kuliah ekg aritmia
TRANSCRIPT
Introduksi AritmiaDiagnosis dan Penatalaksanaan aritmia
Peranan EKG
DR., dr., Muhammad Munawar SpJP, FACC, FESC, FSCAI
Divisi Aritmia
Departemen Kardiologi dan Kedokteran Vaskular
FKUI,, Jakarta
Sejarah berkenaan EKG• Einthoven yang pertama merekam EKG pada manusia• EKG saat ini 12 lead, 3 bipolar limb lead, 3 unipolar limb lead, 6
unipolar precordial lead• Holter monitor• Exercise electrocardiography• His bundle electrocardiography• Late potential• Heart rate variability• Interventional electrophysiology
– Device therapy– Catheter ablation
Prinsip EKG permukaan• Rekaman aktivitas listrik jantung, dari SA
node, internodal pathway, otot atrium, AVN, his-P, otot ventrikel
Filosofi EKG
• EKG yang normal, belum tentu jantungnya normal
• Sebaliknya EKG yang abnormal, belum tentu pada jantung yang abnormal
Tujuan merekam EKG
• Analisis morfologi P-QRS-T– hipertrofi atrum (ka dan ki)
– hipertrofi ventrikel (ka dan ki)
– miokardial iskemi dan infark
– intraventricular conduction defect
– gangguan elektrolit
– perikarditis dll
• Analisis aritmia– menganalisis hubungan P dan QRS
– bradikardia
– takikardia
Holter monitoring
• Rekaman EKG dalam periode tertentu (biasanya 24 jam)– Menentukan iskemi– Analisis ada tidaknya aritmia– Analisis sinkope– Evaluasi intervensi
Diagramatic of the mechanisms of SVT and VT
Atrial fibrillation
Atrial flutter
AVRT AVNRT
V Tach
V Fibrillation
SNRT
AT
JT
TACHYCARDIA
AVNRT mechanism
AVNRT
Treatment strategies of AVNRT
PharmacologicalAcute Tx (Adenosine iv, Verapamil iv)Chronic Tx (Verapamil, Betablocker, Digoxin)
Non-pharmacology1980’s sharp dissection or cryosurgical modificationHis bundle ablation using DC shockRadiofrequency catheter ablation
Accessory pathway (AP)Conduction can be antegrade or retrograde
Preexcitation (WPW): antegrade conduction which shows on ECG as delta waveConcealed AP: Retrograde conduction only with normal ECG (no delta wave)
AV Reentrant Tachycardia
Delta wave +Delta wave -Delta wave +
AP
AV Reentrant Tachycardia
Accessory pathwayRight sided AP can be challenging
More area around TV than MV10% of R AP’s have Ebstein’s anomalyMultiple APsAcute angle of attachment of TV annulus
Left sided APs have different challengesUsually easier to achieve stable catheter contactCS catheterApproach (transeptal or retrograde via aorta)
Wolf-Parkinson-White syndrome
•Delta wave•QRS lebar•PR interval pendek•Secondary ST-T wave change
AVRT
Management of AVRT (accessory pathway)
• A. Pharmacological treatment– Acute phase
• AVRT (ortho and antidromic)– Adenosine iv, verapamil iv
• Bystander (AF & access. P)– DC cardioversion + drug, class III
– Digitalis is contraindicated
– Long-term• Verapamil, Digitalis, Diltiazem, Betablockers• Class III
Management of AVRT (accessory pathway) (cont’d) 1
• Non-pharmacological– Surgery, now is very limited– Catheter ablation
• RF energy
• safe and effective
• high success rate
• very low morbidity and mortality
Management of AVRT (accessory pathway)
Atrial fibrillation
Atrial fibrillation and WPW
ATRIAL FIBRILLATION
I
II
III
V1
V2
V6
ATRIAL FLUTTER
II
HAL
MAL
LAL
MPL
LPS
MPS
HPS
MCS
DCS
HAL
MAL
LAL LPS
MPS
HPS
MCS
DCS
Approaches to Treatment Any or all may apply
• Anticoagulation (acute and chronic)
• Ventricular rate control
• Maintenance of sinus rhythm
I
II
III
aVR
aVL
aVF
v1
v2
v3
v4
v5
v6
VENTRICULAR TACHYCARDIA
Torsade de pointes
Ventricular fibrillation
Management Malignant Ventricular arrhythmia
• Pharmacological– Class I– Class III– Class II, Beta blocker
• Non-pharmacological– Surgical arrhythmias– Catheter ablation– Device : AICD
Bradycardia
• Gangguan AV node– Derajat satu– Derajat dua– Derajat tiga
• Gangguan SA node– SA block– SA arrest
• Vasovagal syncope
Gangguan SA node
Blok AV derajat 1
Blok AV derajat 2
Blok AV derajat 3
VVI– Single chamber ventricular pacing
–
VVIR– Single chamber ventricular pacing with rate response
–
AAI– Single chamber atrial pacing
–
AAIR– Single chamber atrial pacing with rate response
–
DDD– Dual chamber pacing with atrial tracking (ie. RR)
–
Kesimpulan
• EKG pemeriksaan yang sangat sederhana, sangat mobile, segera didapatkan hasil dan sangat bermanfaat di bidang kardiologi
• EKG hanya sebagai alat bantu diagnosis
• Sebagian besar aritmia dapat didiagnosis berdasarkan EKG
• Semua dokter umum seyogyanya menguasai EKG