第三篇第三章心律失常.pptx

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,第三篇第三章心律失常,心脏传,导系统,激动顺,序与心,动周期,得关系,传导系统神经支配与血供,1、,交感神经与迷走神经支配,2、,窦房结动脉供血,右冠状动脉,60%,左冠回旋支,40%,3、,房室结动脉供血,右冠状动脉,80%,左冠状动脉,20%,心律失常得定义,1、,冲动形成异常,部位、频率、节律,2、,冲动传导异常,传导阻滞、传导途径,冲动形成异常,窦性心律,异位心律,被动性:逸搏,逸搏心律,主动性:早搏,心动过速,心律失常分类,(,一,),bradycardia,tachycardia,心律失常分类,(,一,),冲动传导异常,生理性:干扰性房室脱节,病理性:不同部位传导阻滞,房室间传导径途异常:预激综合征,bradycardia,tachycardia,心律失常分类,(,二,),快速性,早搏,心动过速,扑动、颤动,缓慢性,激动形成障碍,传导阻滞,12,大家应该也有点累了，稍作休息,大家有疑问的，可以询问和交流,交界区,心房下部,窦房结,心房上部,心室,QRS,相同,心室,早搏起源部位,交界区逸搏,室性逸搏,房性逸搏,窦房阻滞或停搏,房室,希氏束,右束支,左束支,房内,窦房,阻滞发生各水平,心律失常发生机制(一),冲动形成异常,1,、自律性增高或降低,原有自律性得心肌细胞 异常,原无自律性得心肌细胞 异常,2,、触发活动,动作电位后产生得除极活动(后除极),低钾高钙,缺血再灌注,洋地黄中毒,CA,增高,传导阻滞,生理性或干扰脱节,病理性,心律失常发生机制(二),冲动传导异常,心律失常发生机制(二),折返得形成,1、,存在折返环:两个以上部位,2、,单向阻滞,3、,另一通道传导缓慢,4、,原先阻滞得通道再次激动,折返得形成机制,心律失常得诊断(一),病史,存在？类型？,诱发因素？,频率？起止方式？,影响及后果？,体检:,PR/,心音;左束支,/S2,分裂;,CSM/,心率变化,心电图(最重要得非侵入性检查),动态心电图,食道心电图,运动试验,心室晚电位,心内电生理,心律失常得诊断,(二),SA Node,AV Node,His-Purkinje,System,正常得窦性节律顺序下传,His-,Purkinje,System,窦性节律,Implies normal sequence of conduction,originating in the sinus node and proceeding to the ventricles via the AV node and His-Purkinje system、,EKG Characteristics:Regular narrow-plex rhythm,Rate 60-100 bpm,Each QRS plex is proceeded by a P wave with normal PR interval,P wave is upright in leadI/II/avF&downgoing in lead aVR,窦性心律失常,1、,窦性心动过速,2、,窦性心动过缓,3、,窦性停搏,4、,窦房传导阻滞,5、,病态窦房结综合征,窦性早搏,窦性,P,波,100,次,/,分,窦性心动过速,临床意义,病因:,刺激性物质,/,情绪反应,/,体力活动,病理状态:发热,/,甲亢,/,贫血,/,休克,/,心肌缺血,/HF/,药物应用,治疗:,病因或诱因,beta,阻滞剂,/,非二氢吡啶,CCB,特征:,窦性,P,波频率,2,秒,),长得,P-P,与短得,P-P,不成倍数,关系,窦性停搏,P,P,P,P,Sinus bradycardia,Sinus arrest,Slow junctional escape rhythm,(,with retrograde p waves,),Sinus Arrest,临床意义,迷走张力高或,/,颈动脉窦过敏,急性下壁心梗,SSS,脑血管意外,洋地黄药物,/,乙酰胆碱类药物,Sinoatrial(SA)Exit Block-Definitions,First Degree:,Prolonged SA conduction time (non-detectable on EKG;no missing P waves),Second Degree:,Intermittent non-conduction(intermittent absence of P waves),Third Degree:,Persistent non-conduction(plete absence of P waves;escape rhythms only),Sequence of P Wave Generation,Sinus,Node,SA,Junction,Atrium,(P wave),Non-visible process on the EKG,Second Degree SA Exit Block-Type