Penyakit Aritmia

Penyakit Aritmia
Agung Rizka Pratama
1
2
Linton, Introducing to Medical-Surgical 5 th ed. Adrianne dill, 2011

Sinoatrial node
• The SA node is located less than 1 mm from the epicardial
surface 10-20 mm long, 2-3 mm wide,
• Artery supply from Right coronary artery or Left Circumflex
artery
• The SA node is densely innervated with postganglionic
adrenergic and cholinergic nerve terminals
• Neurotransmitters modulate the SA node discharge rate by
stimulation of beta-adrenergic and muscarinic receptors. Both
beta1 and beta2 adrenoceptors subtypes are present in the SA
node
Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th
ed. Philadelphia, Pa: Saunders Elsevier; 2008. Vol 1:
Internodal and intra-atrial
conduction
• Anterior internodal tract (Bachmann-James bundle)
• Middle internodal tract (Wenkebach bundle)
• Posterior internodal tract (Thoral bundle)
Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017

Atrioventricular node
• atrioventricular (AV) node is a superficial structure located just

beneath the RA endocardium, anterior to the ostium of the
coronary sinus.
• 1x3x5 mm
• The arterial supply to the AV node is a branch from the right
coronary artery (85%-90%) and Left Circumflex Artery (10%-
15%)
Bundle of His
• The bundle of His is a structure that connects with
• Proximal nonpenetrating (distal AV node)
• Middle Penetrating (the tunnel segment within fibrous central
body and membranous septum)
• The distal branching portion (His bundle biffurcates at the crest of
the muscular septum into right and left bundles
• Branches from the anterior and posterior descending coronary
arteries and posterior decending artery
• 20 mm in length and up to 2 mm diameter
Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017

Bundle branches
• The bundle branches originate at the superior margin of the
muscular interventricular septum
Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017C

Terminal Purkinje fibers
• The terminal Purkinje fibers connect with the ends of the

bundle branches to form interweaving networks on the
endocardial surface of both ventricles, which transmit the
cardiac impulse almost simultaneously to the entire right and
left ventricular endocardium
Sinus Rhytm
• There must be a P Wave in front of each QRS
• P Axis must be in range 0 – 90 degree
• P Wave always upright in lead I and always negative in lead
aVR
• The p wave is mostly positive in II,aVF and III, but may also be
biphasic (+/−) in these leads.
• In lead aVL,the p wave may be biphasic (–/+),positive or
negative.
• the normal p wave is positive in all leads V1 to V6,with one
frequent exception: in lead V1 the p is often biphasic (+/−)
Gertsch, The ECG : A Two Step Approach to Diagnosis, Springer. 2004

10

T Wave
• A normal T wave is asymmetric,with a slow upstroke and more
rapid downstroke.
• In the frontal leads the T wave is positive in I and often
positive in aVL,II,aVF ,and III. The T wave is often negative in
lead
• The T wave may be negative also in aVL, but never in lead I.
• In the horizontal leads the T wave is negative or positive (or
isoelectric) in V1 and positive in V2 to V6
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Gangguan Pembentukan impuls di sinus
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Jane Huff, ECCG Workout : Exercise in arrhytmia interpretation. Lippincott williams & wilkins.. 2012
Sinus Node Dysfunction
(SND)
• SinoAtrial Noda (SA node)
 capable of generating impulses at a rate that meets
metabolic demands at rest and during exercise requirements,
such as during exercise.
• Symptoms:
• Asymtomatic Persistent Confirm by ECG
• Palpitation Intermittent Holter/ILR

• Dizzy spells
• Presyncope
• Syncope
Das, Mithilesh K., and Douglas P Zipes. Electrocardiography of Arrhythmias: A Comprehensive Review : A Companion to Cardiac Electrophysiology : From Cell to Bedside.
Philadelphia, Pa.: Elsevier/Saunders, 2012
13
Classification
• Symptomatic sinus bradycardia
• Sinus Pauses/Arrest
• SA Exit Block
• Tachycardia-bradycardia syndrome (SSS)
• Symtomatic chronotropic imcompetence
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Etiology
Intrinsic sinus node disease (e.g., primary conduction system disease, coronary artery disease,
cardiomyopathy, heart failure)
Extrinsic factors such as :
• autonomic imbalance (neurocardiogenic syncope, carotid sinus hypersensitivity, autonomic
neuropathy)
• cardiac surgery (maze surgery, mitral valve surgery)
• electrolyte imbalance (hyperkalemia)
• drug therapy (e.g., antiarrhythmic drugs, clonidine, lithium)
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Symptomatic sinus
• Usually benign
bradycardia
• Present with decreased exercise capacity or fatigue.
• Marked sinus bradycardia (40 bpm)  can result in emergence of a junctional rhythm at 30 to 40 beats
 Sinus bradycardia may be physiologic in well trained athletes because of high vagal tone
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ECG shows sinus bradycardia (heart rate: 50 bpm) and sinus arrhythmia (A).
A few hours later, sinus node dysfunction progressed and the junctional rhythm at 37 bpm appeared (B).
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Sinus Pause/Sinus Arrest
the sinus node is unable to generate impulses regularly
 Because the abnormality is one of impulse formation rather than impulse conduction
 the pauses represented by the long P-P intervals
 are not exact multiples of the shorter P-P intervals representing the basic sinus rhythm
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SA exit block
• Similar to AV block, SA exit block can be divided into first-degree, second-

