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心律失常 cardiac arrhythmia

心律失常 cardiac arrhythmia. 刘磊 , MD. Department of cardiologyZhujiang Hospital Tel: 13189097199 Email: gzliulei@21cn.com. 1. History of electrocardiogram. ECG was invented in 1903. Einthoven was awarded the Nobel Prize in 1924 for his great contribution. 威廉 · 爱因托芬 Willem Einthoven 荷兰生理学家.

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心律失常 cardiac arrhythmia

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  1. 心律失常cardiac arrhythmia 刘磊, MD. Department of cardiologyZhujiang Hospital Tel: 13189097199 Email: gzliulei@21cn.com 1

  2. History of electrocardiogram • ECG was invented in 1903. Einthoven was awarded the Nobel Prize in 1924 for his great contribution. 威廉·爱因托芬 Willem Einthoven 荷兰生理学家 6

  3. 心脏传导系统The conducting system of the heart

  4. The conducting system of the heart

  5. definition of arrhythmia • 心脏冲动的形成（位置、频率、节律）和传导(途径、速度）异常。 • Arrhythmia is an abnormal generating or conducting of impulse, resulting in an abnormal heart rhythm.

  6. Classification of arrhythmia Abnormal origin冲动形成异常 ----sinus arrhythmia窦性心律失常 ----ectopic rhythm异位心律:passivity—escape逸搏 ---premature contraction tachycardia flutter and fibrillation Abnormal conduction传导异常 ----physiological block: ----pathological block: S-AB; A-VB; LBBB; RBBB ----accessory pathway: pre-excitation syndrome

  7. 心律失常分类classification • 冲动形成abnormal impulse generating • 窦性心律失常sinus arrythmia • 异位心律ectopic rhythm • 慢速型－－逸搏escape • 快速型－－早搏premature beat • 正速型－－加速性自主心律accelerated rhythm • 冲动传导abnormal impulse conducting • 传导减慢、阻断、加速 • 异常途径abnormal pathway

  8. 心律失常发生原因（重点）causes of arrhythmia 先天性congenital、缺血ischemia、炎症inflamation、药物drugs、外伤injury、机械刺激mechanical stimulation、电解质紊乱electrolyte disturbance神经体液因素neurohomonal factors、心肌退行性改变 degeneration、特发性idiopathic

  9. 快速性心律失常的机制mechanisms of tachyarrhythmias • 折返Reentry：解剖学上有折返环（4个条件） 突发突止、程序刺激诱发及终止 • 自律性增高Abnormal Automaticity：洋地黄中毒、电解质紊乱、炎症、缺血等诱发，心率逐渐升高和降低，程序刺激不能诱发及终止 • 触发活动：Triggered Activity洋地黄中毒、电解质紊乱等诱发

  10. Diagnosis of arrhythmia心律失常的诊断 • Symptoms症状: syncope (Adams–Stokes attacks), dizziness, palpitation, fatigue • Signs体征: irregular pulse and heart beat • ECG

  11. Diagnosis of arrhythmia by ECG • 常规 ECG • 运动 Exercise Electrocardiography • 动态 ambulatory ECG • 食管Transesophageal Electrocardiography • 心腔内 invasive ECG

  12. 食管心电图及食道调搏Transesophageal Electrocardiography • 心动过速机制初步判断 • 窦房结、房室结功能测定 • SNRT、SACT、房室结文氏点 • 程序刺激诱发室上速 • 超速抑制

  13. 心腔内电生理检查作用invasive cardiac electrophysiological testing • 同食道电生理检查　　　　　 • 希氏束图与传导阻滞　　　　AH • 心动过速机制　　　　　　　HV • 不明原因晕厥　　　　　　　VT诱发

  14. 窦性心律失常 Sinus arrhythmia

  15. 窦性心动过速Sinus Tachycardia

  16. Factors associated with Sinus Tachycardia • Physiologic生理性 Exercise Strong emotion Pain Anxiety states

  17. Factors associated with Sinus Tachycardia Pathologic factorsFever，Hyperthyroidism发热甲亢 Hemorrhage，Shock　出血休克Anemia，Infection贫血，感染 Congestive heart failure　心衰Myocarditis心肌炎 Hypoxia缺氧

  18. Factors associated with Sinus Tachycardia • Drugs • Epinephrine肾上腺素 • Atropine阿托品 • Tea coffee • Alcohol • Tobacco

  19. 窦性心动过速－－病因（重点） • 生理状态：交感兴奋 • 原发病：发热、甲亢、贫血、休克、 　　　　　缺氧、心衰 • 药物：肾上腺素、阿托品

  20. 窦性心动过速－－鉴别诊断differential diagnosis • 房速 • 室上速 • 房扑

  21. 窦性心动过速－－治疗treatment • 去除病因eliminate the causes • 必要时使用β受体阻滞剂（甲亢、β受体功能亢进、更年期）

  22. 窦性心动过缓Sinus Bradycardia

  23. Sinus Bradycardia Bradycardia is defined as a ventricular rate of less than 60 per min, and results from a reduction in the rate of normal sinus pacemaker activity, or from disturbances of atrioventricular (AV) conduction

