Diagnosis dan

Tatalaksana Aritmia di
Layanan Primer
Dr. Ika Prasetya Wijaya, Sp.PD-KKV, FINASIM, FICA, FACP

Divisi Kardiologi, Departemen Ilmu Penyakit Dalam

RS. Pusat Nasional Cipto Mangunkusumo – Fakultas Kedokteran, Universitas Indonesia
Aritmia berdasarkan HR
 Bradiaritmia  Takiaritmia
 Sick sinus syndrome  Supraventricular
 Blok nodus AV derajat I – takikardi
III  Atrial fibrilasi
 LBBB  Atrial flutter
 RBBB  Ventrikular takikardia
 Monomorphic
 Polimorphic
 Ventrikular fibrilasi
Bradiaritmia
Sick Sinus Syndrome

 Conduction problem with no junctional escape during sinus pause

 Diagnose with ECG or Holter. If inconclusive, need electrophysiological

testing.

 If asymptomatic, leave alone. If symptomatic, needs pacemaker.

First Degree AV Block

 Delay at the AV node results in prolonged PR

interval
 PR interval>0.2 sec.
 Leave it alone
Second Degree AV Block Type 1
(Wenckebach)

 Increasing delay at AV node until a p wave is not conducted.

 Often comes post inferior MI with AV node ischemia

 Gradual prolongation of the PR interval before a skipped QRS. QRS are normal!

 No pacing as long as no bradycardia.

 Second Degree AV Block Type 2

 Diseased bundle of HIS with BBB.

 Sudden loss of a QRS wave because p wave was not transmitted beyond
AV node. QRS are abnormal!

 May be precursor to complete heart block and needs pacing.

 Third Degree AV Block

 Complete heart block where atria and ventricles

beat independently AND atria beat faster than
ventricles.
 Must treat with pacemaker.
Third degree AV Block
LBBB
 Left Bundle Branch Block

 Left ventricle gets a delayed impulse

 QRS is widened (at least 3 boxes)
 V5 and V6 have RR’ (rabbit ears)
 Be careful not to miss any hiding q waves!
 Pacemaker if syncope occurs
Sgarbossa’s criteria
Right Bundle Branch Block
 Right Bundle Branch Block

 Right ventricle gets a delayed impulse

 QRS is widened (at least 3 boxes)
 V1 and V2 have rSR’
 Pacemaker if syncope occurs.
Tachyarrhythmias
(HR >100 x/ min)
Tachyarrhythmias
 Supraventricular tachycardia
 Atrial fibrillation
 Atrial flutter
 Ventricular tachycardia
 Monomorphic
 Polymorphic (Torsades de pointe)

 Ventricular fibrillation
Supraventricular Tachycardia
 SVT
 Reentrant arrhythmia at AV node that is spontaneous in onset

 May have neck fullness, hypotension and/or polyuria due to ANP

 Narrow QRS with tachycardia

 First line is vagal maneuvers

 Second line is adenosine or verapamil

 For chronic SVT, class 1A or 1C or amiodarone or sotalol work well

 Ablation will cure it too, but we usually do this only in young patients
Multifocal Atrial Tachycardia
 MAT
 Automatic atrial rhythm from various different foci

 Seen in hypoxia, COPD, atrial stretch and local metabolic

imbalance.

 Three or more types of p waves and a rate > 100

 Digoxin worsens it, so treat with oxygen and slow

channel blocker like verapamil or diltiazem.
Wolf Parkinson White
WPW
 Ventricles receive partial signal normally and
partially through accessory pathway
 Symptomatic tachycardia, short PR interval
(<0.12), a delta wave and prolonged QRS
(>0.12)
 Electrophysiologic testing helps to identify
the reentry pathway and location of the
accessory pathway
WPW
 Because WPW has both normal conduction through the AV node
and accessory pathway conduction that bypasses the AV node,
a-fib can happen via the accessory pathway

 Inhibition of the AV node will end up in worsening the a-fib

because none of the signals are slowed down by the AV node
before hitting the ventricle.

* Do not use any meds that will slow AV node conduction, ie

digoxin, beta-blockers, adenosine or calcium channel blockers.