degree, and third-degree block.
• First- and third-degree SA exit block are not recognizable in the surface ECG
because the sinus node does not leave any imprint when it discharges.
• Only second-degree SA exit block can be identified
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Three subtypes
Type I seconde degree
(Weckenbach) SA Exit block The P-P interval progressively shortens
prior to the pause
Type II second degree SA

The pause equals approximately 2-4
exit block
times the proceeding PP interval
Third degree SA exit block Absence of P waves (diagnosed with an

sinus node electrode, during EP
evaluation)
Philadelphia, Pa.: Elsevier/Saunders, 2012 20
Second Degre Type I (Weckenbach)
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Second degree type II
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Tachycardia-bradycardia
syndrome (SSS)
• When the sinus node fails to function as the pacemaker of the heart ectopic rhythms come to the
rescuedevelop atrial arrhythmias  including atrial tachycardia, atrial flutter, or atrial fibrillation.
• These arrhythmias are usually sustained and most often become the dominant rhythm.
• During tachycardia or during atrial flutter or fibrillation the presence of SND is not obvious  until the
atrial arrhythmia terminates spontaneously.
• If there is SSS the sinus node is unable to take over the pacemaking function of the heart - the long
pause that follows is a frequent  cause of syncope
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Symptomatic chronotropic
imcompetence
• Chronotropic incompetence is diagnosed during exercise testing when the