  24. Common causes of sinus bradycardia Physiologic bradycardia迷走神经activation of vagus nerve • Laborers and trained athletes • Carotid sinus pressure • eyeball pressure • Sleep

  25. Sinus Bradycardia • Pathologic：Systemic diseaseObstructive jaundice黄疸Obstructive diseases of the intestine,kidney or bladdermyxedema沾液性水肿 myocardial infarction(inferior wall or atrial infarction)心肌梗死high intracranial pressure高颅压

  26. Sinus Bradycardia • DrugDigitalis洋地黄Morphine吗啡Quinidine奎尼丁 Propranolol普奈洛尔

  27. 窦性心动过缓－－病因 • 生理状态：运动员、睡眠 • 原发病：病窦、缺血、高颅压、甲减、低温 • 药物：β受体阻滞、钙拮抗剂、 　　　　抗心律失常药物

  28. 窦性心动过缓－－临床表现 • 无症状型 • 脑供血不足：头昏、晕厥 • 心脏供血不足：胸闷、胸痛、心衰、休克

  29. 窦性心动过缓－－治疗treatment • 生理性和无症状型：不治疗或暂缓physiological and nonsymptomatic • 原发病治疗：缺血、甲减、药物 Eliminating the causes of bradycardia

  30. treatment • 药物治疗drug treatment ： • 抗胆碱药：阿托品atropin • β受体激动agonist：异丙肾上腺素isoproterenol (isoprenaline) • 起搏治疗Pacemaker therapy • 临时起搏Temporary ventricular pacing • 永久起搏Permanent pacemaker implantation

  31. pacemaker

  32. 起搏类型　AAI、VVI、DDD

  33. VVI起搏心电图

  34. 窦性停搏Sinus arrest • 病因：同窦缓 • 临床表现：黑蒙、意识丧失、抽搐 • 治疗：同窦缓

  35. 窦房传导阻滞 • 病因、临床表现和治疗：同窦缓

  36. 窦房传导阻滞－－鉴别诊断 • 房性早搏未下传 • 窦性心律不齐

  37. 病态窦房结综合征Sick Sinus Syndrome (SSS) • 由于窦房结功能减退导致以长期心动过缓为主，可合并多种房性快速型心律失常的综合表现。

  38. 病态窦房结综合征－病因causes of SSS • 退行性改变degenerative disease • 慢性缺血chronic ischemia • 炎症后遗症lingering effects of inflamation

  39. 病态窦房结综合征－临床表现 • 心动过缓：头昏、胸闷 • 窦性停搏：黑蒙、意识丧失、抽搐 • 心动过速：心悸、心绞痛、心衰 心动过缓－心动过速综合征

  40. 病态窦房结综合征－心电图表现Sick Sinus Syndrome (SSS) • 主要表现：窦缓Sinus bradycardia (HR<50/min);、窦停Sinus arrest 、交界性逸搏、窦房阻滞SA block • 次要表现：房速Atrial tachycardia、房扑Atrial Flutter、房颤Atrial fibrillation、房室传导阻滞AV block

  41. 窦房结功能测定（重点） • 固有心率测定 • 阿托品试验（＜90次） • 窦房结恢复时间测定 • 窦房传导时间测定 • 24小时最慢心率（＜40次） • 24小时最长R－R间期（＞3秒）

  42. 病态窦房结综合征－鉴别诊断differential diagnosis • 无症状的窦性心动过缓 • 迷走神经张力增高 • 可逆性窦缓：急性心梗、药物

  43. 病态窦房结综合征－治疗 • 药物治疗：抗胆碱药、β受体激动 • 起搏治疗：永久起搏 • 快速心律失常治疗：起搏以后转律和预防快速心律失常

  44. 病窦起搏治疗Pacemaker therapy of SSS • 提高心率（单腔、双腔起搏） • 预防房颤（双房起搏） • 便于应用抗心律失常药物

  45. 房性早搏atrial premature beats • 见于正常人及各种器质性心脏病、甲亢

  46. 房性早搏atrial premature beats • 临床表现：心律不齐，脉搏不齐

  47. 房性早搏－－鉴别诊断differential diagnosis • 伴差异传导者－－室性早搏 • 房早未下传者－－窦停、窦房阻滞

  48. 房性早搏－－治疗 • 原发病治疗 • 无原发病者无需治疗 • 频发早搏症状明显者：胺碘酮、钙拮抗剂、β阻滞剂、普罗帕酮

  49. 房性心动过速＞＝3个房性早搏atrial tachycardia • 洋地黄中毒、电解质紊乱、心肌炎、甲亢、各种器质性心脏病 • 特发性 房性心动过速－－病因（重点）

  50. 房性心动过速－－分类 • 自律性房速 • 折返性房速 • 紊乱性房速治疗

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