Arrhythmias of heart

Department of propedeutic of internal medicine

Etiology.

• Violations of rhythm of cardiac activity cause such defeats of myocardium:

• organic: IHD,defects of heart, AH, myocarditis, cardiomyopathy;

• · toxic: medicines, alcohol;• · hormonal : thyrotoxicosis, myxedema,

pheochromocytoma, climax;• · functional : neurogenic, sporting;• · anomalies of development of heart - more

frequent all WPW.

Pathogenesis

• Theories of origin of arrhythmias:

• Pathological automatism (presence of ectopic focuses)

• Mechanism of re-entry

• trigern (starting) activity.

Classification of violations of rhythm and conductivity of

heart• I. Violations of formation of impulse• Sinus tachycardia

(more than 90 complexes are for a minute)

• Sinus bradycardia (less than 60 complexes are for a minute )

• Sinus arrhythmia • Stop (refuse) of sinus node• Migration of supraventricular driver of rhythm

• Extrasystolia (a synonym is premature depolarization):

• auricle (atrial)

• auricle-ventrical (atrioventricular)

• ventrical

• Tachycardia:

• supraventricular:

• sino - auricle

• (sinoatrial)

• auricle (atrial)

• auricle - ventrical

• (atrioventrical)

• ordinary (to 30 in a hour)

• frequent (30 and anymore in a hour)

• allorythmia (bi-, thre-, quadrigeminia)

• polymorphic

• twin

• early (R on T)

• chronic

• paroxysmal

• noudle

• with the additional ways of leadthrough

• ortodromal

• antidromal

• ventrical:

• unsteady (from 3 ventrical complexes to 30)

• steady (more than 30 seconds)

• monomorphic

• polymorphic

• ІІ. VIOLATION OF LEADTHROUGH OF IMPULSE

- Sinoauricular of blockade- Atrioventricular blockades:

• І st.

• ІІ st.

• ІІІ st.

• III. COMBINED DYSPOIESISS AND LEADTHROUGHS OF IMPULSE

• · auricle

• Parasystole · from AV of connection

• · ventrical

• specified at possibility

• IV. DISEASE, SYNDROMES And PHENOMENA

– Syndromes and ECG phenomena of pre-excitation of ventricles:

• syndrome of WPW

• syndrome of the shortened interval of PR (Launa - Ganonga - Livayna)

• syndrome of early repolarisation of ventricles

• innate

• purchased

• Syndrome of the prolonged interval of QT

• Syndrome of weakness of sinus noudle

• Syndrome of Morganii-Adams-Stoks

• Syndrome of Frederic

• Cardiac sudden death (arrhythmical)

• asystole

• fibrilation of ventricles

• electromechanics dissociation

• Heart arest

• V. ARRHYTHMIAS ARE AT NORMAL OR BROKEN FUNCTION OF CARDIOSTIMULATORS OF DIFFERENT TYPE

• Note: In a diagnosis it is needed to specify cardiac surgery interferences and devices, applied for treatment of arrhythmias and asequences heart (with pointing of method and to give interference) - kateterni (radio frequency et al) destruction, implantation of drivers of rhythm and cardioverters - defibrilyatoriv, leadthrough of cardioversion or defibrilyacii (the date of the last is specified) and others like that.

Description of normal sinus rhythm

• correct rhythm with frequency of heartbeats 60-100 per 1 min.

• the P wave is positive in II, III, AVF leads, negative - in the AVR leads, permanent form of P wave

• a complex QRS follows by every P waveR (if there is not а-v-blockade).

• Interval of P-Q>0.12 (if there are not additional ways of leadthrough).

Sinus tachycardia

• ECG is criteria:• correct rhythm• sinus P waves are ordinary configuration.• 100-180 beats per 1 min.• gradual beginning and completion• Reasons: physical and emotional loading, pain,

fever, hypovolumia, hypotension, anaemia, thyrotoxicosis, action of certain matters (coffeine, alcohol)

Treatment

• liquidation of etiologic factor

• B-adrenoblockers (propranolol 10-40mg, oksprenolol 20mg 3 times per days, pindolol 5 mg 3 times on days, nadolol 20 mg 2 times per days, metaprolol 50 mg 2 times per days)

• sedative facilities

Sinus bradycardia

• ECG is criteria:

• correct rhythm

• less than 60 beats per 1 min

• sinus P waves

• interval of PQ >0,12 sec.

• Reasons: increase of parasympatic tonus, myocarditis, myxedema, hypothermia, mechanical icterus, syndrome of weakness of sinus knot.

Treatment

• to the atropine sulfate of 0,5-1 mg or 0,1% solution 1-2 times per day

• plathyphylinum hydrotartratum 0,5-1 mg or 0,2% solution 1-2 times per day

• extract of beladonnae -0,02 gr. 3-4 times per days

• izadrin 5-10 mg sublingval

The first aid is at the attacks of Morgani-Adams-Stoks

• to the atropine sulfate of 0,5-1 mg or 0,1% solution intravenously

• izadrin 5-10 mg sublingval (at a necessity to repeat)

• alupent for 1-5-10 mg on 500 ml of izotonic soluble-sodium chloride

• electro-cardiostimulation (temporal or permanent)

Sinus arrhythmia

• ECG is criteria:• P wave is sinus origin• interval of PQ >0,12 s• 45-100 beats per 1 min• the rhythm of heart is wrong with the

difference of the longest and shortest interval of R-R 0.16 and anymore

• Treatment: does not require

• a-normal sinus rhythm• б- sinus tachycardia• в- sinus bradycardia• г- sinus arrhythmia

Arest of sinus knot

• EKG is criteria:

• complete asystole (absence of P and QRST)

• the pause of R-R does not make two ordinary intervals, and anymore.

