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Simptome:
datorate DC
datorate stazei
pulmonare
periferice
Semne
de DC
de staz
RVOT
HRA
HBE
CS
Tahicardia sinusala
Extrasistolia atriala
!
!
!
!
!
!
!
!
!
"
" Conducere
" Conducere
V1
D1
V2
D2
V3
D3
aVR
V4
aVL
V5
aVF
V6
Tratamentul TRNAV
AHV
A
A
A H V
A
A
H
H
V
V
A
H
V
H
A H
A H
Sdr. de preexcitatie
asimptomatica
simptomatica
Preexcitatie permanenta
Efectul de acordeon :
unda delta de durata variabila
TRAV cu conducere
antidromica
" tahiaritmie regulata cu QRS largi prin
prezenta undei delta
" raspuns ventricular rapid > 180-200/min
" mecanism:
" Conducere anterograda pe calea accesorie
" Conducere retrograda prin NAV
!Tahiaritmie
250 ms)
A H
RF
Flutter-ul atrial
Caracterele FlA
Tratament
RA
T
LA
M
Tratament:
in BPOC = O2
P -/0 in aVL si + in V1
Da
Nu
Focar AD
Focar AS
P in V180 ms focare
P in D150 V
nonPV
PVs stangi
P in aVR
P
D2,3 aVF
Nu
Inel tricuspidian
Sept i-a
Tahicardii
cristale
PVs drepte
P in D2 100 V
Da
P+
D2,3 aVF
infero-lateral supero-lateral
P sau
in 3 deriv
V2-6
P + in V5,6
durata P in
SVT < RS
anular
superior
septal
Fibrilatia atriala
Epidemiologia FA
Etiologia FA
FA depistata prima
Clasificare
PERSISTENTA
(ne-autolimitata)
PAROXISTICA
(autolimitata)
PERMANENTA
First diagnosed episode of atrial fibrillation
Paroxysmal
(usually <48 h)
Persistent
Long-standing
Persistent (>1 year)
Permanent
(accepted)
ESC Practice Guidelines. EHJ 2010
Fiziopatologie
Permanent
Substrat
Paroxistic
Trigger
Page 9 of 6
,,Perpetuatori
first documented
Rate control
Antiarrhythmic drugs
Ablation
Cardioversion
AF
silent
paroxysmal
persistent
long-standing permanent
persistent
Paroxistic
Persistent
Permanent
Durata
CONVERSIA LA RS
REDUCEREA AV
PROFILAXIA EMBOLIILOR
SISTEMICE
R.V. - Tahiaritmii feb 2012
Conversia la RS
than AF.
Drug
Dose
Follow-up dose
Amiodarone
50 mg/h
P
A
Flecainide
N/A
N
d
in
d
v
Ibutilide
1 mg i.v. over
10 min
C
p
W
Propafenone
Vernakalant
N
d
t
v
c
Second infusion of 2 mg/kg i.v.
over 10 min after15 min rest
Vernakalant has recently been recommended for approval by the European Medicines Agency for rapid car
non-surgical patients; 3 days for surgical patients).68,69 A direct comparison with amiodarone in the AVR
Active-controlled, multi-center, superiority study of Vernakalant injection versus amiodarone in subjects with
amiodarone for the rapid conversion of AF to sinus rhythm (51.7% vs. 5.7% at 90 min after the start of treatm
over 10 min), followed by 15 min of observation and a further i.v. infusion (2 mg/kg over 10 min), if necess
pressure ,100 mm Hg, severe aortic stenosis, heart failure (class NYHA III and IV), ACS within the previo
should be adequately hydrated. ECG and haemodynamic monitoring should be used, and the infusion can b
R.V.heart
- Tahiaritmii
feb
2012
patients with stable coronary artery disease, hypertensive
disease, or mild
heart
failure. The clinical pos
!
!
cardiaca congestiva: 1 pt
" Hipertensiune:
" Varsta:
1 pt
" Diabet:
1 pt
" AVC
1 pt
sau AIT: 2 pt
Rockson SG, Albers GW. JACC 2004;43:929.
