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Aware and urgent heart and vascular diseases such as acute myocardial infarction, aortic dissection, and aortic aneurysm rupture may be referred to a medical institution, but heart diseases such as stable angina, valvular disease, and arrhythmia remain at home. If you do, you will not be aware of it.
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Daily Gendai Healthcare
We will deliver the medical and health articles of the evening paper "Daily Gendai". From everyday health laws to the latest medical information, all articles are based on interviews with doctors and specialists.
Wikipedia related words
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AntonymIs "arrangement", but clinicallyNormal sinus rhythm Often called (NSR: Normal Sinus Rhythm).Normal sinus rhythm has the following characteristics.
- The PR interval is constant.
- QRS width is 0.1 seconds or less.
- There is a P wave.
- The interval between the P wave and the QRS is constant at about 0.1 to 0.2 seconds.
Conversely, arrhythmias are categorized according to which of these conditions are abnormal.Furthermore, there is an idea to include not only the pulse rate but also the pulse cycle, changes in strength, and the rising speed of the electrocardiogram waveform..
The mechanism of arrhythmia is abnormal stimulus generation and abnormal conduction.Most of them are elderly people, but there are universal people who have arrhythmia in each generation.As a cause,Ischemic heart disease,Congenital heart diseaseand so on.
There are various types of arrhythmias, and they are completelySubjective symptomsSome arrhythmias are not accompanied by, but some arrhythmias are life-threatening.Sudden deathIt can also be the cause of.However, even ordinary people often have arrhythmias when they are in poor physical condition, and even people who have constant arrhythmias often have no problems in their daily lives.
心 臓On the whole bodybloodSend outpumpIs working.It is what drives the pump.First,Right atriumIt is inSinus node (SA node) gets excited and electrical stimulationAtriumThroughRight atriumBelowAtrioventricular noduleIs transmitted to.Further excitement is conducted from the atrioventricular node to the His bundle, Purkinje fibers, andMyocardiumElectrical stimulation is transmitted to the whole.Arrhythmia occurs when the excitement of the heart is not transmitted normally due to an impaired stimulation generation or conduction pathway.
For example,Atrial fibrillationOf the atrium筋肉Each part of the heart is in a state of disordered and irregularly excited, and this disordered excitement is transmitted to the ventricles, resulting in an irregular pulse.
Classification by heart rate
At rest in humanspulseIs usually about 50 to 100 beats / minute, but if it is less than thisBradycardia, Many casesTachycardiaCalled.ArrhythmiaHeart rateTherefore, it can be divided into tachyarrhythmia, bradyarrhythmia, and arrhythmia without abnormal heartbeat.
Extra systole (Premature Contraction) is a state in which the RR interval is almost constant, but some heartbeats are shifted forward.Alternatively, normal pulses may be drowned out (compensatory extrasystoles) or occur at regular intervals with normal pulse cycles (intermittent extrasystoles).When symptoms occur, it causes dizziness and fainting mainly when the chest feels incomparable discomfort, and when it occurs repeatedly, it is not life-threatening if left untreated if there is no heart disease.In the worst case, if you have heart disease, it may lead to ventricular fibrillation, which is dangerous.
- Sinus tachycardia
- It is seen after exercise in normal people.If it is also seen at rest, it is necessary to suspect respiratory illness, infectious disease, endocrine illness, neurological illness, psychiatric illness, etc.
- Atrial fibrillation (Af, AF: Atrial fibrillation)
- If the RR interval is completely irregular, it is most often the case.In addition, there is no P wave, and the baseline sways like a fine artifact.
- Atrial flutter (AF, AFL: Atrial Flutter)
- The baseline sways like a serration.
- Multifocal atrial tachycardia (MAT)
- Like Af, the RR interval is completely irregular, but there are P waves with various shapes and directions. It is rare compared to Af.
- Supraventricular tachycardia
- This is a large classification and only means that it is not a ventricular rhythm.It is necessary to classify more finely in order to search for the cause and treat it.
- Reentricular tachycardia
- MechanismAs mentioned in the above, the excitement of the heart is usually transmitted in only one direction, but it occurs when a path in which the excitement is reversed is formed due to a congenital anomaly or after myocardial infarction.
- Premature Atrial Contraction (PAC)
- Atrioventricular junctional contraction
- Ventricular tachycardia (VT: Ventricular tachycardia)
- The width of all QRS is 0.2 seconds or more. There is no P wave.
- Ventricular fibrillation (Vf: Ventricular fibrillation)
- Sine waveA waveform consisting only of waves close to.Do not touch the pulse in the periphery.ClinicallyCardiac arrestIt is in a state.
- Ventricular fibrillation (VF: Ventricular Flutter)
- Premature Ventricular Contraction (PVC (VPC))
- The QRS complex of extra systoles is wide.In particular, a state in which the shape and orientation of the QRS is not constant is called multigenic PVC, and indicates that abnormalities occur in multiple parts or a wide area of the ventricular wall.Especially when it is seen 1 to 6 times or more per minute, it may develop into the above-mentioned ventricular tachycardia.