• Treatment: how to the syndrome of Morgani-Adams-Stoks

Syndrome of weakness of sinus knot

• EKG is criteria:• sinus bradycardia is expressed• refuse of sinus knot with periods asystoles• a duty of sinus bradycardia is with the attacks

of auricle tachycardia, fibrilation (syndrome of «tachy-brady»)

• a sino-atrial blockade is with extra contractions heart beats

• slow renewal of function of sine knot.

Treatment

• effective treatment does not exist

• medical therapy is at the attacks of Morgani-Adams-Stoks

• implantation of permanent electro-cardyostimulator

Extrasystolia

premature excitation and reduction of heart or his separate parts is as a result of increase of activity of hearths of ectopic automatism.

Auricle extrasystolia

• EKG of sign:• premature reduction after which incomplete

scray pause• the P wave is changed, negative• a complex QRS is not changed or aberrant.• Treatment: it is not needed, at presence of

clinical symptoms of b-blockers, verapamil, digitalis.

• a- from the overhead departments of auricle

• б- from the middle departments of auricle

• в- from the lower departments of auricle

• г- is blocked auricle extrasystole

А-V- extrasystoles

• with simultaneous excitation of atriums and ventricles.

• EKG-signs:

• the P wave is not determined

• an extraordinary complex QRS is not extended

• incomplete scray pause

• with previous excitation of ventricles

• EKG-signs:

• an extraordinary complex QRS is not extended

• P wave is after QRS

• complete scray pause

• Treatment: like, as at auricle extrasystolia.

Ventrical extrasystolia

• EKG of sign:

• complex QRS wide without a previous P wave

• complete scray pause

• Treatments need frequent monotopic, politopic, group and early as R/T extrasystoles.

• a- sinistroventrical extrasystole

• b- dextraventrical extrasystole

Paroxysmal tachycardia Supraventricular

tachycardia• EKG is signs:

• frequency of reductions of atriums - 120-250 per 1 min.

• auricle complexes are preceded the complexes of QRS

• the complexes of QRS are not changed

Atrioventricular tachycardia

• EKG-signs:

• 150-200 heart beats per 1 min.

• retrograde P wave (negative) after QRS or accumulates on him

• a- auricle paroxysmal tachycardia• б - atrioventricular tachycardia with previous excitation of

ventricles• в - atrioventricular tachycardia with simultaneous excitation of

atriums and ventricles

Treatment of paroxysmal supraventricular tachycardia

• at leadthrough to the impulse through an a-v knot:

• massage of sinus carotic• izoptin 0,25%-4ml• obzіdan 0,1% - 5ml• dіgoxin 0,025% - 1ml v/v• cordaron 5% - 6 ml

Ventrical tachycardia

• EKG is criteria: - >140 hearts beats per 1 min.

- the complexes of QRS are extended

EKG is at paroxysmal ventrical tachycardia

Trembling and fibrilation of atriums

• EKG is criteria of trembling:

• frequency of auricle waves 250-350 per 1 min. ( waves of f)

• EKG is criteria of fibrilation:

• waves of f

• wrong rhythm (different R-R)

• absence of P wave

Trembling and fibrilation of ventricles

• EKG is criteria:• Sinus wave curve with frequent, rhythmic, wide

and high waves, excitation of ventricles with frequency 200-300 per 1 min.

• it is not possible to distinguish the elements of ventrical complex

• Treatment:• electric cardioversion 200-300 Dzh. At unefficiency

the repeated cardioversion

• a- trembling of ventricles

• b- blinking and fibrilation of ventricles

Sinoauricular blockade

• EKG is criteria:

• periodic fall of cardiac cycles

• increase of pause between the waves of Р-Р in 2 times

Inwardly auricle blockade

• EKG is criteria:

• increase of duration and breaking up of wave Р

Atrioventricular blockade Іst

• permanent lengthening of interval of P-Q anymore as on 0,20s• a- auricle form• б- key form• в- distal form blockade

А-v blockade ІІ ст • the periodic stopping of leadthrough of impulse is

from an auricle to the ventricles. There are three types:

• I type (Mobit I) is the gradual lengthening of interval of P-Q with the subsequent fall of QRST ( periods of Samoylov-Venkenbach)

• ІІ type (Mobit ІІ) is a fall of complexes of QRST without the gradual lengthening of interval of P-Q

• ІІІ type (Mobit ІІІ) of fall every second, or 2 and more complexes successively

А-v blockade ІІІ ст

complete autonomy of reduction of auricle and ventricles.The intervals of P-P and R-R are permanent, but R-R>P-P.

EKG is at the complete blockade of right bundle of bunch of Hiss

EKG is at the complete blockade of left bundle of bunch of Hiss

Syndrome of Wolf-Parkinson-White

• reduction of interval of P-Q (R)• a presence in composition a complex QRS

of additional wave of excitation is d-wave• deformation and increase of duration of

complex QRS• discordant displacement of RS-T and

change of polarity of wave T (inconstant sign)

EKG is at the syndrome of WPW

Conclusions• It is necessary to know for successful diagnostics

and treatment of arrhythmias:• basic nosotropic mechanisms of their development• · to own the methods of diagnostics of

arrhythmias• · to distinguish of high quality, potentially

malignant and malignant arrhythmias• · to understand algorithms diagnostic at the

therapeutic going near the different types of arrhythmias