Arrhythmia

today we are going to talk about Arrhythmia what is arrhythmia ? Arrhythmia is an abnormality in the conductivity of the conductive system of the heart. But what is the conductive system of the heart? The conductive system of the heart is that system which conduct the impulse that initiated in the SA nod to every part of the heart via inter nodal pathway , AV nod , bundle of His , left and right bundle branches and Purkinje fibers .

The impulse should be initiated in the SA nod but if the impulse is initiated elsewhere in the heart it's called ectopic beat (its abnormal) . But is it possible for the impulse to be initiated from another part of the heart ? the answer is yes , because the tissue of the heart is excitable tissue (remember from physiology that there are three kind of excitable tissue : neurons , muscles and endocrine ) .

Ectopic beat : when the impulse initiated elsewhere than SA nod and make abnormal beat .
Causes of ectopic beat are 1- Local area of ischemia 2- Small calcified plaques in the heart We will talk about it later .

In the conductive system there is something we call the refractory period which is period of time come after each action potential and the heart muscles can't be excited through it because of inactivation of fast sodium channel . absolute: the cells can't be exited Refractory period Relative : the cells can be exited Under strong stimuli Causes of cardiac arrhythmias 1- Abnormal rhythmicity of the pacemaker ( SA nod ) or the action potential is not initiated there , and for those patients they do artificial implantation of the pacemaker . 2- Shift of the pacemaker from the sinus node to another place of the heart . That mean that the action potential initiated in AV nod or purkinje fibers but it will affect the heart rate (for example if its initiated in the AV nod the heart rate would be 45 ) . 3- Blocks of different points in the spread of the impulse through the heart which mean no more conductivity . 4- Abnormal pathways of impulse transmission through the heart . 5- Spontaneous generation of spurious impulses in almost any part of the heart(ex is fibrillation) We use ECG which indicate the state of the heart and any abnormality if there is via 12 lead (limb lead ( 1, 2, 3 ,AVR ,AVL and AVF ) and chest lead ( v1 , v2 , v3 , v4 , v5 and v6) each lead reflects specific region of the heart .

The arrhythmia has to do with the intervals : QRS (0.08 sec) , PR (0.18 sec) and QT (0.40 sec) , ST (0.32sec) " you should know these numbers by heart " .

Heart block :
That mean a block in the conductive system which subdivided into several parts I. Block at the level of AV node: A- first degree heart block : every atrial depolarization is followed by conduction to ventricle but delayed . ECG changes prolongation of PR interval to more than 0.22 second but with regular rhythm .

B. Second degree heart block: some P waves conducted but other not(every 2 or 3 P/ QRS/ T waves there is missed QRS ). ECG changes and give two P waves which indicate two atrial contraction .

C. Third degree heart block (complete heart block): Rate: Atrial: 60100 bpm; ventricular: 4060 bpm Rhythm: Usually regular, but atria and ventricles act independently (each one contract with different rate , SA nod is the pace maker of atria and Av nod is the pace maker of the ventricle ) .

Caused by: ischemia , Acute myocardial infarction, calcify aortic stenosis, cardiomyopathy, drugs (Digoxin) .. all these can cause other types of arrhythmia .

2-Block below AV node:

A. block at Bundle of His B. Block at the branches (Right or Left branch which will effect ventricles )

Sinus rhythm:
It is caused by the changes of number of impulses emitted from SA node. Heart rates more than 100/min is called (tachycardia), while less than 60/min is called (bradycardia). Tachycardia could be 1-physiological ex ( exercise , sympathetic stimulation ) 2-pathological ex ( hyperthyroidism , acute heart failure ) Reflex tachycardia : defect in the circulation that effect and increase the heart rate ex (anemia) which considered physiological tachycardia cased by pathological state or defect of circulation (we consider it a physiological because the defect wasnt in the heart itself ) . The ECG of tachycardia

Bradycardia could be physiological ex ( athletes (cardiomegaly) ) pathological ex (heart failure)

The ECG of Bradycardia

Fibrillation :
Which is very dangerous abnormality of the heart that manly occur due to re-entry movement or circus movement ( in multi-foci (many-places ) action potential is initiated) of the action potential . Normally the action potential take one-way ( laminar flow ) not circular . And what happens is that many areas are being contracted and other areas could stay relaxed . The main causes of fibrillation are 1-strong electrical shock 2- sever ischemic heart disease

There is atrial fibrillation and ventricular one but the ventricular is more dangerous because the cardiac output is extremely low which may lead to death. The VF ( ventricular fibrillation ) is the most cause of sudden death of MI ( myocardial infarction) patients . The ECG shape is " bag of worms " ( look like net-work of capillary ). In the emergency we have DC-shock that shock the patient with 50-200 jol in order to treat the fibrillation if it was life threatening by preventing re-entry of action potential . but if we were in street or other place that we dont have DC-shock and the heart stop working we hit the patient forcefully in his chest . The main causes of re-entry 1- Long pathway around the circle 2- Decreased velocity of conduction

3- Shortened refractory period of the muscle

premature beat or ectopic beat

1-premature atrial contraction : The P wave occur too soon in the heart cycle and the QRS is extremely shortened.

2- premature ventricular contraction : Bizarrely shaped , prolonged and high voltage QRS complex The P wave is usually buried in the QRS of the extra-systole The T wave has an electrical potential polarity opposite to the QRS

Ventricular tachy-arrhythmia:
The most important thing here is the shape of ECG is bizarrely ( odd ) .

Remember , in this case cardiac output is decreased

********* Anti-arrhythmic drugs - blocker and calcium or sodium channels blockers .

Very important to know about Digoxin toxicity which we talked about last lecture

Form wiki
Digoxin is widely used in the treatment of various heart conditions, namely atrial fibrillation, atrial flutter and sometimes heart failure. Action of Digoxin It has mechanical effects as it increases myocardial contractility, however, the duration of the contractile response is just slightly increased. Overall, the heart rate is decreased, while blood pressure increases as the stroke volume is increased increase in action potential, followed by a decrease as the K+ conductance increases due to an increased intracellular amounts of Ca 2+ ions. The refractory period of the atria and ventricles is decreased. Digoxin toxicity: is a poisoning that occurs when excess doses of digoxin are consumed acutely or over an extended period. The classic features of digoxin toxicity are nonspecific: fatigue, blurred vision, change in color vision, nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, confusion, delirium.

PS : According to DR , dont study the drugs of CVS from slides .. he put all the drugs of all the CVS disorders in one folder .

Mn el end
Done by : Yanal Althaher Suliman AlQaralleh