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1 심전도연수강좌 : 처음시작하는사람들을위한심전도 강남힘찬병원 이병호 심전도의이해정상 12- Lead 심전도 심전도연수강좌 : 처음시작하는사람들을위한심전도

2 Session III. Tachy Arrhythmias and Sudden Death Axis Horizontal vs Frontal plane AVR AVL (lateral wall ) ( Anteroseptum ) SA RV LV V1 V2 V3 V4 V5 (anterior wall) AV RV LV III AVF II (inferior wall ) RV LV V6 Horizontal plane Frontal plane 심전도연수강좌 : 처음시작하는사람들을위한심전도

3 이병호 Tachy Arrhythmia and Sudden Death M EM O 33 M. seizure disorder Consultation for arrhythmia management 심전도 연수강좌 : 처음 시작하는 사람들을 위한 심전도

4 Session III. Tachy Arrhythmias and Sudden Death 응용문제 Narrow QRS Regular? Yes No No Visible P? A-fib, A-tac, MAT, A-flutter with Yes variable AV conduction Atrial rate greater than V-rate? Yes No A-flutter or AT Analyze RP interval Short (RP shorter than PR) Long (RP longer than PR) RP shorter than 70ms AVNRT RP longer than 70ms AVRT AVNRT AT A-tachycardia PJRT Atypical AVNRT 심전도연수강좌 : 처음시작하는사람들을위한심전도

5 이병호 :Tachy Arrhythmia and Sudden Death Regular narrow QRS complex tachycardia IV adenosine No change in rate Gradual slowing then reacceleration of rate Sudden termination Persisting AT with transient high-degree AVB *Inadequate dose/delivery *Sinus tachycardia *Focal AT *Nonparoxysmal junctional tachycardia *AVNRT *AVRT *Sinus node re-entry *Focal AT *Atrial flutter *AT Sudden cardiac death 심전도연수강좌 : 처음시작하는사람들을위한심전도

6 Session III. Tachy Arrhythmias and Sudden Death Definition of SCD Any cardiac death occuring out of the hospital or taking place in the emergency room or dead on arrival in the emergency room. "natural" death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of acute symptoms. Gillum RF et al. Circulation 1989;79: Epidemiology USA : 300,000~400,000 adult SCDs each year 1~2/1000 population per year 75~80% of SCDs due to CAD 50% of CAD deaths 20~25% of SCDs : no prodromal Sx. Unwitnessed in 40% High recurrence rate : up to 50% within 1yr Causes of SCD Acute Mechanical Causes : 5% Non-structural Heart Disease : 5~10% Coronary Artery Disease : 75~80% Structural Heart Disease : 10~15% 심전도연수강좌 : 처음시작하는사람들을위한심전도

이병호 :Tachy Arrhythmia and Sudden Death SCD without structural heart disease Long QT syndrome The Brugada syndrome SCD with structural heart disease ARVD Idiopathic Long QT Syndrome History 1957 :

7 이병호 :Tachy Arrhythmia and Sudden Death SCD without structural heart disease Long QT syndrome The Brugada syndrome SCD with structural heart disease ARVD Idiopathic Long QT Syndrome History 1957 : Jervell and Lange-Nielsen first described a family with long QT synd. (LQTS) 1979 : Prospective International LQTS Registry 1,200 LQTS Families 46F, syncope RR Q * T * Sinus rhythm with prolonged(?) QT interval and VPCs 심전도연수강좌 : 처음시작하는사람들을위한심전도

8 Session III. Tachy Arrhythmias and Sudden Death Corrected QT interval QT interval changes according to the heart rate Tachycardia (RR interval ) QT interval Bradycardia (RR interval ) QT interval Corrected QT interval (cqt) : QT interval corrected by RR interval Bazett s formula : cqt(ms) = QT(ms) / RR(sec) QT prolongation : cqt > 460ms ( ), 480ms ( ) Mutation-induced ion channel dysfunction Repolarization prolongation due to mutations of Na+ and K+ channel genes prolonged intracellular positivity early afterdepolarization Torsade de pointes Molecular and cellular mechanisms Disease Gene (alternate name) Protein LQT-1 KVLQT1(KCNQ1) I Ks K + channel α subunit LQT-2 HERG(KCNH2) I Kr K + channel α subunit LQT-3 SCN5A I Na K + channel α subunit LQT-4 ANKB ANKRIN-β LQT-5 mink(kcne1) I Ks K + channel β subunit LQT-6 MiRP1(KCNE2) I Kr K + channel β subunit LQT-7 KCNJ2 I Kr K + channel α subunit Incidence Lethality : LQT1 and LQT2 > LQT3 : LQT3 > LQT1 and LQT2 Robert S. Kass et al. J. Clin. Invest : 심전도연수강좌 : 처음시작하는사람들을위한심전도