patient is unable to reach a heart rate equivalent to at least 80% of the
maximum heart rate predicted for the patient's age
• Seen in 20-60% of patients with sinus node dysfunction
• Although the resting heart rates may be normal, may have inability to increase
their heart rate during exercise or have unpredictable fluctuatuins in heart
rate during activity
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SNRT
29
Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt O-A, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. The
Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC) Developed in collaboration with the European Heart Rhythm
Association (EHRA). 2013 2013-08-01 00:00:00;15(8):1070-118.
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Indication for Permanent Pacemaker
PERSISTENT BRADYCARDIA
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Indication for Permanent Pacemaker
INTERMITTENT BRADYCARDIA
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Sinus Tachycardia
• Physiologic or pathologic stress
• Fever, hypotension, thyrotoxicosis, anemia, anxiety
Rhytm : Regular. Rate 100-160. P Wave Normal in size, shape and direction, positife in lead II. PR
Interval 0.12-0.2 second. QRS Complex 0.10 Second
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1
Huff Jane. ECG Workout:Exercise in arrhytmia interpretation. Lppincoott William & Wilkins. 2012
Sinus Bradycardia
• During sleep and in athletes
• Vagal stimulatiom from vomiting
• Increased intracranial pressure
Rhytm : Regular. Rate 40-60, P Wave Normal in size, shape and direction, positife in lead II, one P
wave precedes each QRS complex,. PR Interval 0.12-0.2 second. QRS Complex 0.10 Second
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Sinus Arrhytmia
• Associated with the phase of respiration, during inspiration
the Sinus node fires faster and during expiration it slows down
(common finding among infants, children and young adult)
Rhytm : Iregular. Rate 60-100 or <60, P Wave Normal in size, shape and direction, positife in lead
II, one P wave precedes each QRS complex,. PR Interval 0.12-0.2 second. QRS Complex 0.10
Second
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Sinus Arrest
• Sudden pause in the sinus rhytm in which one or more beat
are missing
• Failure of the SA node to initiate an impulse and is therefore a
disorder of automaticity
Rhytm : basic rhytm regular, Iregular during pause , P Wave Normal in Basic rhytm, absent during
pause. PR Interval 0.16-0.18 second in basic rhytm,. QRS Complex 0.08-0.10 Second in basic
rhytm and absent during pause 38
Atrial Arryhtmias
39
Jane Huff, ECCG Workout : Exercise in arrhytmia interpretation. Lippincott williams & wilkins.. 2012
Premature atrial contraction
• Early beat originating from ectopic size in the atrium which
interupt the regularity of the basic rhytm
• Occur in individual with emotional stress or ingestion of
certain substance such as alcohol, caffein or tobacco
Rhytm : underlying rhytm usually regullar, Rate underlying rhytm, P wave assosiated with the PAC
is premature and abnormal size shape or direction,. PR Interval usually normal, QRS premature
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Nonconducted Premature atrial
contraction
• When an ectopic atrial foucs occurs so early that it finds the
AV node refractory and the impulse isnt conducted to the
ventricles.
Rhytm : underlying rhytm usually regullar, Rate underlying rhytm, P wave assosiated with the
nonconducted PAC is premature and abnormal size shape or direction, often found hidden in
preceding T Wave. PR Interval absent with nonconducted PAC, QRS absent with nonconducted PAC 41
Paroxysmal atrial tachycardia
• Originates in an ectopic pacemaker site in the atria producing
a rapid, regular atrial rhytm
• Precipitate by a PAC
Rhytm : regular, Rate 140-250 b/m, P wave abnormal, usually hidden in preceding T wave. PR
Interval usually nor measurable, QRS < 0.10
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Atrial Flutter
• The atrial muscle respond to this rapid stimulation by producing wavefors that
resemble the teeth of a saw
• If the conduction ratio remains constant (2:1), the ventricular rhytm will be regular
and the rhytm is described as atrial flutter with 2:1 conduction, If the conduction
ratio varies, the ventriular rhytm will be irregular and the rhytm described as atrial
flutter with variable AV conduction
Rhytm : regular or irregular , Rate 250-400 b/m, P wave sawtooth deflection. PR Interval not 43
measurable, QRS normal < 0.10
Atrial Fibrilation
• Chaotic electrical impulse that arise from an ectopic site in the atria
• characterized by seemingly disorganized atrial depolarizations without
effective atrial contraction
Rhytm : Grossly irregular , Rate varies with number of impulses conducted throught AV node to
ventricle, P wave irregulare wave deflections. PR Interval not measurable, QRS normal < 0.10
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• When QRS rate <100  contrrolled atrial fibrilation
• When QRS rate >100  atrial fibriation with a rapid ventricular
response 45
Junctional arrhytmias
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Premature junctional
contraction
• Eary beat that originates in an ectopuc pacemaker site in the
AV junction
• Premature, abnormal P wave
Rhytm : Irregular with PJC , Rate underlying rhytm, P wave inverted in lead II will occur immediately
before the QRS complex, after QRS or is hidden within the QRS. PR Interval short,, QRS normal <
0.10 47
Junctional Rhytm
• Originating in the AV junction with a rate between 40-60
• May be seen in AMI, taking digitalis, or beta blocker
Rhytm : Regular, Rate 40-60beat/min, P Wave invertedd in lead II. PR Interval short,,
QRS normal < 0.10
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AV Heart Block
• Classified
• First degree
• Second degree (Type I and II)
• Third Degree
• Systematic approach
• Look for the P wave
• Measure the regularity of the atrial rhythm and the ventricular
rhythm
• Measure the PR interval. consistent or does it vary?
• Look at the QRS complex
49
First Degree AV Block
• Sinus impulse is normally conducted to the AV node , delayed
longer than usual before being conducted to the ventricles
• May occur from ischemia or injury to the AV node, drug effect,
and unknown causes
Rhytm : Regular, Rate underlying sinus rhytm, P Wave sinus, one wave to each QRS. PR Interval
prolonged (>20 second) ,remain consistent, QRS normal < 0.10
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Second degree AV block Type I
• Failure of some of the sinus impulses to be conducted to the ventricles
• Sinus impulse is normally conducted to the AV node but each succesive
impulse has increasing difficulty passing through the AV node until an
impulse doesn’t pass through
Rhytm : Regular , Rate underlying sinus rhytm, P Wave sinus PR Interval varies, progressively
lenghthens until p wave isn’t conducted, QRS normal < 0.10 51
Second degree AV block Type II
• Failure of some of the sinus impulses to be conducted to the
ventricles
• Potential to progress suddenly to third degree av block
Rhytm : Regular atrial and usually ventricular rhytm, Rate : atrial = underlying sinus rhytm,
ventriles = depending pn number of impulse conducted trhough AV node, P Wave sinus, 2 or 3 p
wave before QRS complex. PR Interval may be prolonged ,remain consistent, QRS normal if block 52
locaed at level of bundle of his
Third Degree AV Block
• Complete absence of conduction between atria and the
ventricles
• The P wave have no relationship with QRS complexe
Rhytm : Regular, Rate : av juntion40-60 b/m ventriles 30-40 b/m, P Wave sinus with no contsatnt
relationship to the QRS, PR Interval varies greatly, QRS normal if block located at level of av node
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Ventricular arrhytmias and
bundle branch block
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Right Bundle-branch Block
Kriteria EKG :
• Interval QRS memanjang > 120 ms
• S yang lebar di V5 dan V6
• R’ yang lebar di V1 and V2
• Bila interval QRS 0,10 – 0,12 detik, disebut RBBB inkomplit
• Bila interval QRS >= 0,12 detik, disebut RBBB komplit
Left Bundle-branch Block
Kriteria EKG :
• Interval QRS melebar >= 120 ms
• Gelombang R yang lebar, sering berlekuk di V5 dan V6
• rS atau QS di V1, disertai rotasi searah jarum jam
• Bila interval QRS 0,10-0,12 detik, disebut LBBB inkomplit
• Bila interval QRS > 0,12 detik, disebut LBBB komplit
Premature Ventricular
Contraction
• Premature, ectopic impulse that arises below the bundle of
His in the ventricles
• Reentry in the ventricles, enhance automaticity of a focus in
the ventricles, or triggered activity occurring during ventricular
repolarization
Rhytm : Usualy regular, Rate : usually sinus, P Wave : none associated with PVC, PR Interval not
measurable, QRS premature, abnormal shape, wide (>0.12)
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Ventricular tachycardia
• Ectopic focus in the ventricles discharging impulse at rate of 40-
250 beats per minute.
• Due to reentry ventricles, but can also be caused by enhanced
automaticity or triggered activity during ventricular
repolarization
Rhytm : Regular, can be slighly irregular, Rate : 14-250 b/m, P Wave : none associated with VT, PR
Interval not measurable, QRS wide (>0.12)
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Ventricular Fibrilation
• Disorganized, cahotic, electrical focus in the ventricles takes
over the heart
• VF with large amplitude waves is called coarse VF and smal
amplitude called fine VF
Rhytm : None,, Rate : none (P wave and QRS comple absent), P Wave : wavy, irregular deflection,
varying in size and shape, PR Interval not measurable, QRS absent
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Idioventricular rhythm
• Very slow rhytm originating from a focus in the ventricles at a
rate 30-40 beats per minute.
• The electrial impulses from the sinus node, the atria, or the AV
juntion fail to reach the ventricles because sinus arest or 3rd
degree av block
Rhytm : Regular,, Rate : 30-40 b/m, P Wave : absent, PR Interval not measurable, QRS wide (>0.12)
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Ventricular standstill
• When the ventriles are inactive, there are no QRS complexes.
• The atria, however may continue to generate electrical
activity, producing P wave
• P waves without QRS complexes or a straight line
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terimakasih
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Richard et all, Guideline for the management of adult patient with SVT. The American Heart Association. 2016
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Vereckei A, current alghoritm for the diagnosis of wide QRS complex tachycardia, 2014
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Antiarrhytmia drugs
• Class I: Fast sodium (Na) channel blockers
• Ia - Quinidine, procainamide, disopyramide (depress phase 0,
prolonging repolarization)
• Ib - Lidocaine, phenytoin, mexiletine (depress phase 0
selectively in abnormal/ischemic tissue, shorten
repolarization)
• Ic - Flecainide, propafenone, moricizine (markedly depress
phase 0, minimal effect on repolarization)
80
• Class II: Beta blockers (partial list)
• Propranolol (decreases slope of phase 4)
• Esmolol (decreases slope of phase 4)
• Timolol (decreases slope of phase 4)
• Metoprolol (decreases slope of phase 4)
• Atenolol (decreases slope of phase 4)
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• Class III: Potassium (K) channel blockers
• Amiodarone (prolongs phase 3; also acts on phases 1, 2, and

