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ARRITMIAS SUPRAVENTRICULARES
LUIS ALVARO ESPINOZA FLORESSERVICIO DE CARDIOLOGIA
HOSPITAL NACIONAL HIPOLITO UNANUE2011
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ARRITMIAS CARDIACAS
• Las arritmias cardiacas constituyen un problema frecuente en las emergencias
• El diagnóstico y tratamiento deben ser precoces por su carácter potencialmente letal y su frecuente repercusión hemodinámica
Crit Care MedCrit Care Med. 2007 Dec 12. Epub ahead of print. 2007 Dec 12. Epub ahead of print
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ARRITMIAS EN EMERGENCIA
• Las taquiarritmias se definen como ritmos cardiacos cuya frecuencia ventricular excede los 100 lpm
• Basándose en la duración del QRS, se dividen en taquicardias de complejo estrecho (QRS de menos de 120 ms) o de complejo ancho (QRS mayor de 120ms)
• Los mecanismos de reentrada son responsables de la mayoría de las taquiarritmias
• La reentrada se refiere a la conducción de una onda retrograda de activación eléctrica hacia la región miocárdica que, inicialmente, estaba refractaria a la conducción anterograda de la onda
The Annals of PharmacotherapyThe Annals of Pharmacotherapy, 2007 March, Volumen 41 , 2007 March, Volumen 41
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ARRITMIAS EN EMERGENCIA
• En el manejo clínico no existen pautas rígidas de tratamiento ni esquemas inflexibles
• Se recomienda habituarse a un número reducido pero suficiente de fármacos ampliamente conocidos
Crit Care MedCrit Care Med. 2007 Dec 12. Epub ahead of print. 2007 Dec 12. Epub ahead of print
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ARRITMIAS EN EMERGENCIADIAGNOSTICO
• Palpitaciones
• Dolor toráxico
• Mareos, disnea
• Síncope
Cardiovascular Therapeutics, Heart Disease, Antman, 2007Cardiovascular Therapeutics, Heart Disease, Antman, 2007
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ARRITMIAS EN EMERGENCIAABORDAJE DE LAS TAQUICARDIAS SUPRAVENTRICULARES Y VENTRICULARES• Debe valorarse si existe estabilidad o inestabilidad
hemodinámica
– Hipotensión
– Perfusión
– Estado de conciencia
Cardiovascular Therapeutics, Heart Disease, Antman, 2007Cardiovascular Therapeutics, Heart Disease, Antman, 2007
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• Buscar signos de ICC
• Prolapso de válvula mitral
• Miocardiopatía hipertrófica
• Sindrome coronario agudo
Cardiovascular Therapeutics, Heart Disease, Antman, 2007Cardiovascular Therapeutics, Heart Disease, Antman, 2007
ARRITMIAS EN EMERGENCIADIAGNOSTICO
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ARRITMIAS EN EMERGENCIAINSTRUMENTOS DIAGNOSTICOS Y ESTUDIOS DE LABORATORIO
• Electrocardiograma
• La valoración ambulatoria continua del electrocardiograma
• Electrocardiograma de esfuerzo
• Estudio electrofisiológico
Cardiovascular Therapeutics, Heart Disease, Antman, 2007Cardiovascular Therapeutics, Heart Disease, Antman, 2007
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ARRITMIAS EN EMERGENCIAABORDAJE DE LAS TAQUICARDIASELECTROCARDIOGRAMA
• Frecuencia cardiaca
• Regularidad o irregularidad del ritmo
• Observación de la onda P
• Morfología de la onda P y su relación con el complejo QRS
• Intervalo RP
• Morfología del complejo QRS
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Sistema de Conducción del CorazónSistema de Conducción del Corazón
Nodo sinoauricularNodo sinoauricular
NodoNodoauriculoventricularauriculoventricular
Aurícula derechaAurícula derecha
Ventrículo derechoVentrículo derecho
Haz de HisHaz de His
Cayado de la aortaCayado de la aorta
Aurícula izquierdaAurícula izquierda
Ramas derecha Ramas derecha e izquierdae izquierdadel Haz de Hisdel Haz de His
Fibras de PurkinjeFibras de Purkinje
Ventrículo izquierdoVentrículo izquierdo
11
22
33
44
55
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TaquiarritmiasArritmia o Disrritmia:Arritmia o Disrritmia:
– Todo ritmo diferente del Todo ritmo diferente del sinusal normal.sinusal normal.
