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台大醫院雲林分院
陳建鈞
• HEART RATE < 50 bpm
• High variability of human heart rate
• Infant
• Athelet
• ECG
• RATE
• RHYTHM
• P, atrial rhythm, QRS, pattern, Knowledge
• Clinical symtpoms/signs
• Low cardiac output
• Dizzine...
• ACLS !!
• Avoid offending drug
• (beta-blocker, CCB, digoxin, AAD)
• Drug increase heart rate
• IV Dopamine, isoproteren...
• Normal sinus rhythm
• HR: 60 - 100 / min
• Bradyarrhythmia
• sinus bradycardia, sick sinus syndrome
• AV block, A fib. w...
• Sinus node is supplied by the
RCA in 60% of people and by
the LCX in 40%.
• AV node is supplied by the
RCA in 90% and by...
• Definition
• Rate / Duration
• Physical conditioning
• Chronotropic incompetence (max HR <100/min)
• Etiology (intrinsic...
• History / Physical examination
• Thyroid function / electrolyte
• ECG
• UCG
• Holter ECG / Loop event recorder
• Treadmi...
HR: 91bpm, PR:142bpm
• Sinus nodal recovery time
• cSRT < 550 ms
• SRT/NSR < 150%
• Total recovery time < 5 sec
• Sinoatrial conduction time
• ...
• Autonomic nerve modulation
• Vagal dominant
• Intrinsic heart rate (107-0.53x age)
• Total autonomic blockade (Atropine/...
• First-degree: PR interval > 0.2 sec
• Second-degree:
• Mobitz type I (Wenchebach): inconstant PR interval
• Progressive ...
• Ischemic heart disease
• Infectious and inflammatory heart disease
• Infiltrative heart disease
• Degenerative processes...
1. Identify the mechanism
HR: 44bpm, PR: 292ms
HR: 41bpm, PR: 192ms
HR: 43bpm
HR: 45bpm
 Complete AV block
• When the ventricles are not stimulated as
a result of automaticity or conduction
problems
• Marked sinus bradycardia, si...
HR: 50bpm
HR: 27bpm
• Key point
• QRS width, site of block
• Escape rate
• Syncope
• His electrogram
• AH block; Intra-His block; HV block
• H...
2.Identify Etiology
2.Identify Etiology
• AV 1:1 conduction
• Alternating RBBB and LBBB
• Fixed RBBB with alternating LAH and LPH block
• RBBB + prolonged HV inte...
• Level of Evidence (Cardiology)
A. data derived from multicenter randomized
trials
B. data from limited or non-randomized...
Symptomatology +
Documented Events
ECG documentation in the medical record is
essential !
Reliable Indications
for Pacing
=
• Sick Sinus Syndrome
• Heart Block
• Carotid Sinus Hypersensitivity
and Neurocardiogenic Syncope
• HOCM, DCM
• Sinus Bradycardia
• Sinus Arrest
• SA Exit Block
• Bradycardia-
Tachycardia
Syndrome
• Symptomatic
chronotropic
incompet...
1. Symptomatic bradycardia or frequent
symptomatic sinus pauses (Level of Evidence:
C)
2. Symptomatic chronotropic incompe...
Max
Rest
Heart
Rate
Time
Start
Activity
Stop
Activity
Quick
Unstable
Slow
1. Identify the mechanism
1. SN dysfunction occurring spontaneously or as a
result of necessary drug therapy, with HR <40
bpm, when a clear associat...
Class IIb
2. In minimally symptomatic patients, chronic heart rates <40
bpm, while awake.
Class III
1. SN dysfunction in a...
1. Third-degree or advanced second-degree AV block
at any anatomic level with:
a) Symptoms (including heart failure) attri...
2. Asymptomatic third-degree AV block at any
anatomic site with an average awake ventricular
rate >40bpm in patients with ...
1. Advanced second-degree or third-degree AV block at any anatomic
site with an average ventricular rate >40bpm in the abs...
1. AV block due to drug use or toxicity when the block
is expected to recur even after withdrawal of the
drug (B)
2. Neuro...
1. Asymptomatic first-degree AV block (B)
2. Asymptomatic type I second-degree AV block at a site
above the His level or n...
