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#16 av block sinus node dysfunction
 

#16 av block sinus node dysfunction

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Dr.Nabil Paktin,MD,FACC. Trainer Specialist of Clinical Cardiology Postgraduate Program of Cardiology Afghanistan Cardiovascular(cardiology) society Lecture series

Dr.Nabil Paktin,MD,FACC. Trainer Specialist of Clinical Cardiology Postgraduate Program of Cardiology Afghanistan Cardiovascular(cardiology) society Lecture series

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  • Once a sinus P wave is not conducted to the ventricle , the AV block has advanced to second degree ;)
  • No symptom except , the simultanous contraction of both atrial and ventricle cause symptom of low cardiac out put .
  • There are four P wave for every three QRS complexes 5:4
  •  infra-hisian block: infrahisian block describes block of the distal conduction system. types of infrahisian block include: type 2second - damage to any of the conducting cells in or below the bundle of his are collectively referred to as 'infra-hisian blocks.' specifically, - the impairment is usually below the av node although the terms infranodal block or infrahisian block are often applied to this disorder,
  • A complete failure of all atrial impulse to conduct to the ventricle , therefore , only P waves will be present . These p waves are unable to reach the ventricles because they are blocked or interrupted somewhere in the AV conduction system .
  • except the tachycardia bradycardia syndrome , these arrhythmias may be difficult to differentiate from extrinsic and reversible cause of SND

#16 av block sinus node dysfunction #16 av block sinus node dysfunction Presentation Transcript

