Cardiac arrhythmia from Guyton's book

Cardiac Arrhythmias
All the following are written in Guyton it is not what the dr said. The causes of the cardiac arrhythmias are usually one or a combination of the following abnormalities in the rhythmicity-conduction system of the heart: 1. Abnormal rhythmicity of the pacemaker 2. Shift of the pacemaker from the sinus node to another place in the heart 3. Blocks at different points in the spread of the impulse through the heart 4. Abnormal pathways of impulse transmission through the heart 5. Spontaneous generation of spurious impulses in almost any part of the heart

**Abnormal Sinus Rhythms: 1) TACHYCARDIA:

2) BRADYCARDIA: - means a slow heart rate, usually defined as fewer than 60 beats per minute. - R-R interval long - we have 2 types of bradycardia: 1) Bradycardia in Athletes: The athletes heart is larger and stronger pump a large output per beat even during periods of rest. When the athlete is at rest more blood pumped into the arterial tree with each beat initiate feedback circulatory reflexes or other effects to cause bradycardia.

**Abnormal Rhythms That Result from Block of Heart Signals within the Intracranial Conduction Pathways 1) Sinoatrial Block:
- The impulse from the sinus node is blocked before it enters the atrial muscle. - P wave disappear or very small - QRS-T normal but slower in rate because it is controlled by A.V node.

2) Atrioventricular Block: - decrease or block the conduction through A.V node - causes: 1) Ischemia of the A-V node or A-V bundle fibers 2) Compression of the A-V bundle by scar tissue or by calcified portions of the heart 3) Inflammation of the A-V node or A-V bundle, like myocarditis due to diphtheria or rheumatic fever. 4) Extreme stimulation of the heart by the vagus nerves - we have 2 types of this arrhythmia: A) INCOPLETE A.V HEART BLOOK: 1) First degree AV block: - It is delay of conduction from the atria to the ventricles but not actual blockage of conduction. - Long P-R interval (0.3-0.45 sec) normal P-R interval is 0.16-0.2 sec - Slow heart rate

2) second degree A.V block: - partial block of A.V bundle - strong action potential can pass to ventricles, weak one can't pass This will lead to dropped beats (2P:1QRS) OR (3P:1QRS) - QRS Duration normal still controlled by SA node - Rhythm is not normal because P & QRS controlled by SA node and we have partial blockage

B) COMPLETE A.V HEART BLOCK : ( 3 rd degree AV block) - the atria completely separated form the ventricles. - the P waves become dissociated from the QRS-T complexes - Furthermore, there is no relation between the rhythm of the P waves and that of the QRS-T complexes because the ventricles have escaped from control by the atria, and they are beating at their own natural rate, controlled most often by rhythmical signals generated in the A-V node or A-V bundle. - QRS Duration Prolonged because it is controlled by AV node

- Rhythm is normal Look we have 2P then 1 QRS (p control by SA node and QRS controlled by AV node) - Stokes-Adams SyndromeVentricular Escape: A-V block, the total block comes and goes, the duration of block may be a few seconds, a few minutes, a few hours, or even weeks or longer before conduction returns. This condition occurs in hearts with borderline ischemia of the conductive system.

 When this blockage occurs the ventricles start to pump blood after 5-30 sec and this phenomena called overdrive suppression and this will lead to coma because the brain cant remain active for more than 4-7 sec without blood supply. After the ventricular escape the ventricles pump enough blood to resolve the faint and sustain the person. 3) Incomplete Intraventricular BlockElectrical Alternans: block impulse conduction in the peripheral ventricular Purkinje system This electrocardiogram also shows tachycardia (rapid heart rate), which is probably the reason the block has occurred, because when the rate of the heart is rapid, it may be impossible for some portions of the Purkinje system to recover from the previous refractory period quickly enough to respond during every succeeding heartbeat. Also, many conditions that depress the heart, such as ischemia, myocarditis, or digitalis toxicity, can cause incomplete intraventricular block, resulting in electrical alternans

**Premature Contractions:
- A premature contraction is a contraction of the heart before the time that normal contraction would have been expected. This condition is also called extrasystole, premature beat, or ectopic beat. - Causes: 1. local area ischemia 2. small calcified plaques 3. Toxic irritation of the A-V node, Purkinje system, or myocardium caused by drugs, nicotine, or caffeine. 4. During catheterization, when the catheter enters the right ventricle and presses against the endocardium.

