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TachycardiaTachycardia
高雄榮總高雄榮總心臟血管中心心臟血管中心 主治醫師主治醫師 葉同成葉同成
心電圖的波形及間距的意義心電圖的波形及間距的意義
心電圖的波形及間距的意義心電圖的波形及間距的意義 P P 波波 : : 代表左右心房去極化代表左右心房去極化
QRS QRS 複合波複合波 ::代表左右心室去極化代表左右心室去極化
ST-T ST-T 波波 : : 心室再極化心室再極化
U U 波波 : : 此波源起不是很清楚，但可能是去極化後從此波源起不是很清楚，但可能是去極化後從心室來的，最常見於低血鉀心室來的，最常見於低血鉀
心電圖的波形及間距的意義心電圖的波形及間距的意義 PR PR 間距間距 : : 從心房去極化從心房去極化 (P (P 波波 ))到心室到心室去極化去極化 (QRS (QRS 複合波複合波 ))之間的距離之間的距離
QRS QRS 波持續時間波持續時間 : : 心室去極化的時間心室去極化的時間
QTQT波間距波間距 : : 心室去極化和再極化的時間心室去極化和再極化的時間
心電圖的波形及間距的意義心電圖的波形及間距的意義 RRRR間距間距 : : 一心室周期的時間一心室周期的時間
((心室速率心室速率 ))
PPPP間距間距 : : 一心房週期的時間一心房週期的時間 ((心房速率心房速率 ))
測量測量
心跳速率心跳速率 ((心房速率和心室速率心房速率和心室速率 ))
PR PR 間距間距 (( 從從 PP波開始到波開始到 QRSQRS開始之間的距離開始之間的距離 ))
QRS duration (QRS duration ( 看看 QRSQRS的寬度的寬度 ) )
QT QT 間距間距 (( 從從 QRSQRS波開始到波開始到 TT波結束波結束 ) )
QRS QRS 波在額平面之心軸波在額平面之心軸
正常心電圖的測量質正常心電圖的測量質
心跳速率心跳速率 : 60 - 100 bpm : 60 - 100 bpm
PR PR 間距間距 : 0.12 - 0.20 sec : 0.12 - 0.20 sec
QRS QRS 持續時間持續時間 : 0.06 - 0.10 sec : 0.06 - 0.10 sec
QT QT 間距間距 (QT(QTcc << 0.40 sec) 0.40 sec)
Bazett‘s Bazett‘s 公式公式 :: QT QTcc = (QT)/SqRoot RR (in seconds) = (QT)/SqRoot RR (in seconds)
頻脈頻脈窄的窄的 QRSQRS 波波 (<3(<3 小格）小格）
1.1. 規則的規則的 : PSVT(AVNRT/AVRT)/MAT etc.: PSVT(AVNRT/AVRT)/MAT etc.2.2. 不規則的不規則的 : Atrial fibrillation/Atrial flutter: Atrial fibrillation/Atrial flutter
Atrial fibrillationAtrial fibrillation
Atrial flutter
頻脈頻脈寬的寬的 QRSQRS波（波（ >3>3 小格）小格）
1.1. 規則的規則的 : Monomorphic VT: Monomorphic VT2.2. 不規則的不規則的 : Polymorphic VT: Polymorphic VT
Monomorphic VTMonomorphic VT
心室頻脈心室頻脈 (VT)(VT)上心室頻脈併左束枝傳導阻礙上心室頻脈併左束枝傳導阻礙
(PSVT with LBBB)(PSVT with LBBB)上心室頻脈併右束枝傳導阻礙上心室頻脈併右束枝傳導阻礙
(PSVT with RBBB)(PSVT with RBBB)上心室頻脈有上心室頻脈有 aberrant conductionaberrant conduction
(PSVT with aberrant conduction)(PSVT with aberrant conduction)
單形性寬的單形性寬的 QRSQRS 波波治療治療 :
1. Amiodarone1. Amiodarone2. 2. 整流術整流術
Characteristics of the 12-lead ECG during the Characteristics of the 12-lead ECG during the tachycardia that suggest a ventricular origin tachycardia that suggest a ventricular origin for the arrhythmiafor the arrhythmia
• A A QRS complex >0.14 sQRS complex >0.14 s in the absence of in the absence of antiarrhythmic therapy antiarrhythmic therapy
• AV dissociationAV dissociation (with or without fusion or (with or without fusion or captured beats) or variable retrograde captured beats) or variable retrograde conduction conduction
• A A superior QRS axissuperior QRS axis in the presence of a right in the presence of a right bundle branch block patternbundle branch block pattern
• Concordance of the QRS patternConcordance of the QRS pattern in all in all precordial leads (i.e., all positive or all negative precordial leads (i.e., all positive or all negative deflections) deflections)
