5bdiz ssizuinjb boe 4veefo %fbui · 2012-02-29 · session iii. tachy arrhythmias and sudden death...

심전도 연수강좌 : 처음 시작하는 사람들을 위한 심전도

강남힘찬병원

이 병 호


정상 12- Lead 심전도심전도의 이해

MEMO

Session III. Tachy Arrhythmias and Sudden Death


Axis

Horizontal vs Frontal plane

LVRV

SA

AV

LVRV

III AVF II

AVR AVL

(inferior wall )

(lateral wall )

LVRVV6

V1 V2 V3V4

V5

( Anteroseptum )(anterior wall)

Horizontal plane Frontal plane

MEMO

이병호：Tachy Arrhythmia and Sudden Death


33 M. seizure disorderConsultation for arrhythmia management

MEMO



응용문제

Narrow QRS

Regular?

Visible P? A-fib, A-tac, MAT, A-flutter with variable AV conduction

Atrial rate greater than V-rate?

A-flutter orAT

Analyze RP interval

Short(RP shorter than PR)

Long(RP longer than PR)

RP shorter than 70ms RP longer than 70ms

AVNRT

AVRTAVNRT

AT

A-tachycardiaPJRT

Atypical AVNRT

Yes No

Yes

No

Yes No

MEMO



Regular narrow QRScomplex tachycardia

IV adenosine

No change in rate

Gradual slowingthen reacceleration

of rate

Sudden termination

Persisting ATwith transient high-degree

AVB

*Inadequate dose/delivery *Sinus tachycardia

*Focal AT*Nonparoxysmaljunctional tachycardia

*AVNRT*AVRT*Sinus node re-entry*Focal AT

*Atrial flutter*AT

Sudden cardiac death

MEMO



Definition of SCD

Any cardiac death occuring out of the hospital or taking place in the emergency room or dead on arrival in the emergency room.

Gillum RF et al. Circulation 1989;79:756-765

…"natural" death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of acute symptoms.

USA :300,000~400,000 adult SCDs each year1~2/1000 population per year75~80% of SCDs due to CAD50% of CAD deaths 20~25% of SCDs : no prodromal Sx.Unwitnessed in 40%High recurrence rate : up to 50% within 1yr

Epidemiology

Causes of SCD

Coronary ArteryDisease : 75~80%

Acute MechanicalCauses : 5%

Non-structural Heart Disease : 5~10%

Structural Heart Disease : 10~15%

MEMO



Long QT syndromeThe Brugada syndrome

SCD without structural heart disease

SCD with structural heart diseaseARVD

History1957 : Jervell and Lange-Nielsen

first described a family with long QT synd. (LQTS)

1979 : “Prospective International LQTS Registry”1,200 LQTS Families

Idiopathic Long QT Syndrome

46F, syncope

Sinus rhythm with prolonged(?) QT interval and VPCs

QT

RR

* *

MEMO



Corrected QT intervalQT interval changes according to the heart rateTachycardia (RR interval↓) QT interval↓Bradycardia (RR interval↑) QT interval↑

Corrected QT interval (cQT) : QT interval corrected by RR interval

Bazett’s formula : cQT(ms) = QT(ms) / √RR(sec)

QT prolongation : cQT > 460ms (♂), 480ms (♀)

Mutation-induced ion channel dysfunction Repolarization prolongation due to mutations of Na+ and K+ channel genes prolonged intracellular positivity

early afterdepolarization Torsade de pointes

Molecular and cellular mechanisms

Disease Gene (alternate name) Protein

LQT-1 KVLQT1(KCNQ1) IKs K+ channel α subunit

LQT-2 HERG(KCNH2) IKr K+ channel α subunit

LQT-3 SCN5A INa K+ channel α subunit

LQT-4 ANKB ANKRIN-β

LQT-5 minK(KCNE1) IKs K+ channel β subunit

LQT-6 MiRP1(KCNE2) IKr K+ channel β subunit

LQT-7 KCNJ2 IKr K+ channel α subunit

Robert S. Kass et al. J. Clin. Invest. 2003. 112:810-815

Incidence : LQT1 and LQT2 > LQT3 Lethality : LQT3 > LQT1 and LQT2

MEMO



.

