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Semnificaie manifestri clinice

Simptome:

datorate DC

cerebral: vertij-lipotimii sincopa ( sd. Adams-Stokes)


cardiace: angina pectorala
renale: respiraie acidotic com
musculare: astenie fizic / fatigabilitate

datorate stazei
pulmonare
periferice

Semne

de DC
de staz

NB!: manifestrile clinice depind de mecanismul


tahidicardiei i de substratul pe care apar
NB!: simptomele se pot datora i bradiaritmiilor
induse de tahiaritmii
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EGM intracavitare: EPS

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Mecanismele TSV sustinute


" Reintrare:
" in NSA
" la nivelul caii lentecale rapida: TRNAV
" la nivelul atriului =
FiA, Fl A
" pe cale accesorie: TRAV
" Automatice:
" Aritmii atriale automatice
" Aritmii jonctionale
automatice:
" TJNP pura
" TJNP cu bloc
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Tahicardia sinusala

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Aritmia sinusala respiratorie

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Extrasistolia atriala

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Tahicardia atriala multifocala

!
!
!
!
!
!
!
!
!
"

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Tahicardia jonctionala neparoxistica

Context clinic sugestiv: regularizarea frecventei

cardiace la pt cu FA cronica tratat cu digitala

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Tahicardia prin reintrare in NAV


(TRNAV): mecanism

" Conducere

anterograda = pe calea lenta in AD posteroseptal

" Conducere

retrograda = pe calea rapida in AD


R.V. anteroseptal
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V1
D1
V2
D2

V3

D3
aVR

V4

aVL
V5
aVF

V6

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Tratamentul TRNAV

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Sdr. de preexcitatie

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Situatii clinice posibile in prezenta


caii accesorii atrio - ventriculare

asimptomatica

simptomatica

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Preexcitatie permanenta

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Efectul de acordeon :
unda delta de durata variabila

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Tahicardia reintranta atrioventriculara (TRAV)

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TRAV cu conducere
antidromica
" tahiaritmie regulata cu QRS largi prin
prezenta undei delta
" raspuns ventricular rapid > 180-200/min
" mecanism:
" Conducere anterograda pe calea accesorie
" Conducere retrograda prin NAV

" dg diferential cu TV monomorfa sustinuta


" Risc crescut de moarte subita cardiaca in
caz de aparitia FA FV
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TSV in sdr. WPW cu conducere antidromica

!Tahiaritmie

regulata cu QRS largi; P ne-evidentiabil; dg dif TV monomorfa


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Sdr. WPW cu fibrilatie atriala

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Evaluarea riscului vital in WPW

250 ms)

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Tratamentul in sdr. WPW

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Tahicardiile atriale focale

Tratament:

de obicei rezistenta la tratament

Stop digitala; fenitoina


-blocante, potasiu, Ca-blocante

in BPOC = O2

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Fibrilatia atriala

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Epidemiologia FA

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Etiologia FA

FA IDIOPATICA: pana la 30% din cazuri !


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FA depistata prima

of spontaneous conversion is low and anticoagulation must


considered (see Section 4.1).
(3) Persistent AF is present when an AF episode either la
longer than 7 days or requires termination by cardioversi
oara
either with drugs or by direct current cardioversion (DCC
(4) Long-standing persistent AF has lasted for 1 year wh
it is decided to adopt a rhythm control strategy.
(5) Permanent AF is said to exist when the presence of
arrhythmia is accepted by the patient (and physician). Hen
rhythm control interventions are, by definition, not pursu
in patients with permanent AF. Should a rhythm cont

Clasificare

PERSISTENTA
(ne-autolimitata)

PAROXISTICA
(autolimitata)

PERMANENTA
First diagnosed episode of atrial fibrillation
Paroxysmal
(usually <48 h)
Persistent

(>7 days or requires CV)

Long-standing
Persistent (>1 year)
Permanent
(accepted)
ESC Practice Guidelines. EHJ 2010

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Fiziopatologie

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Permanent

Substrat

Paroxistic

Trigger

Page 9 of 6

strip (recorded at 25 mm/s) by six. The


ications is not different between short
d forms of the arrhythmia.12 It is theret paroxysmal AF in order to prevent
Persistent
(e.g. stroke). However,
short atrial highed by pacemakers, defibrillators, or other
ot be associated with thrombo-embolic
r duration exceeds several hours (see

,,Perpetuatori

y as an ischaemic stroke or TIA, and it is


most patients experience asymptomatic,
hythmia episodes before AF is first diagcurrence is 10% in the first year after the

Upstream therapy of concomitant conditions


Anticoagulation

first documented

Rate control
Antiarrhythmic drugs
Ablation
Cardioversion
AF
silent

paroxysmal

persistent

long-standing permanent
persistent

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Paroxistic

Persistent

Permanent

Durata

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Consecintele FA. Implicatii terapeutice

CONVERSIA LA RS

REDUCEREA AV

PROFILAXIA EMBOLIILOR
SISTEMICE
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Conversia la RS

50% din FA paroxistice = conversie spontana in 24-48 ore de la debut


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Similar to flecainide, propafenone should be avoided in patients

than AF.