• Other Other QRS patterns (morphology) QRS patterns (morphology) with with prolonged duration that are inconsistent with prolonged duration that are inconsistent with typical right or left bundle branch block patterns typical right or left bundle branch block patterns
ECG CRITERIA THAT FAVOR ECG CRITERIA THAT FAVOR VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA
• AV dissociationAV dissociation • QRS width: QRS width:
>0.14 s with RBBB>0.14 s with RBBB configuration configuration >0.16 s with LBBB>0.16 s with LBBB configuration configuration
• QRS axis: QRS axis: Left axis deviation with RBBBLeft axis deviation with RBBB morphology morphology Extreme left axis deviationExtreme left axis deviation (northwest (northwest axis) axis) with LBBBwith LBBB morphology morphology
• Concordance of QRSConcordance of QRS in precordial leads in precordial leadsHarrison's Principles of internal Medicine, 16th Edition
ECG CRITERIA THAT FAVOR ECG CRITERIA THAT FAVOR VENTRICULAR TACHYCARDIAVENTRICULAR TACHYCARDIA
• Morphologic patterns Morphologic patterns of the QRS of the QRS complex RBBB:complex RBBB:Mono- or biphasic Mono- or biphasic complex in V1complex in V1RS (RS (only with left only with left axis deviationaxis deviation)) or or QSQS in V6 in V6
• LBBB: LBBB: Broad R wave in V1 or Broad R wave in V1 or V2 V2 0.04 s0.04 s
• Onset of QRS to nadir Onset of QRS to nadir of S wave in V1 or V2 of S wave in V1 or V2 of of 0.07 s0.07 s
• Notched downslope Notched downslope of Sof S wave in V1 or V2 wave in V1 or V2
• Q waveQ wave in V6 in V6
Harrison's Principles of internal Medicine, 16th Edition
Differential Diagnosis of Wide Differential Diagnosis of Wide Regular QRS TachcardiaRegular QRS Tachcardia
Absence of an RS complex in all precordial leads
Favor VT
Yes No
R to S interval > 100 ms in one precordial lead?
Yes
Favor VT
No
Atrio-ventricular dissociation?
Yes
Favor VT
No
Morphology criteria
Four-step AlgorithmFour-step Algorithm (by (by BrugadaBrugada et al) et al)
1
2
3
4
Differential Diagnosis of Wide Differential Diagnosis of Wide Regular QRS TachcardiaRegular QRS Tachcardia
Morphology criteria for VT present both in precordial leads V1-2 and V6?
RBBB LBBB
Yes
Yes
Favor VT
Four-step AlgorithmFour-step Algorithm (by (by BrugadaBrugada et al) et al)
Polymorphic VTPolymorphic VT
Torsade de pointTorsade de point Congenital Long QT syndromeCongenital Long QT syndrome
多形性寬的多形性寬的 QRSQRS 波波• MgSO4 MgSO4
• Overdrive pacingOverdrive pacing
• IsoproterenolIsoproterenol
• PhenytoinPhenytoin
• LidocaineLidocaine
Tachycardia
Assess QRS width
Narrow QRS(<0.12 s)
SVT
Wide QRS (>0.12 s)
Ventricular tachycardia
Supraventriculartachycardia
Preexcitedtachycardia
