B i h th
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Accelerated idioventricular rhythm.
There are no P waves, the QRS complexes are
wide, and the rate is about 75 beats per minute.
Benign rhythm
Regular
50-100 bpm
< 50 bpm called Idioventricular rhytm
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Torsades de pointes.
The QRS complexes seem to spin around thebaseline, changing their axis and amplitude
= Twisting of the Point
In pt with Prolong QT interval
Congenital or electrolit imbalance
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SUMMARY : Ventr icu lar A rrhy thm ias
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Rules of Malignancyfor PVCs :
1. Frequent PVCs
2. Consecutive PVCs3. Multiform PVCs
4. R-on-T phenomenon
5. Any PVC occurring during an AMI(or in any patient with underlying
heart disease)
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The heart rate of a 72-year-old woman isrescued from VT by a shock delivered by
an implantable cardioverter-defibrillator.
P ibl it f d ti bl k
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Possible sites for conduction block
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Sinoatrial (SA) block
Sinus rhythm for three beats, then a 'sinus pause' P waves arrowed
The expected P wave is not seen, but the SA node must
have been depolarized because the next P wave
appears at the predicted time
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Any rhythm other than sinus rhythm is
called an 'arrhythmia'.
The term 'dysrhythmia' - which means
essentially the same thing
Properly speaking,
conduction disorders are not
arrhythmias.
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RBBB
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RBBB
Sinus rhythm with a normal PR interval
RSR1 pattern in V1
The dominant R wave is characteristic of RBBB, and does not
indicate RV hypertrophy
Wide and slurred S wave in V6
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LBBB
Sinus rhythm
Broad QRS complexes with notch in the R wave in I, VL, V5, V6
Inverted T waves are associated with bundle branch block, and
have no other significance.
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ECG Interpretation
A mystery?
An enigma?
Confusing?
Difficult?
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ECG INTERPRETATION
If the normal
ECG is knowntheninterpretation
of abnormalsbecomeseasier
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Summary
This Module introduced you to:
Abnormal ECG : ARRHYTMIA
Dont worry too much right now about
trying to remember all the details.
Youll focus more on advanced ECG
interpretation inyour clinical years !!
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Thanks forattention
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