I,(Wenkebach),P,P,P,P,4:3 pattern,Missing,P wave,PP intervals shorten prior to block,Note unaffected,fixed,PR intervals,PP:,Schema of a Typical 4:3 Second Degree,SA Exit Block(Type I)Sequence,Second PP(AA)shortens due to diminution in the incre-ment of SA-A prolongation,Pause enpassing blocked beat 2 x normal PP,Sinus,Node,SA,Junct、,A,Second Degree SA Exit Block-Type II,PP:,P,P,P,P,P,One P wave abruptly“drops out”on time,Missing,P wave,X,2X,2X,X,P,P,P,P,P,P,P,P,2:1 SA Exit Block,(Every Other P wave is“Dropped”),Atrial rate is abruptly cut in half,Resolution of block,P,病态窦房结综合征,窦房结病变,-,功能减退,多种心律失常,病因,冠心病、心肌病,窦房结退行性变及其周围组织发生缺血、纤维化、炎症,鉴别诊断:,迷走神经张力增高、甲减及抗心律失常药物,SSS,心电图特征,持续而显著得窦性心动过缓(,50,次,/,分),窦性停搏、窦房阻滞,常同时合并房室传导阻滞,心动过缓,心动过速综合征:,多合并自律性增高得房性心律失常,Tachycardia-Bradycardia,(Form of“Sick Sinus”)Syndrome,Atrial Flutter,Sinus arrest,Junctional,escape(tardy),Atrial Flutter,terminates,Sinus Arrest,Asystole,Sinus rhythm,Sinus brady、,Sinus,arrest,V、escape,rhythm,Failure of V、,escape rhythm,Asystole,P,P,P,P,P,P,P,P,?,临床表现,症状:,心动过速:心悸,心动过缓:体位性头昏,/,黑曚,/,晕厥,活动性胸闷,/,体力下降,心绞痛,SSS,诊断,典型心电图结合临床症状,Holter,阿托品试验(,2mg iv,15min2000ms,SSS,治疗,1、,观察,2、,起搏器治疗,SSS,心室起搏,房性心律失常,源于窦房结外心房任何部位,见于,60%,得,holter,记录,分类:,1、,房性早搏,2、,房性心动过速,3、,心房扑动,4、,心房颤动,正常心脏兴奋传导,特征:,1、,于,导联可见一提前出现得,P,波,P-R,间期,0、12,秒,2、P,后,QRS,波群正常,3、,其后代偿间歇不完全,房性前期收缩,(,atrial premature beats,),P,Timing of,Expected P,P-SN conduction time,Resetted,SR cycle,SSS?,房性心动过速,连续,3,次得,P,150,200,(,250,)次,/,分,P,可按不同比例下传,RP,大多不等鉴于,SVT,RPPR,多见,房速分类,自律性房性心动过速,折返性房性心动过速,紊乱性房性心动过速,3,种以上形态得,P,100,130,次,/,分,PP,、,RR,不规则,易致房颤,心房扑动,锯齿状,高低一致,频率规律,250,350/min,不同比例下传,典型房扑得折返机制示意,Atrial Flutter,2:1,Conduction,(mon),2:1&3:2,Conduction,1:1,Conduction,(rare but,dangerous),V、rate,140-160,beats/min,Chaotic,rapid,atrial rate at,400-600,beats per min,Focal firing,or,multiple,wavelets,心房颤动,V,1,P,波消失,代之以,“,f,”,波,频率,350-600,次,/min,伴房室结不规则传导,心室律不规则,QRS,室上性,Atrial Fibrillation:Autonomic Modulation of Ventricular Response,Baseline,Immediately after exercise,V1,V5,Regular ventricular rate reflects dissociated,slow junctional escape rhythm,房颤患者心室率变为规则,1,恢复窦性心律,2,三度,AVB,3,房性心动过速,4 