重醫(yī)大內(nèi)科學(xué)教案03循環(huán)系統(tǒng)疾病-3心律失常

PAGE授課教案課程名稱內(nèi)科學(xué)年級(jí)20級(jí)授課專業(yè)臨床醫(yī)學(xué)教師職稱授課方式大課學(xué)時(shí)5題目章節(jié)心律失常教材名稱內(nèi)科學(xué)（全國高等學(xué)校教材）作者主編：葉任高陸再英出版社人民衛(wèi)生出版社版次第6版教學(xué)目的要求掌握常見心律失常的心電圖診斷；熟悉常見心律失的臨床意義及其治療。教學(xué)難點(diǎn)快速性心律失常的發(fā)生機(jī)制；各種心律失常的心電圖診斷及治療原則；心律失常的非藥物治療。教學(xué)重點(diǎn)過早搏動(dòng)的分類和臨床意義，以及其治療原則；陣發(fā)性室上性心動(dòng)過速的機(jī)制（折返機(jī)制），診斷要點(diǎn)（心電圖及臨床表現(xiàn)），及治療方法的選擇（藥物治療/射頻消融術(shù)根治）；室性心動(dòng)過速與室上性心動(dòng)過速的鑒別診斷和處理原則。心房纖顫的臨床意義及治療；房室傳導(dǎo)阻滯的心電圖診斷、藥物治療和起搏治療。外語要求雙語教學(xué)（英語與漢語）教學(xué)方法手段多媒體講課與小班心電圖示教。參考資料1、全國醫(yī)藥院校七年制教材<內(nèi)科學(xué)>。，2、MayoClinic3、心臟病學(xué)4、Arrhythmias.教研室意見同一通過教學(xué)組長：教研室主任：20年月日Arrhythmias（心律失常）Anatomyofcardiacconductionsystem（心臟傳導(dǎo)系統(tǒng)解剖）：Sinusnode—normalpacemaker，highestautomacityInternodaltracts—connectsinustoAVnodeAtrioventricularnode—secondpacemakerHisbundleTheleftandrightbundlebranchesTerminalPurkinjefibersDefinitionofarrhythmias（心律失常定義）Theabnormalitiesinfrequency、rhythm、sourceorspeedofconductionofcardiacpulses。Classificationofarrhythmias（心律失常分類）★Accordingtomechanismsofarrhythmogenesis，theyareclassifiedasarrhythmiascausedbyabnormalsourceofpulseformationandabnormalitiesofpulseconduction☆A(yù)bnormalsourceofpulseformation●Sinusarrhythmias：○Sinustachycardia;○Sinusbradycardia;○Sinusirregularity;○Sinuscardiacarrest?！馝ctopicrhythms(異位心律)：○Passiveectopicrhythms（被動(dòng)性異位心律）：◎Escapebeats（atrial,junctional、ventricular）逸搏（房性、結(jié)性、室性）；◎Escaperhythms（atrial，junctional、ventricular）逸搏心律（房、結(jié)、室性）；○Activeectopicrhythms（主動(dòng)性異位心律）：◎Prematuresystole(atrial,junctional,ventricular)期前收縮或過早搏動(dòng)（房、結(jié)、室性）；◎Paraxysmaltachycardias（atrial，junctional、atrioventricularreentrant，ventricular）陣發(fā)性心動(dòng)過速（房性、結(jié)性、房室折返性、室性）；◎Flutter、fibrillation（撲動(dòng)、顫動(dòng)）。☆A(yù)bnormalitiesofpulseconduction(沖動(dòng)傳導(dǎo)異常)●Physiological(生理性)：○Interferenceandatrioventriculardissociation（干擾和房室分離）?！馪athophysiological（病理性）：○Sino-atrialblock（竇房傳導(dǎo)阻滯）；○Intra-atrialblock（房內(nèi)傳導(dǎo)阻滯）；○Atrial-ventricularblock（房室傳導(dǎo)阻滯）；○B(yǎng)ranchblock（束支或分支阻滯）或Intraventricularblock（室內(nèi)阻滯）。●AbnormalAVconnection-preexcitationsyndrome（房室間傳導(dǎo)異?！A(yù)激綜合征）。Accordingtoheartrate（根據(jù)心律快慢）☆Fastspeedarrhythmias（快速性心律失常）；☆Slowspeedarrhythmias（緩慢性心律失常）。