TOMASZ WIKAREK

SMALL REVIEW
CARDIAC CONDACTION SYSTEM

ECG

What is the cardiac condaction system?

Cardiac condaction system consist of:

Sinoatrial node (SA node)

Internodal pathways
Atrioventricular node (AV node) Atrioventricular bandle

Bandle of the Purkinje system

SA node
also called the sinus node is the impulse-generating (pacemaker) tissue located in the right atrium of the heart
SA node is a generator of sinus rhythm (60100/min) these cells are modified cardiac myocytes.

Role as a pacemaker
Although all of the heart's cells possess the ability to generate the electrical impulses that trigger cardiac contraction, the sinoatrial node normally initiates it, simply because it generates impulses slightly faster than the other areas with pacemaker potential.
Because the sinoatrial node is responsible for the rest of the heart's electrical activity, it is sometimes called the primary pacemaker.

Role as a pacemaker
If the SA node does not function, or the impulse generated in the SA node is blocked before it travels down the electrical conduction system, a group of cells further down the heart will become the heart's pacemaker

Innervation of the SA node

The SA node is richly innervated by parasympathetic nervous system fibers (CN X) and by sympathetic nervous system fibers (Spinal Nerve). Stimulation of the vagus nerve (the parasympathetic fibers) causes a decrease in the SA node rate. Stimulation via sympathetic fibers causes an increase in the SA node rate (thereby increasing the heart rate and force of contraction)

ECG
The ECG is a recording of the activity of the heart. The electrical currents generated by the heart spread throught the body to the skin, where they can be sensed by appropiately placed electrodes.

ECG
Adventages: Very cheap diagnostic metod Available Easy to do
Disadventages: No 100% specyfic diagnostic metod

How to do ECG???

Limb leads

Placement of electrodes ???

ECG
C

Precordial leads Limb leads

V1 V2 V3 V4

In the fourth intercostal space (between ribs 4 & 5) just to the right of the sternum (breastbone). In the fourth intercostal space (between ribs 4 & 5) just to the left of the sternum. Between leads V2 and V4.

In the fifth intercostal space (between ribs 5 & 6) in the mid-clavicular line (the imaginary line that extends down from the midpoint of the clavicle (collarbone).
Horizontally even with V4, but in the anterior axillary line. (The anterior axillary line is the imaginary line that runs down from the point midway between the middle of the clavicle and the lateral end of the clavicle; the lateral end of the collarbone is the end closer to the arm.) Horizontally even with V4 and V5 in the midaxillary line. (The midaxillary line is the imaginary line that extends down from the middle of the patient's armpit.)

V5

V6

V1: right 4th intercostal space V2: left 4th intercostal space V3: halfway between V2 and V4

V4: left 5th intercostal space, mid-clavicular line

V5: horizontal to V4, anterior axillary line

V6: horizontal to V5, mid-axillary line

Precordial leads

Holter monitor
is named for Dr. Norman J. Holter who invented telemetric cardiac monitoring in 1949 is a portable device for continuously monitoring various electrical activity of the central nervous system for at least 24 hours. The most common use is for monitoring the heart or ECG, but can also be used for monitoring EEG

Therapeutic use of Holter monitor

And olso another therapeutic use

Difrencess between interval and segmet

Normal ECG

Diagram of the ECG and representative depolarrization and repolarization of the atria and ventricle

Normal ECG
It is important to remember that there is a wide range of normal variability in the 12 lead ECG. Measurements
Heart Rate: 60 - 90 bpm PR Interval: 0.12 - 0.20 sec QT Interval (QTc 0.40 sec) P duration < 0.12 sec and P amplitude < 2.5 mm QRS duration 0.12 sec

Normal ECG
Rhythm Normal sinus rhythm: the P wave before every QRS complex and in leads I and II must be upright (positive) if the rhythm is coming from the sinus node. Axis The normal QRS axis should be between - 30 and +90 degrees

Axis
The fastest, non-specific method to determine the QRS axis is to find the major direction of the QRS complex (positive or negative) in leads I and aVF. If the QRS complex is upright (positive) in both lead I and lead aVF, then the axis is normal (see the picture).

Axis
If the QRS is upright in lead I and downward (negative) in lead aVF, then the axis is between 0 and -90 degrees, likely left axis deviation. However, in this scenario the axis could fall between 0 and -30 which is technically a normal QRS axis. To further distinguish normal from left axis deviation in this setting, look at lead II. If lead II is downward (negative), then the axis is more towards -90 and left axis deviation is present. If the QRS complex in lead II is upright (positive), then the axis is more towards 0 degrees and the QRS axis is normal.

Axis
If the QRS is predominantly downward in both leads I and aVF, then the axis is indeterminate. If the QRS is downward (negative) in lead I and upward (positive) in lead aVF, then the axis is rightward.

Heart Rate
Because ECG paper usually moves at a standardized 25mm/sec, the vertical lines can be used to measure time. There is a 0.20 sec between 2 of the large lines. Therefore, if you count the number of heart beats (QRS complexes) in between 30 large boxes (6 seconds) and multiply by 10, you have beats per minute. Conveniently, ECG paper usually has special markings every 3 seconds so you don't have to count 30 large boxes.

