Aritmia

Joko Anggoro Bagian Penyakit Dalam FK Unram/RSUP NTB

Electrical System of the Heart

Irama yang berasal dari nodus SA, yang datang teratur dengan frekuensi 60-100 x/mnt, dengan hantaran tak mengalami hambatan pada tingkat manapun.

Definisi ARITMIA
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Irama yang bukan berasal dari nodus SA Irama yang tidak teratur, meskipun berasal dari nodus SA misal sinus aritmia Frekuensi < 60x/mnt (sinus bradikardi), > 100x/mnt (sinus takikardi) Terdapat hambatan impuls supra dan intra ventrikular

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Definisi
Lokasi Aritmia supraventrikular Aritmia (infra) ventrikular Frekuensi denyut jantung Bradiaritmia Takiaritmia

Mekanisme aritmia
Pengaruh persarafan otonom (simpatis & parasimpatis) yg mempengaruhi heart rate

Nodus SA yg mengalami depresi fokus jantung diambil alih yg lain

Fokus yg lain lebih aktif dari nodus SA dan mengontrol irama jantung Impuls Nodus SA tdk keluar (sinus arrest) atau mengalami hambatan (SA block) Terjadi hambatan impuls sesudah keluar nodus SA

Etiologi
Persarafan otonom dan obt2an yg mempengaruhinya
Keadaan sistemik seperti beratnya iskemik, pH, kadar elektrolit, dan obat2an Kelainan jantung: IHD, decomp cordis Inflamasi, kalsifikasi, kelainan katup, Fibrosis, peny degeneratif Rangsangan dari luar jantung (pace maker)

ARITMIA

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Klasifikasi irama jantung & Aritmia

Irama yang berasal dari nodus SA

ARITMIA

Aritmia atrial Aritmia Supraventrikular Aritmia Ventrikular

Gangguan hantaran berkas His dan cabangnya

Diagnosis of Arrhythmia
Medical history Physical examination Electrocardiograph

Palpitation, dizziness, syncope, angina, fatigue, chest incomfortable, short of breathness

S1 and rhythm is irregular, hypotension, heart failure and shock

Sinus tachycardia
Sinus rate > 100 beats/min (100-180) Causes: 1. Some physical condition: exercise, anxiety, exciting, alcohol, coffee 2. Some disease: fever, hyperthyroidism, anemia, myocarditis 3. Some drugs: Atropine, Isoprenaline Neednt therapy

Sinus Bradycardia
Sinus rate < 60 beats/min Normal variant in many normal and older people Causes: Trained athletes, during sleep, drugs (blocker) , Hypothyriodism, CAD or SSS Symptoms: 1. Most patients have no symptoms. 2. Severe bradycardia may cause dizziness, fatigue, palpitation, even syncope. Neednt specific therapy, If the patient has severe symptoms, planted an pacemaker may be needed.

Aritmia sinus

Sinus Arrest / henti sinus

Sinus arrest or standstill is recognized by a pause in the sinus rhythm. Causes: myocardial ischemia, hypoxia, hyperkalemia, higher intracranial pressure, sinus node degeneration and some drugs (digitalis, -blocks). Symptoms: dizziness, syncope

Sinoatrial exit block (SAB)/blok sinoatrial

SAB: Sinus pulse was blocked so it couldnt active the atrium. Causes: CAD, Myopathy, Myocarditis, digitalis toxicity, et al. Symptoms: dizziness, fatigue, syncope Therapy is same to SSS

Sick Sinus Syndrome (SSS)

SSS: The function of sinus node was degenerated. SSS encompasses both disordered SA node automaticity and SA conduction. Causes: CAD, SAN degeneration, myopathy, connective tissue disease, metabolic disease, tumor, trauma and congenital disease. Bradycardia-tachycardia syndrome

Atrial premature contractions (APCs)/ekstrasistol atrial

APCs arising from somewhere in either the left or the right atrium.

