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    Aritmia Cordis

    Yudistira Panji Santosa

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    Important aspects in understanding arrhythmias1. The mechanism:

    - problems of impulse formation(automaticity)

    - problems of impulse conduction (block orreentry)

    2. The site of origin: - supraventricular

    - ventricular

    I

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    The parts of Supraventricular and Ventricular Areas

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    Sino-atrialnode (SAnode)

    Atrio-ventricularnode (AV node)

    Left bundlebranch

    Right bundlebranch

    Hisbundle

    Purkinje

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    (SAN

    )

    (AVN)

    ()

    (H)

    RA

    LA

    V

    V

    SAN

    LA

    H

    V

    RA

    AVN

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    !"#HAN$S! AN%R!AL $!P&LS'%R!A$%N

    * +e,ressed

    autoaticit.

    /* "nhanced

    autoaticit.

    0* riggered

    autoaticit.

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    +e,ressed autoaticit.

    $ntrinsic

    rate

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    "nhanced autoaticit.

    Atrial or junctional or ventricular

    rate e2ceed sinus rate(tach.cardia)

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    A #

    + "

    riggered activit.

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    AVR

    AVNR-t.,ical

    - at.,ical

    R"-"NR3

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    Ventricular as.stole

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    Sinus tach.cardia

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    Sinus tach.cardia

    normal physiologic response to exerciseor emotional stress or may bepharmacologically induced by such drugs

    as epinephrine, ephedrine, or atropine. Exposure to alcohol, cafeine, or nicotine. Persistence o sinus tachycardia usually

    signals an underlying disorder such asheart ailure, pulmonary embolism,hypo!olemia, or hypermetabolic states"

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    Preature Atrial $,ulsesAtrial e2tras.stoles or ,reature atrial

    contractions (PA#s)

    #ound in normal indi!iduals$ myocardial ischemia,rheumatic heart disease, myopericarditis, congesti!eheart ailure, and a !ariety o systemic abnormalitiesincluding acid%base&electrolyte disturbances and

    pulmonary diseases. Cafeine, tobacco, or alcohol use as 'ell as

    emotional stress may initiate or exacerbatepremature atrial contractions.

    Asymptomatic patients 'ith no underlying heartdisease re(uire no treatment other than remo!al othe underlying or precipitating actors.

    ) patients are symptomatic, beta%adrenergic

    bloc*ing agents may pro!ide relie.

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    su,raventricular tach.cardia (SV)

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    Su,raventricularach.arrh.thias

    All tachyarrhythmias that originate abo!ethe biurcation o the bundle o +is

    he atrial rate must be - or more beats

    per minute or a diagnosis, but the!entricular

    rate may be less 'hen A/ conduction isincomplete.

    classi0ed asparoxysmal (lasting secondsto hours), persistent (lasting days toweeks), or chronic (lasting weeks to

    years).

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    AN$ARRH3H!$# +R&4S

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    AN$ARRH3H!$# +R&4S

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    V"NR$#&LARA#H3#AR+$A

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    Ventricular tach.cardia

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    Ventricular tach.cardia and the diagnostic signi5cance of

    ventricular e2tras.stole

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    V is triggered b. 6R on 7 ventricular,reature beat

    6R on7

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    AR$AL 'L&"R

    broad, atrial de1ections23#4 or 1utter'a!es2'hich ha!e a sa'toothcon0guration in leads )), ))), and a/#.

    t'o types o atrial 1utter5 type ), orclassic, and type )) ype ) 1utter can be entrained and

    interrupted 'ith atrial pacing

    techni(ues.)t has an atrial rate o 67 to86 per minute ype )) 1utter has an atrial rate aster

    than 89 per minute and cannot be

    terminated by pacing

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    usual atrio!entricular conduction ratio is 65- or95-

    :ost commonly it is associated 'ith some ormo chronic heart disease, such as !al!ular

    disease, congenital heart disease, orcardiomyopathy

    reatment o choice in hemodynamicallycompromising atrial 1utter is lo' energy - to;

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    AR$AL '$R$LLA$%N

    disorgani=ed atrial de1ections and anirregular A/ conduction se(uenceresulting in a grossly irregular pattern o

    the >?S complexes. Atrial 0brillatory 'a!es are best seen in

    standard lead /- and are usually e!identin )), ))), and a/#.

