kuliah 3 gangguan irama jantung

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GANGGUAN IRAMA JANTUNG

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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)

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• 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

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• 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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• 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).

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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

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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

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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.

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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 FibrillationLone” Atrial Fibrillation Absence of identifiable cardiovascular, pulmonary, or associated systemicAbsence of identifiable cardiovascular, pulmonary, or associated systemic

diseasedisease

Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham Study)Study)11

In one series of patients undergoing electrical cardioversion, 10% had In one series of patients undergoing electrical cardioversion, 10% had lone AF.lone AF.22

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

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

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Symptoms and Signs Atrial Fi Symptoms and Signs Atrial Fi brillationbrillation

PalpitationsPalpitationsPresyncopePresyncopeFatigueFatigue

Chest painChest painDyspneaDyspneaSyncopeSyncope

Signs:•Irregularly irregular pulse•Raised JVP/Absent ‘a’ Waves•Cardiomegaly•RA dilatation•Valvular disease

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Control of Ventricular Rate in Control of Ventricular Rate in Atrial FibrillationAtrial Fibrillation

DigoxinDigoxin

Calcium channel blockersCalcium channel blockers

Verapamil, diltiazemVerapamil, diltiazem

Beta blockersBeta blockers

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Medication for Rate Control in Atrial Medication for Rate Control in Atrial FibrillationFibrillation

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

Agent ActionImmediate

IV dose

Oralmaintenance

therapy Avoid use in

DigoxinDigoxin CardiacCardiac 0.5 mg +0.5 mg + 0.125-0.5 mg/day;0.125-0.5 mg/day; WPW, HCMWPW, HCMglycosideglycoside 0.25 mg in 4-6 h +0.25 mg in 4-6 h + renalrenal0.25 mg in 4-6 h0.25 mg in 4-6 h

DiltiazemDiltiazem CalciumCalcium 20 mg (or 25-3520 mg (or 25-35 120-360 mg/day;120-360 mg/day; WPW, constipation,WPW, constipation,channelchannel mg/kg) over 2 minmg/kg) over 2 min hepatic hepatic peripheral edema,peripheral edema,blockerblocker + 2nd bolus+ 2nd bolus CHF CHF allowed afterallowed after 20 min + 5, 10,20 min + 5, 10,15 mg/h infusion15 mg/h infusion

VerapamilVerapamil CalciumCalcium 5-10 mg every5-10 mg every 120-240 mg/day;120-240 mg/day; Same as diltiazem,Same as diltiazem,channelchannel 30 min or 5 mg/h30 min or 5 mg/h hepatic hepatic risks with CHF risks with CHF blockerblockerpossibly greaterpossibly greater

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Medication for Rate Control in Atrial Medication for Rate Control in Atrial FibrillationFibrillation

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

Agent ActionImmediate

IV dose

Oralmaintenance

therapy Avoid use in

Propranolol ß-blocker 0.5-1.0 mg every 40-320 mg/day; Bronchospastic5 min up to 5 mg hepatic lung disease,total CHF

Metaprolol ß-blocker 5 mg every 5 min 50-200 mg/day; Same asup to 15 mg total hepatic propranolol

Esmolol ß-blocker 0.5 mg/kg/min None Same asload over 1 min propranolol + 0.05-0.3 mg/kg/min

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Ventricular ArrhythmiaVentricular Arrhythmia

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Ventricular TachycardiaVentricular Tachycardia An irritable focus in theAn irritable focus in the ventricles fires regularly at a rate of 150-250 ventricles fires regularly at a rate of 150-250

beats per minute beats per minute to override higher sites for control of the heart. to override higher sites for control of the heart. Regularity:Regularity: This rhythm is usually regular, although it can be slightly This rhythm is usually regular, although it can be slightly

irregular. irregular. Rate:Rate: Atrial rate cannot be determined. The ventricular rate range is Atrial rate cannot be determined. The ventricular rate range is

150-250 beats per minute. 150-250 beats per minute. If the rate is below 150 bpm, it is considered If the rate is below 150 bpm, it is considered a slow VTa slow VT. If the rate exceeds 250 bpm, its called Ventricular Flutter. . If the rate exceeds 250 bpm, its called Ventricular Flutter.

P Wave:P Wave: None of the QRS complexes will be preceded by P waves; you None of the QRS complexes will be preceded by P waves; you may see dissociated P waves intermittently across the strip. may see dissociated P waves intermittently across the strip.

