Cardiac arrhythmias

Abnormal of Cardiac Rhythm

Prof. dr. Peter Kabo PhD, MD, SpJP, SpFK, FIHA

Cardiac conduction system

Normal cardiac rhytm

Classification
Sinus node diseases
Sinus tachycardia/ bradicardia SA block Wandering pace-maker Hypersensitive carotid sinus syndrome Sick sinus syndrome (sss)

Disturbance of atrial rhythm

Atrial fibrillation Atrial flutter

Disturbance of AV junction rhythm

Supra ventricular tachycardia

Pre-excitation syndrome
Wolff Parkinson white syndrome ( wave)

Disturbance of ventricular rhythm

Ventricluar extra systole: quadrigemini, Trigemini, <> Duplex, Triplex, quadriplex Ventricular tachycardia

Heart block
1st degree HB 2nd degree HB Wenckebach (mobitz type I) (mobitz type II) 3rd degree HB (total AV block) Temporary pace-maker Permanent pace-maker

Sympathomimetics : Ephedrine Anticholonergic : Atrophine

Mechanism of Cardiac Arrhytmias

Enhanced automaticity Sinus Tachycardia Triggered automaticity Multifocal atrial tachycardia VES VT Torsade de Pointes

Reentry
Atrial Fibrilation (AF) Atrial flutter SVT VT

Block 1st degree AV block 2nd degree AV block 3rd degree AV block (total AV block)

Trigger automaticity
Afterdepolarization

Early Afterdepolarization

Delayed Afterdepolarization

Reentry

The commonly found arrthymias

Sinus tachycardia/ sinus bradycardia Atrial-/ ventricular- extrasystole Supra-ventricular tachycardia Atrial fibrilation/flutter

Common underlying diseases causing arrhythmias

Ischemic heart disease
Acute myocardial infarction Myocardial ischemic (HHD, LVH, CAD) Left ventricular aneurysm

Cardiomyopathy Valvular heart disease Myocarditis Congenital heart diseases Conduction system abnormality
Sinus R AV node disease By pass tract

Chronic pulmonary disease

Hypokalemia

Endocrine
Thyrotoxicosis

Electrolyte imbalance Drug induce

Sympathomimetic, caffeine

Increase sympathetic/ vagal activity

Parasimpatomimetik (Kolinergik) Parasimpatolitik (antikolinergik)

Simpatomimetik (Adrenergik) Simpatolitik (Antiadrenergik)

FAAL SSO
Parasimpatis Sympathies
Conservative Reservation Fight Flight reaction

Transmisi Neurohormonal

Ion Channel in Cell Membrane

Ca+2

Functional Consequences of The Arrhythmias

Palpitation Dizziness Syncope/ pre-syncope Fatigue Dyspnea Chest pain

The Physical Examination (ECG are complemantery)

Jugular venous pulse Arterial pulse Heart sound

Mechanism of anti arrhythmias drug action

Decreased phase 4 slope
blocker

Increased threshold
Na+ channel blocker Ca++ channel blocker

Increased max diastolic potential

Adenosine Acetylcholine

Increased action potential duration

K+ channel blocker

Ant arrhythmic drugs can cause arrhythmias Some arrhythmias should not be treated

Classification of anti arrhythmia drugs

Sodium channel blocker
Sodium channel (++) Diisopyramide, Quinidine, Procainamide Blocks K+ Efflux (+) Lidocaine, Mexiletine, Tocainide Sodium channel (+++) Flecainide, Encainide, Propafenone

Anti adrenergic
blocker

K+ channel Efflux blockers also Na+ blockers

Amiodarone Sotalol

Ca++ channel blockers

Verapamil & Diltiazem

Autonomic Effects
Vagus stimulation Digoxin Adenosine receptor activation Adenosine

Farmakokinetik
O KINIDIN PROKAINAMID + + P + + Dosis 3 X 200 mg 3X (250000 500) mg Kadar puncak 60 90 45 70 Metab H H Eks G/H G Indikasi AF, SVT VES, SVT Lupus like syndrome, leukopeni Efek samping

DIISOPIRAMID

3X 100 mg

60 120

VES, SVT

Mulut kering, konstipasi, penglihatan kabur

hipotensi

LIDOKAIN

1 MG/ KG bb =1mg/ jam

VT (pasca miokard infark)

PROPAFENON

3 x(150 -300) mg

60 180

VES

Kardiovaskular
QRS Interval Long QT

Hipotensi / Sinkop SA block AV block Torsades de Poentes ventrikuler rate (efek anti kolinergik)

Cinchonism Demam Tinitus Penglihatn kabur Diplopia Sakit kepala Delirium Prikosis Gangguan GIT

Amiodaron
Farmakokinetik O + P + T1/2 25 60 jam Dosis Loading 600 s/d 800 mg/ hari Maintenance 300mg/ hari indikasi VT, AF Efek samping Pro aritmik, Hipotensi, gangguan fungsi: hati, tiroid, paru & mata

Sotalol
Farmakokinetik indikasi Efek samping

O
+

P
-

T1/2
11 jam

Dosis
800 s/d 320 mg/hari

SVT, VT

Gagal jantung

Bradicardy
Sinus Bradicardy
1. Ephedrine 2. Aminophyline 3. Atropine (I.V.)

Heart Block
1. Atropine (I.V.) 2. Temporary Pacemaker 3. Permanent Pacemaker

Permanent Pacemaker