Atrial flutter
Etiology: 1. It can occur in patients with normal atrial or with abnormal atrial. 2. It is seen in rheumatic heart disease (mitral or tricuspid valve disease), CAD, hypertension, hyperthyroidism, congenital heart disease, COPD. 3. Related to enlargement of the atria 4. Most AF have a reentry loop in right atrial

Atrial fibrillation
1. 2. 3. 1. 2. Etiology: Morbidity rate increase in older patients Etiology just like atrial flutter Idiopathic Mechanism: Multiple wavelet re-entry; Rapid firing focus in pulmonary vein, vena cava or coronary sinus.

Atrial fibrillation

Gelepar Atrial/Atrial flutter

denyutan atria yang cepat dan teratur, Adanya gelombang geletar/flutter; gelombanggelombang P yang teratur, frekuensi 250350/menit, berbentuk gergaji (terutama di II,III,dan aVF)

3. Atrioventricular Junctional arrhythmia

Paroxysmal tachycardia
Most PSVT (paroxysmal supraventricular tachycardia) is due to reentrant mechanism. Occur in any age individuals, usually no structure heart disease.

Takikardi supraventrikular paroksismal

irama yang mutlak teratur dengan frekuensi 150250 x/menit, seringkali gelombang P terbenam pada kompleks QRS dan tidak dapat diidentifikasi sama sekali

Paroxysmal tachycardia
Therapy: 1. Increase vagal tone: carotid sinus massage, Valsalva maneuver.if no successful, 2. Drug: verapamil, adrenosine, propafenone 3. DC shock

4. Ventricular arrhythmia

Ventricular Premature Contractions (VPCs)/ ekstrasitol ventrikel

Etiology: 1. Occur in normal person 2. Myocarditis, CAD, valve heart disease, hyperthyroidism, Drug toxicity (digoxin, quinidine and anti-anxiety drug) 3. electrolyte disturbance, anxiety, drinking, coffee

Ventricular tachycardia
Etiology: often in organic heart disease CAD, MI, DCM, HCM, HF, Sustained VT (>30s), Nonsustained VT Monomorphic VT, Polymorphic VT

Ventricular flutter and fibrillation

Often occur in severe organic heart disease: AMI, ischemia heart disease, electrolyte disturbance, Anaesthesia, lightning strike, electric shock, heart operation Its a fatal arrhythmia

Atrioventricular (AV) Block

AV block is a delay or failure in transmission of the cardiac impulse from atrium to ventricle. Etiology: Atherosclerotic heart disease; myocarditis; rheumatic fever; cardiomyopathy; drug toxicity; electrolyte disturbance, collagen disease, levs disease.

AV Block
AV block is divided into three categories: 1. First-degree AV block 2. Second-degree AV block: further subdivided into type I and type II 3. Third-degree AV block: complete block

AV Block
Treatment: 1. I or II degree AV block neednt antibradycardia agent therapy 2. II degree II type and III degree AV block need antibradycardia agent therapy 3. Implant Pace Maker

Intraventricular Block
Intraventricular conduction system: 1. Right bundle branch 2. Left bundle branch 3. Left anterior fascicular 4. Left posterior fascicular

RBBB

LBBB

Therapy Principal of Arrhythmia

Pathogenesis therapy Stop the arrhythmia immediately if the hemodynamic was unstable Individual therapy

Anti-tachycardia agents
Modified Vaugham Williams classification: I class: Natrium channel blocker Ia: less use in clinic Ib: Lidocaine , Mexiletine VT Ic: Moricizine , Propafenone II class: -receptor blocker: propanolol, metoprololCAD III class: Potassium channel blocker: Amiodarone, sotalolCAD,HF IV class: Calcium channel blocker Verapamil, DiltiazemSVT Others: Adenosine, DigitalisSVT

Anti-bradycardia agents
1. -adrenic receptor activator 2. M-cholinergic receptor blocker 3. Non-specific activator Isoprenaline Epinephrine Atropine Aminophylline

Non-drug therapy
Cardioversion: For tachycardia especially hemodynamic unstable patient Radiofrequency catheter ablation (RFCA): For those tachycardia patients (SVT, VT, AF) Artificial cardiac pacing: For bradycardia, heart failure and malignant ventricular arrhythmia patients.

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