-risk of sudden death or
progression to complete heart
block
1. Intermittent third-degree or advanced second-
degree AV block (B)
2. Type II second-degree AV block (B)
3. Alternating ...
1. Syncope not demonstrated to be due to AV block
when other likely causes, specifically ventricular
tachycardia, have bee...
Class IIa
1. Neuromuscular diseases…with any degree of
fascicular block, with or without symptoms (C)
Class III
1. Fascicu...
• Without congenital heart disease
• Symptomatic
• Wide QRS escape rhythm
• EP test: Infra-Hisian block
• <55 bpm in infan...
Class I
Recurrent syncope caused by carotid sinus hypersensitivity, defined as minimal
carotid sinus pressure inducing ven...
• Protocol
• Fast > 2 hours
• continuous ECG and blood
pressure mornitering
• Tilt to 60~80°
• 20~45 minutes
2.Identify Et...
2.Identify Etiology
I
Chamber
Paced
II
Chamber
Sensed
III
Response
to Sensing
IV
Programmable
Functions/Rate
Modulation
V
Antitachy
Function(s...
Factor to consider when choosing pacing mode
• Underlying rhythm disturbance
• Overall physical condition
• Associated med...
• DDD/AAI (atrial based pacing) vs. VVI (ventricular based
pacing)
•lower mortality
•lower Af incidence
• ACC/AHA 2008 Gui...
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
Arrhythmia :ECG-Bradycardia_20120916_南區
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Arrhythmia :ECG-Bradycardia_20120916_南區

  1. 1. 台大醫院雲林分院 陳建鈞
  2. 2. • HEART RATE < 50 bpm • High variability of human heart rate • Infant • Athelet
  3. 3. • ECG • RATE • RHYTHM • P, atrial rhythm, QRS, pattern, Knowledge • Clinical symtpoms/signs • Low cardiac output • Dizziness, near syncope, syncope, ischaemic chest pain, and hypoxic seizures • Sudden death risk • Drug, medical condition (thyroid…) •
  4. 4. • ACLS !! • Avoid offending drug • (beta-blocker, CCB, digoxin, AAD) • Drug increase heart rate • IV Dopamine, isoproterenol, atropine… • Aminophylline, beta-agonist • Permanent pacemaker !
  5. 5. • Normal sinus rhythm • HR: 60 - 100 / min • Bradyarrhythmia • sinus bradycardia, sick sinus syndrome • AV block, A fib. with SVR • Hypersensitive carotid sinus syndrome
  6. 6. • Sinus node is supplied by the RCA in 60% of people and by the LCX in 40%. • AV node is supplied by the RCA in 90% and by the LCX in 10% of patients. • Right bundle supplied by LAD • Left bundle supplied by branches of the RCA and LAD Zimetbaum PJ, Josephson ME. NEJM, 2003 Taken from www.baptistoneword.org
  7. 7. • Definition • Rate / Duration • Physical conditioning • Chronotropic incompetence (max HR <100/min) • Etiology (intrinsic vs. extrinsic) • Degeneration • Ischemia • Drug / Electrolyte • Surgery / Transplantation • Family history • Neurocardiogenic
  8. 8. • History / Physical examination • Thyroid function / electrolyte • ECG • UCG • Holter ECG / Loop event recorder • Treadmill testing • EP study
  9. 9. HR: 91bpm, PR:142bpm
  10. 10. • Sinus nodal recovery time • cSRT < 550 ms • SRT/NSR < 150% • Total recovery time < 5 sec • Sinoatrial conduction time • 45 to 125 ms • Sinus nodae electorgram • SACT: 60-110 ms • Depolarization duration < 200 ms
  11. 11. • Autonomic nerve modulation • Vagal dominant • Intrinsic heart rate (107-0.53x age) • Total autonomic blockade (Atropine/Esmolol) • More specific, less sensitive • Sensitivity: 54% (35-93%) • Specificity: 88% (combined with SACT) • Other issue: • Secondary pause: SA exit block • Pacing rate and duration • SA entrance block