Heart Rate

Disorders of the cardiac rhythm:

Tachycardia - >100/min Normocardia 60-100/min Bradycardia - <60/min

Bradycardia
is defined as a resting heart rate of under 60 beats per minute
Classification: Atrial bradycardia Atrioventricular nodal bradycardia Ventricular bradycardia

Causes of bradycardia
1. Cardiac causes (acute or chronic ischemic
heart disease, valvular heart disease, or degenerative primary electrical disease)

2. Non-cardiac causes (drug use, metabolic

or endocrine issues, especially in the thyroid)

Tachycardia
In tachycardia, heart pumps less efficiently and provides less blood flow to the rest of the body, including the heart itself.
The increased heart rate also leads to increased work and oxygen demand for the myocardium, which can cause a heart attack if it persists.

Causes of tachycardia
Autonomic causes
Endocrine causes Hemodynamic responses - If blood pressure
decreases, the heart beats faster in an attempt to raise it. This is called r e f l ex ta c hy c a r d i a . This can happen in response to a decrease in blood volume (through dehydration or bleeding), or an unexpected change in blood flow.

Types of tachycardia
Sinus tachycardia Ventricular tachycardia Supraventricular tachycardia rhythms include:
Atrial fibrillation AV nodal reentrant tachycardia (AVNRT) AV reentrant tachycardia (AVRT) Junctional tachycardia

Atrial flutter
It is a supraventricular tachcardia an atrial rate of ap. 240 to 350 beats/minute
the impact and symptoms of atrial flutter depend on the heart rate of the patient it is usually associated with a fast heart rate or tachycardia (230380/minute)

Heart rate
is a measure of the ventricular rather than atrial activity in atrial flutter and atrial firbillation the AV node exerts a protective effect on heart rate by blocking atrial impulses in excess of about 180 beats/minute (If the flutter rate is 300/minute only half of these impulses will be conducted, giving a ventricular rate of 150/minute, or a 2:1 heart block)

Atrial flutter

Atrial fibrillation (AF)

is the most common cardiac arrhythmia It is a supraventricular tachycardia indicator of AF is the absence of P waves on an ECG, which are normally present when there is a coordinated atrial contraction at the beginning of each heart beat risk increases with age, 8% of people over 80 having AF

Atrial fibrillation
Atrial fibrillation is diagnosed on an electrocardiogram (ECG), an investigation performed routinely whenever an irregular heart beat is suspected.

Atrial fibrillation
Characteristic are the absence of P waves, with unorganized electrical activity in their place, and irregular R-R intervals due to irregular conduction of impulses to the ventricles

Sinus rhythm

Atriall fibryllation

Classification of atrial fibrillation

AF Category Defining Characteristics

First detected

only one diagnosed episode recurrent episodes that self-terminate in less than 7 days recurrent episodes that last more than 7 days an ongoing long-term episode and accepted

Paroxysmal

Persistent

Permanent

Management of atrial fibrillation

Electrical cardioversion involves the restoration of normal heart rhythm through the application of a electrical shock.
Chemical cardioversion is performed with drugs (amiodarone)

Cardioversion
energy corresponds to the R wave of the QRS complex on the ECG.

Ventricular tachycardia
HR >100/min that originates in one of the ventricles of the heart
Ventricular tachycardia can be classified based on its morphology
Monomorphic ventricular tachycardia Polymorphic ventricular tachycardia

Non-sustained ventricular tachycardia.

Polymorphic ventricular tachycardia or Torsades de Pointes.

Ventricular flutter
over 200 beats/min it is characterized on the ECG by a sinusoidal waveform without clear definition of the QRS and T waves ventricular fibrillation

Ventricular fibrillation (VF)

is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart. when this happens, chambers contract in a rapid, unsynchronized way.
The heart pumps little or no blood.

S TA R T C P R ! ! !

Ventricular fibrillation (VF)

ventricular fibrillation is very serious event. collapse and sudden cardiac death will follow in minutes unless medical help is provided immediatel
to STOP VF defibrillator

Defibrillation
is the definitive treatment for the lifethreatening cardiac arrhythmias: ventricular fibrillation and pulseless ventricular tachycardia terminates the arrhythmia, and allows normal sinus rhythm to be reestablished by the body's natural pacemaker, in the sinoatrial node of the heart.

cardioverter-defibrillator
Today one effective way to correct lifethreatening rhythms is by using an electronic device called an implantable cardioverterdefibrillator (ICD). This device shocks the heart to normalize the heartbeat if the heart's own electrical signals become disordered.

cardioverter-defibrillator

cardioverter-defibrillator

Heart Block

A heart block is a disease in the electrical system of the heart. A heart block can be a blockage at any level of the electrical conduction system of the heart.

Types of heart block

Blocks that occur within the sinoatrial node (SA node) are described as S A n o d a l b l o c k s .
Blocks that occur within the atrioventricular node (AV node) are described as AV n o d a l b l o c k s . Blocks that occur below the AV node are known as i n f ra H i s i a n b l o c k s ( n a m e d a f te r t h e b u n d l e o f H i s ) . Blocks that occur within the left or right bundle branches are known as b u n d l e b ra n c h b l o c k s . Blocks that occur within the fascicles of the left bundle branch are known as h e m i b l o c k s .

