Objective :

To understand physiology of heart

rhythm
To understand patophysiology of
rhythm disorders
Know some tachy arrhytmias
Know some bradi arrhytmias
Learn about rhythm emergency (VT
and VF)

Normal Heart conduction :

Normal conduction pathway

Clinical symptoms suggest

arrhytmias :

Syncopal attack
Fatigue
Tachycardia
Frog sign
Chest pain
Seizure
Hypotension

Ancilary procedures :
Holter monitoring
Stress test
EP study

Action potentials of the Heart

 Electrolyce disorders
mainly Involve
the heart rhythm

Arrhytmia mechanism :
Impulse initiation :
Automaticity :
Tachycardia and bradyardia

Trigered activity (phase 3 or 4):

EAD
DAD

Conduction disorders :
Reentry :
Microreentrant
Macroreentrant
Acessory pathway

 Automaticity :
If, ICa-L, ICa-T, IK, IK1
Suppression/acceleration of phase 4
Sinus bradycardia, sinus tachycardia

Triggered automaticity
Calcium overload, ITI
DADs Digitalis toxicity, reperfusion VT
ICa-L, IK, INa
EADs Torsades des pointes, congenital and
acquired

 Pathomechanism of reentry
Most common mechanism of arrhytmia

Reentry :
Unifocal
Multifocal multifocal VT
Microreentrant :
Most of cardiac arrhytmias:
SVT, AF

Marcroreentrant :
Atrial fluter sawtooth appearance

Acessory pathway :
WPW sydrome deltra wave

Atrial
tachycardias
SVT / AVNRT
Atrial fibrilation
Atrial Flutter
Multifocal atrial
tachycardias

Ventricular
tachycardias
Monomorfic
ventricular
tachycardias
Polymorfic
ventricular
tachycardias

Management :
Specific to the current abnormalities
AVNRT / SVT
Digoxin, verapamile, diltiazem, adenosine

MAT :
Digoxin

AF / A flu :
Rate control
Rhythm control
Anticoagulation

VT
Anti arrhytmic agent : amiodarone
Magnesium sulfate

Use of specific anti

arrhytmias :
Most of anti arrhytmic agents are
proarrhytmics
Limited to documented structural
heart disease
Limited to sustained ventricular
tacycardias

Intravenous anti arrhytmics

commonly used

Intravenous anti arrhytmics

commonly used

Latest anti arrhytmias :

Ivabradine, a funy channel
inhibitor
Used in patients with enchanced
automaticity disorders.
Treatment range 5 30 mg
Safe and limited side effects

Treatment spesific for arrhytmias :

SVT
AF
Atrial Flutter

Special inherited diseases related

with malignant arrhytmias :
Brugada syndrome SCN5A INa channel

Catecholaminergic VT Ry R2 Ryanodine receptor,

calsequestrin receptor

LQT1
LQT2
LQT3
LQT4
LQT6
LQT7
LQT8

KCNQ1 Iks channel subunit

KCNH2 (HERG) IKr channel subunit
SCN5A INA channel subunit
ANK2 Ankyrin-B LQT5 KCNE1 IKs channel subunit
KCNE2 IKr channel subunit
KCNJ2 IK1 channel subunit
CACNA1C ICa channel subunit

 Patients can manifest bidirectional

VT, nonsustained polymorphic VT, or
recurrent VF
Triggered by stress

Brugada syndrome
ST segment elevation in V1 to V3 that
typically can be provoked with the
sodium channel-blocking drugs
ajmaline, flecainide, and
procainamide and a risk of
polymorphic ventricular arrhythmias

Specific treatment :
ICD implantation.

Bradyarrhytmias :
Extrinsic :

Autonomic
Drugs
Hypothyroidism
Hypotermia
Vagal manouvers
Increase ICP

Intrinsic

Sick sinus syndrome

CAD
Inflamatory
Familial

 AV node disease
CAD
Vasovagal
Drug related
Infectious
Congenital
Inflamatory
Infiltrative
Neoplastic
Degenerative

Permanent pacemaker (Class I

recommendation) :
Indicated in Symptomatic AV block
Inicated in Assymptomatic 3rd degree
and 2nd degree type 2 AV block.
Periods of asystole>3 s or any
escape rate <40 beats/min while
awake
Atrial fibrillation with bradycardia and
pauses >5s

Pacemaker mnemonics:
The first letter indicates the chamber(s) that is
paced (O, none; A, atrium; V, ventricle; D,
dual; S, single).
The second is the chamber(s) in which sensing
occurs (O, none; A, atrium; V, ventricle; D,
dual; S, single),
The third is the response to a sensed event (O,
none; I, inhibition; T, triggered; D, inhibition +
triggered)

Pacemaker
Transcutaneous
Transvenous
Permanent

 The fourth refers to the programmability or rate

response (R, rate responsive)
The fifth refers to the existence of antitachycardia
functions if present (O, none; P, antitachycardia
pacing; S, shock; D, pace + shock).

 Almost all modern pacemakers are

multiprogrammable and have the
capability for rate responsiveness
using one of several rate sensors:
activity or motion, minute
ventilation, or QT interval.
The most commonly programmed
modes of implanted single- and dualchamber pacemakers are VVIR and
DDDR,