PRI:PRI: Since the rhythm originates in the ventricles, there will be no PRI. Since the rhythm originates in the ventricles, there will be no PRI. QRS:QRS: The QRS complexes will be wide and bizarre, measuring at The QRS complexes will be wide and bizarre, measuring at

least .12 seconds. It is often difficult to differentiate between the QRS least .12 seconds. It is often difficult to differentiate between the QRS and the T wave.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 PENANGGULANGAN ARITMIA VENTRIKELVENTRIKEL

• 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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KELUHAN PENDERITA

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DIAGNOSIS TAHAP AWAL

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DIAGNOSIS TAHAP LANJUT

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NILAI PROGNOSTIK ARITMIA NILAI PROGNOSTIK ARITMIA VENTRIKELVENTRIKEL

Arti klinis aritmia ventrikel Arti klinis aritmia ventrikel tergantung padatergantung pada

A.Penyebabnya:mempunyai nilai A.Penyebabnya:mempunyai nilai prognostik sendiriprognostik sendiri

B.Frekuensi dan kompleksitasnyaB.Frekuensi dan kompleksitasnya

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1.KLASIFIKASI ARITMIA 1.KLASIFIKASI ARITMIA VENTRIKELVENTRIKEL

A.Denyut ventrikel prematur : bbrp A.Denyut ventrikel prematur : bbrp kategori.(ekstra sistole),menurut kategori.(ekstra sistole),menurut berat rngannya dibagi bbrp kategori.berat rngannya dibagi bbrp kategori.

B.Takhikardi Ventrikel tdk tetapB.Takhikardi Ventrikel tdk tetap C.Takhikardi Ventrikel tetapC.Takhikardi Ventrikel tetap

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A.Denyut Ventrikel PrematurA.Denyut Ventrikel Prematur Ekstra sistole ventrikel,kompleks Ekstra sistole ventrikel,kompleks

Ventrikel prematur.Ventrikel prematur. Aritmia ini ,menurut berat ringannya di Aritmia ini ,menurut berat ringannya di

bagi lagi atas beberapa kategoribagi lagi atas beberapa kategori Secara umum ekstra sistole yg sering Secara umum ekstra sistole yg sering

terjadi,tetapi tidak berlandaskan terjadi,tetapi tidak berlandaskan penyakit jantung tertentu,prognosis penyakit jantung tertentu,prognosis nya baik dan resiko mati mendadak nya baik dan resiko mati mendadak kecilkecil

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KLASIFIKASI ARITMIA VENTRIKELKLASIFIKASI ARITMIA VENTRIKELDenyut ventrikel prematur,menurut berat ringannya dibagi:Denyut ventrikel prematur,menurut berat ringannya dibagi:

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B.TAKIKARDI VENTRIKEL(TV) B.TAKIKARDI VENTRIKEL(TV) TIDAK MENETAPTIDAK 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 TETAPC.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 2.PEMBAGIAN BERDASAR Hirarki Frekuensi dan BentukFrekuensi dan Bentuk

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PENYAKIT JANTUNG YG PENYAKIT JANTUNG YG MENJADI LANDASAN MENJADI LANDASAN

• 1.Penyakit jantung koroner• 2.Kardiomiopati Kongestif• 3.Kardiomiopati Hipertropik• 4.Prolaps Katup Mitral

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1.Penyakit Jantung Koroner1.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.

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Atherothrombosis: a Atherothrombosis: a Generalized and Progressive Generalized and Progressive

ProcessProcess

NormalFattystreak

Fibrousplaque

Athero-scleroticplaque

Plaquerupture/fissure &

thrombosis MI

Ischemicstroke/TIA

Critical leg ischemia

Clinically silent

Cardiovasculardeath

Increasing age

Stable anginaIntermittent claudication

Unstableangina }ACS

ACS, acute coronary syndrome; TIA, transient ischemic attack

Normal Fatty StreakNormal

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2.KARDIO MIOPATI KONGESTIF2.KARDIO MIOPATI KONGESTIF

• ESV derajad tiggi sering dijumpai terutama bila disertai dg payah jantung.

• Aritmia ini meninggikanresio mati mendadak

404040 of 48

CardiomyopathyCardiomyopathy

Nursing Review, 2001Dilated/Congestive

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3.KARDIO MIOPATI 3.KARDIO MIOPATI HIPERTROFIKHIPERTROFIK

TV yg menetap,merupakan faktor resiko TV yg menetap,merupakan faktor resiko mati mendadak pada kelainan ini.mati mendadak pada kelainan ini.

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42 of 48

Functional ClassificationFunctional ClassificationDilated (Congestive, DCM, IDC)Dilated (Congestive, DCM, IDC)

Ventricular dilation, hypokinetic left ventricle, and systolic Ventricular dilation, hypokinetic left ventricle, and systolic dysfunctiondysfunction

Hypertrophic (IHSS, HCM, HOCM, ASH)Hypertrophic (IHSS, HCM, HOCM, ASH) Inappropriate myocardial hypertrophy, with or without left Inappropriate myocardial hypertrophy, with or without left

ventricular obstructionventricular obstructionRestrictive (Infiltrative)Restrictive (Infiltrative)

Abnormal ventricular filling with diastolic dysfunctionAbnormal ventricular filling with diastolic dysfunctionArrhthymogenic Right Ventricular (ARVD)Arrhthymogenic Right Ventricular (ARVD)

Fibroadipose replacement of right ventricleFibroadipose replacement of right ventricle

