LOGO

ARRHYTMIA
HARVI PUSPA WARDANI
FAKULTAS KEDOKTERAN UNISBA
21 MEI 2013

Sistem Konduksi Jantung

Pacemaker cell action potential

 Your Subtopics Go Here

 Layak Baca
Identitas : Nama, umur, sex, (ras),
tanggal, waktu

Analisis Gambaran EKG

-

Irama
Frekuensi
Gelombang P
Interval PR

: reguler ireguler
: normal cepat lambat
: ada tidak ada
: normal memanjang
memendek
- Gelombang QRS : lebar sempit

Irama dan Regularitas

R-R interval, P-P interval
Teratur (reguler) : interval sama
Tidak teratur (ireguler) : interval
tidak sama

Frekuensi HR (Teratur)
Frekuensi
300______
kotak besar R-R
__ __1500_ ____
kotak kecil R-R
Kecepatan standar 25
mm/detik

Frekuensi HR (Tidak Teratur)

Frekuensi
Strip 6 detik :
komp. QRS X 10
Strip 12 detik :
komp. QRS X 5

Normal Sinus Rhythm (NSR)

Irama Sinus Normal

Aritmia
Tidak

memenuhi kriteria NSR Aritmia

(Disritmia)
Terbagi atas :
Gangguan pembentukan impuls
Gangguan penghantaran impuls
Sumber impuls : SA node, atrium,
AV node (junction), ventrikel

Gangguan pembentukan impuls

Enhanced automaticity :
- Increased automaticity of SA node
- Increased automaticity of latent pacemakers
- Abnormal automaticity
Triggered activity
Decreased automaticity of SA node

Mechanisms of Cardiac Arrhythmias

Figure 11.8. Triggered activity. A delayed afterdepolarization (arrow) arises

after the cell has fully repolarized. If the delayed afterdepolarization reaches
the threshold voltage, a propagated action potential (AP) is triggered (dashed
curve).

Early afterdepolarizations are changes of

the membrane potential in the positive direction that interrupt normal repolarization (see
Fig 11.7). They can occur either during the
plateau of the action potential (phase 2) or
during rapid repolarization (phase 3). Early
afterdepolarizations are more likely to develop
in conditions that prolong the action potential duration (and therefore the electrocardiographic QT interval), as may occur
during therapy with certain drugs (see Chapter 17) and in the inherited long-QT syndromes
(see Chapter 12).
The ionic current responsible for an early
afterdepolarization depends on the membrane

states of high intracellular calcium, as may be

present with digitalis intoxication (see Chapter
17), or during marked catecholamine stimulation. It is thought that intracellular Ca accumulation causes the activation of chloride
currents or of the Na Ca exchanger that
results in brief inward currents that generate
the delayed afterdepolarization.
As with early afterdepolarizations, if the
amplitude of the delayed afterdepolarization
reaches a threshold voltage, an action potential
will be generated. Such action potentials can
be self-perpetuating and lead to tachyarrhythmias. Some idiopathic ventricular tachycardias
that occur in otherwise structurally normal

Gangguan penghantaran impuls

Blok
Reentry

LOGO

SINUS

RHYTM

Sinus Bradycardia (SB)

Sinus Tachycardia (ST)

Sinus Arrhythmia

LOGO

SUPRAVENTRICULAR
ARRHYTMIAS

Atrial Premature Beats/Atrial Extrasystole

Gelombang P
Rhythm
QRS

: premature,abnormal
: irregular
: sempit

Atrial Fibrillation (AF)

Atrial Flutter (Af)

Atrial Fibrillation Atrial Flutter

Frekuensi
< 60 x/m
60-100 x/m
>100 x/m

: slow response (SVR)

: normo response (NVR)
: rapid response (RVR)

Atrial Tachycardia (AT)

Multifocal Atrial Tachycardia

Rate 100-250/bpm
P wave two or more ectopic P waves with different
morphologies (min 3 different P wave morphology)
QRS normal
Conduction P-R intervals vary
Rhythm irregular

Ventricular Preexcitation Syndrom

Wolff-Parkinson-White/WPW
PR interval memendek
Delta wave
Wide QRS complex

Chapter 12

Paroxysmal Supraventricular Tachycardia

(PSVT)
Chapter 12

Irama teratur, HR > 150

x/m
Gelombang P kecil,
kadang (-)
Interval PR memendek
atau (-),
Kompleks QRS 0,12
detik (sempit)
Sebagian besar
AVNRT

Impulse from
SA node

Fast pathway

Compact
node
Slow pathway

To
bundle of His

Atrial
premature
beat

Unidirectional
block

Retrograde
conduction

To
bundle of His
Figure 12.15. Common mechanism of AV nodal reentry. In most patients, the AV node
(gray region in the drawing) is a lobulated structure consisting proximally of several atrial
extensions and distally of a compact node portion. A. In patients with AV nodal reentry,

Supraventricular Tachycardia (SVT)

ATRIOVENTRICULAR REENTRANT TACHYCARDIA (AVRT)

Chapter 12

Figure 12.17. WolffParkinsonWhite syndrome. A. During normal sinus rhythm, the shortened PR interval, delta wave,
and widened QRS complex indicate fusion of ventricular activation via the AV node and accessory pathway. B. An atrial
premature beat can trigger an orthodromic atrioventricular reentrant tachycardia, in which impulses are conducted anterogradely down the AV node and retrogradely up the accessory pathway. Retrograde P waves are visible immediately after the
QRS complex. There is no delta wave because anterograde ventricular stimulation passes exclusively through the AV node.
C. Antidromic atrioventricular reentrant tachycardia in which impulses are conducted anterogradely down the accessory
tract and retrogradely up the AV node. The QRS complex is very widened because the ventricles are stimulated by abnormal
conduction through the accessory pathway. SA, sinoatrial.