Conversia la RS: chimica sau electrica


Table 12

Drugs and doses for pharmacological conversion of (recent-o

Drug

Dose

Follow-up dose

Amiodarone

5 mg/kg i.v. over 1 h

50 mg/h

P
A

Flecainide

2 mg/kg i.v. over


10 min,
or
200300 mg p.o.

N/A

N
d
in
d
v

Ibutilide

1 mg i.v. over
10 min

1 mg i.v. over 10 min after


waiting for 10 min

C
p
W

Propafenone

2 mg/kg i.v. over


10 min,
or
450600 mg p.o.

Vernakalant

3 mg/kg i.v. over


10 min

N
d
t
v
c
Second infusion of 2 mg/kg i.v.
over 10 min after15 min rest

Vernakalant has recently been recommended for approval by the European Medicines Agency for rapid car
non-surgical patients; 3 days for surgical patients).68,69 A direct comparison with amiodarone in the AVR
Active-controlled, multi-center, superiority study of Vernakalant injection versus amiodarone in subjects with
amiodarone for the rapid conversion of AF to sinus rhythm (51.7% vs. 5.7% at 90 min after the start of treatm
over 10 min), followed by 15 min of observation and a further i.v. infusion (2 mg/kg over 10 min), if necess
pressure ,100 mm Hg, severe aortic stenosis, heart failure (class NYHA III and IV), ACS within the previo
should be adequately hydrated. ECG and haemodynamic monitoring should be used, and the infusion can b
R.V.heart
- Tahiaritmii
feb
2012
patients with stable coronary artery disease, hypertensive
disease, or mild
heart
failure. The clinical pos

Profilaxia recurentei: chimica

AA de clasa Ic preferabil asociate cu B

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Controlul frecventei cardiace


- in FA permanenta sau in caz de contraindicatii de conversie -

!
!

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Riscul de AVC in FA: CHADS2


"

Elemente scorului CHADS2:


" Insuficienta

cardiaca congestiva: 1 pt

" Hipertensiune:
" Varsta:

1 pt

" Diabet:

1 pt

" AVC

1 pt

sau AIT: 2 pt
Rockson SG, Albers GW. JACC 2004;43:929.

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Age 6574
1
Vascular disease
sk factors.OAC
(b) comes
Risk factor-based
approachpublished
expressed asanaa point based
Sex category (i.e. female sex)
1
pproach
from various
scoring system, with the acronym CHA2DS2-VASc
tients
at maximum
moderate
defined
Maximum score
9
(Note:
score isrisk
9 since(currently
age may contribute
0, 1, or 2 points)
1, i.e.
risk factor) still derive significant Score
Riskone
factor
(c) Adjusted stroke rate according to CHA2DS2-VASc score
OAC
(or aspirin)
overCongestive
aspirinheart
use,failure/LV
oftendysfunction
with low rates of 1
CHA2DS2-VASc
Patients (n = 7329)
Adjusted stroke
Nothing (or aspirin)
Importantly,
prescription
of
an
antiplatelet
score
Hypertension
1
rate (%/year)b
iatedAgewith
>75 a lower risk of adverse events. 2
0
1
0%
score
does
not include many stroke risk 1
Diabetes
mellitus
e prevention in AF. AF atrial fibrillation; OAC oral anticoagulant;
1
422
1.3%
roke
risk
need to be considered 2
Stroke/TIA/thrombo-embolism
be found
on modifiers
page 13.
2
1230
2.2%
trokeVascular
risk disease
assessment
(Table 8).
a
1
ors Age
(previously
referred to as high risk 1
3
1730
3.2%
6574
troke
TIA,(i.e.
or
thrombo-embolism,
and the
Table
10
Clinical
characteristics comprising
Sexor
category
female
sex)
1
4
1718
4.0%
bleeding
risk
score
s). HAS-BLED
The
presence
of
some
types
of
valvular
Maximum score
9
5
1159
6.7%
stenosis
or
prosthetic
heart
valves)
would
(c) Adjusted stroke rate according
to CHA2DS2-VASc score
Letter
Clinical characteristica
Points awarded
6
679
9.8%
valvular
AF
patients
as
high
risk.
CHA2DS
-VASc
Patients
(n
=
7329)
Adjusted stroke
2
HscoreHypertension
1
rate (%/year)b
ant non-major
risk factors (previously
7
294
9.6%
Abnormal renal and liver
A factors)
1 or 2 0%
rate risk
[especially
0 function (1are
1
8
82
6.7%
pointheart
each) failure
systolic SLV1 Stroke
dysfunction, defined
422 arbitrarily 1as 1.3%
9
14
15.2%
on fraction
(LVEF) 40%],1230
hypertension, or
B 2 Bleeding
1 2.2%
cally relevant
risk
L 3 Labilenon-major
INRs
1 3.2%
1730 factors (preSee text for definitions.
a
s less validated
riskagefactors)
include
female
E 4 Elderly (e.g.
>65 years)
1
1718
4.0%
Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates
of stroke in contemporary cohorts may vary from these estimates.
and vascular
disease
(specifically,
D 5 Drugs
or alcohol
(1 point
each) myocardial
1 or 2 6.7%
1159
b
Based on Lip et al. 53
ortic plaque
and
PAD).
Note
that
risk
factors
Maximum
9 points
6
679
9.8%
AF atrial fibrillation; EF ejection fraction (as documented by
he simultaneous presence of two or more
echocardiography, radionuclide ventriculography, cardiac catheterization, cardiac
7
294
9.6%
a
Hypertension is defined as systolic blood pressure .160 mmHg. Abnormal magnetic resonance imaging, etc.); LV left ventricular;
n-major risk factors would justify a stroke
kidney function
is defined as the presence
8
82 of chronic dialysis or renal
6.7%
TIA transient ischaemic attack.
gh transplantation
to requireoranticoagulation.
serum creatinine 200 mmol/L. Abnormal liver function is
R.V. - Tahiaritmii feb 2012
a