Age 6574
1
Vascular disease
sk factors.OAC
(b) comes
Risk factor-based
approachpublished
expressed asanaa point based
Sex category (i.e. female sex)
1
pproach
from various
scoring system, with the acronym CHA2DS2-VASc
tients
at maximum
moderate
defined
Maximum score
9
(Note:
score isrisk
9 since(currently
age may contribute
0, 1, or 2 points)
1, i.e.
risk factor) still derive significant Score
Riskone
factor
(c) Adjusted stroke rate according to CHA2DS2-VASc score
OAC
(or aspirin)
overCongestive
aspirinheart
use,failure/LV
oftendysfunction
with low rates of 1
CHA2DS2-VASc
Patients (n = 7329)
Adjusted stroke
Nothing (or aspirin)
Importantly,
prescription
of
an
antiplatelet
score
Hypertension
1
rate (%/year)b
iatedAgewith
>75 a lower risk of adverse events. 2
0
1
0%
score
does
not include many stroke risk 1
Diabetes
mellitus
e prevention in AF. AF atrial fibrillation; OAC oral anticoagulant;
1
422
1.3%
roke
risk
need to be considered 2
Stroke/TIA/thrombo-embolism
be found
on modifiers
page 13.
2
1230
2.2%
trokeVascular
risk disease
assessment
(Table 8).
a
1
ors Age
(previously
referred to as high risk 1
3
1730
3.2%
6574
troke
TIA,(i.e.
or
thrombo-embolism,
and the
Table
10
Clinical
characteristics comprising
Sexor
category
female
sex)
1
4
1718
4.0%
bleeding
risk
score
s). HAS-BLED
The
presence
of
some
types
of
valvular
Maximum score
9
5
1159
6.7%
stenosis
or
prosthetic
heart
valves)
would
(c) Adjusted stroke rate according
to CHA2DS2-VASc score
Letter
Clinical characteristica
Points awarded
6
679
9.8%
valvular
AF
patients
as
high
risk.
CHA2DS
-VASc
Patients
(n
=
7329)
Adjusted stroke
2
HscoreHypertension
1
rate (%/year)b
ant non-major
risk factors (previously
7
294
9.6%
Abnormal renal and liver
A factors)
1 or 2 0%
rate risk
[especially
0 function (1are
1
8
82
6.7%
pointheart
each) failure
systolic SLV1 Stroke
dysfunction, defined
422 arbitrarily 1as 1.3%
9
14
15.2%
on fraction
(LVEF) 40%],1230
hypertension, or
B 2 Bleeding
1 2.2%
cally relevant
risk
L 3 Labilenon-major
INRs
1 3.2%
1730 factors (preSee text for definitions.
a
s less validated
riskagefactors)
include
female
E 4 Elderly (e.g.
>65 years)
1
1718
4.0%
Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates
of stroke in contemporary cohorts may vary from these estimates.
and vascular
disease
(specifically,
D 5 Drugs
or alcohol
(1 point
each) myocardial
1 or 2 6.7%
1159
b
Based on Lip et al. 53
ortic plaque
and
PAD).
Note
that
risk
factors
Maximum
9 points
6
679
9.8%
AF atrial fibrillation; EF ejection fraction (as documented by
he simultaneous presence of two or more
echocardiography, radionuclide ventriculography, cardiac catheterization, cardiac
7
294
9.6%
a
Hypertension is defined as systolic blood pressure .160 mmHg. Abnormal magnetic resonance imaging, etc.); LV left ventricular;
n-major risk factors would justify a stroke
kidney function
is defined as the presence
8
82 of chronic dialysis or renal
6.7%
TIA transient ischaemic attack.
gh transplantation
to requireoranticoagulation.