The block described here is a conduction disorder.
- (SA block)
- A state in which the excitatory conduction generated in the sinus node is not transmitted to the atrium.
- Atrioventricular block (AV block)
- Incomplete or no excitatory conduction from the atrium to the ventricles.
- I degree atrioventricular block
- There is a P wave, and the interval between the P wave and the QRS is constant, but the PR interval is 0.21 seconds or more.
- II degree atrioventricular block
- Arrhythmia in which QRS falls out after P wave.
- Wekkenbach type atrioventricular block
- After the PR interval gradually opens, the QRS falls out.
- Mobits Type II Atrioventricular Block
- Sometimes the QRS is missing, but the PR interval for heartbeats that are not missing is constant.
- III degree atrioventricular block
- There is a P wave, but there is no temporal relationship between the P wave and the QRS complex.
- (AV dissociation)
- Junctional rhythm
- Sick sinus syndrome (SSS: Sick sinus syndrome)
- Respiratory Arrhythmia
- The pulse rises during inspiration and falls during exhalation.Often seen in young people.The pulse is irregular but not ill.
- Bundle branch block
- Bundle branch block (BBB) is a condition in which nerve transmission is interrupted in either the left or right ventricular wall.The interrupted ventricular wall contracts later than the other due to myocardial conduction, resulting in a bimodal (rabbit ear) waveform.
- Classification by part
- Bundle branch block depends on where it is blockedRight bundle branch block(Ukyaku Black, English Right bundle branch block: RBBB)Left bundle branch blockThere are two types, (Sakyaku Black, English Left bundle branch block: LBBB).WilliaM MorroWI remember.That is, in the chest lead electrocardiogram, V1 is downward bimodal, V6 is upward bimodal, left bundle branch block, and right bundle branch block is the opposite.
- Classification by degree
- Bundle branch block is classified according to the degree of blockage.
- From the aboveComplete right leg blockIt is classified into four types: ,,,.
When it is completely asymptomatic, it is called asymptomatic arrhythmia, and when it is symptomatic, it is called symptomatic arrhythmia.As a symptom,Palpitation,dizzy,syncope(Adam-stoks attacks), chest discomfort, shortness of breath, chest pain, etc.
- Holter ECG
- Echocardiography(Ultrasound tomography)
- Cardiac catheterization
- His bundle electrocardiogram
See the section on individual arrhythmias from the above classification.
For arrhythmias that require treatmentAntiarrhythmic drugDrug treatment that suppresses arrhythmia and controls pulse,pacemaker,Implantable cardioverter defibrillator (ICD) etc.surgicalNon-drug treatment is performed.Ventricular fibrillationIn dangerous arrhythmias such asDefibrillatorIt is necessary to shock the heart (defibrillation) and restore the rhythm of the heart to normal.
ACLSIn, all antiarrhythmic drugs give priority to electrical treatment first, recognizing that they can cause arrhythmia by themselves.Drug treatmentIt is also recommended to use as few types of drugs as possible.
Sudden cardiac death
arrhythmia,Myocardial infarction,Cardiomyopathy,Valvular diseaseSudden death due to heart disease such as is called sudden cardiac death.The cause of sudden cardiac death isIschemic heart disease,Ventricular fibrillationIt is said that there are many.Long QT syndrome,Brugada syndromeArrhythmias that show special electrocardiographic waveforms such as are also known to cause sudden cardiac death.
How to read an electrocardiogram
First of all, the diagnosis of arrhythmiaelectro-cardiogramTherefore, I will show you how to read it.
Since the process of diagnosis from the method of taking ECG findings is enormous, the classification by Takeshi Yamashita of the Cardiovascular Institute is described here.Whatever electrocardiogram you see, what you do with it can be divided into three categories: "leave it alone", "clean it up by yourself", and "urgently borrow the help of others".Vital signs are more pronounced than electrocardiograms in assessing urgency.If you look at the monitor electrocardiogram and there is a waveform like VT and the circulatory dynamics are poor and you have impaired consciousness, you need to take urgent measures, but if you are asked "What?" It is a problem only on the electrocardiogram, and the hemodynamics have not deteriorated at all.
Procedure for taking basic findings
- Regarding tuning and heart rate
- Measure the interval between P wave and P wave, and the interval between R wave and R wave, and obtain the atrial and ventricular beats from the reciprocals.The interval averages 3 heartbeats.When there is no P wave such as atrial fibrillation, the PP interval is not described.
- (Seconds),RR interval, Atrial beat (60-100), ventricular beat (60-100).
- Make a tuning judgment.This determines whether it is a normal arrhythmia, sometimes an arrhythmia, or an absolute arrhythmia.
- Measure QRS average electrical axis and transition zone
- The electric shaft is normally -30 to 100, and the transition band is OK if it is around V3.
- Basic measurement
- P wavePotential (0.25 or less) and amplitude (0.10 or less)
- , Has a width of 0.04 or more or an amplitude of 1/4 of the R wave.
- Suspect cardiac hypertrophy, especially if RV5 + SV1 exceeds 3.5, or RaVL exceeds 1.2.Also check for low potential.