Af,AF(,房扑,),伴规则传导,5,交界性或室性心动过速,房颤分类,急性房颤:,24,48h,慢性房颤:阵发性,持续性,永久性,心房颤动得危害,血流动力学,心输出量减少、,CHF,心房血栓形成、栓塞,心房纤颤,/,心房扑动病因,心脏病,高血压心脏病、冠心,、各种心肌病,风心二狭,老年退行性变,甲亢,“,正常人,”,少数,(,孤立性房颤,),家族性,房颤发生率,0、77%,80,岁以上人群达,10%,临床表现,症状,心悸 栓塞,诱发或加重心衰,体征 三个不一致,S1,强弱不一致,快慢不一致,心率脉率不一致(脉搏短绌),心房纤颤得治疗,阵发性房颤(急性房颤,),有血流动力学改变,-,同步电复律,无血流动力学改变,减慢心室率,(洋地黄、,阻滞剂、维拉帕米),复律 药物:奎尼丁、胺碘酮,电复律:同步,射频消融,防,Af,起搏器？,慢性房颤,复律,?,控制心室率抗凝(华法令),?,孰优孰劣？,特征:,1、,提前出现得正常得,QRS,波群,其前面中后有逆行,P,波,P-R0、12,秒,RP,0、20,秒,2、,其后代偿间歇不完全,交界性早搏,(,junction premature beats,),交界性心律的心电图特点,前后无,P,波,1,未传至心房,2,重叠于,QRS,其前有逆,P,其后有逆,P,SA,Node,(+Atria),AV Junction,(=AVN/His Bundle),Ventricles,(=Distal Purkinje System),Intrinsic Rate of Firing,60-100 min,1,40-60 min,1,30-40 min,1,交界性逸搏,交界性逸搏心律,EKG Appearance of Escape Beats,Sinus,Rhythm,Atrial,Junctional,Ventricular,(Retrograde P waves require,intact retrograde AVN cond、),P,P,Narrow,QRS,Wide,QRS,逸搏意义在于潜在起搏作用,无需针对性逸搏节律治疗,非阵发性交界性心动过速,常见于洋地黄中毒,下壁心梗,急性心肌炎,风湿热与心外手术,起始与结束有,warm up cool off,现象,70-150,次,/,分;洋地黄中毒者可心室侧文氏传导,室性心律失常,1、,室性早搏,2、,室性心动过速,3、,心室扑动,4、,心室颤动,心电图特点,1,提前宽大畸形,QRS,无相关,P,波;,2,代偿间歇完全,3,配对间期恒定或不恒定:,单个、成对,多源性、插 入性,Left bundle branch,Left anterior fascicle,Septal fascicle,Left posterior,fascicle,Right bundle branch,His-Purkinje Conduction System,(,AV node,),His bundle,Rule for QRS Width,:,Any electrophysiologic process that,Engenders a departure from synchronous,Activation of the ventricles tends to widen,the QRS,Generation of Narrow QRS plex,(,、10 sec 2、5 little boxes),Intact Purkinje system,assures synchronous,overlapping activation,of right ventricle(RV),and left ventricle(LV),Horizontal,plane with,precordial,leads:,RV,LV,Normal synchronous,overlapping activation,of both ventricles:,On,time,Asynchronous,scenario I:,Late,Head start,On,time,(or late),Asynchronous,scenario II:,QRS,Narrow,Wide,Wide,QRS Width:Synchronous vs、Asynchronous,Ventricular Activation,病因,1,正常人,-,随年龄增长而增加,2,心外因素,药物中毒:洋地黄、抗心律失常药物,电解质紊乱,烟、酒、咖啡,3,心脏因素,-,各种心脏病,冠心、心肌病、风心、二尖瓣脱垂,临床表现,症状,可有可无,1,心悸、头晕、晕厥,2,心绞痛、低血压,体症,听诊:提前长间歇,桡动脉:搏动减弱或消失,室性期前收缩,并 行,折 返,配对间期,不恒定,恒定,长短异位搏动间期,倍数关系,有,无,室性融合波,有,无,插入性早搏,QRS,1,宽大、畸形,类似,LBBB,2,无相关,P,波,V5,正常,右室心律的心电图特点,室性心动过速,(,ventricular