Cardiac Rhythm and Related

Disorders
• Marshell Tendean, MD

• Department of Internal Medicine UKRIDA Jakarta

 Objective :
• To understand physiology of heart rhythm
• To understand patophysiology of rhythm
disorders
• Know some tachy-arrhytmias and the
treatment approach
• Know some bradi-arrhytmias and the
treatment approach
Normal Heart conduction :
Normal conduction pathway
 Clinical symptoms suggest arrhytmias :

• Syncopal attack
• Fatigue
• Tachycardia
• Frog sign
• Chest pain
• Seizure
• Hypotension
Action potentials of the Heart
• Electrolyce disorders
mainly Involve
the heart rhythm
 Arrhytmia mechanism :
• Impulse initiation :
– Automaticity :
• Tachycardia and bradyardia
– Trigered activity (phase 3 or 4):
• EAD
• DAD
• Conduction disorders :
– Reentry :
• Microreentrant
• Macroreentrant
• Acessory pathway
• Automaticity  :
– If, ICa-L, ICa-T, IK, IK1
– Suppression/acceleration of phase 4
– Sinus bradycardia, sinus tachycardia

• Triggered automaticity 
– Calcium overload, ITI
  DADs Digitalis toxicity, reperfusion VT  
– ICa-L, IK, INa
  EADs Torsades des pointes, congenital and acquired
• Pathomechanism of reentry
• Most common mechanism of arrhytmia
 Reentry :
• Unifocal.
• Multifocal “multifocal VT”.
• Microreentrant :
– Most of cardiac arrhytmias :
• SVT, AF
• Marcroreentrant :
– Atrial fluter “ sawtooth appearance”
• Acessory pathway :
– WPW sydrome “ delta wave”
Atrial tachycardias Ventricular
tachycardias
•SVT / AVNRT •Monomorfic
•Atrial fibrilation ventricular
•Atrial Flutter tachycardias
•Multifocal atrial •Polymorfic
tachycardias ventricular
tachycardias
 Management :
• Specific to the current abnormalities
– AVNRT / SVT
• Digoxin, verapamile, diltiazem, adenosine
– MAT :
• Digoxin
– AF / A flu :
• Rate control
• Rhythm control
• Anticoagulation
– VT
• Anti arrhytmic agent : “ amiodarone”
• Magnesium sulfate
 Use of specific anti arrhytmias :
• Most of anti arrhytmic agents are
proarrhytmics
• Limited to documented structural heart
disease
• Limited to sustained ventricular tacycardias
Intravenous anti arrhytmics commonly used
Oral anti arrhytmics commonly used
 Latest anti arrhytmias :
• Ivabradine, a “ funy channel inhibitor”
• Used in patients with enchanced automaticity
disorders.
• Treatment range 5 – 30 mg
• Safe and limited side effects
Arrhytmias
 Ancilary procedures :
• Holter monitoring
• Stress test
• EP study
 Treatment spesific for arrhytmias :
• SVT
• AF
• Atrial Flutter
• MAT
Ventricular arrhythmias
 • CAD Post ACS related VT
FORM OF VENTRICULAR • Idiopathic outflow tract VT
ARRHYTMIAS
• Idiophatic LV septal VT
• VT associated with dilated
cardiomyopathy
• Bundle branch related VT
• VT associated with hypertrophic
cardiomyopathy
• VT with other infiltrative
cardiomyopathies
• Arrhytmogenic RV dysplasia
• VT after tetralogy of falot repair
 Special inherited diseases related with
malignant arrhytmias :