- Is there ST, ST elevation, or ST elevation?
- Isn't it high (more than 12 mV, this isHyperkalemia(Suspect), is there a negative T wave? This suspects cardiomyopathy or myocardial ischemia.
- Isn't there a U wave?HypokalemiaNegative U wave suggests ventricular load and myocardial ischemia.
- arrhythmiaIsn't it?Bradycardia,Tachycardia,,,Atrial fibrillation,Atrial flutter, Others.
- State the overall findings.
In medical practice, there are only three patterns that medical professionals do.The first is to leave it alone, the second is to clean it up by yourself, and the third is to urgently use the power of others.The same is true when looking at an electrocardiogram.Of particular importance is the decision to rely on the help of others.this isvital signsOther information such as is very helpful.This judgment can usually be resolved with pre-ECG knowledge of arrhythmias.Judgment of arrhythmia is mainlyelectro-cardiogramIs done by.If you just want to screen for arrhythmia, only leads II and V12 out of 1 leads are sufficient.Especially for lead IIP waveIs easy to read and useful.It should be noted that this method overlooks other than arrhythmia. In order to avoid overlooking ST changes, it is important to exclude only ST changes in 12 leads in advance.It is important to recognize that there is no ST information on monitor electrocardiograms.Empirically, if the heart rate is normal and the QRS complex is narrow, hemodynamics are usually stable.If the QRS complex is wide due to tachycardia, it is necessary to confirm the patient's condition.In the case of arrhythmia, there is always anxiety that it will get worse if left alone.However, the first question is whether treatment is needed now, and the future is usually considered later.If it gets worse, there are many cases of underlying heart disease, and it is often impossible to do anything just by looking at the electrocardiogram.
- First, is it sinus rhythm with 12 leads? Investigate whether there is ST change.
- Next, arrhythmia is screened by lead II and lead V1.Of particular importance is the patient's appearance,Heart rate,QRS width.
Heart rateNormal value is 50-100 / min, below 50 / minBradycardiaIt is said.The pulse fluctuates during the day and tends to be late at night.That is, it is not necessary to worry about the pulse at night even if it is slightly below the normal value.What to worry aboutarrhythmiaThis should be considered from episodes and electrocardiographic findings, such as when the pulse suddenly slowed down or when the pulse stopped for 2 seconds or more.Diagnosis of bradyarrhythmia is very simple.P waveIf exists normallyAtrioventricular blockAnd if there is no P waveSinus node dysfunction syndromeIs.The difference between the two is very important.Atrioventricular block is a disorder of the ventriclesSudden deathBecause it is at risk.If you see this, screen for heart disease and save your life if you do not know the causepacemakerIt becomes an adaptation of.In the case of sinus node dysfunction syndrome, if there are no symptoms, it is left untreated, and even if there are symptoms, there is no change in the prognosis, so the treatment is aimed at improving QOL.
The idea of tachycardia
Heart rateThe normal value for is 50 to 100 / min, and above 100 / minTachycardiaIt is said.There is also sinus tachycardia in tachycardia, and it is an extremely normal reaction that tachycardia gradually occurs during exercise, so from the viewpoint of arrhythmia, episodes and electrocardiographic findings that suddenly become faster are important.In the case of tachycardia as an arrhythmiaQRS widthIs very important. A QRS complex of less than 0.12 seconds, or 3 mm, is a supraventricular (usually atrial) arrhythmia, and a QRS width of 0.12 seconds, or 3 mm or more, is a ventricular arrhythmia.Ventricular arrhythmia is an emergency and requires immediate attention. The fact that the site of arrhythmia can be identified by the QRS width is a rule of thumb that if the stimulus is conducted through a normal special myocardium, the conduction will be completed within 0.12 s.The word is an important exception.This is a supraventricular arrhythmia with a wide QRS complex.However, although the QRS complex is narrow, the phenomenon of ventricular arrhythmia is hardly known, so if the QRS complex is wide, there are few mistakes if it is considered an emergency.If you can judge whether it is ventricular or supraventricular, if it is supraventricular, then the atrial beat rate is ventricular.RR intervalCheck the ventricular beat rate with, thereby naming the arrhythmia.Separately, it is important to count the effective pulse rate by palpation.This is a grasp of the patient's condition and is not very important for diagnosing arrhythmias.Which is the case for tachyarrhythmiaP waveIt is often difficult to define waveforms one by one.In that case, it is done with an image, but it is difficult without experience.Basically, if the electrical beat is 100 to 250 / min, it is 250 to 350 / min, and if it exceeds 350 / min.However, the term ventricular flutter does not exist clinically.If you get a fast pulse once in a whileExtra systoleThat.
- ^ Hitoshi Maruyama, Risk Management Vital Signs, Society of Physical Therapy Science, 2005, Vol. 20, No. 1, p.53-58, Doi: 10.1589 / rika.20.53,
"Non-drug treatment guidelines for arrhythmia (2006 revised edition)Joint Research Group Participating Society: Japanese Circulation Society and others (Minds Medical Information Service