simple presentation of different kind of heart blocks with ECG findings, helpful for beginners of medicine
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HEART BLOCK
PRESENTER--- Dr Sibadatta Das
MODERATER----Dr Indu Khurana INTRODUCTION
A "heart block" is a disease in the
electrical system of the heart
.Heart Block is a type of bradycardia
(too-slow heartbeat) that also is called atrioventricular, or AV block. Cunducting system of heart S.A.NODE Intranodal INTRA ATRIAL tracts TRACT OF BACHMAN
electrical activity of intigrated myocardial tissue Interpreted as different waves like P Q R, S ,T etc. Ventricular depolarization
Atrial depolarization Ventricular repolarization HIS BUNDLE ELECTROGRAM
Recording of electrical activity
of heart by intra cardiac ring electrode placed near the tricuspid valve
From comparative study
Ventricular With ECG accurate site of block depolarization can be calculated
Transmission Of impulse Activation Through of AV node His bundle Comparative study
This is done by calculating 3 intervals
PA Int:-conduction from SA node to
AV node normal— (27 ms)
AH Int:-AV nodal conduction time
( 92 ms)
HV Int:-bundle conduction ( 43 ms) DISEASE TARGETS SA NODE DISTURBANCES Occurs mainly in 2 ways 1. sinus failure (failure of impulse generation)
2. sinus exit block (failure of conductance of impulse to
atrium) manifestation Mostly presented in 2 way 1.SICK SINUS SYNDROM mostly found in old patients Presented as sudden dizziness , fatigue , & syncope ECG: persistent bradycardia i.e recognised by a pause which is multiple of PP interval or progressive shortening of PPinterval followed by a pause TACHY-BRADY syndrome •reentry of ventricular stimulation causing
• atrial tachycardia followed by a pause.
•Then started with a slower rate .
•Again &again the cycle is repeated.
investigation
24 hr holter monitering is the chief mode.
Interpretation shd be done cautiously as hyper vagotonia in athelates & sleep sinus pause causes the same pattern Accurate detection occurs throiugh sinus node electrogram and calculating the sinus recovery time indirectly TREATMENT Most of the patients are symptom free Symptomatic patients are difficult to treat Oral theophylin is some how effective But most of the patients require pace maker Permanent pace maker is the T/t of choice in recurrent symptomatic Pt.s Dual chamber pace maker is preferred as SA node dysfunction is usually associated with AV node dysfunction. Affected AV Node
This is mainly affected by 3 ways
1. First degree AV block. 2. Second degree AV block. 3. Third degree AV block. First degree AV block All the impulses from atria reaches ventricle but delay occurs in conduction. Etiology is not specified ECG is almost normal except prolongation of PR interval hence it is sited as diagnostic criteria PR interval > 0.2s is almost diagnostic second degree AV block (intermittent AV block) Not all impulses arising from atria reach ventricle 2 types . Mobitz I . Mobitz II Mobitz I (Wenckebach AV block) PR interval gradually prolongs till 1 P wave is dropped. After dropped P wave the PR interval is shorter than the last long PR interval. The difference between longest & shortest PR interval > 100 ms. ETIOLOGY : inferior wall infarction drug intoxications like digitalis, β blockers, Ca channel blockers etc. Mobitz II There is sudden stoppage of conduction without previous change in PR interval. So, 2 to 3 consecutive P wave comes following 1 QRS complex accordingly it is named as 2:1 or 3:1 block. ETIOLOGY : Anteroseptal infarction calcific disease of fibrous skeleton of heart Typically it has a tendency to proceed towards complete heart block THIRD DEGREE HEART BLOCK
No atrial impulse conducted
into ventricle QRS complex comes alone in ECG P wave has no relation with the QRS complex Rate is as per AV node rhythm I;e 40-45/min with normal QRS complex Or as per HIS-PURKINJE rhythm i.e 15-40 /min with wide QRS complex. Bundle branch block Etiology – long standing HT severe valvular disease cardio myopathy
Typical manifestations found in ECG is opposite direction of T wave to that
of QRS complex due to reverse direction of repolarization
2 types
RIGHT BUNDLE-BRANCH BLOCK
LEFT BUNDLE-BRANCH BLOCK
RIGHT BUNDLE-BRANCH BLOCK
•Electrical impulse cannot travel
through it to the right ventricle
• Activation reaches the right
•ventricle by proceeding from the • left ventricle. •It then travels through the septal and right ventricular muscle mass •This progress is, of course, slower •leads to a QRS-complex wider than 0.1 s •QRS >0.12s is diagnostic RBBB causes an abnormal terminal QRS-vector that is directed to the right ventricle (i.e., rightward and anterior). This is seen in the ECG as a broad terminal S-wave in lead I. Another typical manifestation is seen in lead V1 as a double R- wave. This is named an RSR'-complex LEFT BUNDLE-BRANCH BLOCK
The situation in left bundle-branch block (LBBB)
is similar, but activation proceeds in a direction opposite to RBBB.
Again the duration criterion for complete block is QRS > 0.12s
. Because the activation wave front travels in more or less the normal direction.
However, because of the abnormal sites of initiation
of the left ventricular activation front and the presence of normal right ventricular activation the outcome is complex seen as a broad and tall R-wave, usually in leads I, aVL, V5, or V6. OTHER COMBINATIONS OF BLOCK BIFASCICULAR BLOCK RBB + Lt. Ant. Fascicle block or Rt. Ant. Fascicle block TRIFASCICULAR BLOCK Bi fascicular block + PR prolongation etc. CONCLUSION Still an enigma for medical science Highly unpredictable in character Through out monitoring is essential Non interventional T/t option is rare is present day scenario. Hope is there for something better in future days. REFERENCES
Text book of physiology 1st- Indu khurana
Review physiology 22nd-Ganong Physiology 13th- Samson wright Internal medicine16th- Harrison Clinical diagnosis of ECG- K.P. Mishra