serum creatinine 200 mmol/L. Abnormal liver function is
R.V. - Tahiaritmii feb 2012
a
14
15.2%
Indicatorii riscului
Tratament
Risc scazut
varsta 65 ani
fara FR aditionali
Intermediar
DZ
sau ASA
B coronara
Inalt
Terapia ablativ
PVI
PVp
PVp
PVp
TAHIARITMIILE
VENTRICULARE
Tahiaritmii cu QRS larg
Extrasistolele ventriculare
Clasificare si semnificatie
clinica
Tratamentul ESV
Studiul CAST-I:
Mecanismele TV
TV monomorfa sustinuta
TV monomorfa: diagnostic
tahiaritmie regulata >
120/
QRS larg > 120 msec
Disociatie AV
Batai de fuziune
Capturi ventriculare
R.V. - Tahiaritmii feb 2012
Criterii morfologice
Tahicardia ventriculara
neparoxistica (RIVA) =
AUTOMATISM CRESCUT
Tratament TV
Tratamentul profilactic al TV
Fibrilatia
ventriculara
Unde fibrilatorii de amplitudine diferita, in absenta
complexelor QRS
Asistola mecanica urmata de asistola electrica
Colaps, stop respirator si deces in 3-5 minute de la
instalare in absenta CPR
Cauze:
Ischemia acuta din IMA
aritmii V spontane
severe
Cardiomiopatii (CMHO !)
FA din WPW
CHT cu HVS
hipoxia din BPOC
Iatrogen: medicamente, diselectrolitemii, cateterism cardiac
Sdr. de QT lung cu TdP
SEE nesincron
Precedata sau nu de TV
Tratament:
R.V. - Tahiaritmii feb 2012
III
CMH
CAVD
LQT
Brugada
SQT
R.V. - Tahiaritmii feb 2012
51%
73%
Control
54%
ICD
39%
20%
38%
20
36%
31%
41%
23%
10
0
Prevenie secundar
Prevenie primar
RMVT Gallavardin
Caracteristici
70% din VT idiopatice
Origine
90-85% RV
septul RVOT
zona de admisie
rdcina a.P.
mecanisme
denervri simpatice localizate
alterri localizate ale recaptrii
NA# $catech sinaptice i
% rec
20-30Y, XXXY, >anduran
asimtomatici / discret (dup efort)
palpitaii
vertij discret
sincopa excepional
ECG
TV 140-180/min
BRS cu ax inferior
tranziia (>precoce = >septal/stg)
EPS - PDT
induse de burst/catech
oprite de A, V, B
Evoluie
benign la majoritatea
MSC rar
tachyCMP
forma malign (short-coupled)
ARVC/D
risc$
sincop
AV f. rapid (>230bpm)
frecvente (>20 000/zi)
ESV cu cuplaj foarte scurt
R.V. - Tahiaritmii feb 2012
TV fascicular Belhassen
20-40 ani
rspunde la V
nu depinde de efort
simtomatic (rar sincop)
evoluie
benign
rar MSC
excepional tachyCMP
ECG
BRD cu ax sup. >> ax inferior
EPS
indus de programat
entrainment
isuprel NU induce (poate fi util
asociat cu pacingul)
Tratament:
V B
ablaia
LQT
Genetica LQT
SQT
tip 1: $-fx HERG/KCNH2, IKr
tip 2: $-fx KVLQT1/KCNQ1, IKs
tip 3: $-fx KCNJ2/Kir2.1, IK1; ECG caracteristic
unde T ample i marcat asimetrice
ram ascendent cvasinormal
ram descendent extrem de abrupt
Sd. Brugada
FV idiopatic
sd. de repolarizare precoce malign
ARVC/D
Manifestri clinice
vrsta medie 30y (10-50)
simptome
MSC
n timpul activitilor de rutin
10% perioperator
3,5% sport
sincopa 32%
palpitaii 67%
dureri toracice atipice 27%
dispnee 11%
IC dr. tardiv 6%
asimptomatici descop. ntpltor
ECG
ESV/TVNS Holter/ECG de efort
Aritmiile V
% cu severitatea bolii
de obicei simptomatice
ESV#TV susinute
morfologie BRS
ax inf#RVOT
ax sup
QS n toate precordialele (m.a.V3,4) #
apex VD
ax inf, QS <V4 # subtricuspidian
Aritmii SV
# 25%
FA / TA (macroreinrari AD) / FL.A
ECG
ECG
40-50% au ECG normal
initial, n 6 ani TOI au
ECG
QRS largit >110 ms (24-75%)
BRD incomplet
ECG evolutive
$ pantei S cu >10 ms #69%
$QRS cu >10 ms #66%
extensia T ,,-
1 deriv precord
Localizare
Boulos M. et al.
J Am Coll Cardiol 2001