tachycardia,),自发得连续三个室性期前收缩称为室速,分非持续室速(发作时间,30,秒,非持续性,形态,单形性,多形性,尖端扭转型,室性心动过速(,ventricular tachycardia,),特征:,1、,为一系列快速、基本整齐得,QRS,波群(频率,150,200,次,/,分),QRS,波群时间,0、12,秒,2、,如见到与,QRS,波群无关得,P,波、或心室夺获或,室性融合波,则诊断明确,图中箭头所示为心室夺获,室性心动过速,(,ventricular tachycardia,),图示一例扩张型心肌病患者发作室性心动过速时得心电图,ORS,波宽大畸形,多形性室速,Torsade de Pointes,鉴别,宽大,QRS,室上性束支阻滞,室上性预激,治疗方法选择得影响因素,1、,基础心脏病,2、,血流动力学改变,3、VT,得类型,多形室速危险度引起缺血与复极异常,室速属恶性心律失常,常引起血液动力学,障碍或致死,需处理,室性心动过速得治疗,原发病治疗,纠正电解质,补钾,补镁,抗心律失常药物,I,类,B/C/A,利多卡因,胺碘酮、,-B,异搏定,电复律,室速预防,抗心律失常药物:奎尼丁,/,胺碘酮,/beta,阻滞剂,/,索她洛尔,手术:切除疤痕,交感神经切除,RFCA,ICD,:室颤史,高危患者,室速有症状不能根治者,室速合并心肌病或离子通道疾病,家族病史且电生理阳性,室扑室颤,为致命性心律失常,临床表现为突然意识丧失,抽搐,呼吸停止甚至死亡,无血压、脉搏,无心音,病因同室速,除颤,ICD,置入,QRS,T,消失，出现形态、高低、频率不一的,Vf,波,QRS,T,消失，出现形态、高低、频率相似的,VF,波,QRS,T,存在,同步电复律,非同步电复律,室上速、房扑、房颤、室速,室颤,电复律与电除颤,阵发性,突发突止,室上性,QRS,窄,P,不明确,心房,交界区,心房交界,心房心室,150-250 bpm,阵发性室上性心动过速,心动过速,阵发性室上性心动过速得心电图,特征:,1、P,波不能明视,2、,快速整齐得,QRS,波群为室上性,频率,160,220,次,/,分,房室结内折返性心动过速,F=,fast,AV,nodal pathway,S=,slow AV,nodal pathway,(His,Bundle),During sinus rhythm,impulses conduct preferentially via the fast pathway,PAC,触发,AVNRT,PAC,房室结双径理象及折返,房室折返性心动过速,AP,Anterogade,conduction,via normal,pathway,Retrograde,conduction,via accessory,pathway(AP),PAC,触发,AVRT,AVN,Ventricles,Atria,AP,PAC=premature atrial,plex(beat),PAC,AVRT,维持,Atria,AP,AVN,Ventricles,Retrograde Ps fall,in the ST segment,with fixed,short RP,Rate 150-250,beats per min,显性旁道示意图,Fusion,activation,of the ventricles,“Delta”Wave,AP,PR 0、20,秒,度,AVB,型房室传导阻滞,特征,:,P-R,间期逐渐延长,直至脱落一个,QRS,波群后,P-R,间期缩短,继之又延长,周而复始,房室传导阶梯图,P,QRS,典型,4:3 AV Wenckebach,现象,Second RR(VV)shortens due to diminution in the increment of AV prolongation,Pause enpassing blocked beat 2 x PP,不典型,Wenckebach,V1,？,型房室传导阻滞,特征,:,P-R,间期固定,P,波呈比例脱落,下传得,QRS,波群正常室上性,特征:,1、P-P,间期相等,R-R,间期相等,2、P,波与,QRS,波群无固定时间关系,(P-R,间期不等,),3、,心房率快于心室率,(P-P,间期,R-R,间期,),4、QRS,波群正常,(,提示心室起搏点在房室交界区,),房室传导阻滞(交界性心律),Pacemaker Hierarchy,(Dominant vs Subsidiary/Escape Pacemakers),SA,Node,(+Atria),AV Junction,(=AVN/His Bundle),Ventricles,(=Distal Purkinje System),Intrinsic Rate of Firing,60-100 min,1,40-60 min,1,30-40 min,1,EKG Appearance of Escape Beats,Sinus,Rhythm,Atrial,Junctional,Ventricular,(Retrograde P waves require,intact retrograde