AMI与心律失常并发症.ppt
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Arrhythmias Complicating Acute Myocardial Infarction
Sinus Bradycardia
* Most common arrhythmia occurring during the early hours after MI and may occur in up to 40% of inferior and posterior infarcts.
* May be related to autonomic imbalance or to atrial and sinus node ischemia or both.
* Profound bradycardia may predispose the patient to ventricular ectopy.
* Usually resolves spontaneously, treatment is reserved for hemodynamically symptomatic arrhythmias and those with bradycardia dependent vent. Arrhythmias.
* Atropine usually successful for symptomatic bradycardia. Temporary pacing is rarely required.
Indications for Temporary Pacing
in the Peri-infarct Period
* Sinus bradycardia with hypotension, brady-dependent vent. arrhythmias, angina, syncope/presysnope, or congestive heart failure and refractory to atropine.
* Accelerated idioventricular rhythm with symptoms and rate less than 40 beats/min.
* Prolonged (>3 s) sinus pauses.
* Atrial fibrillation with inadequate vent. response.
* Asystole.
* Mobitz II second degree AVB.
* Third degree block
* New or progressive bifascicular block
Sinus Tachycardia
* May occur in up to 1/3 of patients in the peri-infarct period, esp. with ant. MI.
* The ischemic left ventricle may have a relatively fixed stroke volume; thus augmenting CO by increasing HR.
* It may occur as a result of sympathetic stimulation from locally released and circulating catecholamines, concurrent anemia, hypo or hypervolemia, hypoxia, pericarditis, inotropic drugs, pain, fever.
* Treatment includes optimizing hemodynamics, oxygenation, correction of anemia, electrolyte and acid base abnormalities, pain control, and anxiolytic agents.
* Beta blockers are indicated for patients without evidence of significant LV dysfunction or hypovolemia.
* Persistent sinus tachycardia as an early manifestation of heart failure is an indicator of poor prognosis.
Premature atrial Contractions
* Up to one half of patients with MI
* May be due to atrial or sinus node ischemia, atrial fibrillation, pericarditis, anxiety or pain.
* The combination of atrial asystole and rapid ventricular rate markedly decreases cardiac output and increase oxygen demands.
* Attempts should be made to restore sinus rhythm; if not, rate should be controlled aggressively to minimize oxygen demand.
* May have no prognostic significance after MI.
First degree AVB
* 5 % to 10 % patients with MI at some times during peri-infarct period.
* Almost all have supra-Hisian conduction abnormalities.
* Rare cases of infranodal block are seen with anterior MI and associated fascicular block; these patients are at risk for progressive block, including third degree block with ventricular asystole.
* May be associated with drugs that prolong AV conduction.
2nd degree Mobitz Type I Block
* May be seen with up to 10% cases of MI, typically inferior infarcts, and is due to increased vagal tone and ischemia.
* Conduction defect is usually in the AV node.
* When seen early after MI, usually responds to atropine and resolves within 48-72 hours.
* Late occurring Wenckebach is less sensitive to atropine and may be due to recurrent ischemia.
* Very rarely it may progress to higher grades of block that require permanent pacing.
* It has no impact on long-term prognosis.
Second-degree Mobitz Type II Block
* 1% of cases of MI and more common with anterior MI.
* High risk of progression to higher degrees of block, including sudden complete heart block with ventricular asystole.
* Should have temporary pacing wire placed prophylactically.
* Conduction defect is most likely infranodal.
* Most patients need permanent pacing and if it is uncertain, EP evaluation should be performed before discharge to assess integrity of the infranodal conduction system.
* Long term prognosis is related to size of infarct rather than conduction abnormality.
Complete Heart Block
* With either anterior or inferior infarct.
* With inferior infarcts ,the defect is likely to be in the AV node, with escape rhythms exceeding 40 beats/min and exhibiting a narrow QRS complex.
* With anterior infarct, the conduction defect is infranodal and the escape rhythm (if present) is usually less than 40 beats/min with a wide QRS complex.
* Typically CHB seen with ant. MI is preceded by progressive fascicular, bundle, or mobitz type II block.
* Temporary pacing may be required with inferior MI if the patient is hemodynamically unstable. It should always be used with anterior MI if progressive or CHB is present.
Complete Heart Block - Continued
* Permanent pacing is almost always required for high grade block in the setting of anterior MI.
* The prognosis is poor for these patients because of the large amount of myocardium involved.
* EP evaluation should be considered for patients with Anterior MI and transient CHB to assess the integrity of the infranodal conduction system.
* Transient CHB with inferior MI rarely requires permanent pacing and usually resolves spontaneously.
BBB
* New BBB has been reported in about 15% of cases of MI and is associated with an increased risk of CHB, CHF, cardiogenic shock, vent. arrhythmias and sudden death.
* Most commonly seen is RBBB; LBBB or alternating BBB being less common. This may be related to discrete anatomical location of RB compared to broad, fan shaped LB.
* The highest incidence of BBB occurs with LAD.
BBB
* Progressive infra-Hisian block indicates a significant risk of sudden CHB and asystole, and patients demonstrating progression should have temporary pacing wires placed.
* Persistent BBB confers a significantly higher mortality, because of the large amount of myocardium that must be involved to include the BB.......（后略) ......
