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Physiology of normal cardiac rhythm
Definition and mechanisms of
arrhythmias
Classification of drugs to treat
arrhythmias
Important anti-arrhythmic drugs
(mechanism and pharmacological
characteristics)
Arrhythmias in clinical practice
Physiology of cardiac rate
andarerhythm
Cardiac myocytes electrically
excitable
Resting intracellular voltage of myocardial
cells is negative -90mV (SA node is -40mV)
Resting state - K+ inside and Na+ outside cell
(Na+/K+ pump)
Action potential occurs when Na+ enters
the cell and sets up a depolarising current
Stimulation of a single muscle fibre causes
electrical activity to spread across the
myocardium
Phases of action potential of
cardiac cells
Phase 0 rapid depolarisation
(inflow of Na+)
Phase 1 partial repolarisation
(inward Na+ current Phase 1
deactivated, outflow of K+) IV
Phase 2
Phase 2 plateau (slow inward0 mV
calcium current)
Phase 3 repolarisation Phase 0 III
I Phase 3
(calcium current inactivates,
K+ outflow)
Phase 4 pacemaker potential -80mV Phase 4
(Slow Na inflow, slowing of
+
II
K outflow) autorhythmicity
+
Sympathetic over-activity
Electrolytes disturbances ( K, Ca, Mg )
Acid Base disturbances (Acidosis)
Myocardial Ischemia
Drugs (Cardiac & Non-cardiac)
Myocardial diseases
Over-stretching of myocardial fibers
Other
CARDIAC ARRHYTHMIAS
IMPULSE PROPAGATION ARRHYTHMIAS
RE-ENTRY ARRHYTHMIA:
Its the most common mechanism
FACTORS REQUIRED:
Unidirectional block
PRE-EXCITATION SYNDROMES
Occurrence: 1 in 1000
Wolf-Parkinson-White Syndrome
Long-Ganong-Levine Syndrome
CARDIAC ARRHYTHMIAS
TRIGGERED ACTIVITY
Premature Beat
Jenis Aritmia
Sinus takikardi/sinus bradikardi
Venticular -/Atrial extrasystole
Supra-ventricular tachycardia
Ventricular tachycardia
Atrial fibrillation
Block
Atrial fibrillation / Flutter
http://www.emedu.org
Supraventricular tachycardia
http://www.emedu.org
Junctional tachycardia
http://www.emedu.org
Ectopic atrial tachycardia
http://www.emedu.org
Multifocal Atrial tachycardia
Mechanical arrest
Great O2 consumption +++
Before CPB: critical ischemia (Left main, severe
CAD)
During CPB: poor myocardial protection
On weaning from CPB: Reperfusion
After CPB: Myocardial ischemia, electrolyte
PVC (ESV)
Bigeminism
PVC (ESV)
paired
PVC (ESV)
Polymorphic
PVC (ESV)
Triplet
PVC (ESV)
Ischemic
Ventricle irritation
http://www.emedu.org
PVC (ESV)
http://www.emedu.org
Ventricular tachycardia
Ventricular tachycardia
Beta-blockers
Calcium Channel blockers Katrina Kardos, MD
PGY-3
Albany Medical Center
LBBB
His Bundle
L Bundle
R Bundle
Katrina Kardos, MD
PGY-3
Albany Medical Center
RBBB
Beta blockers
Frequent in elderly
AV node (valve surgery, MI) http://www.emedu.org
1 Degree AV block
st
Beta blockers
Frequent in elderly
AV node (valve surgery, MI)
http://www.emedu.org
2 Degree AV block type 1
nd
http://www.emedu.org
3 Degree AV block
rd
http://www.emedu.org
Junctional Escape Rhythm
http://www.emedu.org
CARDIAC ARRHYTHMIAS
CLINICAL MANIFESTATIONS:
ASYMPTOMATIC
PALPITATIONS
EMBOLISM
HEART FAILURE
Acute pulmonary edema
Muscle weakness, fatigue
MYOCARDIAL INFARCTION
SUDDEN DEATH
Anti Arrhytmic drugs
Vaughan Williams classification of
antiarrhythmic drugs
Class I: block sodium channels
Ia (quinidine, procainamide,
disopyramide) AP
Ib (lignocaine) AP Phase 1
Ic (flecainide) AP IV
Class II: -adrenoceptor Phase 2
0 mV
antagonists (atenolol, sotalol)
Class III: prolong action
potential and prolong refractory Phase 0 III
I Phase 3
period (suppress re-entrant
rhythms) (amiodarone, sotalol)
Class IV: Calcium channel
-80mV Phase 4
antagonists. Impair impulse
propagation in nodal and II
damaged areas (verapamil)
Mechanism of anti arrhythmias drug action
Cinchonism
Demam
Tinitus
Penglihatn kabur
Diplopia
Sakit kepala
Delirium
Prikosis
Gangguan GIT
Amiodaron
Farmakokinetik indikasi Efek samping
O P T1/2 Dosis VT, AF Pro aritmik,
Hipotensi, gangguan fungsi:
+ + 25 60 jam Loading 600 hati, tiroid, paru & mata
s/d 800
mg/ hari
Maintenanc
e 300mg/
hari
Sotalol
Farmakokinetik indikasi Efek samping
O P T1/2 Dosis SVT, VT Gagal jantung
+ - 11 jam 800 s/d 320
mg/hari
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