Vous êtes sur la page 1sur 13

BRADYARRHYTMIAS

CARINA ADRIANA
• defined as a heart rate less than 60
beats/min
• Physiologic, as in wellconditioned
athletes and asymptomatic Av block in
young, healthy individuals or during
sleep
• Pathologic can be categorized on the
basis of the level of disturbance in the
hierarchy of the normal impulse
generation and conduction system
Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.
Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.

Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac
resynchronization therapy. European Heart Journal. 2013 June 23; 34: 2281–2329
Sinus Bradycardia
ECG Recognition
rate less than 60 beats/min
P waves have a normal contour and occur before each QRS complex, usually with
a constant PR interval >120 milliseconds
Sinus arrhythmia often coexists.
Clinical Features
from excessive vagal or ↓sympathetic tone, effect of medications (amiodarone, beta
adrenoceptor–blocking drugs, clonidine, propafenone, Ivabradine, calcium antagonists), or from
anatomic changes in the sinus node.
Management
not usually necessary unless cardiac output is inadequate or arrhythm as result from the slow rate.
Atropine (0.5 mg intravenously as an initial dose, repeated if necessary) is generally effective
acutely
For recurrent symptomatic episodes, temporary or permanent pacing may be needed
Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.
Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Sinus Arrhythmia

ECG Recognition
On occasion, the pacemaker focus can wander within the sinus node, or its exit to the atrium may
change and produce P waves of a slightly different contour (but not retrograde) and a slightly
changing PR interval that exceeds 120 milliseconds
Clinical Features
occurs in the young, especially those with slower heart rates or after enhanced vagal tone
(administration of digitalis or morphine or athletic training), and decreases with age or with
autonomic dysfunction (diabetic neuropathy)
if the pauses are excessively long : palpitations or dizziness
Management
atropine, ephedrine, or isoproterenol administration, as for the treatment of sinus bradycardia

Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.


Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.
Hypersensitive Carotid Sinus Syndrome Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.

ECG Recognition
ventricular asystole caused by cessation of atrial activity as a result of sinus arrest or SA exit
block
AV block is observed less frequently, probably in part because the absence of atrial activity
from sinus arrest precludes the manifestations of AV block
Clinical Features
• Cardioinhibitory carotid sinus hypersensitivity
ventricular asystole >3 seconds during carotid sinus stimulation,
although normal limits have not been definitively established.
• Vasodepressor carotid sinus hypersensitivity
↓in systolic blood pressure (SBP) of 50 mm Hg or more without associated cardiac slowing or
↓ in SBP >30 mm Hg when the patient’s symptoms are reproduced.
Management
Cardioinhibitory : atropine, symptomatic patient→pacemaker implantation
Vasodepressor : elastic support hose, sodium-retaining drugs
Sick Sinus Syndrome

ECG Recognition
several sinus nodal abnormalities,
including (1) persistent spontaneous sinus bradycardia not caused by drugs and inappropriate
for the physiologic circumstance, (2) sinus arrest or exit block
Clinical Features
Symptomatic patients with sinus pauses or SA exit block :
abnormal responses on electrophysiologic testing, relatively high incidence of atrial fibrillation.
In children, most frequently occurs in those with congenital or acquired heart disease,
particularly after corrective cardiac surgery
can occur in the absence of other cardiac abnormalities, the course of the disease is frequently
intermittent and unpredictable because it is influenced by the severity of the underlying heart
disease.
Management
Pacing for the bradycardia, Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.
combined with drug therapy to treat the tachycardia Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
First-Degree
Atrioventricular Block

ECG Recognition

every atrial impulse is conducted to the ventricles and a regular ventricular rate is produced, but
the PR interval >0.20 second in adults.
skipped P waves : PR intervals as long as 1.0 second have been noted and can at times exceed
the P-P interval.
PR interval prolongation can result from a conduction delay in the AV node (A-H interval), in
the His-Purkinje system (H-V interval), or at both sites.
Acceleration of the atrial rate or enhancement of vagal tone by carotid massage →first-degree
AV nodal block to progress to type I second-degree AV block.

Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.


Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Second-Degree
Atrioventricular Block

Blocking of some atrial impulses conducted to the ventricle at a time when physiologic
interference is not involved constitutes second degree AV block, the non conducted block several
P waves in a row

the two types of block : Mobitz type I (Wenckebach) and Mobitz type II

Type I AV block : more benign & doesn’t progress to more advanced forms of AV conduction
disturbance
Type II AV block : the development of Adams-Stokes syncope & complete AV block

Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.


Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Second-Degree
Atrioventricular Block

Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.


Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Second-Degree
Atrioventricular Block

Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.


Braunwald’s Heart Disease:A Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
Third-Degree (Complete)
Atrioventricular Block

• Occurs when no atrial activity is


conducted to the ventricles and therefore the atria and ventricles are
controlled by
independent pacemakers.
• One type of complete AV dissociation
• Can accompanied by signs and symptoms of reduced cardiac output,
syncope or presyncope,
angina or palpitations from ventricular tachyarrhythmias.
• Can result from a block at the level of the AVnode (usually congenital),
within the bundle of His, or distal to it in the Purkinje system (usually
acquired)
• Transcutaneous or temporary transvenous Olgin pacingJE, ZipesisDP. preferable
Bradyarrhytmias and Atrioventricular Block.
• Symptomatic AV block or highgrade AV block : permanent
Braunwald’s Heart Disease:Apacemaker
Textbook of Cardiovascular
Medicine. 11. Elsevier Saunders;2018. p. 772-779.
placement is the treatment of choice
Olgin JE, Zipes DP. Bradyarrhytmias and Atrioventricular Block.

Atrioventricular Dissociation Braunwald’s Heart Disease:A Textbook of Cardiovascular


Medicine. 11. Elsevier Saunders;2018. p. 772-779.

• dissociated or independent beating of the atria and ventricles.


• AV dissociation is never a primary disturbance of rhythm
• a “symptom” of an underlying rhythm disturbance produced by one of
three causes or a combination of causes that prevents the normal
transmission of impulses from atrium to ventricle.

Classification
1. Slowing of the dominant pacemaker of the heart (usually the sinus
node), which allows escape of a subsidiary or latent pacemaker
2. Acceleration of a latent pacemaker
3. A block, generally at the AV junction, that prevents impulses formed at
a normal rate in a dominant pacemaker from reaching the ventricles and
allows the ventricles to beat under the control of a subsidiary pacemaker
4. A combination of causes, as when excess digitalis results in the
production nonparoxysmal AV junctional tachycardia associated with
sinoatrial (SA) or AV block.