Arrhythmias Complicating Acute Myocardial Infarction
Sinus Bradycardia
* Most common arrhythmia occurring during the early hours after MI and may occur in up to 40% of inferior and posterior infarcts.
* May be related to autonomic imbalance or to atrial and sinus node ischemia or both.
* Profound bradycardia may predispose the patient to ventricular ectopy.
* Usually resolves spontaneously, treatment is reserved for hemodynamically symptomatic arrhythmias and those with bradycardia dependent vent. Arrhythmias.
* Atropine usually successful for symptomatic bradycardia. Temporary pacing is rarely required.
Indications for Temporary Pacing
in the Peri-infarct Period
* Sinus bradycardia with hypotension, brady-dependent vent. arrhythmias, angina, syncope/presysnope, or congestive heart failure and refractory to atropine.
* Accelerated idioventricular rhythm with symptoms and rate less than 40 beats/min.
* Prolonged (>3 s) sinus pauses.
* Atrial fibrillation with inadequate vent. response.
* Asystole.
* Mobitz II second degree AVB.
* Third degree block
* New or progressive bifascicular block
Sinus Tachycardia
* May occur in up to 1/3 of patients in the peri-infarct period, esp. with ant. MI.
* The ischemic left ventricle may have a relatively fixed stroke volume; thus augmenting CO by increasing HR.
* It may occur as a result of sympathetic stimulation from locally released and circulating catecholamines, concurrent anemia, hypo or hypervolemia, hypoxia, pericarditis, inotropic drugs, pain, fever.
* Treatment includes optimizing hemodynamics, oxygenation, correction of anemia, electrolyte and acid base abnormalities, pain control, and anxiolytic agents.
* Beta blockers are indicated for patients without evidence of significant LV dysfunction or hypovolemia.
* Persistent sinus tachycardia as an early manifestation of heart failure is an indicator of poor prognosis.
Premature atrial Contractions
* Up to one half of patients with MI
* May be due to atrial or sinus node ischemia, atrial fibrillation, pericarditis, anxiety or pain.
* The combination of atrial asystole and rapid ventricular rate markedly decreases cardiac output and increase oxygen demands.
* Attempts should be made to restore sinus rhythm; if not, rate should be controlled aggressively to minimize oxygen demand.
* May have no prognostic significance after MI.
First degree AVB
* 5 % to 10 % patients with MI at some times during peri-infarct period.
* Almost all have supra-Hisian conduction abnormalities.
* Rare cases of infranodal block are seen with anterior MI and associated fascicular block; these patients are at risk for progressive block, including third degree block with ventricular asystole.
* May be associated with drugs that prolong AV conduction.
2nd degree Mobitz Type I Block
* May be seen with up to 10% cases of MI, typically inferior infarcts, and is due to increased vagal tone and ischemia.
* Conduction defect is usually in the AV node.
* When seen early after MI, usually responds to atropine and resolves within 48-72 hours.
* Late occurring Wenckebach is less sensitive to atropine and may be due to recurrent ischemia.
* Very rarely it may progress to higher grades of block that require permanent pacing.
* It has no impact on long-term prognosis.
Second-degree Mobitz Type II Block
* 1% of cases of MI and more common with anterior MI.
* High risk of progression to higher degrees of block, including sudden complete heart block with ventricular asystole.
* Should have temporary pacing wire placed prophylactically.
* Conduction defect is most likely infranodal.
* Most patients need permanent pacing and if it is uncertain, EP evaluation should be performed before discharge to assess integrity of the infranodal conduction system.
* Long term prognosis is related to size of infarct rather than conduction abnormality.
Complete Heart Block
* With either anterior or inferior infarct.
* With inferior infarcts ,the defect is likely to be in the AV node, with escape rhythms exceeding 40 beats/min and exhibiting a narrow QRS complex.
* With anterior infarct, the conduction defect is infranodal and the escape rhythm (if present) is usually less than 40 beats/min with a wide QRS complex.
* Typically CHB seen with ant. MI is preceded by progressive fascicular, bundle, or mobitz type II block.
* Temporary pacing may be required with inferior MI if the patient is hemodynamically unstable. It should always be used with anterior MI if progressive or CHB is present.
Complete Heart Block - Continued
* Permanent pacing is almost always required for high grade block in the setting of anterior MI.
* The prognosis is poor for these patients because of the large amount of myocardium involved.
* EP evaluation should be considered for patients with Anterior MI and transient CHB to assess the integrity of the infranodal conduction system.
* Transient CHB with inferior MI rarely requires permanent pacing and usually resolves spontaneously.
BBB
* New BBB has been reported in about 15% of cases of MI and is associated with an increased risk of CHB, CHF, cardiogenic shock, vent. arrhythmias and sudden death.
* Most commonly seen is RBBB; LBBB or alternating BBB being less common. This may be related to discrete anatomical location of RB compared to broad, fan shaped LB.
* The highest incidence of BBB occurs with LAD.
BBB
* Progressive infra-Hisian block indicates a significant risk of sudden CHB and asystole, and patients demonstrating progression should have temporary pacing wires placed.
* Persistent BBB confers a significantly higher mortality, because of the large amount of myocardium that must be involved to include the BB.......（后略) ......
附件资料：
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