• Brugada syndrome SCN5A  INa channel

• Catecholaminergic VT Ry R2  Ryanodine receptor,
calsequestrin receptor
• LQT1 KCNQ1  Iks channel subunit
• LQT2 KCNH2 (HERG)  IKr channel subunit
• LQT3 SCN5A  INA channel subunit
• LQT4 ANK2  Ankyrin-B LQT5 KCNE1  IKs channel subunit
• LQT6 KCNE2  IKr channel subunit
• LQT7 KCNJ2  IK1 channel subunit
• LQT8 CACNA1C  ICa channel subunit
• Patients can manifest bidirectional VT,
nonsustained polymorphic VT, or recurrent VF
• Triggered by stress
 Brugada syndrome
• ST segment elevation in V1 to V3 that typically
can be provoked with the sodium channel-
blocking drugs ajmaline, flecainide, and
procainamide and a risk of polymorphic
ventricular arrhythmias
 Long QT syndromes
• LQT1 represents the most common genotypic abnormality.
• The most common trigger for potentiating cardiac arrhythmias in patients with LQT1 is
exercise, followed by emotional stress.
• Jervell and Lange-Nielsen syndrome, with more dramatic QT prolongation and deafness
and a worse arrhythmia prognosis.
• LQT2 is the second most common genotypic abnormality. (RESPOND TO BETA
BLOCKER)
• The T wave tends to be notched and bifid.
• LQT2 patients, the most common precipitant is emotional stress, followed by sleep or
auditory stimulation.
• LQT3 is due to a mutation in the gene that encodes the cardiac sodium channel on
chromosome 3.
• LQT3 patients have either late-onset peaked biphasic T waves or asymmetric peaked T
waves. The arrhythmia events tend to be more life-threatening, and thus the prognosis for
LQT3 is the poorest of all the LQTs.
• Most events in LQT3 patients occur during sleep, suggesting that they are at higher risk
during periods of slow heart rates. (NOT RESPOND TO BETA BLOCKER)
 Prevention of Reccurent VT
• Beta Blocker (Ia).
• ICD implantation (Ia).
• Catheter ablation (Ia).

ESC 2015
 Bradyarrhytmias :
– Extrinsic :
• Autonomic
• Drugs
• Hypothyroidism
• Hypotermia
• Vagal manouvers
• Increase ICP
– Intrinsic
Check for Autonomic Incompetence
• Sick sinus syndrome
• CAD
• Inflamatory
• Familial
• AV node disease • Vasovagal incopetence
– CAD evaluation :
– Vasovagal – Intrinsic (unresponsive
– Drug related with atropine or stress)
– Infectious – Extrinsic (responsive with
– Congenital atropine or stress)
– Inflamatory
– Infiltrative
– Neoplastic
– Degenerative
 Permanent pacemaker (Class I
recommendation) :

• Indicated in Symptomatic AV block

• Inicated in Assymptomatic 3rd degree and 2nd
degree type 2 AV block.
• Periods of asystole >3 s or any escape rate <40
beats/min while awake
• Atrial fibrillation with bradycardia and pauses
>5s
 Pacemaker mnemonics’:
• The first letter indicates the chamber(s) that is paced (O,
none; A, atrium; V, ventricle; D, dual; S, single).
• The second is the chamber(s) in which sensing occurs (O,
none; A, atrium; V, ventricle; D, dual; S, single),
• The third is the response to a sensed event (O, none; I,
inhibition; T, triggered; D, inhibition + triggered)
 Pacemaker
• Transcutaneous
• Transvenous
• Permanent
• The fourth refers to the programmability or rate response (R,
rate responsive)
• The fifth refers to the existence of antitachycardia functions if
present (O, none; P, antitachycardia pacing; S, shock; D, pace +
shock).
• Almost all modern pacemakers are
multiprogrammable and have the capability for
rate responsiveness using one of several rate
sensors: activity or motion, minute ventilation,
or QT interval.
• The most commonly programmed modes of
implanted single- and dual-chamber
pacemakers are VVIR and DDDR,
 Further Readings :
1. Treatment guidelines for AF 2016, -ESC
2. Treatment guidelines SVT 2015, - ESC
3. Treatment guidelines VT 2015, -ESC