Tachycardia : Which Fast is too

Furious
Firman Fauzan A.L, MD, FIHA
PEMBENTUKAN IMPULS

• SA node dikenal dg native pacemaker karena dlm keadaan

normal sebagai generator utama pencetus impuls yg
menentukan laju jantung

• Sel lain sebagai sistem konduksi namun memiliki sifat

pembentukan impuls jika diperlukan disebut latent pacemakers
(or ectopic pacemakers)

• SSA node : 60-100 bpm, AV node dan HIS 40-60 bpm, Purkinjr
30-40 bpm
AVNRT

❑ SVT – AVNRT merupakan penyebab tersering kejadian

palpitasi pada org dengan jantung normal. (60% SVT)
❑ Disebabkan oleh dual AV node
❑ Typical AVNRT → slow-fast (90%)
❑ Atypical AVNRT → fast-slow, slow-slow
❑ Didasari oleh mekanisme reentry yang dipicu oleh prematur
beat
 Typical AVNRT

❑ 80-90% AVNRT

❑Saat premature beat

Anterograde → slow Path
Retrograde → fast path

❑slow path → fast RP

fast path → slow RP
Gambaran ECG pada typical AVNRT
• Non visible P, bersamaan dg kompleks QRS
• Very short RP
• Retrograde P dalam bentuk
• Pseudo R di V1 atau V2
• Pseudo S di lead II,III,aVF
Atypycal AVNRT

• Fast-Slow AVNRT
• 10% AVNRT
• Anterograde melalui Fast Pathway
• Rretrograde melalui Slow Pathway
• VA conduction lebih lama dari konduksi ventrikel -LONG RP (ECG)
Slow-Slow AVNRT
• ✓ 1-5% AVNRT
• ✓Associated with Slow AV nodal pathway for anterograde
conduction and Slow left atrial fibres as the pathway for
retrograde conduction.
• ✓ Tachycardia with a P-wave seen in mid-diastole
effectively appearing “before” the QRS complex.
• ✓Confusing as a P wave appearing before the QRS complex
in the face of a tachycardia might be read as a sinus
tachycardia.
AVRT

• Atrioventricular reentrant tachycardias (AVRTs) are similar to AVNRTs

except that in the former one limb o the reentrant loop is constituted
by an accessory pathway (bypass tract)
• Accessory pathways allow an impulse to conduct rom atrium to
ventricle (anterograde conduction), from ventricle to atrium
(retrograde conduction), or in both directions
AVRT
ECG features of WPW in sinus rhythm

• PR interval <120ms
• Delta wave – slurring slow rise of initial portion of the QRS
• QRS prolongation >110ms

WPW may be described as type A or B.

• ◦Type A has a positive delta wave in all precordial leads with R/S > 1
in V1 “Left sided Accesory pathway”
• ◦Type B has a negative delta wave in leads V1 and V2
“Right sided Accesory pathway”
KLASIFIKASI
•Orthodromic reentry
Impuls berjalan antegrade melalui AV
node dan retrograde melalui AP, gel
QRS sempit
•Antidromic reentry
Impuls berjalan antegrade melalui AP
dan retrograde melalui AV node, gel
QRS lebar
Atrial Flutter

• Paroxysmal AFL→ Prolonged→25-35% Atrial Flutter

• Persistent→ Kongenital / struktural
• Variable Av block : 2:1, 3:1 , 4:!
• 1:1→accesory pathway, Unstable
Atrial Flutter
Negative flutter waves at ~ 300bpm are best seen in the inferior leads II, III and aVF
(= anticlockwise pattern).
There is a 3:1 relationship between the flutter waves and the QRS complexes, resulting in a
ventricular rate of 100 bpm
Atrial Takikardi

• AT dapat merupakan bentuk SVT dengan short RP ataupun long RP

tergantung AV conduction delay

• Terdapat satu fokus di atrial ektopik

• Paroxismal/Sustained

• Rate > 100 bpm dengan > 3 bentuk gel P MAT (automatisitas)
• Fokal AT memiliki karakter berupa aktivasi atrial dari area yang kecil
yang menyebar secara sentrifugal di atrial caused by automaticity,
trigered activity, mikro-reentry
• Atrial rate > 100 bpm, usually 130-240
• Gel P berbeda secara morfologi dg gel P sinus
• Abnormal axis gel P
• Morfologi QRS normal kecuali dengan BBB,AP,Aberansi
• P (+) di V1, P(-) di aVL LA ectopik
• P (-) di V1, P(+) di aVL RA ectopik
Atrial Takikardi
Ventrikel Takikardi

• VT adalah adanya gambaran 3 atau lebih VPC dengan rate >120 kpm
• Non sustained VT : autoconvert dalam kurang dari 30 detik
• Sustained VT : VT dengan durasi > 30 detik
• AV dissosciation(capture,fusion beats)
Capture Beat
• At a particular time the slow sinus waves passes through the AV node
when it is no longer refractory and hence conducts down the
ventricles..ventricular capture beat, momentary activation of the
ventricles by sinus impulse in AV dissosciation.

Fusion Beat
• It is due to the combination of the sinus impulse and the ectopic
impulse leading to a QRS c0mplex that varies in the morphology with
the change in the occurrence of fusion from the AVnode.
Brugada Criteria
RVOT VT

most common IPVT-70%

• LBBB/Inf axis
• Female 2x than male
• Triggered by exercise or stress, and may also occur during hormonal
cycles in women
• Third to fifth decade of life
LVOT VT

• LBBB /inferior axis/ precordial transition earlier than their RVOT-VT .

• The precordial R-wave transition typically occurs at or before lead V3

ILVT (Fascicular VT origin)
Anti Aritmia Class 1.
Class II anti aritmia
Class III Anti Aritmia
Class IV Anti aritmia
-Matur Nuwun-
Brugada Criteria