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Simon Salim
Cardiology Division, Department of Internal Medicine
Cipto Mangunkusumo National General Hospital
Fakultas Kedokteran Universitas Indonesia
Indonesia
Presenter Disclosure Information
• Simon Salim
– Mechanism of Arrhythmia
– Bradycardia and conduction block
• FINANCIAL DISCLOSURE
– None to declare
Outline
•Arrhythmia
• Epidemiology
• Pathophysiology
• Pathogenesis
•Bradycardia
•Conduction Disruption
Epidemiology
• Arrhythmia Prevalence
• In general:
• Idiopathic incidence 51.9/100,000 (2005-2013): Females 62.0/100,000 vs.
males 42.4/100,000 (p<0.001)1
• In elderly:
• The prevalence of arrhythmia is increasing with age2
• ≥66 yo: persistent (10%) and paroxysmal (5.5%) AF found in 200
outpatient3
• Common types of tachy-arrhythmia in elderly (>60 years old):
• Atrial fibrillation (2x/10 years)2
• Atrial flutter (3x)4
• Ventricular tachycardia (1.3x)1
1. Sirichand et al. Circ Arrhythm Electrophysiol 2017; 10(2): e004662
2. Franken Ra et al. Journal of Geriatric Cardiology : JGC. 2012; 9 :91-100.
3. Lindberg et al., Clinical Interventions in Aging 2016; 11: 1083-1090
4. Juan Granada et al. Journal of the American College of Cardiology. 2000;36.
Pathophysiology – Basic1
Electrical Normal
Impulse Conduction2
Formation2
ARRHYTHMIA3
-90mV
• Triggered Activity
• Overload Ca2+ activating sodium-calcium channel6
• Early or Delayed Depolarization7,8
1. Hatch F, Lancaster MK and Jones SA. Aging Is A Primary Risk Factor For Cardiac Arrhythmias : Disruption of Intracellular
Ca2+ Regulation As A Key Suspect. Expert Review of Cardiovascular Therapy. 2011.
2. De Azevodo et al. Chest 1973; 64: 732-740
PP : Pacemaker Potensial, perlahan –
lahan depolarisasi
MDP : Maximal diastolic potensial,
pada SA : - 70 mV
AP : Action Potensial
TP : Treshold Potensial
Increased Automaticity
Pathogenesis of Arrhythmia
• Triggered Activity
• Overload Ca2+ activating sodium-calcium channel6
• Early or Delayed Depolarization7,8
• Early after-depolarization
• Shifts in membrane potential reactivating Ca2+ channels1
• Spontaneous Ca2+ releases from sarcoplasmic2
• Late after-depolarization
• Excessive intracellular Ca2+ or overload3 at resting potential (phase 4)
• Re-Entry
• Conduction Disruption1
• Obstacle
• Anatomical2
• Functional3
• Reflections 4
• Phase 25
Definition: ≤ 60 bpm1
• Sinus node Dysfunction2
• Atrial origin, AV node / junction origin, His-Purkinje system origin
• Atrio-Ventricular Block2
• Chronic Multi-fascicular Blocks2
1. Glover B & Brugada P (eds). Clinical Handbook of Cardiac Electrophysiology. Springer; 2016
2. Runge, MS, Stouffer, GA, et Patterson, C (eds). Netter’s Cardiology 2nd ed, Saunders Elsevier; 2010
Bradycardia / conduction block
1. Furberg CD, et al. Cardiovascular Health Study Collaborative Research Group. Am J Cardiol 1992;69(16):1329–1335
2. Ostor E et al. Eur Heart J 1981;2(4):317–328.
3. Kannel WB et al. Am J Cardiol 1987;60(17):85I–9
Bradycardia / conduction block
Note: Level of AV Block → supraHIS,
• Sinus node Dysfunction paraHIS, and infraHIS
• Atrio-Ventricular Block
• 1st degree AV Block
• 2nd degree AV Block Mobitz I (Wenckebach)
• 2nd degree AV Block Mobitz II
• 3rd degree AV Block
• Chronic Multi-fascicular Blocks
1. Furberg CD, et al. Cardiovascular Health Study Collaborative Research Group. Am J Cardiol 1992;69(16):1329–1335
2. Ostor E et al. Eur Heart J 1981;2(4):317–328.
3. Kannel WB et al. Am J Cardiol 1987;60(17):85I–9
Electrocardiography
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