心律失常arrhythmia

CardiacArrhythmia--BradycardicArrhythmiaHuGangyingDepartmentofCardiologyRenminHospitalofWuhanUniversityEducationAimsandRequirementsMasterEtiologyManifestationDiagnosisTherapeuticPrinciplesAimsandRequirementsTobefamiliarwithTheelectrocardiogramcharacterDiagnosisofarrhythmiaTounderstandThemechanismofarrhythmiaSinusatrianodalInternodalbunchAtriaventricularnodalHisbunchLeftandrightbundlePurkinjefibersComponentsofconductionsystem(inorder)Generaldiscription•Anatomyofcardiacconductionsystem心脏传导系统示意图浦肯野氏纤维BloodsupplySinusNode•10to20mmlong,2to3mmwide•liesatthejunctionofthesuperiorvenacavaandrightatrium•Thearterysupplyingfromtheright(55to60%ortheleftcircumflex(40to45%coronaryartery•Nodalcells,alsocalled“Pcells”andthoughttobethesourceofnormalimpulseformation•TRANSITIONALCELLS:Alsoknownas“Tcells”mayprovidetheonlyfunctionalpathwayfordistributionofthesinusimpulseformedinthenodalcellstotherestoftheatrialmyocardiumSinusNodeINTERNODALANDINTRAATRIALCONDUCTION•ImpulsestravelfromthesinustotheAVnodethroughthreeintraatrialpathways•Theanteriorinternodalpathway,alsocalledtheBachmannbundle•Themiddleinternodaltract•TheposteriorinternodaltractAVNODE•ThenormalAVjunctionareacanbedividedinto3distinctregionsTHEBUNDLEOFHIS•ConnectswiththedistalpartofthecompactAVnode,perforatesthecentralfibrousbody,andcontinuesthroughtheannulusfibrosis,whereitiscalledthenonbranchingportionasitpenetratesthemembranousseptum•BranchesfromtheanteriorandposteriordescendingcoronaryarteriessupplythebundleofHis•Bundleofhis–bundlebranchesTHEBUNDLEBRANCHES•Includingtheleftbundlebranchandtherightbundlebranch•LeftbundlebranchincludinganterosuperiorfascicleandposteroinferiorfasciclePURKINJEFIBERS•ConnectwiththeendsofthebundlebranchestoforminterweavingnetworksontheendocardialsurfaceofbothventriclesImpulseconductionAVSARVLVRALATVMVCSPRntervalQRSSTSegmentInnervationofcardiacconductonsystem•Vagus(-)•Sympathetics(+)CLASSIFICATIONOFARRHYTHMOGENESISDisordersofimpulseformationDisordersofimpulseconductionDisordersofImpulseFormationSINUSNODALDISTURBANCES–Sinustachycardia–Sinusbradycardia–Sinusarrhythmia–SinusarrestECTOPICRHYTHM–PassiveectopicrhythmEscapebeatsEscapebeatsrhythm–ActiveectopicrhythmPrematurebeatParoxysmaltachycardiaAtrialflutter,atrialfibrillationVentricularflutter,ventricularfibrillationDisordersofImpulseFormationDisordersofimpulseconduction•Physical:interfereceanddissociation•Pathological:–Sinoatrialblock–Intraatrialblock–AVblock–Bundlebranchorfasciclularblock•AccessoryAVpathway:preexcitationsyndrome(W-P-W)MECHANISMSOFARRHYTHMOGENESISDisordersofimpulseformationAbnormalityofautorhythmicityTriggeredActivityDisordersofimpulseconductionReentryAutomaticityNormalSinusRhythmIncreasephase4=increaseHRHyperpolarization=slowerHRTriggeredActivity•Leakageofpositiveionsintothecardiaccellcreatingabumpofafterdepolarization(AD)•Mightgenerateanotheractionpotential.EarlyDelayedTriggeredActivity•Ischemia-repurfusion•Digitalisintoxication•LowerkaliiTachyarrhythmias•Automaticity•TriggeredActivity•ReentryabAabBDiagnosisofArrhythmia•History•PhysicalExamination•ECG•HolterECG•TreadmillECG•TransesophagealECG•ClinicalElectrophysiologicalStudyHISTORY•Carefulcollection•Patient’sdiscriptionofpalpitation•Trytogetfollow:–Exitandtypeofarrhythmia–Causition:cigarette,alcohol,coffeeandmentalpressure–Frenqunceofarrhythmia–ImpactofArrhythmiaonpatient–Reactionofarrhythmiatomedicineandnon-drugthereapysuchasposture,breath,excisePhysicalExamination•Rate•Rhythm•heartsound•ReactiontomassageofcoratidsinusELECTROCARDIOGRAM(ECG)•Mostimportantnon-invasivemethod•12LEADSrecording•LeadIIorV1foranalysisofPWAVE•Rhythmandrateofatriumorventricle?•PRinterval:fixedorchangeattime?•ShapeofPwaveandQRScomplex?•RelationshipofPwaveandQRScomplex?HolterECGMonitering•ContinuerecordingofECGfor24hours•Whetherpalpitationorsyncopeisrelatedtoarrhythmia?•Whetherarrhythmiaorischemiaisrelatedtodailyactivities?•Toevaluatetheeffectofanti-arrhythmicdrugs•ToevaluatetheeffectandfunctionofpacemakerorICDEventrecorder•Portable•ImplantableExerciseECG•Treadmilltest•Normalpatientmayhavearrhythmiaduringorafterexcise•SensitivityandspecificityofExerciseECGTransesophagealECG•Leftatriumclosetoesophageal•Transesophagealatrialpacingandrecording•DiagnosisofW-P-WorDAVNP•Toinduceandterminatetachycardia:terminatethetachycardia(PSVT)•evaluatetheeffectsofsomeAAD•DiagnosisofsicksinussyndromeClinicalElectrophysiologicalStudy•Transveniousinsertionofseveralelectrodestomultipositionoftheheart•Highrightatrium,Hisbundle,Apexofrightventricle,coronarysinus•ProgrammedstimulusClinicalElectrophysiologicalStudy•Diagnosis•Treatment•Prognosis•Indication–DeterminationofthefunctionofSinusnode–Atrialventricularblockorintra-ventricularblock–Tachycardia–Unknownsyncopy心律失常心电图的导联系统TheStandardECG•常规十二导联体系（Einthoven体系）•标准肢体导联Ⅰ、Ⅱ、Ⅲ•加压单极肢体导联aVR、aVL、aVFEinthovensystemStandardlimbleadsⅠ、Ⅱ、ⅢAugmentedunipolarleadsaVR、aVL、aVF胸前导联V1~V6UnipolarprecordialleadsV1~V6V1:胸骨右缘第四肋间V2：胸骨左缘第四肋间V4：左胸骨中线与第五肋间交接处V3：V2与V3之间V5：左腋前线V4水平处V6：左腋中线V4水平处V1:right4thintercostalspace