Short Run VT Non-sustain VT Sustain VT
Monomorphic VT
Polymorphic VT
Afib/AFL
Cardiac Conduction System
Triangle of Koch
Location of Accessory Pathways by anatomical region
Left side Accessory Pathway (Type A)
From heartpearls.com
Right side Accessory Pathway (Type B)
Accessory Pathway Ablation Site
Accessory Pathway
Atrioventricular (AV) Node Reentry Jump
Atrioventricular (AV) Node Reentry RA S1S2 Jump
Slow-Fast AVNRT
Atrioventricular (AV) Node Reentry RV S1S2 Jump
Fast-Slow AVNRT
Three variants of AVNRT
Accelerated junctional rhythm
Atrial Tachycardia
Atrial Flutter
Cavotricuspid Isthmus Ablation
上心室頻脈的治療上心室頻脈的治療((不穩定病患不穩定病患 ))
Unstable sign: 3 Symptom/5 SignUnstable sign: 3 Symptom/5 Sign 3 Symptom: Conscious change; Chest pain; 3 Symptom: Conscious change; Chest pain; Dyspnea.( Dyspnea.( 暈、痛、喘暈、痛、喘 )) 5 Sign: AMI 5 Sign: AMI CHF CHF Pulmonary edema Pulmonary edema Shock Shock HypotensionHypotension
Unstable sign Unstable sign DC cardioversion DC cardioversion
上心室頻脈的治療上心室頻脈的治療((穩定病患穩定病患 ))
迷走神經刺激法迷走神經刺激法 Adenosine (rapid push)Adenosine (rapid push)乙型阻斷劑乙型阻斷劑鈣離子阻斷劑鈣離子阻斷劑毛地黃毛地黃 AmiodaroneAmiodarone整流術整流術
心房纖維顫動心房纖維顫動 // 心房撲動心房撲動 Unstable condition – Unstable condition – 整流術整流術穩定病患穩定病患
- - 心房纖維顫動心房纖維顫動 > 48 hrs > 48 hrs heparization heparization- - 左心室射出率左心室射出率 > 40% > 40% 和和 左心室射出率左心室射出率 < 40%< 40%- - 控制心跳控制心跳 / / 控制心律控制心律
心房纖維顫動心房纖維顫動 // 心房撲動心房撲動((控制心跳控制心跳 ))
左心室射出率左心室射出率 > 40%> 40%-- 鈣離子阻斷劑鈣離子阻斷劑 ,, 乙型阻斷劑乙型阻斷劑 (Class I)(Class I)
左心室射出率左心室射出率 < 40 %< 40 %- Digoxin; Diltiazem; Amiodarone - Digoxin; Diltiazem; Amiodarone (Class IIb) (Class IIb)
心房纖維顫動心房纖維顫動 // 心房撲動心房撲動((控制心律控制心律 ))
開始發作到治療的時間小於四十八小時開始發作到治療的時間小於四十八小時1.1. 左心室射出率左心室射出率 > 40 %> 40 % - Amiodarone; Propafenone; Procainamide; - Amiodarone; Propafenone; Procainamide; Ibutilide; Flecainide (Class IIa ) Ibutilide; Flecainide (Class IIa )2.2. 左心室射出率左心室射出率 < 40 %< 40 % - - 整流術整流術 - Amiodarone (Class IIb ) - Amiodarone (Class IIb )
心房纖維顫動心房纖維顫動 // 心房撲動心房撲動((控制心律控制心律 ))
開始發作到治療的時間大於四十八小時開始發作到治療的時間大於四十八小時1.1.早期整流早期整流 :: - - 一開始就給一開始就給 heparin heparin - - 食道超音波排除心房血栓食道超音波排除心房血栓 - - 二十四小時內心臟整流二十四小時內心臟整流 - - 抗凝血劑再使用四星期抗凝血劑再使用四星期 2. 2. 延遲整流延遲整流 :: - -抗凝血劑先使用三星期抗凝血劑先使用三星期 --心臟整流心臟整流 --抗凝血劑再使用四星期抗凝血劑再使用四星期
WPW WPW 症候群併有心房纖維顫症候群併有心房纖維顫動動
WPW WPW 症候群併有心房纖維顫症候群併有心房纖維顫動動
不規則不規則 ,,寬的寬的 QRSQRS波的頻脈波的頻脈 心臟傳導如何從心房傳到心室心臟傳導如何從心房傳到心室
1.1. 從房室竇和附屬路徑傳下來的複合波從房室竇和附屬路徑傳下來的複合波
2.2. 或只從房室竇傳下來窄的複合波或只從房室竇傳下來窄的複合波 ((沒有沒有 deltadelta 波波 ) )
3.3. 或只從附屬路徑傳導下來有一個帶有或只從附屬路徑傳導下來有一個帶有 deltadelta波寬波寬的的 QRSQRS 波波
病患若有此心律會有非常短的病患若有此心律會有非常短的 R-R R-R 間距，而且間距，而且有很高的機率發展成心室纖維顫動有很高的機率發展成心室纖維顫動
WPW WPW 症候群併有心房纖維顫症候群併有心房纖維顫動動
有下列四種葯不能用有下列四種葯不能用 ::AdenosineAdenosineB-blockerB-blockerCa-channel blockerCa-channel blockerDigoxinDigoxin
THANK YOU FOR YOUR ATTENTION !!
