PATIENT WITH ARRHYTHMIA IN DENTIST S OFFICE. Małgorzata Kurpesa, MD., PhD. Chair&Department of Cardiology
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1 PATIENT WITH ARRHYTHMIA IN DENTIST S OFFICE Małgorzata Kurpesa, MD., PhD. Chair&Department of Cardiology Medical University of Łódź
2 The heart is made up of four chambers Left Atrium Right Atrium Left Ventricle Right Ventricle
3 What makes the heart pump? Natural Electric Impulses Which stimulate heart muscle to contract The heart is made primarily of muscle When the muscle contracts, it squeezes the blood through the heart and out to the lungs or to the body
4 Normal pathway for electricity to travel through the heart SA node AV node Bundle of His Left bundle branch Right bundle branch = Myocardium contracts
5 SA Node (inherent rate of ) When we lose power! Atrial foci (inherent rate of 60 80) Junctional foci (inherent rate of 40 60) Ventricular foci (inherent rate of 20 40) The lower the level in the heart, where the foci is located that is doing the pacing, the lower is the inherent rate (heart rate) produced by that area). A foci is a potential pacemaker (or cell) that is capable of pacing in emergency situations.
6
7 I II III
8 What is an arrhythmia? Normal cardiac function relies on the flow of electrical impulses through the heart in an exquisitely coordinated fashion. Any abnormality in this rhythm of the heart is by definition an arrhythmia.
9 COMMON SYMPTOMS OF CARDIAC ARRHYTHMIAS 1.Palpitations 2. Hemodynamic dysfunction Dizziness Syncope Chest pain
10 CARDIAC CONDUCTION SYSTEM AV node Bundle of His SA node Right bundle branch Electrophysiologically the Purkinje heart fibre is two-chambered with the atrial and ventricular myocardium separated from each other by the fibrous tissue of the atrioventricular rings. The only link between the two chambers of the atria and the ventricles, is a thin muscular bridge, the AV conduction system Left bundle branch
11 DIVISION OF ARRHYTHMIAS 1.. SUPRAVENTRICULAR ISOLATED PREMATURE BEATS TACHYCARDIA ATRIAL FIBRILLATION AND ATRIAL FLUTTER 2. VENTRICULAR ISOLATED PREMATURE BEATS TACHYCARDIA (INCLUDING TORSADE DE POINTES ) VENTRICULAR FIBRILLATION
12 DIVISION OF ARRHYTHMIAS 1. BRADYARRHYTHMIAS HR < 60/min 2. TACHYARRHYTHMIAS HR > 100/min
13 SINUS BRADYCARDIA
14 SINUS ARREST AND SINOATRIAL EXIT BLOCK Sinus Arrest SA Exit Block
15 Sinus Rhythm Junctional Rhythm Ventricular Rhythm
16 Premature Beats Not a rhythm, just a single early beat Three Options: If it arises from the Atria, it will have a normal PR Interval This is a Premature Atrial Contraction or PAC If it arises from the Junctional area, it will have a PR Interval which is less than normal or no P wave at all This is a Premature Junctional Contraction or PJC If it arises from the Ventricular area, it will be a QRS which is wide and bizarre shaped This is a Premature Ventricular Contraction or PVC
17 No P Wave SR with P Wave Close to QRS PJC SR with PJC A wide bizarre QRS Junctional Rhythm with PVC
18 Variability of Ventricular Ectopy with Age Effect of age on probability (%) of having more than a given number of PVCs per 24 hours in subjects with normal hearts. 60% 50% 40% 30% 20% 10% > 0 PVCs > 50 PVCs > 100 PVCs Data from Kostis JB. Circulation. 1981;63(6): % Age
19 Ventricular bigeminy = every other beat is a PVC Ventricular trigeminy = every 3rd beat is a PVC
20 Ventricular Tachycardia (VT) 3 or more ventricular beats in a row Rate > 100 bpm 6 beats of VT
21 I I II III
22 Ventricular Fibrillation (VF) Squiggly line
23
24 VF is a type of cardiac arrest, for there is no pumping action by the heart. It requires immediate CPR and defibrillation
25 ICD Indications Generally Used in cases where there was a previous cardiac arrest Or, patients with undetermined origin or continued VT or VF despite medical interventions
26 Atrial Flutter Can count the # of flutter waves (F waves) Atrial Fibrillation (Afib) Atrial Fibrillation (Afib) Unable to count the # of waves
27 ATRIAL FIBRILLATION f
28
29 AF: Anticoagulation - General Points AF most common significant rhythm disorder Prevalence: 1.5%-3% of patients in their 60s 5%-7% of patients in their 70s 10% of patients in their 80s AF most potent common risk factor for stroke Relative risk = 5 Patients with AF can be stratified according to risk of stroke Feinberg WM e al. Arch Intern Med 1995;155:469 Wolf PA et al. Stroke1991;22:983
30 ATRIAL FIBRILLATION INCREASES THE EMBOLIC RISK ESPECIALLY THE RISK OF ISCHEMIC STROKE TO REDUCE THIS RISK PATIENTS WITH AF SHOULD BE TRAETED WITH ORAL ANTICOAGULANTS ORAL ANTICOAGULANTS - ANTIVITAMINS K : WARFARIN, ACENOCUMAROL TREATMENT WITH ORAL ANTIVITAMINS K PROLONGS THE BLEEDING TIME THE DOSE OF ORAL ANTIVITAMINS K DEPENDS ON THE PROTHROMBIN INDEX (INR) WHICH SHOULD BE PROLONGED 2,5 3,5 TIMES
31 INR 3 = TIME OF BLEEDING IS 3 TIMES LONGER THAN NORMAL UNDER SUCH CIRCUMSTANCES THERE IS HIGHER PROBABILITY OF PROLONGED BLEEDING DURING SURGICAL PROCEDURE HOWEVER TOOTH EXTRACTION IS NOT CONTRAINDICATED FOR PATIENTS RECEIVING ORAL ANTICOAGULANTS
32 lightest Types of Atrio A Ventricular Blocks First Degree 1 AVB Second Degree Wenckebach/Mobitz I Mobitz II worst Third Degree 3 AVB
33 First Degree AV Block (1º AVB) PR interval >.20 ms A // V
34 Mobitz I: Wenckebach PR interval gradually longer until a QRS is dropped B indicates a Blocked Beat Pattern is repeated Typically not harmful normal longer longer dropped QRS
35 Mobitz II PR interval consistent except some QRS missing Harmful--may indicate serious heart disease or progress to 3rd degree block Blocked QRS
36 3rd Degree AV Block (3º AVB) Atria & ventricles act independently Regular P waves Regular QRS complexes But P waves and QRS not working together blocked normal blocked blocked short blocked normal blocked
37 Pacemaker Basics Provides electrical stimuli to cause cardiac contraction when intrinsic cardiac activity is inappropriately slow or absent Sense intrinsic cardiac electric potentials
38 Pacemaker Indications Absolute indications Sick sinus syndrome Symptomatic sinus bradycardia Tachy-brady syndrome Afib with slow ventricular response 3 rd degree heart block Chronotropic incompetence Inability to increase heart rate to match exercise
39 Bigger s classification 1. Benign arrhythmia different kinds of premature beats,, no structural heart disease,, no sustained ventricular tachycardia - good prognosis 2. Potential malignant arrhythmia - different kinds of premature beats,, no sustained VT, structural heart disease, various degree of left ventricular dysfunction 3. Malignant arrhythmia - different kinds of premature beats, episode of ustained VT or VF, presence of structural heart disease and left ventricular dysfunction poor prognosis
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