Cardiac arrhythmia treatment

Cardiac arrhythmias are one of the most common types of violations, their frequency does not give an accurate assessment of [20]. Transient arrhythmias occur in healthy people. In the event of Internal Medicine, the conditions for the development of cardiac arrhythmias, sometimes becoming the main manifestation of the clinical picture of the disease, as, for example, in thyrotoxicosis, ИБС. Arrhythmias complicate the course of many cardiovascular diseases.

The term "heart rhythm disorders"Understand arrhythmias and heart block. Arrhythmia - a violation of the frequency, regularity and consistency of heart rate. Violations of excitation cause the development of heart block.

All arrhythmias - is the result of changes in the basic functions of the heart: automatism, excitability and conduction. They develop in violation of the formation of the action potential cells and its rate of change as a result of changes in potassium, sodium and calcium channels. Violation of the activity of potassium, sodium and calcium channels depends on sympathetic activity, acetylcholine levels, muskarinopodobnyh M2Receptor, АТФ

Machinery heart rhythm disorders:

1. Violations of pulse formation: - Violations of sinus node automaticity (SU); - Abnormal automaticity and trigger activity (early and late depolarization).

2. The circulation of the excitation wave (re–entry).

3. Violations of the pulse.

4. Combinations of these changes.

Violations of pulse formation. Ectopic foci automatic activity (abnormal automaticity) may be in the atria, коронарном синусе, around the perimeter of the atrioventricular valves, the AV-node, in the bundle of His and the Purkinje fibers. The emergence of ectopic activity contributes to reduction of automatism SU (bradycardia, dysfunction, sick sinus syndrome (SSS)).

Violation of the pulse. Violations of the pulse can occur on any parts of the conducting system of the heart. The blockade in the way of momentum appears asystole, брадикардией, sinoatrial, AV-and intraventricular block. This creates conditions for circular motion re–entry.

Roundabout. To form re–entry You must have a closed loop of, unidirectional block in one of the sections of the circuit and slow the spread of excitation in the other part of the contour. The momentum is slowly spreading on the knee with the stored conductive circuit, rotates and comes in knee, where there was a blockade of. If the conductivity is restored, then the pulse, then looping, returned to their place of origin and reiterates its movement. Wave re–entry can occur in sinusovom and AB-nodes, atria and ventricles, in the presence of accessory pathways and in any portion of the conductive system of the heart, which may appear dissociation of excitation. This mechanism plays an important role in the development of paroxysmal tachycardias, anxiously and Mertz predserdiy.

Triggered Activity. When the trigger activity is the development of trace depolarization at the end or beginning of the repolarization phase of rest. This is due to a violation of transmembrane ion channels.

In the development of arrhythmias, resulting in various diseases and conditions, play an important role of exogenous and endogenous factors, such as psychosocial stress, previous life-threatening arrhythmias in 20-30% of cases [20], neurovegetative imbalance, with a predominance of sympathetic activity and parasympathetic divisions of the autonomic nervous system, toxic effects (alcohol, nicotine, drugs, medications, industrial poisons, etc.), diseases of the internal organs.

The etiology of cardiac arrhythmias:

· Myocardial damage from any cause: coronary atherosclerosis, myocarditis, dilated and hypertrophic cardiomyopathy, heart defects, diabetes mellitus, thyroid disease, climacteric, amyloidosis, sarcoidosis, гемохроматоз, myocardial hypertrophy in hypertension and chronic pulmonary heart, intoxication (alcohol, Nicotine, Drug, industrial substances (mercury, arsenic, cobalt, chloro and organophosphates), closed injury of the heart, involutive processes in aging.

· Defeats SU and cardiac conduction system of the innate and acquired genesis, for example, SSS, sclerosis and calcification of the fibrous skeleton of the heart and primary sklerodegenerativnoe defeat the conduction system of the heart with the development of AV-and intraventricular blockades, additional pathways (for example, синдромы WPW, CLC).

· Heart valve prolapse.

· Tumors of the heart (Myxoma etc.).

· Pericardial disease: pericarditis, plevroperikardialnye adhesions, metastases to the pericardium, etc.

