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Arrhythmia :ECG-Bradycardia_20120909_中區

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Arrhythmia :ECG-Bradycardia_20120909_中區

  1. 1. Bradycardia 大林慈濟醫院心臟內科 李易達醫師 101.09.09
  2. 2. 竇房節 (SA node) 房室結 (AV node) 希氏束 (Bundle of His) 浦金氏纖維 (Purkinje fiber)
  3. 3. Normal sinus rhythm HR: 87bpm, PR interval: 150ms
  4. 4. Normal sinus rhythm • Heart rate: 60~100bpm • A P wave before every QRS complex • Normal P axis (upright in lead II) • PR interval >0.12 second
  5. 5. HR: 61bpm, PR: 128ms  Ectopic atrial rhythm
  6. 6. Rhythm evaluation on ECG • Rate – Regularity • P wave ? • P wave morphology • P wave axis – Normal P wave axis: upright in lead II • PR interval (P & QRS relationship) – Normal PR interval: 120~200ms – Constant
  7. 7. Bradycardia • Bradycardia: heart rate < 60bpm • May be a normal physiological phenomenon or result from a cardiac or non-cardiac disorder – During sleeping – Athletes • Symptoms: – Dizziness, near syncope, syncope, ischemic chest pain, and hypoxic seizures
  8. 8. Pathological etiologies of bradycardia • Medication – B-blocker – Ca channel blocker – Digoxin – Class IA, IC, III • Myocardial infarction • Inflammation/infection – Myocarditis – Infectivce endocarditis – Lyme disease • Metabolic effect – Electrolytes – Hypothyroidism – Hypothermia • Autoimmune diseases – SLE • Surgery • Degeneration – Sick sinus syndrome
  9. 9. Bradyarrhythmia • Sinus node dysfunction – Symptomatic sinus bradycardia – Sinus pause/sinus arrest – Sino-atrial exit block – Tachycardia-bradycardia syndrome • AV block • Junctional/ventricular escape rhythm • Atrial fibrillation with slow ventricular response
  10. 10. Marked sinus bradycardia • May be symptomatic if heart rate < 45bpm • Usually related to – Increased vagal tone – Medication: b-blocker, Ca channel blocker – Sick sinus syndrome (SA node dysfunction)
  11. 11. Marked sinus bradycardia HR: 42bpm, PR: 184ms
  12. 12. Sinus pause/arrest • Transient cessation of impulse formation at the sinoatrial node • A prolonged pause without P activity • The pause is unrelated to the length of the P-P cycle
  13. 13. Sinus pause/arrest
  14. 14. SA exit block • A transient failure of sinus impulse conduction to the atrial myocardium • SA exit block –1st degree SA block –2nd degree SA block • Type I: group beating, shortened PP interval • Type II: the pause length was two times of PP interval –3rd degree SA block: escape rhythm
  15. 15. SA exit block
  16. 16. 2nd degree SA exit block type I HR: 91bpm, PR:142bpm
  17. 17. 2nd degree SA exit block type II
  18. 18. Tachycardia-bradycardia syndrome • Common in sick sinus syndrome (sinus node dysfunction) • Paroxysmal atrial tachyarrhythmia followed by sinus bradycardia, sinus pause or escape rhythm
  19. 19. Tachycardia-bradycardia syndrome
  20. 20. EPS to evaluate sinus node function • Sinus node recovery time (SNRT) – SNRT < 1500 ms – cSNRT (SNRT - BCL) < 550 ms – SNRT/NSR < 150%
  21. 21. EPS to evaluate SA conduction • Sinoatrial conduction time (SACT) –45~125ms
  22. 22. Atrio-ventricular block • First degree AV block • Second degree AV block –Mobitz type I –Mobitz type II –Advance AV block: 2:1, 3:1, 4:1,… AV block • Three degree (Complete) AV block
  23. 23. 1st Degree AV block • Simple prolongation of PR interval (> 0.2 seconds) • No dropped QRS complexes • All P waves are conducted
  24. 24. 1st degree AV block HR: 57bpm, PR: 350ms
  25. 25. 2nd degree Mobitz type I AV block (Wenckebach phenomenon) • PR interval progressively increases before dropped QRS • Intermittent dropping of the QRS • RR interval may progressively decrease • Grouping of QRS
  26. 26. 2nd degree Mobitz type I AV block (Wenckebach phenomenon) HR: 44bpm, PR: 292ms
  27. 27. 2nd degree Mobitz type II AV block • Fixed PR interval before dropped QRS complex
  28. 28. 2nd degree Mobitz type II AV block HR: 59bpm, PR: 136ms
  29. 29. 2:1 AV block • QRS complex dropped in every other beat • Constant PR interval • Mobitz type I or II
  30. 30. 2:1 AV block HR: 41bpm, PR: 192ms
  31. 31. HR: 40bpm, PR: 186ms  2: 1 AV block
  32. 32. Three degree (Complete) AV block • Complete interruption of atrial conduction • Independent atrial and ventricular rhythms (AV dissociation) • Regular PP and RR interval • Atrial rate > ventricular rate • P wave march through the QRS complexes
  33. 33. Three degree (Complete) AV block HR: 43bpm
  34. 34. HR: 45bpm  Complete AV block
  35. 35. HR: 67bpm, PR: 207ms  Non-conducted APC
  36. 36. Escape rhythm • When the ventricles are not stimulated as a result of automaticity or conduction problems • Marked sinus bradycardia, sinus pause, complete AV block • Junctional vs. ventricular escape rhythm –Junctional: narrow, rate: 40~60bpm –Ventricular: wide, rate: 20~40bpm
  37. 37. Escape rhythm HR: 36bpm
  38. 38. Sinus bradycardia with junctional escape rhythm HR: 50bpm
  39. 39. Complete AV block with ventricular escape rhythm HR: 27bpm
  40. 40. Atrial fibrillation with slow ventricular response • Atrial rate in Af: 350~700bpm • The ventricular rate depends on the AV conduction ability • Impaired AV conduction
  41. 41. Atrial fibrillation with slow ventricular response HR: 48bpm
  42. 42. Af with regular RR interval  Af with complete AV block and junctional escape rhythm
  43. 43. 感恩聆聽 !

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