Junctional Extrasystole
Gel P

: inverted, tidak ada, setelah komplek QRS

Junctional Rhythm (JR)

Accelerated Junctional Rhythm (Acc JR)

LOGO

VENTRICULAR
ARRHYTHMIAS

Idioventricular Rhythm (IVR)

Accelerated Idioventricular Rhythm (Acc IVR - AIR)

Ventricular Extrasystole (VES)

Premature Ventricular Contraction (PVC)
Irama tidak teratur, karena ada extrasystole
HR tergantung irama dasar
Gelombang P (-), Interval PR (-)
Kompleks QRS > 0,12 detik (lebar)
VES unifocal, multifocal
VES couplet, triplet, consecutive (Salvo)
VES bigemini, trigemini, quadrigemini
VES R on T

Ventricular Extrasystole (VES)

Unifocal

Ventricular Extrasystole (VES)

Multifocal

Ventricular Extrasystole (VES)

Coupled

Ventricular Extrasystole (VES)

Triplet

Ventricular Extrasystole (VES)

Bigeminal

Ventricular Extrasystole (VES)

Quadrigeminal

Ventricular Extrasystole (VES)

R on T

Ventricular Fibrillation (VF)

Ventricular Fibrillation (VF)

Ventricular Tachycardia (VT)

Irama teratur, HR >100 x/m

Gelombang P (-), Interval PR (-)
Kompleks QRS > 0,12 detik (lebar)
Monomorphic, Torsade de Pointes

Ventricular Tachycardia (VT)

Torsade de Pointes

Ventricular Asystole

LOGO

CONDUCTION
DISTURBANCES

CLASSIFICATION OF CONDUCTION
DISTURBANCES
1.
2.

3.

SINOATRIAL BLOCK
ATRIOVENTRICULAR BLOCK
a. Incomplete AV Block
- 1st degree AV Block
- 2nd degree AV Block :
Mobitz type I (Wenckebach)
Mobitz type II
b. Total AV Block :
- 3rd degree AV Block
INTRAVENTRICULAR BLOCK
RBBB, LBBB, Fascicular Block

First Degree AV Block

Perlambatan atau
obstruksi transmisi
impuls dari atrium ke
ventrikel (conduction
delay in the AV junction)

First Degree AV Block

Irama teratur, HR umumnya 60-100 x/m

Gelombang P normal, P : QRS = 1 : 1
Interval PR memanjang, > 0,20 detik, konstan
Kompleks QRS 0,12 detik (sempit)

Second Degree AV Block

Sebagian impuls dari
atrium terhambat secara
total pada AV node dan
gagal untuk diteruskan ke
ventrikel
Sebagian gelombang P
tidak diikuti kompleks
QRS

Second Degree AV Block

Mobitz Type 1 (Wenckebach)
Secara anatomis
umumnya hambatan
berada pada daerah
di atas AV junction

Second Degree AV Block

Mobitz Type 1 (Wenckebach)

Second Degree AV Block

Mobitz Type 2
Secara anatomis
umumnya hambatan
berada pada daerah
di bawah AV junction

Second Degree AV Block

Type 2

Irama atrial teratur, irama ventrikel tidak teratur

Gelombang P normal, ada satu atau lebih gelombang P
tidak diikuti kompleks QRS
Interval PR normal atau memanjang, namun konstan
Kompleks QRS sempit/lebar

Third Degree AV Block

Hantaran impuls
terhambat secara total
dari atrium ke ventrikel
Lokasi :
- AV junction
- Bundle of His

Third Degree AV Block (TAVB)

Irama teratur
Gelombang P bentuk dan ukuran normal, tidak
berhubungan dengan kompleks QRS
Interval PR tidak dapat diukur karena tidak ada hubungan
antara gelombang P dengan kompleks QRS
Kompleks QRS sempit / lebar tergantung dari mana
aktivitas berasal
Lebar : dari ventrikel, sempit : dari AV node

Third Degree AV Block (TAVB)

INTRAVENTRICULAR BLOCK
Block in the intraventricular conduction
system :
1. Bundle Branch Block
a. RBBB (complete/incomplete)
b. LBBB (complete/incomplete)
2. Fascicular Block
a. LAFB (LAHB)
b. LPFB (LPHB)
3. Nonspecific Intraventricular Block

RBBB
RSR di V1,V2
Wide & slurred S di
V5,V6,I,aVL
T inverted di V1,V2
Complete dan
incomplete RBBB :
lihat durasi QRS

LBBB
RSR di V5,V6,I,aVL
Wide & slurred S di
V1,V2
T inverted di
V5,V6,I,aVL
Complete dan
incomplete RBBB :
lihat durasi QRS

Kegawatdaruratan EKG
LAMBAT (HR < 60 X/m)
Sinus bradicardia
Atrial Fibrillation SVR
Atrial Flutter SVR
Junctional rhythm
Idioventricular rhythm
Total AV block

CEPAT (HR > 100 X/m)

Sinus tachycardia
Atrial Fibrillation RVR
Atrial Flutter RVR
Supra Ventricular
Tachycardia (SVT)
Ventricular Fibrillation
Ventricular Tachycardia