· Electrolyte abnormalities (potassium imbalance, Calcium, sodium, Magnesium).

· Mechanical stimulation of the heart (catheterization, angiography, heart surgery).

· Reflex influence of the internal organs if swallowed, straining, change of body position, etc..

· Disorders of the nervous regulation of the heart (vegetative dystonia syndrome, organic lesions of the central nervous system).

· When stress (with the development of giperadrenalinemii, hypokalemia, stress ischemia).

· Idiopathic cardiac arrhythmia.

Examination of the patient with cardiac rhythm includes patient feedback form, clinical and instrumental methods of investigation. It is aimed at identifying the causes of arrhythmias, those adverse factors, which may contribute to their further progression, define exactly the types of arrhythmias, diagnosis of heart (valvular, the size of the heart chambers, thickness, contractility).

On questioning the patient pay attention to the medical history: the first appearance of unpleasant sensations in the region of the heart and associated phenomena; diagnosis (if it was carried out) the objective of the cardiovascular system and other organs and systems, that could lead to the development of heart rhythm; previously conducted by the treatment and its effectiveness; the dynamics of development of symptoms up to the time reference of the patient to the doctor. It is important to find out, Does the patient have had bad habits, industrial hazards, what diseases he suffered, as well as to know the family history. Identification of patient complaints is of great importance, because a breach of a heart rhythm, often accompanied by unpleasant sensations. They are determined by the type of rhythm, degree of hemodynamic disorders, the nature of the underlying disease. The most frequent complaint of patients with arrhythmias is an unpleasant feeling in the heart: heartbeat (sense of rhythmic or neritmičnyh heartbeats), interruptions, feelings fade and the "stop" of the heart, various kinds of pain or a feeling of compression, a feeling of heaviness in the chest and t. e. Feelings can be of different duration and frequency, develop suddenly or gradually, from time to time, with or without a pattern. Moreover, can be sudden weakness, headache, dizziness, nausea, sincopale State, that is an indicator of the development of hemodynamic disorders. By reducing contractility of left heart is shortness of breath, cough, Choking. The emergence or progression of heart failure in aritmiah are prognostically unfavorable.

Arrhythmias often accompanied by a sense of fear and anxiety. Some patients are asymptomatic arrhythmias.

Clinical studies reveal: the condition of the patient may be different (from satisfactory to heavy) Depending on the type of violation and the initial state of the patient. Possible weakness, loss of consciousness (pass out), manifestations of hypoxic encephalopathy up to coma. Violations of the autonomic nervous system are manifested as anxiety, anxious behavior, changes in skin color, Sweating, poliurii, bowel movements etc.. Colouring of the skin may be pale, and slightly hyperemic, especially when you have hypertension, cianotičnoj in heart failure. When left ventricular heart failure are identified changes in physical examination of the respiratory system - the weakening of the vesicular breath or breathing hard, unvoiced moist rales, sometimes in combination with dry wheezing. This may be determined pitch accent II pulmonary artery. The study of the cardiovascular system often reveals changes in heart rate (ЧСС) and pulse frequency - an increase or decrease, disturbance of the heart rhythm tones and pulse waves. Changing the volume of the tones, for example, different volume I tone with atrial fibrillation (MA), boost I-tone when the ventricular èkstrasistole, its decline in paroxizmalna najeludockova tachycardia (PNT). Reduction of filling pulse is defined by vascular insufficiency, When MA was often a deficiency pulse. There are often changes AD-hypo-and hypertension. With right sided congestive heart failure, liver enlargement and soreness of her. By reducing renal blood flow-oliguria. Can also develop tromboamboliceski syndrome.