Mechanismsofarrhythmogenesis（心律失常發(fā)生機(jī)制）Reentry—Mostcommonmechanismoffastspeedarrhythmias（折返—快速性心率失常中最常見的發(fā)生機(jī)制）；★Automaticity（自律性增高）；★Triggeredactivity（觸發(fā)活動(dòng)）。Diagnosisofarrhythmias（心律失常的診斷）★Medicalhistory（病史）?！颬hysicalexamination：Thefourbasicskillsofphysicalexaminationsespeciallyauscultation—veryhelpfultoitsdiagnosis（體格檢查：心臟四診尤其心臟聽診--很有助于診斷）?！顴lectrocardiography，especiallytakenattheonset—mostimportantnon-invasiveapproach（心電圖檢查—最重要的無創(chuàng)檢查技術(shù)）?！頟rolongedECGmonitoring（長時(shí)間心電圖記錄）：●HolterECGmonitoring（動(dòng)態(tài)心電圖記錄）：○Non-invasive、portable、convenient（無創(chuàng)、便攜式和方便）；○Determinetherelationshipofpalpitationorsyncopetoarrhythmias(明確心悸或暈厥與心律失常的關(guān)系)；○Determinetherelationshipofischemiatodailyactivity(明確心肌缺血與日常活動(dòng)的關(guān)系)；○Assessantiarrhythmicdrugefficacyandpacemakerfunction（評(píng)價(jià)抗心律失常藥物療效、起搏器工作情況。）☆Esophagealelectrocardiography（食道心電圖）●Initiationandterminationoftachycardias（誘發(fā)和終止心動(dòng)過速）；●Helpfultodefinethemechanismsofsupraventriculartachycardias（有助于判斷室上性心動(dòng)過速發(fā)生機(jī)制）●Helpfultodiagnosesicksinussyndrome（有助于確定病態(tài)竇房結(jié)綜合征的診斷）。Invasiveeletrophysiologicalstudy（臨床電生理檢查）●Aims（目的）：○Diagnosticallytounderstandthesourceofarrhythmiaanditseletro-physiologicalmechanism）診斷方面：了解心律失常的起源部位和發(fā)生機(jī)制）；○Therapeuticallytoterminatetachycardiaandablatemyocardiuminvolvedinthetachycardia治療方面：終止心動(dòng)過速，消融參與心動(dòng)過速形成的心肌，以達(dá)到治愈心動(dòng)過速的目的；○Prognosticallytoevaluatetheriskofpatientsforsuddencardiacdeath預(yù)后方面：預(yù)測(cè)患者有無發(fā)生心臟性猝死的危險(xiǎn)?！馡ndication（適應(yīng)癥）：○Toevaluatethefunctionofsinusnode（測(cè)定竇房結(jié)功能）；○TodeterminethesiteofAVconductionorintraventricularconductionblock（確定房室與室內(nèi)傳導(dǎo)阻滯部位）；○Todiagnosisandablatetachycardia（診斷與消融心動(dòng)過速）。Classificationofantiarrhythmicdrugs（抗心律失常藥物分類）★Accordingtotheirelectrophysiologiceffects,☆DrugswithclassⅠactionsubclassifiedintoclassⅠA,ⅠB,ⅠC(toblockfastinwardsodiumchannels)(Ⅰ類—阻斷快速鈉通道)egPropafenone（心律平）；☆DrugswithclassⅡactionbeta-adrenergicantagonism☆DrugswithclassⅢactiontoprolongthedurationofthecardiacactionpotential(延長心肌動(dòng)作電位),Amiodarone（胺碘酮）;DrugswithclassⅣactioncalciumchannelantagonism,egVerapamil（維拉帕米），diltiazem（硫氮卓酮）NormalSinusrhythm（正常竇性心律）：●Originateinthesinusnode（起源于竇房結(jié)）；●Ratebetween60and100beats/min（頻率60—100次/分）；●Electrocardiography（心電圖）：○UprightPwaveinleadsⅠ、Ⅱ、aVF，andnegativePwaveinleadaVR（P波在Ⅰ、Ⅱ、aVF導(dǎo)聯(lián)向上，aVR倒置）；○P-Rinterval0.12—0.20s（P-R間期0.12—0.20s）。