Risc AVC in FA: CHA2DS2-VASc

14

15.2%

Recomandarile de tratament anti-trombotic in


functie de profilul de risc in FiA (ACCP/VII)
Nivel de risc

Indicatorii riscului

Tratament

Risc scazut

varsta 65 ani

Aspirina 325 mg/zi

fara FR aditionali
Intermediar

Varsta 65-75 ani

ACO (INR: 2,0-3,0)

DZ

sau ASA

B coronara
Inalt

Varsta > 75 ani

ACO (INR: 2,0-3,0)

Istoric de AVC, AIT sau ES


HTA, DZ
Disfunctie VS sau ICC
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TAHIARITMIILE
VENTRICULARE
Tahiaritmii cu QRS larg

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Extrasistolele ventriculare

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Clasificare si semnificatie
clinica

Myerburg et al. Am J Cardiol 1984;54:1355-8.


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Clasificare si semnificatie clinica

Morganroth et al. JACC 1986.


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Tratamentul ESV

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Studiul CAST-I:

cresterea mortalitatii sub AA clasa I la pacienti cu IM in


antecedente

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TV: definitie si caractere ECG

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Mecanismele TV

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TV monomorfa: diagnostic
tahiaritmie regulata >
120/
QRS larg > 120 msec
Disociatie AV
Batai de fuziune
Capturi ventriculare
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Criterii morfologice

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Tahicardia ventriculara
neparoxistica (RIVA) =
AUTOMATISM CRESCUT

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TV polimorfa: torsada varfurilor


PDP
TV rapida, degenereaza in FV
produsa prin PDP
cu QT lung sau cu QT normal
Cauze:
sdr. de QT lung
hipo K, hipo Mg
AA Ia si III
Tratament:
MgSO4 IV
Overdrive pacing
isuprel lent
xilina, fenitoina
QT lung: AICD, beta-blocante,
flecainida, stelectomie.
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Dg TV vs. TSV cu QRS largi

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Tratament TV

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Oprirea TV prin overdrive pacing

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Tratamentul profilactic al TV

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Fibrilatia
ventriculara
Unde fibrilatorii de amplitudine diferita, in absenta
complexelor QRS
Asistola mecanica urmata de asistola electrica
Colaps, stop respirator si deces in 3-5 minute de la
instalare in absenta CPR
Cauze:
Ischemia acuta din IMA
aritmii V spontane
severe
Cardiomiopatii (CMHO !)
FA din WPW
CHT cu HVS
hipoxia din BPOC
Iatrogen: medicamente, diselectrolitemii, cateterism cardiac
Sdr. de QT lung cu TdP
SEE nesincron

Precedata sau nu de TV
Tratament:
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Tratamentul aritmiilor V maligne:


defibrilatorul implantabil

III

CMH

CAVD

LQT

Brugada
SQT
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