Moss A J et al. Circulation 1995;92:2929-2934

Congenital Long QT SyndromeLQT type 1LQT type 2LQT type 3

Early onset broad based T waves

Low amplitudeT waves

Late onsetT waves

60F, Consultation for SCA

Prolonged cQT interval (= 520ms) and R on T phenomenon

560 960 480

QT

RR

F/U ECG after 48 Hours

cQT interval was shortened after withdrawal of moxifloxacinand correction of electrolyte imbalance

MEMO



QT Prolonging DrugsDAUH, Kim MJ, 5460046

www.qtdrugs.org

Brugada SyndromeHistoryIn 1992, Brugada: 8 pts with a history of aborted SCD

a distinct ECG pattern of RBBB with ST elevation in leads V1-V3 and normal QT interval in the absence of any structural heart diseas

Male predominance, Asian populationSudden arrhythmic death during sleepingST elevation in V1 – V3Na+ channel dysfunction (SCN 5A gene mutation)

Brugada Syndrome

MEMO



Brugada Syndrome

Type 1 Type 2 Type 3J point amplitude ≥ 2mm ≥ 2mm ≥ 2mm

T wave negative positive or biphasic

positive

ST-T configuration

coved type saddleback saddleback

ST (terminal portion) gradually descending

elevated ≥1mm elevated<1mm

Brugadaleads

Standard leads

The sensitivity of the ECG for Brugada syndrome can be increased with placement of ECG leads in the intercostal space above V1 and V2 (V1ic3 and V2ic3)

Brugada Leads

Dynamic Change of ST Segment2009-06-18 2009-06-242009-05-13

V1

V2

Dynamic change of ST segment in V1 & V2

2009-06-16

MEMO



Management of Brugada Syndrome

JM Juang et al. Cardiology 2004;101:157-169

Symptomatic(Syncope or SD)

Spontaneous ECG (+) Resting ECG (-)

Inducible ECG (+) by pharmacologic tests

PES (positive of negative)Family history (positive or negative)

ICD

Management of Brugada Syndrome

JM Juang et al. Cardiology 2004;101:157-169

Asymptomatic

Spontaneous ECG (+)Resting ECG (-)

Pharmacologic test

Inducible ECG (+) Inducible ECG (-)

PES (-) PES (+) PES (-)

Family Hx (-) Family Hx (+) Family Hx (-)

Clinical F/U Clinical F/UICD

Relatively newly recognized disease, first published in 19823~5% of unexplained SCD under the age of 65 yrs3 genes : ryanodine receptor (RyR2), plakoglobin(JUP),

desmoplakin (DSM)Fatty or fibrofatty infiltration of the right ventricle (RV), dilatation and dysfunction of the right ventricle as well as electrical instability, ventricular arrhythmia of right ventricular origin, heart failure and sudden deathFamilial disorder in 30%, Autosomal dominant in 1/3 pts

Arrhythmogenic RV Dysplasia

MEMO



Pathology of ARVD

Dilatation of the RV

Pathology replacemant of myocardium by fat with scattered fibrous tissue and residual myocardial cells

Signal Averaged ECG

MEMO



ECG Characteristics of ARVC QRS width ≥ 110 ms in V1 (100%) + RBBB config.

T wave inversions (60%) in Rt. Precordial leads

Epsilon wave (30%) : delayed RV activation

Low voltage QRS complex

Late potentials in signal averaged ECG (specificity 95%)

Summary

EKG is logical testTachycardia – QRS morphology & regularity– P wave correlation

Check QT intervalBrugada– DDX with RBBB : ST-elevation

ARVD – epsilon wave– RBBB pattern

MEMO

5bdiz ssizuinjb boe 4veefo %fbui · 2012-02-29 · session iii. tachy arrhythmias and sudden death...

Documents