arrhythmia(心律失常)英文版

心律失常cardiacarrhythmia12Historyofelectrocardiogram•ECGwasinventedin1903.EinthovenwasawardedtheNobelPrizein1924forhisgreatcontribution.威廉·爱因托芬WillemEinthoven荷兰生理学家63心脏传导系统Theconductingsystemoftheheart4Theconductingsystemoftheheart5definitionofarrhythmia•心脏冲动的形成（位置、频率、节律）和传导(途径、速度）异常。•Arrhythmiaisanabnormalgeneratingorconductingofimpulse,resultinginanabnormalheartrhythm.6ClassificationofarrhythmiaAbnormalorigin冲动形成异常----sinusarrhythmia窦性心律失常----ectopicrhythm异位心律:passivity—escape逸搏---prematurecontractiontachycardiaflutterandfibrillationAbnormalconduction传导异常----physiologicalblock:----pathologicalblock:S-AB;A-VB;LBBB;RBBB----accessorypathway:pre-excitationsyndrome7心律失常分类classification•冲动形成abnormalimpulsegenerating–窦性心律失常sinusarrythmia–异位心律ectopicrhythm•慢速型－－逸搏escape•快速型－－早搏prematurebeat•正速型－－加速性自主心律acceleratedrhythm•冲动传导abnormalimpulseconducting–传导减慢、阻断、加速–异常途径abnormalpathway8心律失常发生原因（重点）causesofarrhythmia先天性congenital、缺血ischemia、炎症inflamation、药物drugs、外伤injury、机械刺激mechanicalstimulation、电解质紊乱electrolytedisturbance神经体液因素neurohomonalfactors、心肌退行性改变degeneration、特发性idiopathic9快速性心律失常的机制mechanismsoftachyarrhythmias•折返Reentry：解剖学上有折返环（4个条件）突发突止、程序刺激诱发及终止•自律性增高AbnormalAutomaticity：洋地黄中毒、电解质紊乱、炎症、缺血等诱发，心率逐渐升高和降低，程序刺激不能诱发及终止•触发活动：TriggeredActivity洋地黄中毒、电解质紊乱等诱发10Diagnosisofarrhythmia心律失常的诊断•Symptoms症状:syncope(Adams–Stokesattacks),dizziness,palpitation,fatigue•Signs体征:irregularpulseandheartbeat•ECG11DiagnosisofarrhythmiabyECG•常规ECG•运动ExerciseElectrocardiography•动态ambulatoryECG•食管TransesophagealElectrocardiography•心腔内invasiveECG12食管心电图及食道调搏TransesophagealElectrocardiography•心动过速机制初步判断•窦房结、房室结功能测定–SNRT、SACT、房室结文氏点•程序刺激诱发室上速•超速抑制13心腔内电生理检查作用invasivecardiacelectrophysiologicaltesting•同食道电生理检查•希氏束图与传导阻滞AH•心动过速机制HV•不明原因晕厥VT诱发14窦性心律失常Sinusarrhythmia15窦性心动过速SinusTachycardia16FactorsassociatedwithSinusTachycardia•Physiologic生理性ExerciseStrongemotionPainAnxietystates17PathologicfactorsFever，Hyperthyroidism发热甲亢Hemorrhage，Shock出血休克Anemia，Infection贫血，感染Congestiveheartfailure心衰Myocarditis心肌炎Hypoxia缺氧FactorsassociatedwithSinusTachycardia18•Drugs–Epinephrine肾上腺素–Atropine阿托品•Teacoffee•Alcohol•TobaccoFactorsassociatedwithSinusTachycardia19窦性心动过速－－病因（重点）•生理状态：交感兴奋•原发病：发热、甲亢、贫血、休克、缺氧、心衰•药物：肾上腺素、阿托品20窦性心动过速－－鉴别诊断differentialdiagnosis•房速•室上速•房扑21窦性心动过速－－治疗treatment•去除病因eliminatethecauses•必要时使用β受体阻滞剂（甲亢、β受体功能亢进、更年期）22窦性心动过缓SinusBradycardia23SinusBradycardia•Bradycardiaisdefinedasaventricularrateoflessthan60permin,andresultsfromareductionintherateofnormalsinuspacemakeractivity,orfromdisturbancesofatrioventricular(AV)conduction24CommoncausesofsinusbradycardiaPhysiologicbradycardia迷走神经activationofvagusnerve•Laborersandtrainedathletes•Carotidsinuspressure•eyeballpressure•Sleep25SinusBradycardia•Pathologic：SystemicdiseaseObstructivejaundice黄疸Obstructivediseasesoftheintestine,kidneyorbladdermyxedema沾液性水肿myocardialinfarction(inferiorwalloratrialinfarction)心肌梗死highintracranialpressure高颅压26SinusBradycardia•DrugDigitalis洋地黄Morphine吗啡Quinidine奎尼丁Propranolol普奈洛尔27窦性心动过缓－－病因•生理状态：运动员、睡眠•原发病：病窦、缺血、高颅压、甲减、低温•药物：β受体阻滞、钙拮抗剂、抗心律失常药物28窦性心动过缓－－临床表现•无症状型•脑供血不足：头昏、晕厥•心脏供血不足：胸闷、胸痛、心衰、休克29窦性心动过缓－－治疗treatment•生理性和无症状型：不治疗或暂缓physiologicalandnonsymptomatic•原发病治疗：缺血、甲减、药物Eliminatingthecausesofbradycardia30treatment•药物治疗drugtreatment：–抗胆碱药：阿托品atropin–β受体激动agonist：异丙肾上腺素isoproterenol(isoprenaline)•起搏治疗Pacemakertherapy–临时起搏Temporaryventricularpacing–永久起搏Permanentpacemakerimplantation31pacemaker32起搏类型AAI、VVI、DDD33VVI起搏心电图34窦性停搏Sinusarrest•病因：同窦缓•临床表现：黑蒙、意识丧失、抽搐•治疗：同窦缓35窦房传导阻滞•病因、临床表现和治疗：同窦缓36窦房传导阻滞－－鉴别诊断•房性早搏未下传•窦性心律不齐37病态窦房结综合征SickSinusSyndrome(SSS)由于窦房结功能减退导致以长期心动过缓为主，可合并多种房性快速型心律失常的综合表现。38病态窦房结综合征－病因causesofSSS•退行性改变degenerativedisease•慢性缺血chronicischemia•炎症后遗症lingeringeffectsofinflamation39病态窦房结综合征－临床表现•心动过缓：头昏、胸闷•窦性停搏：黑蒙、意识丧失、抽搐•心动过速：心悸、心绞痛、心衰心动过缓－心动过速综合征40病态窦房结综合征－心电图表现SickSinusSyndrome(SSS)主要表现：窦缓Sinusbradycardia(HR50/min);、窦停Sinusarrest、交界性逸搏、窦房阻滞SAblock次要表现：房速Atrialtachycardia、房扑AtrialFlutter、房颤Atrialfibrillation、房室传导阻滞AVblock41窦房结功能测定（重点）•固有心率测定•阿托品试验（＜90次）•窦房结恢复时间测定•窦房传导时间测定•24小时最慢心率（＜40次）•24小时最长R－R间期（＞3秒）42病态窦房结综合征－鉴别诊断differentialdiagnosis•无症状的窦性心动过缓•迷走神经张力增高•可逆性窦缓：急性心梗、药物43病态窦房结综合征－治疗•药物治疗：抗胆碱药、β受体激动•起搏治疗：永久起搏•快速心律失常治疗：起搏以后转律和预防快速心律失常44病窦起搏治疗PacemakertherapyofSSS•提高心率（单腔、双腔起搏）•预防房颤（双房起搏）•便于应用抗心律失常药物45房性早搏atrialprematurebeats•见于正常人及各种器质性心脏病、甲亢46房性早搏atrialprematurebeats•临床表现：心律不齐，脉搏不齐47房性早搏－－鉴别诊断differentialdiagnosis•伴差异传导者－－室性早搏•房早未下传者－－窦停、窦房阻滞48房性早搏－－治疗•原发病治疗•无原发病者无需治疗•频发早搏症状明显者：胺碘酮、钙拮抗剂、β阻滞剂、普罗帕酮49房性心动过速＞＝3个房性早搏atrialtachycardia•洋地黄中毒、电解质紊乱、心肌炎、甲亢、各种器质性心脏病•特发性房性心动过速－－病因（重点）50房性心动过速－－分类•自律性房速•折返性房速•紊乱性房速治疗51房速治疗•去除诱因及原发病：洋地黄中毒、电解质紊乱、心肌炎、甲亢•短暂性发作：不治疗•持续性发作–药物治疗：同房颤–射频消融（单起源点）52心房扑动AtrialFlutter•机制：大折返环Atrialflutteriscausedbyamacrore-entrantcircuitintheatrium,whichproducesatypicalelectrocardiographic'sawtooth'patternofatrialactivitywitharatecloseto300/min.53macrore-entrantcircuitintheatrium54心房扑动AtrialFlutter5556心房扑动－－病因•原发性（特发性）：查不到病因•继发性：–各种器质性心脏病–继发性心脏病–心房扩大心房扑动常发展为房颤57心房扑动－－临床表现•视诊：可能见到快速颈静脉扑动•心律：可以整齐或不整齐•听诊：可能听到心房音•心律正常者：易漏诊58心房扑动－－鉴别诊断•窦速•室上速59心房扑动－－治疗•同阵发性房颤