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4.Prolaps Katup Mitral4.Prolaps Katup MitralWalau jarang,dapat terjadi TV yg Walau jarang,dapat terjadi TV yg menetap dan dapat mati mendadakmenetap dan dapat mati mendadak

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Valves of the HeartValves of the Heart

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Management(Pengobatan)Vaughan Williams classification Management(Pengobatan)Vaughan Williams classification of antiarrhythmic drugsof antiarrhythmic drugs

Class IClass I: : block sodium channels block sodium channels Ia (quinidine, procainamide, Ia (quinidine, procainamide,

disopyramide) disopyramide) Ib (lignocaine) Ib (lignocaine) Ic (flecainide) Ic (flecainide)

Class IIClass II: : ß-adrenoceptor ß-adrenoceptor antagonists (atenolol, sotalol)antagonists (atenolol, sotalol)

Class IIIClass III:: prolong action prolong action potential and prolong refractory potential and prolong refractory period (suppress re-entrant period (suppress re-entrant rhythms) (amiodarone, sotalol)rhythms) (amiodarone, sotalol)

Class IVClass IV:: Calcium channel Calcium channel antagonists. Impair impulse antagonists. Impair impulse propagation in nodal and propagation in nodal and damaged areas (verapamil)damaged areas (verapamil)

Phase 4

Phase 0

Phase 1

Phase 2

Phase 3

0 mV

-80mVII

I III

IV

4646

PENGOBATANPENGOBATAN

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DASAR PENGOBATAN ARITMIA DASAR PENGOBATAN ARITMIA VENTRIKELVENTRIKEL

Paradoks tentang resiko pro aritmia yg mungkin lebih berbahaya dari Paradoks tentang resiko pro aritmia yg mungkin lebih berbahaya dari pada aritmianya sendiri ikut menambah konflik antara “perlu” dan pada aritmianya sendiri ikut menambah konflik antara “perlu” dan “urgensi”pengobatan aritmia ini.“urgensi”pengobatan aritmia ini.

Pengobatan hendknya secara individual,tidak ada pedoman yg berlaku Pengobatan hendknya secara individual,tidak ada pedoman yg berlaku untuk semua kasus.untuk semua kasus.

Prinsip ada 2 alasan unt mengobati,Prinsip ada 2 alasan unt mengobati, A.Keluhan yg mengganggu pola hidupA.Keluhan yg mengganggu pola hidup

B.Denyut ventrikel prematur derajad tinggi yg mempunyai nilai B.Denyut ventrikel prematur derajad tinggi yg mempunyai nilai prognostik.prognostik.

Penderita tanpa kelainan organik:bila keluhan menetap,meskipun Penderita tanpa kelainan organik:bila keluhan menetap,meskipun telah diyakini,bahwa tidak ada gangguan jantung berat.hendaknya telah diyakini,bahwa tidak ada gangguan jantung berat.hendaknya diobati dg obat yg paling ringan.diobati dg obat yg paling ringan.

Penghambat reseptor beta dosis kecil dianjurkan sg pilihan pertamaPenghambat reseptor beta dosis kecil dianjurkan sg pilihan pertama

4848

DASAR PENGOBATAN ARITMIA DASAR PENGOBATAN ARITMIA VENTRIKELVENTRIKEL

Payah jantung kongesti berat:apapun Payah jantung kongesti berat:apapun sebabnya,umumnya disertai ESV derajat sebabnya,umumnya disertai ESV derajat tinggi,dg resiko mati mendadak.tinggi,dg resiko mati mendadak.

Amiodaron mrpakan obat efektif.Amiodaron mrpakan obat efektif.Pada penelitian pengobatan ACE inhibitor Pada penelitian pengobatan ACE inhibitor

menunjukkan hasil yg bagus bagi payah menunjukkan hasil yg bagus bagi payah jantungnya sendiri dan ekstra sistole jantungnya sendiri dan ekstra sistole ventrikuler.ventrikuler.

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SummarySummary Anti-arrhythmic drugs are classified by their Anti-arrhythmic drugs are classified by their

effect on the cardiac action potentialeffect on the cardiac action potential Not all drugs fit this classificationNot all drugs fit this classification In clinical practice treatment of arrhythmias is In clinical practice treatment of arrhythmias is

determined by the type of arrhythmia (SVT, VT) determined by the type of arrhythmia (SVT, VT) and clinical condition of the patientand clinical condition of the patient

Anti-arrhythmic drugs are efficacious but may Anti-arrhythmic drugs are efficacious but may have serious adverse effectshave serious adverse effects

Not all arrhythmias are treated with drug Not all arrhythmias are treated with drug therapy alonetherapy alone

Eff:mnjur

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THE END

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TER MATER MA KAS HKAS H

JAUHILAH TABIAT MEROKOK

SEKIRANYA ANDA MENYAYANGI

DIRI DAN KELUARGA ANDA

kuliah 3 gangguan irama jantung

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