ARRHYTHMIA

Chaerul Achmad
Department of Cardiology and Vascular
Medicine
Dr. Hasan Sadikin Hospital
 AETIOLOGY OF CARDIAC ARRHYTHMIAS
Cardiac Disease Common cardiac diseases
‘arrhythmogenic’ cardiac disorder
Electrolyte derrangements Hypokalaemian and hyperkalaemia
Hypomagnesaemia
Hypercalcaemia
Drugs Digitalis
Antiarrhythmia drugs
Sympathomimetic drugs
Psychotropic drugs
Endocrine disorders Thyrotoxicosis
Phaeochromocytoma
Hyperparathyroidism
Myxoedema
Catheters/electrodes introduced into cardiac cavities
Miscellaneous Pulmonary embolism, acute infections
Hypotension, shock, hypoxaemia, anaemia
Cardiac surgery, major surgery
Bronchoscopy, gastroscopy, etc.
Changes of autonomic nervous tone
Unknown Arrhythmia in apparently healthy individual 2
 Basic Approach in Arrhythmia Classification
Impulse origin Supraventricular arrhythmia
- Atrial arrhythmia
- AV junctional arrhythmia
Ventricular arrhythmia

Type & sequence Extrasystole/premature beat

of impulse formation Bradycardia
Tachycardia
Flutter
Fibrillation
Escape
Escape rhythm
Mode of impulse Block
conduction AV dissociation
Pre-excitation
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 ARRHYTHMIA :
any cardiac
I rhythm which deviates from normal sinus
rhythm

Important aspects in understanding arrhythmias

1. The mechanism :
- problems of impulse formation (automaticity)
- problems of impulse conduction (block or reentry)
2. The site of origin : - supraventricular
- ventricular
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The parts of Supraventricular and Ventricular Areas

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 Atrio-ventricular node
(AV node)

Sino-atrial node
(SA node) His bundle

Left bundle branch

Right bundle branch

Purkinje
R R R

Q S

R R

R’

Q S QS S
SINUS RHYTHM

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Normal Sinus Rhythm

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Sinus bradycardia.

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Sinus tachycardia
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SUPRAVENTRICULAR
ARRHYTHMIAS

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 Sinus rhythm R
Atrial rhythm

P T

Q S

R
Junctional rhythm (narrow QRS)
Ventricular rhythm (wide QRS) T

Q S
 AV Junctional Impulses

The contrasting appearances of P waves originating from the sinus

node and the AV junction (arrows)
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 Supraven-
tricular
extrasystole

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Atrial flutter with high-grade AV block.

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Atrial fibrillation with controlled ventricular response.

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Paroxysmal supraventricular tachycardial (PSVT)

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VENTRICULAR
ARRHYTHMIAS

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Premature ventricular complex with fully compensatory pause
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Premature ventricular complex

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MALIGNANT PREMATURE BEATS

1.FREQUENT

2.MULTIFOCAL OR MULTIFORM

3.SALVO

4.“R ON T” PHENOMENON
Unifocal premature ventricular complexes. Note occurrence of
wide, premature QRS complexes. Interval between preceding
normal QRS and PVC (coupling interval) remains constant, and
morphology remains the same

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Multiformed premature ventricular complexes. Note variation in
morphology and in coupling interval of PVCs
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Ventricular bigeminy. Note that every other betas is PVC. Both
coupling interval and morphology remain constant; hence they
are unifocal

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Pairs of premature ventricular complexes

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 R-on-T phenomenon
Multiple PVCs are present. On right, a PVC falls on downslope of T wave,
precipitating ventricular fibrillation

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Precipitation of ventricular tachycardia by late-cycle PVC. Note
brief salvo of ventricular tachycardia that is initiated by PVC
occurring well beyond T wave

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Ventricular tachycardia

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Tosardes de pointes

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Coarse ventricular fibrillation

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Fine ventricular fibrillation (“coarse” asystole)

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Ventricular asystole

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CONDUCTION
DISTURBANCES

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Diagrammatic representation of mechanism of reentry

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 CLASSIFICATION OF CONDUCTION DISTURBANCES

 SINOATRIAL BLOCK

 ATRIOVENTRICULAR BLOCK
 * Incomplete AV Block :
 - 1st degree AV Block
 - 2nd degree AV Block : Mobitz type I (Wenckebach)
 Mobitz type II
 * Total AV Block :
 - 3rd degree AV Block

 INTRAVENTRICULAR BLOCK
 - RBBB
 - LBBB
 - Fascicular Block

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