  • Dr.Nabil Paktin,M.D.,FACC Lecturer of Cardiology www.afghanheart.wordpress.com 26,06,2013 AV Block &sinus node dysfunction
  • Types of AV Block Normal AV conduction system , consists of 1- AV node 2- Bundle of His 3- Bundle branches 4- Fascicular branches of LBB Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Anatomy Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Complexity of AV- node =secret Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • There are Three types of AV block ; on the severity of conduction abnormality : 1- First degree AV-block 2- second Degree AV-block - Mobitz type I or AV Wenkebach - Mobitz Type II - advanced or high grade 3- Third- degree or Complete heart block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • 1-First degree AV Blocks Normal AV conduction =0.12-0.20 seconds -PR interval is prolonged and Measures >0.20 seconds . Delay in the way of sinus impulse = from atria to the ventricle Most delay occurring at the level of AV node Beside of Prolonged PR int. all P wave are conducted to the ventricle , always followed by QRS complex . Therefore , first degree conduction delay rather than Actual block . Misnomer Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Common mistakes in First degree AV block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • First Degree AV block Importance when the PR interval is >0.30 seconds > atrial contraction during ventricular ?????? Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Second Degree AV block Second degree AV blcok - Mobitz type 1 AV wankebach -mobitz type 2 -Advance , high grade second degree AV block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Second Degree AV block Dr.Nabil Paktin, MD.,FACC. Copyright © PR PR DROPPED BEAT Mobitz Type I , Wenkebachk
  • Second Degree AV block Dr.Nabil Paktin, MD.,FACC. Copyright © PR PR DROPPED BEAT PR Woldemar Mobitz
  • 2-Type I , second Degree AV block 1- two or more consecutive P waves are conducted . 2- Only single P waves are Blocked . 3- there is gradual prolongation of the PR interval before a ventricular complex is dropped . 4- the PR interval always shortens immediately after the Pause 5- The QRS complex may be narrow or wide but are typically narrow . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Type 1 second degree AV block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Type 1 second degree AV block Conduction ratio Shortening of PR interval Narrow or wide complex Localizing the AV blcok - narrow QRS complex - wide QRS complex Acute MI Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Additional features Group beating “eyeball” - 4:3 Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Additional features R-R intervals are variable Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Localizing the AV block Wide , infranodal due to RBBB Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Narrow , due to nodal involvement of inferior MI But not in anterior MI ??? Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • ECG findings of type 1 AV block 1- two or more consecutive P wave 2- only single P wave are blocked 3- gradual prolongation PR 4- the PR interval always shortens immediately 5- the QRS complex are usually narrow 6- group beating 7 PR are variableDr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • 3-Type 2 second degree AV block 1- two or more consecutive P wave is conducted . 2- only single P waves are blocked . 3- All PR intervals measure the same throughout . 4- the PR int. is fixed and does not Prolonged before or shorten after a pause 5- the QRS complexes are usually wide because of the presence of bundle branch block 5- the R-R intervals are constant and measure the same throughout as long as the sinus rhythm is stable – that is , the heart rate or P-P intervals are regular . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Mobitz Type I nodal = narrow complex Mobitz type II infranodal = wide complex - Type II is always an infranodal block and occurs exclusively at the level of the His-Purkinjie system . - Type II is unlikely unless there is evidence of intranodal disease such BBBs or Anterior MI . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • The narrow QRS complex Mobitz type two Nodal , intra-his block , not infra? Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • 4-Advanced 2:1 second degree AV block Advanced second degree AV block: 2:1 is an example - In 2:1 block , every other P wave is conducted alternating with every other P wave that is blocked . - The QRS complex may be narrow or wide . - A common error is to include 2:1 av block as a type 2 block because PR interval is fixed, it’s neither type 1 nor type 2 . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Ventriculophasic sinus arrhythmia : - Sinus arrhythmias 2:1 present - If the P-P interval with a QRS complex is shorter than P-P interval without a QRS complex. - If the 2:1 is associated with type I = nodal - If the 2:1 is associate with type II = infranodal Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • When the conduction improve and 2:1 block is seen in associate with type 1 block , the block is AV nodal . When conduction improve and 2:1 block is seen in association with type 2 block ( fixed PR interval and wide QRS complex ) , the block is infranodal . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Acute MI and AV block : when 2:1 block complicate acute MI , the location of the infarct is helpful in identifying the level of the AV block . If the infarct is inferior and QRS complex are narrow the AV block is at the level of AV node, Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Advanced second –degree AV block 3:1 and higher When 2:1 , 3:1 , 4:1 or higher the AV block can’t be classified by first or second degree AV block . Because only one P is conducted two or more blocked . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • ECG findings of Advanced 2nd degree AV block 1-A form of 2nd degree av block that 2 or more consecutive P waves are not conducted as 3:1,4:1.5:1 the 2:1 is also advanced because only single P wave is conducted , 2- the QRS complex narrow or wide 3- the long pause are often terminated by escape beat. Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Third degree or Complete AV block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Localizing the AV block Av nodal block : - AV junctional escape rhythm Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Ventricular escape rhythm : - Infranodal and wide complex Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Infranodal Block Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Acute anterior MI Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Acute inferior MI Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Junctional Vs. Ventricular escape rhythm Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Complete AV block can occur regardless of the atrial rhythm which could be normal sinus 1, atrial flutter 2 , atrial fibrillation 3 . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • ECG finding of complete AV Block 1- in complete AV block , there is complete failure of the atrial impulse to capture the ventricles . 2- only P wave will be present , unless an escape rhythm comes to rescue v ventricular asystole will occur , 3- the escape rhythm ( the QRS complexes) can be narrow or wide, 4- the P wave and QRS complex are completely dissociatedDr.Nabil Paktin, MD.,FACC. Copyright ©
  • Complete AV dissociation Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • ECG findings P wave and QRS complex are completely dissociated and have no relation to each other In complete AV dissociation the underlying rhythm may be ventricular tachycardia , junctional tachy cardia , accelerated junctional rhythm , or complete AV block . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Sinus node : pacemaker , automatic properties, generating electrical impulse , no imprint in the ECG, when propagate to atria can be recognized as a P wave, this impulse called normal sinus rhythm . Sinus node dysfunction : sinus node fails to function as a pacemaker, slowing the heart rate of this should not be confused with AV block. Sinus dysfunction : completely fails as a pacemaker of the heart , asystole long period occur , long flat line without P waves , this long pause terminated by escape complexes from the atria or ventricles , Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • AV block : Complete AV block , sinus P are present , but are not conducted to the ventricle . Presence of sinus P waves indicate that sinus node functioning normally , and generating impulse to conduct to atria , but blocked on its way to the ventricle , Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Arrhythmias associated with SSS: sss is suspected if any of the following arrhythmias occur : Inappropriate sinus brady cardia , Sinus arrest , sinus pause , and SA exit blok Tachycardia bradycardia syndrome Chronic atrial fibrillation Escape rhythm arising from the atria , AV junction , or ventricles , Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Inappropriate sinus bradycardia : structural heart disease of SN , it cause sinus bradycardia, defined as <60bpm, during rest or sleep its normal , its seldom cause of concern unitll become < 50bpm. Sinus bradycardia 40-5-bpm is often seen in normal healthy , well- conditioned athletes , Thus , marked sinus bradycardia occurring in healthy individuals may be difficult to differentiate from inappropriate sinus bradycardia in patient with SSS , The sinus bradycardia is inapproperiate when it is unusually slow , is persistent , and does not increase sufficiently with exercise , For example , sinus brady cardia < 50bpm may be appropriate for a patient who is asleep , but not for an individual who is physically active . Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Sinoatrial Exit Block , Sinoatrial exit block and sinus arrest : failure to conduct to atria , or failure of the sinus node to generate an impulse , Sinoatrial exit block : SN continuers to discharge at regular interval , but some impulses are blocked and are unable to reach surrounding atria ,this result in complee absence of P-QRS –T complex. Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Sinus arrest : the pulse represented by the long P-P interval , are not exact multiple of the shorter P-P interval representing the basic sinus rhythm , Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Sinus pause = sinus arres Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Sinoatrial Wenckabach SA , Wenchebach ,: Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Escape rhythm Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • ECG findings 1- inappropriate sinus bradycardia 2- Sinoatrial block , sinus arrest , and sinus pauses 3- tachycardia- Brady cardia syndrome 4- chronic atrial fibrillation 5- escape rhythm from the atria , AV junction or ventricles Dr.Nabil Paktin, MD.,FACC. Copyright ©
  • Afghanistan Cardiovascular (cardiology) society All information reserved © www.afghanheart.wordpress.com Dr.Nabil Paktin, MD.,FACC. Copyright ©