4)
• Sotalol (prolongs phase 3, decreases slope of phase 4)
• Ibutilide (prolongs phase 3)
• Dofetilide (prolongs phase 3)
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• Class IV: Slow calcium (Ca) channel blockers
• Verapamil (prolongs phase 2)

• Diltiazem (prolongs phase 2)
• Class V: Variable mechanism
• Adenosine
• Digoxin
• Magnesium sulfate
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Agung Rizka Pratama

Linton, Introducing to Medical-Surgical 5 th ed. Adrianne dill, 2011

Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017

• atrioventricular (AV) node is a superficial structure located just

Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017

Vijay Raghwana, Clinical examination in Cardiology, 2 nd Edition,Elsevier. 2017C

• The terminal Purkinje fibers connect with the ends of the

Gertsch, The ECG : A Two Step Approach to Diagnosis, Springer. 2004

Gertsch, The ECG : A Two Step Approach to Diagnosis, Springer. 2004

Gertsch, The ECG : A Two Step Approach to Diagnosis, Springer. 2004

• Palpitation Intermittent Holter/ILR

• Similar to AV block, SA exit block can be divided into first-degree, second-

Type II second degree SA

Third degree SA exit block Absence of P waves (diagnosed with an

• Chronotropic incompetence is diagnosed during exercise testing when the

• Seen in 20-60% of patients with sinus node dysfunction

• Amiodarone (prolongs phase 3; also acts on phases 1, 2, and

• Verapamil (prolongs phase 2)

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