Instrumental research methods. Electrocardiography remains the leading method in the recognition of cardiac arrhythmias. Used as a cross-sectional study, and longer: for 3 minute, 1 and 24 hours. For example, in patients with ischemic heart disease jeludockove ekstrasistola on routine ECG detected 5% cases, When the 3-minute check-in 14%, the 1-hour- 38% patients, during 24 hours- 85% patients [20]. Daily Holter monitoring ELECTROCARDIOGRAM provides a study in different conditions (with loads of, in a dream, food, etc.), that allows you to identify precipitating factors in the development of arrhythmias. Holter monitoring allows a qualitative and quantitative assessment of cardiac arrhythmias. Samples with exercise stress applied to the diagnosis of CHD, establish a relationship with arrhythmias and angina with exercise, evaluate the effectiveness of the therapy, and arrhythmogenic effects of drugs. With the lack of effectiveness of the ECG for the diagnosis of the syndrome of premature ventricular, for the diagnosis and treatment of transient or permanent SSSU is Transesophageal ECG. It is not always possible to obtain the necessary information through this method, Therefore, the most reliable method is vnutriserdečnoe electrophysiological study, includes record EKG and èndokardial′noj like èlektrokardiostimulâciû (EX).

Classification of arrhythmia. Arrhythmia najeludockove and jeludockove are divided into. There are many classifications of heart rhythm disorders, the most convenient in the practical application of the classification, the proposed ft.. Kušakovskim, N.B.. Her pictures in the modification and.. Strutynskogo et al. [14]:

(I). Violation of momentum.

(A). Violation of the automatism of the SA-node (nomotopnye arrhythmia): Sinus tachycardia, Sinus bradycardia, Sinus arrhythmia, SSS.

B. Ectopic (geterotopnye) rhythms, due to the predominance of automaticity ectopiceskih centres: 1) Slow (replacement) vyskal′zyvaûŝie rhythms: predserdnye, of compound AB, Ventricular. 2) Accelerated ectopic beats (Nonparoxysmal tachycardia): predserdnye, of compound AB, Ventricular. 3) Migration supraventrikulyarnogo manufacturer Rithmah.

In. Ectopic (geterotopnye) rhythms, mainly due to the mechanism of re-entry of the excitation wave: 1) Beats (Atrial, of compound AB, Ventricular. 2) Paroxysmal tachycardia (Atrial, of compound AB, Ventricular). 3) Trepetanie predserdiy. 4) Flickering (fibrillation) Atrial. 5) Trepetanie and mertsanie (fibrillation) Ventricular.

II. Conduction abnormalities: 1) Sinoatrial block. 2) Intraatrial (interatrial) blockade. 3) Atrioventrikulyarnaya blockade: And the degree of, Level II, III degree (total block). 4) Intraventricular block (His bundle branch block): One branch, two branches, three branches. 5) Ventricular asystole. 6) Preexcitation syndrome (DRI): Wolff-Parkinson-White (WPW), syndrome shortened interval P-Q (R) (CLC).

III. Combined cardiac arrhythmias: 1) Parasystolyya. 2) Ectopic rhythm with exit blockade. 3) Atrioventricular dissociation.

Principles of scale therapy. Treatment depends on the severity of the disease, prognostic values of heart rhythm, having a family history of heredity. The patient does not need scale therapy in asymptomatic occurring violations of rhythm, in the presence of normal heart size and contractility, high tolerance to physical exercise. It, for example, such violations, as sinus bradycardia (in the absence of heart disease and normal hemodynamic parameters), Migrating driver rhythm, Sinus arrhythmia, slow ectopic rhythms. In this case, clinical supervision, preventive measures, exception of bad habits. Causative treatment of arrhythmias (treatment of the underlying disease, Calling the development of arrhythmias) in some cases is effective to eliminate them. "Basic" therapy is aimed at creating a favorable background for the effects of electrolyte antiarrhythmic drugs (ААТ) [12]. In the treatment of paroxysmal supraventricular tachyarrhythmias effective use of reflex stimulation of the vagus nerve - "vagal samples". In severe arrhythmias, accompanied by a progressive deterioration of hemodynamic parameters (Heart Failure, vascular insufficiency), There is a real risk of the sick, used cardioversion (EIT) and EX. There are methods of surgical treatment of certain types of arrhythmias (ventricular tachyarrhythmias, refractory to antiarrhythmic drugs, MA, syndrome DRI with resistant to treatment by bouts of supraventricular and ventricular tachycardia, combined syndromes DRI and SSSU) and Radiofrequency catheter ablation.

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