Intervalo PR 0.12 – 0.20 segIntervalo PR 0.12 – 0.20 seg
Intervalo QRS < 0.12 segIntervalo QRS < 0.12 seg
P:P: onda de despolarización auricular onda de despolarización auricular(amplitud <0.2 mv duración <0.12 seg)(amplitud <0.2 mv duración <0.12 seg)
QRS:QRS: complejo de complejo de despolarización ventricular despolarización ventricular
Q:Q: se denomina a la reflexión negativa se denomina a la reflexión negativa que inicia el QRSque inicia el QRS
R:R: se denomina a toda reflexión positiva se denomina a toda reflexión positiva del QRSdel QRS
S:S: se denomina a la reflexión negativa se denomina a la reflexión negativa que sigue a una positivaque sigue a una positiva
T:T: onda de repolarización ventricular onda de repolarización ventricular
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Electrocardiograma - ECG
El ECG es un registro continuo de la actividad eléctrica cardiaca obtenido El ECG es un registro continuo de la actividad eléctrica cardiaca obtenido mediante la colocación de electrodos en la superficie del cuerpomediante la colocación de electrodos en la superficie del cuerpo
Onda P Onda P – depolarización de la aurícula– depolarización de la aurícula
Complejo QRSComplejo QRS – depolarización ventricular – depolarización ventricular
Onda TOnda T – repolarización ventricular – repolarización ventricular
Segmento PQ Segmento PQ – tiempo de conducción desde la aurícula al ventrículo– tiempo de conducción desde la aurícula al ventrículo
Segmento STSegmento ST – tiempo de contracción y vaciamiento de los ventrículos – tiempo de contracción y vaciamiento de los ventrículos
Segmento TPSegmento TP – tiempo de relajación y llenado ventricular – tiempo de relajación y llenado ventricular
Brazo derecho Brazo izquierdo
Pierna izquierda
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“No Trate al Monitor, Trate al Paciente”
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TAQUICARDIA SINUSAL
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FA es el resultado de múltiples ondas de depolarización que se mueven alrededor de la aurícula, raramente completando un circuito de re-entrada
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FIBRILACION AURICULAR V1
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FIBRILACION AURICULAR
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El flutter atrial es resultado de un circuito de re-entrada único en la aurícula derecha
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FLUTTER ATRIAL
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FLUTTER ATRIAL
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FLUTTER ATRIAL CON BLOQUEO PROGRESIVO POST-ADMINISTRACION DE ADENOSINA
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FLUTTER ATRIAL CON BLOQUEO VARIABLE
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La taquicardia atrial es iniciada por un foco ectópico atrial(la morfología de la onda P difiere de la del sinusal)
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TAQUICARDIA ATRIAL
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TAQUICARDIA ATRIAL MULTIFOCAL
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TAQUICARDIA ATRIAL CON BOQUEO 2:1 EN TOXICIDAD DIGITAL
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MECANISMOS DE REENTRADA
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MECANISMO DE LA TAQUICARDIA POR REENTRADA NODAL AURICULO-VENTRICULAR
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TAQUICARDIA CON REENTRADA NODAL A-V
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MECANISMOS DE LAS TAQUICARDIAS CON REENTRADA AURICULO-VENTRICULAR
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TAQUICARDIA CON REENTRADA A-V ORTODROMICA
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TAQUICARDIA CON REENTRADA A-V ANTI-DROMICA
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FA EN WPW
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Atrioventricular junctional (nodal) beats produce P waves that point upward in lead Atrioventricular junctional (nodal) beats produce P waves that point upward in lead aVR and downward in lead II; this is just the opposite of what is seen with sinus aVR and downward in lead II; this is just the opposite of what is seen with sinus rhythm. The P wave may just precede the QRS complex rhythm. The P wave may just precede the QRS complex (A),(A), follow it follow it (B),(B), or occur or occur simultaneously with it simultaneously with it (C)(C). In the last instance, no P wave is visible.. In the last instance, no P wave is visible.
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Delacrétaz E. Supraventricular Tachycardia. N Engl J Med 2006;354:1039-51
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Delacrétaz E. Supraventricular Tachycardia. N Engl J Med 2006;354:1039-51
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Delacrétaz E. Supraventricular Tachycardia. N Engl J Med 2006;354:1039-51
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2005 AHA Guidelines for CPR and Emergency Cardiovascular Care. Circulation 2005;112 (Suppl 1): IV 51-57
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2005 AHA Guidelines for CPR and Emergency Cardiovascular Care. Circulation 2005;112 (Suppl 1): IV 51-57
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2005 AHA Guidelines for CPR and Emergency Cardiovascular Care. Circulation 2005;112 (Suppl 1): IV 51-57
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