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Arrhythmias:

Terminology, Definitions, and Mechanisms

Terminology and Basics


Ectopic Beats or Rhythms
beats or rhythms that originate in places other than the SA node
the ectopic focus may cause single beats or take over and pace
the heart, dictating its entire rhythm

they may or may not be dangerous depending on how they affect


the cardiac output

Causes of Ectopic Beats or Rhythms


hypoxic myocardium - chronic pulmonary disease, pulmonary embolus
ischemic myocardium - acute MI, expanding MI, angina
sympathetic stimulation - nervousness, exercise, CHF, hyperthyroidism
drugs & electrolyte imbalances - antiarrhythmic drugs, hypokalemia,
imbalances of calcium and magnesium

bradycardia - a slow HR predisposes one to arrhythmias


enlargement of the atria or ventricles producing stretch in pacemaker cells

Terminology and Basics


Arrhythmia or Dysrhythmia?
dysrhythmia accurate, but arrhythmia most widely
Supraventricular: origin is above the ventricle, i.e., SA, atrial
muscle, AV or HIS origin
Ventricular: origin is in ventricle
Arrhythmia is generally named for anatomical site or
chamber of origin

Mechanisms
Automaticity: Spontaneous Phase 4 Depolarization (SA, AV,
Purkinje tissue)
rate dependent on:
Threshold potential
slope of phase 4 depolarization
resting membrane potential

Mechanisms of Arrhythmias
Altered automaticity
Normal, enhanced normal, abnormal

Triggered activity

Reentry

1. Altered Automaticity

Change slope,
change rate. 1o
sympathetic
mechanism;

PNS dec phase 4


slope and
hyperpolarize

Change threshold,
change rate.

Change RMP,
change rate

From: Berne and Levy, Physiology, Mosby,


1983.

From: Berne and Levy, Physiology, Mosby,


1983.

hypothermia decrease, hyperthermia increase phase 4 slope


hypoxia & hypercapnia both increase phase 4 slope
cardiac dilation increases phase 4 slope
local areas of ischemia or necrosis increases automaticity of neighboring cells
hypokalemia increases phase 4 slope, increases ectopics, prolongs
repolarization
hyperkalemia decreases phase 4 slope; slow conduction, blocks

2. Triggered Activity

Afterdepolarization reaches threshold

Early: interrupt repolarization

Congenital or acquired long QT syndrome: altered K+ and Na+


currents during phase 2 can produce dangerous V-tach

Delayed: after completion of AP.

3. Reentry (circus movement, reciprocal or echo beat, reciprocating tachycardia)

Anatomic: nodal tissue, Purkinje, BB, accessory path

Example: WPW

Functional

Local differences in conduction velocity and membrane characteristics

Anisotropic:

circuit determined by difference in conduction velocity through length of fiber

Reflection

Parallel pathways with depressed segments

3. Reentry (circus movement, reciprocal or echo beat, reciprocating tachycardia)

Requires: available circuit, unidirectional block, and different


conduction speed in limbs of circuit

Conditions that depress conduction velocity or shorten refractory period


promote functional block
Exp: WPW reciprocating tachycardia, AV-nodal reentry, V-tach due to bundle
branch reentry, infarcted area.

The Re-Entry Mechanism of Ectopic Beats & Rhythms


Electrical Impulse
Cardiac
Conduction
Tissue
Fast Conduction Path
Slow Recovery

Slow Conduction Path


Fast Recovery

Tissues with these type of circuits may exist:


in microscopic size in the SA node, AV node, or any type of heart tissue
in a macroscopic structure such as an accessory pathway in WPW

The Re-Entry Mechanism of Ectopic Beats & Rhythms


Premature Beat Impulse
Cardiac
Repolarizing Tissue
Conduction
(long refractory period)
Tissue
Fast Conduction Path
Slow Recovery

Slow Conduction Path


Fast Recovery

1. An arrhythmia is triggered by a premature beat


2. The beat cannot gain entry into the fast conducting
pathway because of its long refractory period and
therefore travels down the slow conducting pathway only

The Re-Entry Mechanism of Ectopic Beats & Rhythms


Cardiac
Conduction
Tissue
Fast Conduction Path
Slow Recovery

Slow Conduction Path


Fast Recovery

3. The wave of excitation from the premature beat


arrives at the distal end of the fast conducting
pathway, which has now recovered and therefore
travels retrogradely (backwards) up the fast
pathway

The Re-Entry Mechanism of Ectopic Beats & Rhythms


Cardiac
Conduction
Tissue
Fast Conduction Path
Slow Recovery

Slow Conduction Path


Fast Recovery

4. On arriving at the top of the fast pathway it finds the


slow pathway has recovered and therefore the wave of
excitation re-enters the pathway and continues in a
circular movement. This creates the re-entry circuit

Re-entry Circuits as Ectopic Foci and Arrhythmia Generators


Atrio-Ventricular Nodal Re-entry

supraventricular tachycardia
Atrial Re-entry

atrial tachycardia
atrial fibrillation
atrial flutter

Atrio-Ventricular Re-entry

Wolf Parkinson White


supraventricular tachycardia

Ventricular Re-entry

ventricular tachycardia

Clinical Manifestations of Arrhythmias


many go unnoticed and produce no symptoms
palpitations ranging from noticing or being aware of ones heart
beat to a sensation of the heart beating out of the chest

if Q is affected (HR > 300) lightheadedness and syncope, fainting


drugs & electrolyte imbalances - antiarrhythmic drugs, hypokalemia,
imbalances of calcium and magnesium

very rapid arrhythmias u myocardial oxygen demand r ischemia


and angina

sudden death especially in the case of an acute MI

mechanism differentiation from ECG very difficult to impossible

Clinical Application
No rhythms precisely regular

Incidence: common (PVC, PAC), increase with age

ECG differentiation may be impossible


Monitor leads V1 or MCL1: L&R ventricular ectopy, RBBB &
LBBB, good P-waves

Where to look for clues

P-wave morphology

PR interval

QRS morphology

QTc interval

Matching atrial rate with ventricular

Look for gaps in the rhythm

Clinical Application
Eight basic rhythm disturbances

early beats (extrasystole)

unexpected pauses (nonconducted atrial extrasystole)

bradycardia (sinus bradycardia)

tachycardia (ventricular or atrial)

bigeminal rhythm (ventricular or supraventricular extrasystolic)

group beating (2nd degree heart block)

total irregularity (atrial fibrillation)

regular non-sinus rhythm at normal rate (accelerated AV rhythm)