SUPRAVENTRIKULAR &

VENTRIKULAR ARRHYTMIA
Sistim Konduksi

SA Node
 Internodal branch
 AV Node
 Hiss Bundle
 Purkinje Fiber
 Contraction
 Physiologic Basis of Pacemaker Cells

Pacemaking &
Conduction System
Gelombang P : depolarisasi kedua atrium
Gelombang QRS : Depolarisasi kedua Ventrikel
Gelombang T : Repolarisasi Kedua Ventrikel
 Sel Autoritmik
• Fase Depolarisasi
• Fase Repolarisasi
• Fase Istirahat

Sel Kontraktil
• Fase Depolarisasi
• Fase Plateu
• Fase Repolarisasi
• Fase Istirahat
Mechanisms of Arrhythmogenesis
 Normal Sinus Rhythm

Heart Rhythm P Wave PR Interval QRS

Rate (in seconds) (in seconds)

60 – 100 bpm Regular Before each QRS, 0.12 - 0.20 < 0.12
Increased/Abnormal Automaticity

Sinus tachycardia

Ectopic atrial tachycardia

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Junctional tachycardia
Recognizing altered automaticity on EKG

Gradual onset and termination of the

arrhythmia.

The P wave of the first beat of the arrhythmia is

typically the same as the remaining beats of
the arrhythmia (if a P wave is present at all).
Mechanism of Reentry
Mechanism of Reentry
 Reentrant Rhythms
• AV nodal reentrant tachycardia
(AVNRT)
• AV reentrant tachycardia (AVRT)
– Orthodromic
– Antidromic
• Atrial flutter
• Atrial fibrillation
• Ventricular tachycardia
 Recognizing reentry on EKG

Abrupt onset and termination of the arrhythmia.

The P wave of the first beat of the arrhythmia is

different as the remaining beats of the
arrhythmia (if a P wave is present at all).
Mechanism of AVNRT
 ARRHYTMIA
4 basic types of arrhytmia :
• Sinus origin
• Ectopic Beat
• Conduction Block
• Preexcitation syndromes
 Arrhytmia…

Sinus Origin

• Sinus Bradikardia
• Sinus Takikardia
• Sinus Aritmia
could be normal rate changes (does not
remain regular)
• Sinus Arrest
Escape beat
 Normal Sinus ritme

Heart Rate Irama Gelombang p PR interval Durasi QRS

60-100 bpm regular Before QRS 0,12-0,20 s < 0,12

 Sinus Arrhytmia
Inspiration

Expiration

Heart Rate Irama Gelombang p PR interval Durasi QRS

Usually 60- irregular Before each 0,12-0,20 s < 0,12

100 bpm QRS,
identical
 Tachycardia classification
• Narrow QRS Complex
– Regular
– Iregular
• Wide QRS Complex
– Regular
– Iregular
Classification?
Kompleks QRS

QRS SEMPIT

QRS LEBAR
+ ABBERANCY
 Arrhytmia…
Ectopic Rhytms
originated outside of the SA Node
• Paroxysmal Supraventricular Tachycardia
- Paroxysmal Atrial Tachycardia (PAT)
- Paroxysmal Junctional Tachycardia
• Atrial Flutter
• Atrial Fibrilation
• Multifokal Atrial Tachycardia
note : If normal rate, then called wandering
pace maker
Macroreentrant and Microreentrant
Tachycardias
 Narrow QRS Complex
Tachycardia
– With irregular rhythm :
• Atrial fibrilasi (AF)
• Atrial flutter (Af) with varying block
• Atrial takikardi (AT) with varying block
– With regular rhythm : SVT
• Atrial flutter (Af)
• Atrioventricular Reprocicating Tachycardia (AVRT)
• Atrioventricular Nodal Reentrant Tachycardia (AVNRT)
• AT
• Junctional Tachycardia (JT)
• Narrow complex Ventricle Tachycardia (VT)
Macroreentry Microreentry

Atrial Flutter Atrial Fibrillation

Atrial Fibrillation :

-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
- Ventricular beat slow to rapid
-no uniform atrial depolarization
Atrial Flutter :
-The result of a re-entry circuit within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min), “sawtooth”
-Ventricular beat : < 300 bpm
Atrial Flutter

Atrial Fibrilasi
Junctional rhythm:
-AV junction can function as a pace maker
(40-60 x/min).
-due to the failure of sinus node to initiate
time impulse or conduction problem.
-normal-looking QRS.
-retrograde P wave.
-P wave may preceede, coincide with, or
follow the QRS
Junctional Tachycardia (RJT)
• Reentry within the atrioventriocular (AV) junction can
result in a single junctional premature beat (JPB) or
in sustained junctional tachycardia
• Produces narrow-complex regular tachycardia
without preceding atrial depolarization waves
• RJTs often produce retrograde atrial depolarization
but these waves are usually buried within the QRS
complex
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
Paroxismal Junctional Tachycardia
Supraventricular tachycardia
Wide QRS Complex Tachycardia

– VT
– Supraventrikular Takikardi (SVT) dengan
bundle branch block (BBB)
• Aberrancy
• Pre-existing BBB
– SVT dengan pre-eksitasi
Macroreentrant and Microreentrant
Tachycardias
 Arrhytmia…

Non Sustained Abnormal Beat

• Premature Atrial Contraction

- Can occur on T wave
- May be non conducted
- P way may be missing

• Premature Junctional Contraction

- Retrograde P waves
- P wave after QRS
- P wave may be missing
SR

VES
 Arrhytmia…

Non Sustained Abnormal Beat

• Premature Ventricular Contraction

- Multifokal
- Couplet
- Bigemini or trigemini
• Ventricular Tachycardia
• Ventricular Fibrilation
 Sinus rhythm
with
Multifocal VES

VES VES

SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Premature ventricular contraction
Ventricular Tachycardia
Ventricular Fibrillation
Torsade de Pointes