1 Late onset T waves Low amplitude T waves Early onset

Circulation 1995;92:2929-2934 60F, Consultation for SCA RR

phenomenon F/U ECG after 48 Hours cqt interval was

9 이병호 :Tachy Arrhythmia and Sudden Death. Congenital Long QT Syndrome LQT type 3 LQT type 2 LQT type 1 Late onset T waves Low amplitude T waves Early onset broad based T waves Moss A J et al. Circulation 1995;92: F, Consultation for SCA RR QT Prolonged cqt interval (= 520ms) and R on T phenomenon F/U ECG after 48 Hours cqt interval was shortened after withdrawal of moxifloxacin and correction of electrolyte imbalance 심전도연수강좌 : 처음시작하는사람들을위한심전도

a distinct ECG pattern of RBBB with ST elevation in leads V1-V3 and normal QT

10 Session III. Tachy Arrhythmias and Sudden Death QT Prolonging Drugs DAUH, Kim MJ, Brugada Syndrome History In 1992, Brugada : 8 pts with a history of aborted SCD a distinct ECG pattern of RBBB with ST elevation in leads V1-V3 and normal QT interval in the absence of any structural heart diseas Male predominance, Asian population Sudden arrhythmic death during sleeping ST elevation in V1 V3 Na + channel dysfunction (SCN 5A gene mutation) Brugada Syndrome 심전도연수강좌 : 처음시작하는사람들을위한심전도

이병호 :Tachy Arrhythmia and Sudden Death Brugada

2mm 2mm T wave negative positive or positive

configuration ST (terminal portion) gradually

Standard leads Brugada leads The sensitivity of the

placement of ECG leads in the intercostal space

ST Segment 2009-05-13 2009-06- 16 2009-06-18

11 이병호 :Tachy Arrhythmia and Sudden Death Brugada Syndrome Type 1 Type 2 Type 3 J point amplitude 2mm 2mm 2mm T wave negative positive or positive biphasic ST-T coved type saddleback saddleback configuration ST (terminal portion) gradually descending elevated 1mm elevated<1mm Brugada Leads Standard leads Brugada leads The sensitivity of the ECG for Brugada syndrome can be increased with placement of ECG leads in the intercostal space above V1 and V2 (V1ic3 and V2ic3) Dynamic Change of ST Segment V1 V2 Dynamic change of ST segment in V1 & V2 심전도연수강좌 : 처음시작하는사람들을위한심전도

12 Session III. Tachy Arrhythmias and Sudden Death Management of Brugada Syndrome Symptomatic (Syncope or SD) Spontaneous ECG (+) Resting ECG (-) Inducible ECG (+) by pharmacologic tests PES (positive of negative) Family history (positive or negative) ICD JM Juang et al. Cardiology 2004;101: Management of Brugada Syndrome Asymptomatic Spontaneous ECG (+) Resting ECG (-) Pharmacologic test Inducible ECG (+) Inducible ECG (-) PES (-) PES (+) PES (-) Family Hx (-) Family Hx (+) Family Hx (-) Clinical F/U ICD Clinical F/U JM Juang et al. Cardiology 2004;101: Arrhythmogenic RV Dysplasia Relatively newly recognized disease, first published in ~5% of unexplained SCD under the age of 65 yrs 3 genes : ryanodine receptor (RyR2), plakoglobin(jup), desmoplakin (DSM) Fatty or fibrofatty infiltration of the right ventricle (RV), dilatation and dysfunction of the right ventricle as well as electrical instability, ventricular arrhythmia of right ventricular origin, heart failure and sudden death Familial disorder in 30%, Autosomal dominant in 1/3 pts 심전도연수강좌 : 처음시작하는사람들을위한심전도

scattered fibrous tissue and residual myocardial cells

13 이병호 :Tachy Arrhythmia and Sudden Death Pathology of ARVD Pathology replacemant of myocardium by fat with scattered fibrous tissue and residual myocardial cells Dilatation of the RV Signal Averaged ECG 심전도연수강좌 : 처음시작하는사람들을위한심전도

14 Session III. Tachy Arrhythmias and Sudden Death ECG Characteristics of ARVC QRS width 110 ms in V1 (100%) + RBBB config. T wave inversions (60%) in Rt. Precordial leads Epsilon wave (30%) : delayed RV activation Low voltage QRS complex Late potentials in signal averaged ECG (specificity 95%) Summary EKG is logical test Tachycardia QRS morphology & regularity P wave correlation Check QT interval Brugada DDX with RBBB : ST-elevation ARVD epsilon wave RBBB pattern 심전도연수강좌 : 처음시작하는사람들을위한심전도

<B0E6C8F1B4EBB3BBB0FA20C0D3BBF3B0ADC1C E687770>

<B0E6C8F1B4EBB3BBB0FA20C0D3BBF3B0ADC1C E687770> 심전도연수강좌 : 처음시작하는사람들을위한심전도 연세대학교원주의과대학순환기내과학교실 안민수 Cardiac Electrophysiology I : Automaticity : 60-100 회 /min, His bundle : 40-60 회 /min Bundle branch : 20-40 회 /min Purkinje fiber : 20 회 /min Cardiac Electrophysiology