Cardiac Rhythm and Related

Disorders
Marshell Tendean, MD

Department of Internal Medicine

UKRIDA Jakarta
 Objective :
• To understand physiology of heart rhythm
• To understand patophysiology of rhythm
disorders
• Know some tachy-arrhytmias and the
treatment approach
• Know some bradi-arrhytmias and the
treatment approach
Normal Heart conduction :
Normal conduction pathway
Clinical symptoms suggest arrhytmias :

• Syncopal attack
• Fatigue
• Tachycardia
• Frog sign
• Chest pain
• Seizure
• Hypotension
 Ancilary procedures :
• Holter monitoring
• Stress test
• EP study
Action potentials of the Heart
• Electrolyce disorders
mainly Involve
the heart rhythm
 Arrhytmia mechanism :
• Impulse initiation :
– Automaticity :
• Tachycardia and bradyardia
– Trigered activity (phase 3 or 4):
• EAD
• DAD
• Conduction disorders :
– Reentry :
• Microreentrant
• Macroreentrant
• Acessory pathway
• Automaticity :
– If, ICa-L, ICa-T, IK, IK1
– Suppression/acceleration of phase 4
– Sinus bradycardia, sinus tachycardia

• Triggered automaticity
– Calcium overload, ITI
DADs Digitalis toxicity, reperfusion VT
– ICa-L, IK, INa
EADs Torsades des pointes, congenital and acquired
• Pathomechanism of reentry
• Most common mechanism of arrhytmia
 Reentry :
• Unifocal.
• Multifocal “multifocal VT”.
• Microreentrant :
– Most of cardiac arrhytmias :
• SVT, AF
• Marcroreentrant :
– Atrial fluter “ sawtooth appearance”
• Acessory pathway :
– WPW sydrome “ delta wave”
Atrial tachycardias Ventricular
tachycardias
•SVT / AVNRT •Monomorfic
•Atrial fibrilation ventricular
•Atrial Flutter tachycardias
•Multifocal atrial •Polymorfic
tachycardias ventricular
tachycardias
 Management :
• Specific to the current abnormalities
– AVNRT / SVT
• Digoxin, verapamile, diltiazem, adenosine
– MAT :
• Digoxin
– AF / A flu :
• Rate control
• Rhythm control
• Anticoagulation
– VT
• Anti arrhytmic agent : “ amiodarone”
• Magnesium sulfate
 Use of specific anti arrhytmias :
• Most of anti arrhytmic agents are
proarrhytmics
• Limited to documented structural heart
disease
• Limited to sustained ventricular tacycardias
Intravenous anti arrhytmics commonly
used
Intravenous anti arrhytmics commonly
used
 Latest anti arrhytmias :
• Ivabradine, a “ funy channel inhibitor”
• Used in patients with enchanced automaticity
disorders.
• Treatment range 5 – 30 mg
• Safe and limited side effects
Treatment spesific for arrhytmias :
• SVT
• AF
• Atrial Flutter
Special inherited diseases related with
malignant arrhytmias :
• Brugada syndrome SCN5A INa channel

• Catecholaminergic VT Ry R2 Ryanodine receptor,

calsequestrin receptor

• LQT1 KCNQ1 Iks channel subunit

• LQT2 KCNH2 (HERG) IKr channel subunit
• LQT3 SCN5A INA channel subunit
• LQT4 ANK2 Ankyrin-B LQT5 KCNE1 IKs channel subunit
• LQT6 KCNE2 IKr channel subunit
• LQT7 KCNJ2 IK1 channel subunit
• LQT8 CACNA1C ICa channel subunit
• Patients can manifest bidirectional VT,
nonsustained polymorphic VT, or recurrent VF
• Triggered by stress
 Brugada syndrome
• ST segment elevation in V1 to V3 that typically
can be provoked with the sodium channel-
blocking drugs ajmaline, flecainide, and
procainamide and a risk of polymorphic
ventricular arrhythmias
 Specific treatment :
• ICD implantation.
 Bradyarrhytmias :
– Extrinsic :
• Autonomic
• Drugs
• Hypothyroidism
• Hypotermia
• Vagal manouvers
• Increase ICP
– Intrinsic
• Sick sinus syndrome
• CAD
• Inflamatory
• Familial
• AV node disease • Vasovagal incopetence
– CAD evaluation :
– Vasovagal – Intrinsic (unresponsive
– Drug related with atropine or stress)
– Infectious – Extrinsic (responsive
with atropine or stress)
– Congenital
– Inflamatory
– Infiltrative
– Neoplastic
– Degenerative
 Permanent pacemaker (Class I
recommendation) :

• Indicated in Symptomatic AV block

• Inicated in Assymptomatic 3rd degree and 2nd
degree type 2 AV block.
• Periods of asystole >3 s or any escape rate <40
beats/min while awake
• Atrial fibrillation with bradycardia and pauses
>5s
 Pacemaker mnemonics’:
• The first letter indicates the chamber(s) that is paced (O,
none; A, atrium; V, ventricle; D, dual; S, single).
• The second is the chamber(s) in which sensing occurs (O,
none; A, atrium; V, ventricle; D, dual; S, single),
• The third is the response to a sensed event (O, none; I,
inhibition; T, triggered; D, inhibition + triggered)
 Pacemaker
• Transcutaneous
• Transvenous
• Permanent
• The fourth refers to the programmability or rate response (R,
rate responsive)
• The fifth refers to the existence of antitachycardia functions if
present (O, none; P, antitachycardia pacing; S, shock; D, pace +
shock).
• Almost all modern pacemakers are
multiprogrammable and have the capability
for rate responsiveness using one of several
rate sensors: activity or motion, minute
ventilation, or QT interval.
• The most commonly programmed modes of
implanted single- and dual-chamber
pacemakers are VVIR and DDDR,