    Atrial 0brillation occurring in the absenceo structural heart disease is called loneatrial fbrillation

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    Atrial 5brillation 8ith controlled ventricular res,onse*

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    Signi0cant mitral or aortic !al!e disease,hypertension, coronary artery disease,cardiomyopathy, atrial septal deect, andmyopericarditis are all disease processesre(uently associated 'ith atrial0brillation.

    Pulmonary emboli and thyrotoxicosis are'ell%*no'n causes o atrial 0brillation.

    Consumption o cofee, tobacco, oralcohol and extreme stress or atigue alsopredispose to atrial 0brillation.

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    )n the absence o underlying heartdisease, rest, sedation, and treatment'ith digitalis is the treatment o choice

    or short paroxysms. Chronic therapy is based on the need to

    control the !entricular rate duringrecurrences and may be accomplished

    'ith digitalis, beta bloc*ers, or calciumchannel bloc*ers, as described or atrial1utter.

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    'irst ",isode of Atrial 'ibrillation Paro2.sal Atrial 'ibrillation Persistent Atrial 'ibrillation #hronic Atrial 'ibrillation

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    Anticoagulant in A'

    anticoagulation is to limit the morbidityand mortality rom systemic andpulmonary emboli=ation

    he decision

    the balance bet'een therelati!e ris* o an embolic e!ent !ersusthe ris* o a major bleeding complicationsecondary to anticoagulant therapy

    )nternational @ormali=ed ?atio )@?" o6. to 8..

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    V"NR$#&LARARRH3H!$AS

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    he 9RSco,le2 in

    ventriculararrh.thia

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    he,,rearanceof the 9RSco,le2 in

    ventriculare2tras.stole

    a,,earance

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    a,,earanceof

    e2tras.stole

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    : /:

    #o,lete co,ensator. ,ause

    ;unctional

    interference

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    $ntraventricularinterference

    'usion beat

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    Ventricular 'ibrillation

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    Coarse !entricular 0brillation

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    #ine !entricular 0brillation 3coarse4 asystole"

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    RA+3ARRH3H!$AS

    Sinus radycardia Sic* Sinus Syndrome #irst%Begree Atrio!entricular loc* Second%Begree Atrio!entricular loc* Complete Atrio!entricular loc*

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    'irst-degree AV block* he PR interval is ,rolonged to

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    Second-degree AV block t.,e $

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    Second-degree AV block t.,e $$*

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    hird-degree AV block occuring at level of AV node*

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    i i i i

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    +iagnostic criteriafor bundle branch blocks

    #o,lete left bundle branchblock

    >?S duration -6 msec road, notched ? 'a!es in lateral

    precordial leads /;and /D" and usully

    leads ) and a/l Small or absent initial r 'a!es in right

    precordial leads /-and /6" ollo'ed by

    deep S 'a!es Absent se tal 'a!es in let%sided leads

    +i i i i

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    +iagnostic criteriafor bundle branch blocks

    #o,lete right bundle branch block >?S duration -6 msec

    road, notched ? 'a!es rsr, rs?, orrS?" pattern in right precordial leads /-

    and /6"

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    +i ti it i

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    +iagnostic criteriafor unifascicular blocks

    Left anterior fascicular block #rontal plane mean >?S axis5 %9; to %F

    degrees 'ith rS patterns in lead )), ))) and

    a/ and a (? pattern in lead a/l >?S duration less than -6 msec

    Left ,osterior fascicular block #rontal plane mean >?S axis5 G -6

    degrees rS pattern in leads ) and a/l 'ith (?

    patterns in inerior leads

    >?S duration o less than -6 msec

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    rite= co,lete R= LA+=

    nterior fasicular heiblock (ifasicular bloc

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    Pocket Guide To Basic Dysrhythmias 3rdEd . Robert J Huszar

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    hank 3ou