Cardiac Abnormalities

Departemen Fisiologi Fakultas Kedokteran Universitas Sumatera Utara

NORMAL CARDIAC RATE

In normal human heart, each beat originates

in the SA node -> normal sinus rhythm. At rest, heart beats about 70 times a minute
slowed (bradycardia) during sleep accelerated (tachycardia) by emotion, exercise,

fever, and many other stimuli.

 In healthy young

individuals breathing at a normal rate, the heart rate varies with the phases of respiration

It accelerates during inspiration and decelerates

during expiration, especially if the depth of breathing is increased.

 During inspiration, impulses in the vagi from

the stretch receptors in the lungs inhibit the cardio-inhibitory area in the medulla oblongata. !onic vagal discharge that "eeps the heart rate slow decreases, and the heart rate rises.

Sick Sinus Syndrome = bradycardia-tachycardia syndrome; sinus node dysfunction

is a collection of heart rhythm disorders that

include sinus bradycardia #slow heart rates from the natural pacema"er of the heart$, tachycardias #fast heart rates$, and bradycardia-tachycardia #alternating slow and fast heart rhythms$. is relatively uncommon and usually found in people older than %0, in whom the cause is often a nonspecific, scar-li"e degeneration of the heart&s conduction system.

Abnormal Pacemakers
complete (third-degree) heart block is when

conduction from the atria to the ventricles is completely interrupted, and the ventricles beat at a low rate (idioventricular rhythm) independently of the atria.

due to disease in the A' node (AV nodal block)

or in the conducting system below the node (infranodal block) .

 In A' nodal bloc", the remaining nodal tissue

becomes pacema"er and the rate of the idioventricular rhythm is approximately (% beats)min. In infranodal bloc" due to disease in the bundle of *is, the ventricular pacema"er is located more peripherally in the conduction system and the ventricular rate is lower the resultant cerebral ischemia causes di++iness and fainting (StokesAdams syndrome).

 incomplete heart

blockv is when conduction between the atria and ventricles is slowed but not completely interrupted first-degree heart block, all the atrial impulses reach the ventricles but the ,interval is abnormally long

 second-degree heart block, not all atrial

impulses are conducted to the ventricles.

repeated se.uences of beats in which the ,-

interval lengthens progressively until a ventricular beat is dropped ( enckebach phenomenon) .

 In right or left bundle branch

block, excitation passes normally down the bundle on the intact side and then sweeps bac" through the muscle to activate the ventricle on the bloc"ed side. !he ventricular rate is therefore normal, but the /-S complexes are prolonged and deformed.

 Bloc" can also occur in the anterior or posterior

fascicle of the left bundle branch, producing the condition called hemiblock or fascicular block. 0eft anterior hemibloc" produces abnormal left axis deviation in the 123, whereas left posterior hemibloc" produces abnormal right axis deviation. It is not uncommon to find combinations of fascicular and branch bloc"s ( bifascicular or trifascicular block ).

Ectopic Foci of Excitation

in abnormal conditions, the *is4,ur"in5e

fibers or the myocardial fibers may discharge spontaneously. -> increased automaticity if an irritable ectopic focus discharges once, the result is a beat that occurs before the expected next normal beat and transiently interrupts the cardiac rhythm #atrial, nodal, or ventricular e!trasystole or premature beat $.

 if the focus discharges repetitively at a rate

higher than that of the SA node, it produces rapid, regular tachycardia #atrial, ventricular, or nodal paro!ysmal tachycardia or atrial flutter $.

REENTRY
A more common cause of paroxysmal

arrhythmias is a defect in conduction that permits a wave of excitation to propagate continuously within a closed circuit (circus movement). 6or example, if a transient bloc" is present on one side of a portion of the conducting system, the impulse can go down the other side. If the bloc" then wears off , the impulse may conduct in a retrograde direction in the previously bloc"ed side bac" to the origin and then descend again, establishing a circus movement.

 If the reentry is in the A' node, the reentrant

activity depolari+es the atrium, and the resulting atrial beat is called an echo beat. In addition, the reentrant activity in the node propagates bac" down to the ventricle, producing paroxysmal nodal tachycardia.

ATRIAL ARRHYTHMIAS
1xcitation spreading from an independently

discharging focus in the atria stimulates the A' node prematurely and is conducted to the ventricles. !he , waves of atrial extrasystoles are abnormal, but the /-S! configurations are usually normal !he excitation may depolari+e the SA node, which must repolari+e and then depolari+e to the firing level before it can initiate the next normal beat.

 Atrial tachycardia occurs when an atrial focus

discharges regularly or there is reentrant activity producing atrial rates up to 770)min. Sometimes, especially in digitali+ed patients, some degree of atrioventricular bloc" is associated with the tachycardia (paro!ysmal atrial tachycardia with block).

 In atrial flutter, the atrial rate is 70048%0)min. !his produces a characteristic sawtooth pattern

of flutter waves due to atrial contractions. It is almost always associated with 7 9 or greater A' bloc", because in adults the A' node cannot conduct more than about 780 impulses per minute.

 In atrial fibrillation, the atria beat very rapidly

#8004%00)min$ in a completely irregular and disorgani+ed fashion. Because the A' node discharges at irregular intervals, the ventricles also beat at a completely irregular rate, usually :049;0)min

VENTRICULAR ARRHYTHMIAS
,remature beats that

originate in an ectopic ventricular focus usually have bi+arrely shaped prolonged /-S complexes because of the slow spread of the impulse from the focus through the ventricular muscle to the rest of the ventricle.

 Paro!ysmal ventricular tachycardia is a series

of rapid, regular ventricular depolari+ations usually due to a circus movement involving the ventricles. "orsade de pointes is a form of ventricular tachycardia in which the /-S morphology varies. 'entricular fibrillation , the ventricular muscle fibers contract in a totally irregular and ineffective way because of the very rapid discharge of multiple ventricular ectopic foci or a circus movement.

EFFECTS OF CHANGES IN THE IONIC COMPOSITION OF THE BLOOD

*yper"alemia is a very dangerous and

potentially lethal condition because of its effects on the heart. As the plasma <= level rises, the first change in the 123 is the appearance of tall pea"ed ! waves, a manifestation of altered repolari+ation

 !he resting membrane potential of the

muscle fibers decreases as the extracellular <= concentration increases. !he fibers eventually become unexcitable, and the heart stops in diastole. 2onversely, a decrease in the plasma <= level causes prolongation of the ,- interval, prominent > waves, and, occasionally, late ! wave inversion in the precardial leads. If the ! and > waves merge, the apparent /! interval is often prolonged? if the ! and > waves are separated, the true /! interval is seen to be of normal duration.

Referensi:
Barret KE, Barman SM, Boitano S, Brooks HL, Ganongs Review of Medical P !siolog!, "#t edition, McGraw Hill, Lange, "$%"& Silvert orn '(, H)man P !siolog!, an *ntegrated a++roac , ,t edition, Pearson ed)cation, "$%-& S erwood L, .)ndamentals of P !siolog!, a H)man Pers+ective, -rd edition, / omson Brooks01ole, "$$,

Let it beat!