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Kuliah Pengantar Aritmia
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Definisi
Irama Jantung Normal
• berasal dari nodus SA
• teratur, 60-100x/menit
• tidak mengalami hambatan konduksi
selain irama tersebut Aritmia
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Definisi
Aritmia: gangguan irama jantung
• gangguan frekuensi
• gangguan asal impuls
• gangguan irregularitas
• gangguan konduksi impuls
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SISTEM KONDUKSI NORMAL
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FASE POTENSIAL AKSI SEL JANTUNG
• Fase 0 depolarisasi cepat
(inflow of Na+)
• Fase 1 repolarisasi parsial
(inward Na+ current
deactivated, outflow of K+)
• Fase 2 plateau (slow inwardcalcium current)
• Fase 3 repolarisasi (calcium
current inactivates, K+ outflow)
• Fase 4 potensial pacemaker
(Slow Na+ inflow, slowing of K+
outflow) ‘autorhythmicity’• Periode refrakter (fase 1-3)
Phase 4
Phase 0
Phase 1
Phase 2
Phase 3
0 mV
-80mV
II
IIII
IV
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Etiologi • Fisiologis
• Patologis:
Valvular heart disease.
Ischemic heart disease.
Hypertensive heart diseases.Congenital heart disease.
Cardiomyopathies.
Carditis.
RV dysplasia.
Drug related.Pericarditis.
Pulmonary diseases.
dll
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Faktor faktor Aritmogenik
• Hipoksia
• Iskemia dan
irritabilitas
• stimulasi simpatis• obat-obatan
• gangguan elektrolit
• Bradikardia
• Regangan akibat
dilatasi dan hipertrofi
• kelainan struktursistem konduksi
• pemanjangan interval
QT
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Mekanisme Aritmogenesis
1. Gangguan Pembentukan Impulsa) Automatisasi
b) Triggered Activity.1) Early after depolarization.
2) Delayed after depolarization
2. Gangguan konduksia) Reentry
b) concealed conduction
c) blok
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Takiaritmia
• Ventricular – Ventricular tachycardia (VT)
– Ventricular fibrillation (VF)
– Ventricular premature beats
• Atrial
– Atrial fibrillation (AF) – Atrial flutter
– Atrio-ventricular nodal re-entrant tachycardia (AVNRT)
– Atrioventricular re-entrant tachycardia (AVRT)
– Atrial tachycardia (AT)
– Sinus tachycardia
– Inappropriate sinus tachycardia
– Atrial premature beats
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Bradiaritmia
• Sinus bradikardi
• Sinus arrest
• Sick sinus syndrome• Carotid sinus hypersensitivity
• AV blok derajat 1
• AV blok derajat 2, tipe 1 dan 2• AV blok derajat 3
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Presentasi Aritmia
• Palpitasi
• Dizziness
• Nyeri Dada• Sesak Nafas
• Pingsan
• Sudden cardiac death
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Anamnesis• Usia
• Gejala
– Asymptomatic/ Syncope/ Palpitations/ Chest pain/ Dyspnoea
• Kejadian pertama atau berulang
• Situasi
– Anger / Fright/ Exercise/ Sleep/ Micturition
• Tipe Onset
– Gradual or rapid
• Tipe terminasi
– With a valsalva/ vagal manouevres
• Riwayat obat-obatan
– Anti-arrhythmics/ Stimulants/ Antibiotics- consult the BNF
– Toxicity- accidental overdose
• Riwayat Keluarga
• Riwayat penyakit jantung struktural
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Pemeriksaan Penunjang
• EKG
• 24h Holter monitor
• Ekokardiogram• Stress test
• Angiografi Koroner
• Electrophysiology study
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(Exercise Stress Test)(Exercise Stress Test)
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Electrophysiologic study
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Terapi Non Farmakologis
• Akut – Vagal manoeuvres (Valsalva, carotid sinus massage)
– DC cardioversion
• Profilaksis – Radiofrequency ablation
– Implantable defibrillator
• Pacing (external, temporary, permanent)
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KLASIFIKASI ANTIARITMIA
VAUGHAN WILLIAMS
• Class I: block sodium channels – Ia (quinidine, procainamide,
disopyramide) AP
– Ib (lidocaine, mexiletine, phenytoin) AP
– Ic (flecainide, propafenone) AP
• Class II: ß-adrenoceptor antagonists(atenolol, sotalol)
• Class III: prolong action potential andprolong refractory period (suppressre-entrant rhythms) (amiodarone,dronedarone, sotalol)
• Class IV: Calcium channel
antagonists. Impair impulsepropagation in nodal and damagedareas (verapamil)
Phase 4
Phase 0
Phase 1
Phase 2
Phase 3
0 mV
-80mV
II
IIII
IV
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Strategi
Jangka pendek
• Treat reversible /underlying causes
• Medikasi untukmeningkatkan heart rate
• Temporary pacemaker(TPM)
Jangka Panjang • Permanent pacemaker(PPM)
Faktor yang berpengaruh
• Tipe bradiaritmia
• Severitas gejala
• Severitas patologis
penyebab
• Severitas comorbid
Tatalaksana Bradiaritmia
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TatalaksanaTakiaritmia
Jangka Panjang
RF ablation
Medikasi
AnticoagulationDevices (pacemaker, AICD)
Surgery
Strategi
Jangka Pendek
Electrical TherapyCardioversion, Defibrillation
Kontrol laju dan irama ventrikel
Medical / Electrical Identifikasi dan obati penyebab
Faktor Yang Berpengaruh
Tipe takiaritmia
Mekanisme aritmia
Kelainan KV penyebab
Ekspertise setempat Pasien
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TERIMA KASIH
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Aritmia Yang berasal dari SA
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SINUS TAKIKARDI
• Rate: 101-160/
• P wave: sinus
• QRS: normal
• konduksi: normal
• irama : regular or slightly irregular• Dampak klinis tergantung penyebab. Kadangkala kondisinormal
• Underlying causes:
peningkatan katekolamin ● CHF
hipoksia ● PE
demam ● stress
respons nyeri
• Tatalaksana : identifikasi dan koreksi underlying cause
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SINUS BRADIKARDI
• Rate: 40-59 bpm• P wave: sinus
• QRS: Normal (0.06- 0.12)
• Konduksi : P-R normal
• Irama: regular or slightly irregular
• Variasi normal pada atlet, saat tidur, atau respon darimanuver vagal.
• Tatalaksana:
treat the underlying cause,
atropine,
isuprel, or
Pacu jantung pada pasien dengan hemodinamik tidakstabil dan gangguan perfusi
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SINUS ARITMIA
• Rate: 45-100/bpm
• P wave: sinus
• QRS: normal
• Konduksi : normal
• Irama: regularly irregular
• Biasanya akibat pengaruh respirasi karena fluktuasipada vagal tone
• Rate akan meningkaat saat inspirasi dan turun saatekspirasi
• Tatalaksana jika ditemui gejala
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WANDERING PACEMAKER
• Rate: bervariasi tergantung lokasi pacemaker, biasanya45-100/ bpm
• P wave: morfologi bervariasi
• QRS: normal
• Konduksi : P-R interval bervariasi dtergantung lokasipacemaker
• Irama: irregular
• Bisa terjadi pada jantung normal, penyakit jantungstruktural atau pasien PPOK
• Biasanya tidak memerlukan terapi spesifik
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ECG ARTIFACT
• Artifact occurs when something causes a
disruption in monitoring.
• Some common causes are:
AC interference -causes 60 cycle artifact
Muscle tremors
Respiratory artifact-wandering baseline
Loose electrodeBroken lead wire
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TERIMA KASIH