Introduksi AritmiaDiagnosis dan Penatalaksanaan aritmia

Peranan EKG

DR., dr., Muhammad Munawar SpJP, FACC, FESC, FSCAI

Divisi Aritmia

Departemen Kardiologi dan Kedokteran Vaskular

FKUI,, Jakarta

Sejarah berkenaan EKG• Einthoven yang pertama merekam EKG pada manusia• EKG saat ini 12 lead, 3 bipolar limb lead, 3 unipolar limb lead, 6

unipolar precordial lead• Holter monitor• Exercise electrocardiography• His bundle electrocardiography• Late potential• Heart rate variability• Interventional electrophysiology

– Device therapy– Catheter ablation

Prinsip EKG permukaan• Rekaman aktivitas listrik jantung, dari SA

node, internodal pathway, otot atrium, AVN, his-P, otot ventrikel

Filosofi EKG

• EKG yang normal, belum tentu jantungnya normal

• Sebaliknya EKG yang abnormal, belum tentu pada jantung yang abnormal

Tujuan merekam EKG

• Analisis morfologi P-QRS-T– hipertrofi atrum (ka dan ki)

– hipertrofi ventrikel (ka dan ki)

– miokardial iskemi dan infark

– intraventricular conduction defect

– gangguan elektrolit

– perikarditis dll

• Analisis aritmia– menganalisis hubungan P dan QRS

– bradikardia

– takikardia

Holter monitoring

• Rekaman EKG dalam periode tertentu (biasanya 24 jam)– Menentukan iskemi– Analisis ada tidaknya aritmia– Analisis sinkope– Evaluasi intervensi

Diagramatic of the mechanisms of SVT and VT

Atrial fibrillation

Atrial flutter

AVRT AVNRT

V Tach

V Fibrillation

SNRT

AT

JT

TACHYCARDIA

AVNRT mechanism

AVNRT

Treatment strategies of AVNRT

PharmacologicalAcute Tx (Adenosine iv, Verapamil iv)Chronic Tx (Verapamil, Betablocker, Digoxin)

Non-pharmacology1980’s sharp dissection or cryosurgical modificationHis bundle ablation using DC shockRadiofrequency catheter ablation

Accessory pathway (AP)Conduction can be antegrade or retrograde

Preexcitation (WPW): antegrade conduction which shows on ECG as delta waveConcealed AP: Retrograde conduction only with normal ECG (no delta wave)

AV Reentrant Tachycardia

Delta wave +Delta wave -Delta wave +

AP

AV Reentrant Tachycardia

Accessory pathwayRight sided AP can be challenging

More area around TV than MV10% of R AP’s have Ebstein’s anomalyMultiple APsAcute angle of attachment of TV annulus

Left sided APs have different challengesUsually easier to achieve stable catheter contactCS catheterApproach (transeptal or retrograde via aorta)

Wolf-Parkinson-White syndrome

•Delta wave•QRS lebar•PR interval pendek•Secondary ST-T wave change

AVRT

Management of AVRT (accessory pathway)

• A. Pharmacological treatment– Acute phase

• AVRT (ortho and antidromic)– Adenosine iv, verapamil iv

• Bystander (AF & access. P)– DC cardioversion + drug, class III

– Digitalis is contraindicated

– Long-term• Verapamil, Digitalis, Diltiazem, Betablockers• Class III

Management of AVRT (accessory pathway) (cont’d) 1

• Non-pharmacological– Surgery, now is very limited– Catheter ablation

• RF energy

• safe and effective

• high success rate

• very low morbidity and mortality

Management of AVRT (accessory pathway)

Atrial fibrillation

Atrial fibrillation and WPW

ATRIAL FIBRILLATION

I

II

III

V1

V2

V6

ATRIAL FLUTTER

II

HAL

MAL

LAL

MPL

LPS

MPS

HPS

MCS

DCS

HAL

MAL

LAL LPS

MPS

HPS

MCS

DCS

Approaches to Treatment Any or all may apply

• Anticoagulation (acute and chronic)

• Ventricular rate control

• Maintenance of sinus rhythm

I

II

III

aVR

aVL

aVF

v1

v2

v3

v4

v5

v6

VENTRICULAR TACHYCARDIA

Torsade de pointes

Ventricular fibrillation

Management Malignant Ventricular arrhythmia

• Pharmacological– Class I– Class III– Class II, Beta blocker

• Non-pharmacological– Surgical arrhythmias– Catheter ablation– Device : AICD

Bradycardia

• Gangguan AV node– Derajat satu– Derajat dua– Derajat tiga

• Gangguan SA node– SA block– SA arrest

• Vasovagal syncope

Gangguan SA node

Blok AV derajat 1

Blok AV derajat 2

Blok AV derajat 3

VVI– Single chamber ventricular pacing

–

VVIR– Single chamber ventricular pacing with rate response

–

AAI– Single chamber atrial pacing

–

AAIR– Single chamber atrial pacing with rate response

–

DDD– Dual chamber pacing with atrial tracking (ie. RR)

–

Kesimpulan

• EKG pemeriksaan yang sangat sederhana, sangat mobile, segera didapatkan hasil dan sangat bermanfaat di bidang kardiologi

• EKG hanya sebagai alat bantu diagnosis

• Sebagian besar aritmia dapat didiagnosis berdasarkan EKG

• Semua dokter umum seyogyanya menguasai EKG