  12. 12. • First-degree: PR interval > 0.2 sec • Second-degree: • Mobitz type I (Wenchebach): inconstant PR interval • Progressive increase in PR interval • RR interval may progressively decrease • Grouping of QRS • Mobitz type II: constant PR interval before and after single block beat • Advanced: 2:1; 3:1; 4:1… AV block • Third-degree (complete): AV dissociation [PACE 1993; 16: 1221-1226]
  13. 13. • Ischemic heart disease • Infectious and inflammatory heart disease • Infiltrative heart disease • Degenerative processes • Congenital • Surgical, RFCA and alcohol septal ablation • Drug and toxin • Electrolyte disturbances • Neuromyopathic disorders (HLA-B27)
  14. 14. 1. Identify the mechanism
  15. 15. HR: 44bpm, PR: 292ms
  16. 16. HR: 41bpm, PR: 192ms
  17. 17. HR: 43bpm
  18. 18. HR: 45bpm  Complete AV block
  19. 19. • 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
  20. 20. HR: 50bpm
  21. 21. HR: 27bpm
  22. 22. • Key point • QRS width, site of block • Escape rate • Syncope • His electrogram • AH block; Intra-His block; HV block • HV time: < 55 ms • Stress test • Incremental atrial pacing • After ventricular pacing • pharmacological test
  23. 23. 2.Identify Etiology
  24. 24. 2.Identify Etiology
  25. 25. • AV 1:1 conduction • Alternating RBBB and LBBB • Fixed RBBB with alternating LAH and LPH block • RBBB + prolonged HV interval • LBBB + prolonged HV interval • During second- or third-degree AV block • Permanent trifasicular block: complete AV block • Permanent bifasicular block • RBBB with alternating LAH and LPH block • Alternating RBBB and LBBB [PACE 1993; 16: 1221-1226]
  26. 26. • Level of Evidence (Cardiology) A. data derived from multicenter randomized trials B. data from limited or non-randomized studies or observational studies C. expert consensus but no formal studies Gregoratos, Circ 1998; 97: 1325-1335
  27. 27. Symptomatology + Documented Events ECG documentation in the medical record is essential ! Reliable Indications for Pacing =
  28. 28. • Sick Sinus Syndrome • Heart Block • Carotid Sinus Hypersensitivity and Neurocardiogenic Syncope • HOCM, DCM
  29. 29. • Sinus Bradycardia • Sinus Arrest • SA Exit Block • Bradycardia- Tachycardia Syndrome • Symptomatic chronotropic incompetence
  30. 30. 1. Symptomatic bradycardia or frequent symptomatic sinus pauses (Level of Evidence: C) 2. Symptomatic chronotropic incompetence (Level of Evidence: C) 3. Symptomatic bradycardia that results from required drug therapy (Level of Evidence: C)
  31. 31. Max Rest Heart Rate Time Start Activity Stop Activity Quick Unstable Slow 1. Identify the mechanism
  32. 32. 1. SN dysfunction occurring spontaneously or as a result of necessary drug therapy, with HR <40 bpm, when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented (Level of Evidence: C) 2. Syncope of unknown etiology when SN dysfunction is provoked or discovered during EP testing that is thought to be clinically significnat (Level of Evidence: C)
  33. 33. Class IIb 2. In minimally symptomatic patients, chronic heart rates <40 bpm, while awake. Class III 1. SN dysfunction in asymptomatic patients(Level of Evidence: C) 2. SN dysfunction in patients with symptoms that are clearly documented in the absence of bradycardia (Level of Evidence: C) 3. SN dysfunction with symptomatic bradycardia due to nonessential drug therapy.