1) Premature Atrial Contractions: - The P wave of this beat occurred too soon in the heart cycle. - the P-R interval is shortened, indicating that the ectopic origin of the beat is in the atria near the A-V node. - the interval between the premature contraction and the next succeeding contraction is slightly prolonged, which is called a compensatory pause. - The reason for compensatory pause is that the premature contraction originated in the atrium some distance from the sinus node, and the impulse had to travel through a considerable amount of atrial muscle before it discharged the sinus node. Consequently, the sinus node discharged late in the premature cycle, and this made the succeeding sinus node discharge also late in appearing. - Causes: 1. smoking 2. lake of sleep 3. ingestion of too much coffee compensatory pause 4. alcoholism 5. drugs

2) A-V Nodal or A-V Bundle Premature Contractions: - The QRS complex is usually considerably prolonged. The reason is that the impulse is conducted mainly through slowly conducting muscle of the ventricles rather than through the Purkinje system. - The QRS complex has a high voltage - the T wave has an electrical potential polarity exactly opposite to that of the QRS complex, because the slow conduction of the impulse through the cardiac muscle causes the muscle fibers that depolarize first also to repolarize first.

**Paroxysmal Tachycardia:
- in atria, the Purkinje system, or the ventricles - Beginning suddenly and lasting for a few seconds, a few minutes, a few hours, or much longer. Then the paroxysm usually ends as suddenly as it began, with the pacemaker of the heart instantly shifting back to the sinus node. - Paroxysmal tachycardia often can be stopped by: 1. eliciting a vagal reflex. A type of vagal reflex sometimes elicited for this purpose is to press on the neck in the regions of the carotid sinuses, which may cause enough of a vagal reflex to stop the paroxysm. 2. drugs quinidine and lidocaine 1) Atrial Paroxysmal Tachycardia: - sudden increase in the heart rate from about 95 to about 150 beats per minute - during the rapid heartbeat, an inverted P wave is seen before each QRS-T complex, and this P wave is partially superimposed onto the normal T wave of the preceding beat. - This indicates that the origin of this paroxysmal tachycardia is in the atrium, but of this paroxysmal tachycardia is in the atrium, but not near the sinus node.

2) Ventricular Paroxysmal Tachycardia - series of ventricular premature beats occurring one after another without any normal beats interspersed. - It is a serious condition for 2 reason does not occur unless considerable ischemic damage is present in the ventricles. initiates the lethal condition of ventricular fibrillation

** Ventricular Fibrillation:
- most serious if not stopped within 1 to 3 minutes, is almost invariably fatal. - results from cardiac impulses that have gone wild within the ventricular muscle mass, When this happens, many small portions of the ventricular muscle will be contracting at the same time, while equally as many other portions will be relaxing no coordinate contraction. - Pumping either no blood or negligible amounts. Therefore, after fibrillation begins, unconsciousness occurs within 4 to 5 seconds for lack of blood flow to the brain - Causes: 1. Sudden electrical shock of the heart. 2. Ischemia the heart muscle, of its specialized conducting system. - Relived by :A strong high voltage alternating electrical current passed through the ventricles for a fraction of a second this can stop fibrillation by throwing all the ventricular muscle into refractoriness simultaneously.

** Atrial Fibrillation:
- The mechanism of atrial fibrillation is identical to that of ventricular fibrillation, except that the process occurs only in the atrial muscle mass instead of the ventricular. - Cause: 1. Atrial enlargement resulting from heart valve lesions that prevent the atria from emptying adequately into the ventricles. 2. Ventricular failure with excess damming of blood in the atria. 3. The dilated atrial walls provide ideal conditions of a long conductive pathway as well as slow conduction, both of which predispose to atrial fibrillation. - is not significant as ventricular fibrillation because in atrial fibrillation we lose 20-30% of the efficincy of ventricular contraction (passive filling still active) so we can live with that. - Numerous small depolarization waves spread in all directions waves are weak and many of them are of opposite polarity at any given time. - They usually almost completely electrically neutralize one another. Therefore, in the electrocardiogram, one can see either no P waves from the atria or only a fine, high-frequency, very low voltage wavy record. Conversely, - The QRS-T complexes are normal unless there is some pathology of the ventricles.

A.fibrillation

normal

** Atrial Flutter:
- different from atrial fibrillation, in that the electrical signal travels as a single large wave always in one direction around and around the atrial muscle mass - Causes a rapid rate of contraction of the atria, usually between 200 and 350 beats per minute. - because one side of the atria is contracting while the other side is relaxing, the amount of blood pumped by the atria is slight - Signals reach the A-V node too rapidly for all of them to be passed into the ventricles, because the refractory periods of the A-V node and A-V bundle are too long to pass more than a fraction of the atrial signals. Therefore, there are usually two to three beats of the atria for every single beat of the ventricles. - ECG: 1. P wave: strong 2. QRS wave: follows an atrial P wave only once for every two to three beats of the atria, giving a 2:1 or 3:1 rhythm.

** Cardiac arrest:
- cessation of all electrical control signals in the heart, That is, no spontaneous rhythm remains. - Causes: deep anesthesia, hypoxia.

Done by: shifa summarizing groupe