First-degree AV heart block

First-degree heart block, or first-degree AV block, is when the electrical impulse moves through the AV node more slowly than normal. The time it takes for the impulse to get from the atria to the ventricles (the PR interval) should be less than about 0.2 seconds. If it takes longer than this, it's called first-degree heart block.

First-degree heart block

What is a second-degree heart block?

In this condition, some signals from the atria don't reach the ventricles. This causes "dropped beats."
On an ECG, the P wave isn't followed by the QRS wave, because the ventricles weren't activated

There are two types of second-degree heart block :

Type I second-degree heart block, or Mobitz Type I, or Wenckebach's AV block. Electrical impulses are delayed more and more with each heartbeat until a beat is skipped. This condition is not too serious but sometimes causes dizziness and/or other symptoms.
Type II second-degree heart block, or Mobitz Type II. This is less common than Type I but generally more serious. Because electrical impulses can't reach the ventricles, an abnormally slow heartbeat may result. In some cases a pacemaker is needed.

Mobitz Type I = Wenckebach's AV block

Mobitz Type II

Third-degree heart block

Complete heart block, also referred to as thirddegree atrioventricular (AV) block
is a disorder of the cardiac conduction system where there is no conduction through the AV node

SA impulse is blocked and an accessory pacemaker in the lower chambers will typically activate the ventricles.

Third-degree heart block

Since this accessory pacemaker also activates independently of the impulse generated at the SA node, two independent rhythms can be noted on the electrocardiogram (ECG). One of the most important characteristic of this block is the absolute absence of the opportunity for atrial impulses to enter and capture the ventricles

Third-degree heart block

the most common cause is coronary ischemia

Third-degree heart block

Left ventricular hypertrophy

while ventricular hypertrophy occurs naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease, or high blood pressure.

The principal method to diagnose LVH is echocardiography

Left ventricular hypertrophy

Sokolow + Lyon (Am Heart J, 1949;37:161)
S in V1 + R in V5 or V6 (whichever is larger) 35 mm R in aVL 11 mm

Left ventricular hypertrophy

Right ventricular hypertrophy

Right ventricular hypertrophy is commonly associated with any form of right ventricular outflow obstruction or pulmonary hypertension

Wolf-Parkinson-White Syndrome (WPW)

This is characterized by an extra electrical pathway (bypass tract) that is present at birth
The bypass tract connects the atrium to the ventricle and conducts the electrical impulse between upper and lower chambers more quickly than the normal conduction pathway. WPW is also dangerous in patients who have atrial fibrillation, because the rapid, chaotic atrial impulses in the atrium can travel through the bypass tract to the ventricle and result in a very rapid heart rate.

Wolf-Parkinson-White Syndrome

Wolff-Parkinson-White syndrome
Ventricular Pre-excitation is represented by the short P-R interval, wide QRS complex, and delta wave

Long QT syndrome (LQTS)

is a congenital disorder characterized by a prolongation of the QT interval on ECG and a propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death. the QT interval on the ECG, measured from the beginning of the QRS complex to the end of the T wave, represents the duration of activation and recovery of the ventricular myocardium

QTc
QT intervals corrected for heart rate (QTc) longer than 0.44 seconds are generally considered abnormal, however a normal QTc can be more prolonged in females (up to 0.46 sec). The Bazett formula is used to calculate the QTc, as follows:

QTc = QT/square root of the R-R interval.

Long QT syndrome
In LQTS, QT prolongation can lead to polymorphic ventricular tachycardia, or torsade de pointes, which itself may lead to ventricular fibrillation and sudden cardiac death.

Acute myocardial infarction

non-ST-elevated myocardial infarction

ST-elevated myocardial infarction

Localization of ischemia

V1-V4 correspond to the anterior wall

II, III, aVF correspond to the inferior wall V5, V6, I, aVL correspond to the lateral wall

The changes in the ECG

The changes in the ECG are seen in the leads adjacent to the infarct. In the first few hours the T waves become abnormally tall and the ST segments begin to rise. In the first 24 hours the T wave will become inverted, as the ST elevation begins to resolve. Pathological Q waves may appear within hours or may take greater than 24 hr. Long term changes of ECG include persistent Q waves in 90% In non Q-wave infarcts, ST depression and T wave inversion occur without ST elevation.

Sequence of Changes in Myocardial Infarction

Sudden cardiac death.

is death resulting from an abrupt loss of heart function. The victim may or may not have diagnosed heart disease. The time and mode of death are unexpected. It occurs within minutes after symptoms appear. The most common underlying reason for patients to die suddenly from cardiac arrest is coronary heart disease.

Causes of sudden cardiac death

Most of the cardiac arrests that lead to sudden death occur when the electrical impulses in the diseased heart become rapid (ventricular tachycardia) or chaotic (ventricular fibrillation) or both. This irregular heart rhythm (arrhythmia) causes the heart to suddenly stop beating