  34. 34. 1. Third-degree or advanced second-degree AV block at any anatomic level with: a) Symptoms (including heart failure) attributable to AV block (C) b) Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia (C) c) Documented asystole 3.0 sec. any escape rate <40 bpm, or any escape rhythm below the AV junction in awake, asymptom-free patients (C) d) A documented asystole >5 sec in awake, asymptomatic patients in atrial fibrillation (C) e) After catheter ablation of the AV junction (C) f) Postoperative AV block not expected to resolve after cardiac surgery (C) g) Neuromuscular diseases with AV block, with or without symptoms of bradycardia (B)
  35. 35. 2. Asymptomatic third-degree AV block at any anatomic site with an average awake ventricular rate >40bpm in patients with cardiomegaly or LV dysfunction (C) 3. Second-degree or third-degree AV block during exercise in the absence of myocardial ischemia (C) 4. Symptomatic second-degree AV block regardless of type or site of block (B)
  36. 36. 1. Advanced second-degree or third-degree AV block at any anatomic site with an average ventricular rate >40bpm in the absence of cardiomegaly (C) 2. Asymptomatic type second-degree AV block at intra- or infra-His levels found at EP study (B) 3. First- or second-degree AV block with symptoms similar to those of "pacemaker syndrome“(B) 4. Asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, including isolated RBBB, pacing becomes a class I recommendation (B)
  37. 37. 1. AV block due to drug use or toxicity when the block is expected to recur even after withdrawal of the drug (B) 2. Neuromuscular diseases with any degree of AV block (including first degree AV block), with or without symptoms (B)
  38. 38. 1. Asymptomatic first-degree AV block (B) 2. Asymptomatic type I second-degree AV block at a site above the His level or not known by EP study (B) 3. AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme disease, etc), or during hypoxia in sleep apnea syndrome in absence of symptoms (B)
  39. 39. -risk of sudden death or progression to complete heart block
  40. 40. 1. Intermittent third-degree or advanced second- degree AV block (B) 2. Type II second-degree AV block (B) 3. Alternating bundle-branch block (C)
  41. 41. 1. Syncope not demonstrated to be due to AV block when other likely causes, specifically ventricular tachycardia, have been excluded (B) 2. Incidental finding at EP study of markedly prolonged HV interval (≧ 100 ms) in asymptomatic patients (B) 3. Incidental finding at EP study of pacing-induced infra-His block that is not physiological (B)
  42. 42. Class IIa 1. Neuromuscular diseases…with any degree of fascicular block, with or without symptoms (C) Class III 1. Fascicular block without AV block or symptoms (B) 2. Fascicular block with first-degree AV block without symptoms (B)
  43. 43. • Without congenital heart disease • Symptomatic • Wide QRS escape rhythm • EP test: Infra-Hisian block • <55 bpm in infants; • <50bpm with long pause (2~3X BCL) • Special consideration in Congenital heart disease • Post-op • HF<70bpm in infants; • <40bpm or pause >3sec
  44. 44. Class I Recurrent syncope caused by carotid sinus hypersensitivity, defined as minimal carotid sinus pressure inducing ventricular asystole of >3 seconds in patients not receiving medications that depress the sinus node or AV conduction (Level of Evidence: C) Class IIa Syncope in the absence of definite provocative event with a pause of ≥3 seconds with carotid massage (Level of Evidence: C) Class IIb Recurrent symptomatic neurocardiogenic syncope with a cardioinhibitory response during tilt-table testing (Level of Evidence: B) Class III A cardioinhibitory response during carotid sinus stimulation without symptoms or with vague symptoms (Level of Evidence: C) Situational vasovagal syncope in which avoidance behavior is effective (Level of Evidence: C)
  45. 45. • Protocol • Fast > 2 hours • continuous ECG and blood pressure mornitering • Tilt to 60~80° • 20~45 minutes 2.Identify Etiology
  46. 46. 2.Identify Etiology
  47. 47. I Chamber Paced II Chamber Sensed III Response to Sensing IV Programmable Functions/Rate Modulation V Antitachy Function(s) V: Ventricle V: Ventricle T: Triggered P: Simple programmable P: Pace A: Atrium A: Atrium I: Inhibited M: Multi- programmable S: Shock D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S) O: None O: None O: None R: Rate modulating O: None S: Single (A or V) S: Single (A or V) O: None 3.Identify Treatment
  48. 48. Factor to consider when choosing pacing mode • Underlying rhythm disturbance • Overall physical condition • Associated medical condition • Exercise capacity • Chronotropic response to exercise • Effect of pacing mode on long-term morbidity and mortality
  49. 49. • DDD/AAI (atrial based pacing) vs. VVI (ventricular based pacing) •lower mortality •lower Af incidence • ACC/AHA 2008 Guidelines for Choice of Pacemaker ~AV synchrony~

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