Cardiac arrhythmias

Abnormal of Cardiac Rhythm

Prof. dr. Peter Kabo PhD, MD, SpJP, SpFK, FIHA

Cardiac conduction system
Normal cardiac rhytm
Classification
Sinus node diseases
• Sinus tachycardia/ bradicardia
• SA block
• Wandering pace-maker
• Hypersensitive carotid sinus syndrome
• Sick – sinus – syndrome (sss)

Disturbance of atrial rhythm

• Atrial fibrillation
• Atrial flutter

Disturbance of AV junction rhythm

• Supra ventricular tachycardia

Pre-excitation syndrome
• Wolff – Parkinson – white syndrome (δ – wave)

Disturbance of ventricular rhythm

• Ventricluar extra systole: quadrigemini, Trigemini, <┼> Duplex, Triplex, quadriplex
• Ventricular tachycardia

Heart block
• 1st degree HB
• 2nd degree HB
• Wenckebach (mobitz type I)
• (mobitz type II)
• 3rd degree HB (total AV block) Sympathomimetics : Ephedrine
• Temporary pace-maker Anticholonergic : Atrophine
• Permanent pace-maker
Mechanism of Cardiac Arrhytmias
Enhanced automaticity
• Sinus Tachycardia
Triggered automaticity
• Multifocal atrial tachycardia
• VES → VT Torsade de Pointes
Reentry
• Atrial Fibrilation (AF)
• Atrial flutter
• SVT
• VT

Block
• 1st degree AV block
• 2nd degree AV block
• 3rd degree AV block (total AV block)
Trigger automaticity
Afterdepolarization

Early Afterdepolarization

Delayed Afterdepolarization
Reentry
Macroreentry Microreentry

Atrial Flutter Atrial Fibrillation

The commonly found arrthymias
 Sinus tachycardia/ sinus bradycardia
 Atrial-/ ventricular- extrasystole
 Supra-ventricular tachycardia
 Atrial fibrilation/flutter
 Common underlying diseases causing arrhythmias
Ischemic heart disease
• Acute myocardial infarction
• Myocardial ischemic (HHD, LVH, CAD)
• Left ventricular aneurysm
Cardiomyopathy

Valvular heart disease

Myocarditis

Congenital heart diseases

Conduction system abnormality

• Sinus R AV – node disease
• By pass tract
Chronic pulmonary disease
• Hypokalemia

Endocrine
• Thyrotoxicosis

Electrolyte imbalance

Drug – induce
• Sympathomimetic, caffeine

Increase sympathetic/ vagal activity

Parasimpatomimetik (Kolinergik) Simpatomimetik (Adrenergik)
Parasimpatolitik (antikolinergik) Simpatolitik (Antiadrenergik)
 FAAL SSO

• Conservative
Parasimpatis • Reservation

• Fight
Sympathies • Flight reaction

Transmisi Neurohormonal
Ion Channel in Cell Membrane

Ca+2 ↓
Functional Consequences of The
Arrhythmias

 Palpitation
 Dizziness
 Syncope/ pre-syncope
 Fatigue
 Dyspnea
 Chest pain
The Physical Examination (ECG
are complemantery)

 Jugular venous pulse

 Arterial pulse
 Heart sound
Mechanism of anti arrhythmias drug action
Decreased phase 4 slope
• β blocker

Increased threshold
• Na+ channel blocker
• Ca++ channel blocker

Increased max – diastolic potential

• Adenosine
• Acetylcholine

Increased action potential duration

• K+ channel blocker

Ant arrhythmic drugs can cause arrhythmias

Some arrhythmias should not be treated
Classification of anti arrhythmia drugs
Sodium channel blocker
• Sodium channel (++)
• Diisopyramide, Quinidine, Procainamide
• Blocks K+ Efflux (+)
• Lidocaine, Mexiletine, Tocainide
• Sodium channel (+++)
• Flecainide, Encainide, Propafenone

Anti adrenergic
• β blocker

K+ channel Efflux blockers also Na+ blockers

• Amiodarone
• Sotalol

Ca++ channel blockers

• Verapamil & Diltiazem

Autonomic Effects
• Vagus stimulation
• Digoxin
• Adenosine receptor activation
• Adenosine
Farmakokinetik
O P Dosis Kadar Metab Eks Indikasi Efek samping
puncak
KINIDIN + + 3 X 200 mg 60 – 90’ H G/H AF, SVT
PROKAINAMID + + 3X (250000 – 45 – 70’ H G VES, SVT Lupus like
500) mg syndrome,
leukopeni
DIISOPIRAMID + - 3X 100 mg 60 – 120’ H G VES, SVT Mulut kering,
konstipasi,
penglihatan kabur
LIDOKAIN - + 1 MG/ KG bb H VT (pasca hipotensi
=1mg/ jam miokard infark)

PROPAFENON + + 3 x(150 -300) 60 – 180’ VES

mg

Hipotensi / Sinkop
Kardiovaskular
• SA block
• QRS – Interval • AV block
• Long QT • Torsades de Poentes
• ↑ ventrikuler rate (efek
anti kolinergik)

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: hati,
+ + 25 – 60 jam Loading 600 tiroid, paru & mata
s/d 800 mg/
hari
Maintenance
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