AVN cond、),P,P,Narrow,QRS,Wide,QRS,III AVB,房室分离阶梯图示,Faster atrial rate,Slower ventricular(escape)rhythm,Note that impulses block anterogradely and retrogradely,within the AV conduction system,室性逸搏在,III AVB,中不可靠,P,P,(P),P,P,P,P,P,P,P,P,P,No QRS plexes!,P,P,P,(P),P,15 s,缓慢性心律失常得治疗,病因治疗,药物治疗,1、,阿托品,2、,异丙肾,3、,氨茶碱,4、,糖皮质激素,起搏器,起搏器治疗指征,SSS,2,度,2,型以上,AVB,长,R,R,间期,伴有血流动力学异常得表现,起搏器类型,临时起搏器,永久起搏器,Left bundle branch,Left anterior fascicle,Septal fascicle,Left posterior,fascicle,Right bundle branch,His-Purkinje Conduction System,(,AV node,),His bundle,RBBB,Late,right ventricular,activation,with slow,muscle-to-muscle,conduction,RV is activated,via the left bundle,QRS,或心电图向量形成示意图,Note terminal rightward,delay with QRS widening,(,、12 sec 3 little boxes,with,“plete”RBBB),rSR,pattern,Broad,S wave,Initial,QRS,inscription is,normal,due to,normal LV activation,Note T wave pointing in direction,opposite,to,late rightward ponent(2,repolarization effect),plete RBBB,图形,V1,V6,rsR,plex,Broad,S wave,(Lead I,similar),LBBB,Delayed,left ventricular,activation,with slow,muscle-to-muscle,conduction,LV is activated,via the right bundle,QRS Distortion Induced by LBBB,Broad,monophasic,R wave,Entire QRS dominated by,marked leftward delay,and is wide(,、12 sec,3 little boxes,with,“plete”LBBB),Broad,S wave,Note absence of“septal-q”in V6;andT wave pointing,in direction,opposite,to QRS(2,repolarization effect),Broad,S wave,Broad,R wave,(Lead I,similar),plete LBBB,图形,V1,V6,分支阻滞,额面电轴四象限图,Lead I,Lead AVF,(+),(,),(+),(,),I,AVF,r,S in Lead II for Left Axis deviation,LAFB,1)Initial QRS forces,directed inferiorly,to the right,LV is activated via the,left posterior fascicle,2)Bulk of QRS forces,directed superiorly,to the left,Left Axis,Deviation,(to-45,or beyond),3)Minimal or no,QRS widening,LAFB,心电图,I,II,III,起始向量朝右,(negative in Lead I),朝下,(positive in Leads II and III,rS,rS,qR,之后主向量朝左,(positive in I),朝上,(negative in II and III),LPFB,LV is activated via the,left anterior fascicle,1)Initial QRS forces,directed superiorly,to the left,2)Bulk of QRS forces,directed inferiorly,to the right,Right Axis,Deviation,(beyond,+90,),3)Minimal or no,QRS widening,