* The best choice is procainamide as it slows the accessory

pathway. *If patient becomes hypotensive, cardiovert
immediately!
Atrial Flutter
Atrial Flutter
 Atrial activity of 240-320 with sawtooth pattern.
Usually a 2:1 conduction pattern; if it is 3:1 or
higher, there is AV node damage

 Treatment is to slow AV node conduction with

amiodarone, propafenone or sotalol

 DC cardiovert if <48 hours or unstable

 You can also ablate the reentry pathway within the

atrium between the tricuspid and the IVC.
Atrial Fibrillation
 A-Fib
 Can be due to HTN, cardiomyopathy, valvular heart
desease, sick sinus, WPW, thyrotoxicosis or ETOH

 Therapy is either rate control via slowing AV node

conduction with stroke prophylaxis or rhythm control
 Rate control
 Beta-blockers
 Continuation after CABG may prevent a-fib
 Good for hyperthyroid or post-MI patients with a-fib
 Carvedilol decreases mortality in patients with CHF
 Esmolol is good for acute management

 Digoxin actually increases vagal tone, thus indirectly

slowing AV node conduction. But it is used essentially
only in patients with LV dysfunction because it’s
inotropic.
 Rate control
 Calcium Channel Blockers
 Nondihydropyridines (verapamil or dilitiazem) block AV node
conduction but also have negative inotropy, so don’t use in
CHF.
 Dihydropyridines (nifedipine, amlodipine, felodipine) have
no effect on AV node conduction

 Adenosine is too short acting to be of any use in a-

fib
 Last choice is AV node ablation and permanent
pacing
 Rhythm control
 Rhythm control does not decrease thromboembolic
risk and may be proarrhythmic
 Class 1A (quinidine, procainamide, disopyramide) slows
conduction through HIS can cause torsades de pointes during
conversion. They also enhance AV node conduction, so they
should be used only after rate is controlled
 Class 1B (lidocaine, meilitine, tocainide) are useless for a-fib
 Class 1C (propafenone, and flecainide) slow conduction through
HIS are good first choice.

 Amiodarone is good if patient is post-MI or has

systolic dysfunction.
 Cardioversion for A-Fib
 Cardiovert if symptomatic

 Patients with a-fib for more than 2 days should be

receive 3 weeks of anticoagulation before electrical
cardioversion.

 Give coumadin for 4 weeks after cardioversion

 Anticoagulation Rules for A-Fib
 Everybody who has rheumatic heart disease should be
anticoagulated

 If <65 yo and with h/o DM, HTN, CHF, CVA, prosthetic valves,
thyrotoxicosis, LV dysfunction or LA enlargement, then give
coumadin

 If no risk factors, do nothing.

 65-75 yo with any of above risk factors, give coumadin; if no
additional risk factors, give coumadin or aspirin

 >75 yo give coumadin but keep INR 2-2.5 due to increased risk
of bleed
Ventricular Tachycardia
Ventricular Tachycardia

 Impulse is initiated from the ventricle itself

 Wide QRS, Rate is 140-250
 If unstable DC cardiovert
 If not, IV Amiodarone and/or DCCV
 Consider procainamide
 Nonsustained ventricular tachycardia needs no treatment
Torsades de Pointes

 “Twisting of the points” is usually caused by

medication (quinidine, disopyramide, sotalol,
TCA), hypokalemia or bradycardia especially
after MI
 Has prolonged QT interval
 Acute: Remove offending medication. Shorten
the QT interval with magnesium, lidocaine,
isoproterenol, or temporary overdrive pacing
 Chronic: may need pacemaker/ICD,
amiodarone, beta-blockers
 Fibrilasi Ventrikel (VF)

 Most common in acute MI, also drug overdose, anesthesia,

hypothermia & electric shock can precipitate
 Absence of ventricular complexes
 Usually terminal event

 Use Amiodarone if refractory to DCCV.

 Perhatikan irama apakah
memerlukan terapi kejut
listrik?

 Lakukan resusitasi jantung –

paru yang berkualitas

 Rekam aktivitas dan

pemakaian obat – obatan
Terapi
Classification of Anti-arrhythmics
Jika ragu…Amiodarone

Amiodarone
IV

SVT VT Atrial Fib or flutter

Indikasi Magnesium
 Torsade de pointes
 Aritmia karena hipomagnesemia.
 Pertimbangkan pada iskemia akut untuk
mencegah aritmia ventrikel.
 Aritmia karena penggunaan digoksin.
Pacemaker
 Syncope, presyncope or exercise intolerance that can be
attributed to bradycardia

 AV blok derajat 2 dan 3 dengan gejala

 AV blok derajat 3 dengan kompleks QRS lebar

 AV blok setelah operasi jantung

 AV blok derajat 2 tipe 2 yang berulang setelah serangan jantung

 AV blok derajat 3 dengan komplek QRS lebar atau BBB

Thank you!