Partea I.

Sistemul cardiovascular

qRs qR R bifid rSR QS QS bifid

Figura 31. Tipuri de complex QRS. Primele douà exemple sunt liziologice, urmätoarele, patologice

4.6.1. Caracteristici ale complexului QRS

Forma QRS este de tip rS în deriva ile V1-V2, raportul amplitudinii undelor r i S
fiind subunitar (R/S < 1), _i de tip qRs în V5, V6, unde raportul amplitudinii undelor R i s
este supraunitar (R/S > ).

Axa QRS reprezint vectorul rezultant al activärii ventriculare în plan frontal; este
numit i axa electric a inimi. Fiziologic este cuprins între -30° i +90°.

Durata complexului QRS fiziologic este mai mic de 0,11 s, fiind msuratîn
derivaia cu cel mai larg complex. Dac dep_e_te aceast limit, conducerea ventricular pe
calea fiziologic este len ori blocat (bloc de ram), sau depolarizarea ventricular este
iniiat în miocardul ventricular (extrasistole ventriculare) i transmiterea PA se face numai

prin fibre de lucru, i nu prin reteaua Purkinje. Deflexiunea intrinsecoid estimeaz durata
propagrii transmurale a PA în dreptul electrodului pozitiv al unei derivaii precordiale (V1,
V2 pentru VD; V5, V6 pentru VS). Se determin de la vârful ultimei unde R pån la punctul
de debut al complexului QRS. Valorile normale ale dellexiunii intrinsecoide sunt: < 0,035 s

in VI, V2 _i < 0,045 s în V5, V6.

QRS DI DI

Figura 32. Deteminarea deflexiunii intrinsecoide (DI).

Ampliudinea QRS se determin insumánd algebrie amplitudinile undelor

componente, pentru undele Q i S folosindu-se semnul algebric minus _i pentru unda R,
semnul plus. Fiziologic este mai mare de I mV intr-una dintre derivaiile precordiale, _i mai
mare de 0,5 mV intr-o derivaie standard. Amplitudinea undelor R i S este important pentru
diagnosticul hipertrofiei ventriculare.

47
 Partea 1. Sistemul cardiovascular

6.2. Tulburrile de conducere

Reprezint una din cauzele majore de producere a aritmiilor. Presupun perturbarca
transmiterii fiziologice a potenialului de actiune, cu modificarea traseului _i/sau a vitezei de
conducere prin miocard.

6.2.1. Tulbur ri de conducere atrioventriculare

Tulbur ri de conducere atrioventriculare includ blocurile de conducere i conducerea

aberant (fascicule de conducere accesorii).

Blocurile atrioventriculare pot fi incomplete (de gradul I sau 2) sau complete (bloc
AV de grad 3).
Blocul arioventricular de gradul I este caracterizat de o întârziere a transmiterii

tonus vagal
potenialuli de aciune nodul atrioventricular, care poate fi cauzat de:
prin
diselectrolitemii,
crescut, ischemie, medicamente (beta-blocante, calciu-blocante, digitalä),
PR la mai mult
modific ri fibrotice la acest nivel. Pe ECG se remarc alungirea intervalului
de 0.20 secunde; ritmul este regulat, iar restul criteriilor ritmului sinusal sunt respectate.

PR] alungit
1 alungirea intervalului PR > 0.20 secunde.
ECG de bloc atrioventricular de gradul cu
Figura 47. Aspecte

2 poate fi de tip Mobitz I sau Mobitz II. Blocul

Blocul atrioventricular de gradul
atrioventricular de gradul 2 Mobitz I se caracterizeaz prin apariia perioadelorLuciani
cu fiecare ciclu cardiac pân
Wenckebach: conducerea prin NAV se prelunge_te progresiv
impulsul electric nemaifiind transmis la ventriculi, dup
care
când o und Peste blocat,
ciclul se reia. Pe ECG, ritmul are neregularitate
o "regulat", ciclic; undele P sunt normale:
cu fiecare ciclu, pâna când o und P nu mai este urmat
intervalul PR se alunge_te progresiv
a 4-a sau a n-a und P), apoi aceea_i secvena se repet, cu
de un complex QRS (fiecare 3,
a

complexele QRS sunt normale.

primul P-R de durat normal;

63
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6.2. Estimarea performantei cardiace

6.2.1. Indici care caracterizeaz funcia sistolic ventriculará
Se pot grupa in urnmåtoarele
categorii: a. indici care evalueaz functia de pomp a
inimii _i care nu sunt dependeni doar de contractilitate, ci _i de presarcina sau postsarc1na -
acestea din urmà pul id fi intluenate spre exemplu, de statusul hemodinamic (nivelul
intoarcerii venoase, sau presiunea din arborele circulator), de integritatea anatomo-
functional a aparatului valvular, sau de integritatea sacului pericardic; b. indici care
evalueaz funcia contractil (intrinsec) a miocardului - comparativ cu indicii de pomp,
estimeaz inotropismul cu o acuratete mai mare, dar nu sunt ni_te indicatori absolui, putánd
fi influenai iîntr-o oarecare msur de variaiile presarcinii su postsarcinii; c. indici cu
caracter dual (în unele cazuri estimeaz functia de pomp, în altele contractilitatea); d. indici
sistolici ai poligrafiei indirecte care estimeaz funcia de pompä, säu contractilitatea. Din
acelea_i considerente care stau la baza clasificri de mai sus, nu existã o sinonimie între
insuficiena miocardic i insuficienta cardiac, prima find cauzat strict de o alterare a
contractilitajii miocardice, în timp ce a doua se poate datora fie unei alterri a funciei
contractile, fie unor factori mecanici (ex. barajul valvular determinat de stenoza aortic
severä), fie asocierii acestor condiii.

6.2.1.1. Indici care evalueaz functia de pomp

Debiul cardiac (Indexul cardiac), este un indice global al funeiei ventriculare, care
reflect activitatea întregului sistem ,inim - vase sânge". Prin raportare la frecvena
cardiac, se obine volumul btaie (indexul sistolic).
Lucrul mecanic sistolic al inimii reprezint aria de sub curba,,volum-presiune" de pe

parcursul sistolei. Se folose_te îns mai frecvent Indexul lucrului btaie al VS; dac lucrul
mecanic sistolic se raporteaz la VTD, se obtine un indice foarte valoros, indicele de
contractilitate al VS, care a_a cum îi spune numele, este un indicator de evaluare a functiei

inotrope).
unde P presiunea intracavitara a sângelui, r
Stresul parietal sistolic (o P. r/ 2h,
-
-

ventriculului), reprezint forta de întindere din

raza camerei ventriculare, h - grosimea
(dependent deci de tensiunea
peretele ventricular, ce acioneaz pe unitatea de suprata
direct proporionalitate postsarcina. Stresul parietal se
parietala). Reflect într-o relaie de
intra impreun cu ali parametri într-un algoritm
poate calcula (procedeu laborios) _i poate
suferind prezint un deficit al funciei de pomp
diagnostic pentru a stabili dac o inim
sau al functiei inotrope.

111
 cardiovascular
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