Sinustachycardia（竇性心動(dòng)過速）：●Electrocardiography（心電圖）：○NormalPwavecontour（P波符合竇性心律的特征）；○Sinusrateexceeding100beats/mininadults，mostlywithin100-150beats/min（成人竇性心律頻率超過100次/分，大多在100-150次/分）?！馛linicalsignificance（臨床意義）：○Normalreactiontoavarietyoffactorssuchasphysicallaborandsentimentalexcitement（生理情況：健康人對(duì)諸如體力活動(dòng)和情緒激動(dòng)等因素的正常反應(yīng)）；○Commonlyseeninpatientswithfever、anemia、hyperthyroidism、shockandheartfailure（病理情況：常見于發(fā)熱、貧血、甲狀腺機(jī)能亢進(jìn)癥休克、心力衰竭）；○Administeringnicotine、alcohol、caffeine、adrenalineandatropine（藥物：應(yīng)用尼古丁、酒精、咖啡因、腎上腺素、阿托品等）?！馦anagement（治療）：○Focusontheunderlyingcause，eliminatethepredisposingcause（應(yīng)針對(duì)其病因，祛除誘因）；○Mayuseβ-blockerstoslowthesinusratewhennecessary（必要時(shí)β受體阻滯劑可用于減慢心率）。Sinusbradycardia（竇性心動(dòng)過緩）：●Electrocardiography（心電圖）：○NormalPwavecontour（P波符合竇性心律的特征）；○Sinusratelessthan60beats/mininadults（成人竇性心律頻率慢于60次/分）；○Oftencoexistswithsinusarrhythmia—differencebetweenP-Pinterval＞0.12s（常同時(shí)伴有竇性心律不齊—即不同P-P間期差異＞0.12s）?！馛linicalsignificance（臨床意義）：○Commonlyseeninexcessivevagalordecreasedsympathetictonesuchashealthyyoungadults、athletesandapersoninsleepingstatus（常見于迷走神經(jīng)張力過高、交感神經(jīng)張力過低，如健康青年人、運(yùn)動(dòng)員、睡眠狀態(tài)）；○Commonlyseeninintracranialdiseases、severehypoxia、hypothermia、hypothyroidism（見于顱內(nèi)疾患、嚴(yán)重缺氧、低溫、甲狀腺功能減退等）?！餉dministrationofantiarrhythmaticdrugs（藥物：應(yīng)用抗心律失常藥物）?！餝icksinussyndrome、acuteinferiormyocardialinfarction（病態(tài)竇房結(jié)綜合征、急性下壁心肌梗塞）?！馦anagement（治療）：○Notnecessarytotreatasymptomaticsinusbradycardia（無癥狀竇緩?fù)ǔo需治療）；○EffectivetouseAtropineandIsoprenalinetoraiseheartratewhichisassociatedwithsymptomsforshorttime，nocertaineffectforlong-termuse，preferabletoimplantartificialpacemaker（與癥狀有關(guān)的竇緩，可以短期阿托品、異丙基腎上腺素藥物，但長期應(yīng)用效果不肯定，應(yīng)起搏治療）。Sinusarrest（竇性停搏）●Apauseinthesinusrhythm（竇性節(jié)律暫停）?！馝lectrocardiography（心電圖）：LongP-PintervaldelimitingthepausedoesnotequalamultipleofthebasicP-Pinterval（長的P-P間期與基本的竇性P-P間期無倍數(shù)關(guān)系）。Sicksinussyndrome（病態(tài)竇房結(jié)綜合征）●Definition（概念）：Asyndromewithavarietyofarrhythmiacausedbysinusnodaldysfunctionduetosinusnodalabnormalities(由竇房結(jié)病變導(dǎo)致功能減退，產(chǎn)生多種心律失常的綜合表現(xiàn)?？赏瑫r(shí)合并快速房性失常).●Etiology(病因)：○Insufficientblood-supplyofsinusnode(竇房結(jié)供血減少)；○Pathologicalchangeofsinusnode（竇房結(jié)病變）?！馛linicalfeatures（臨床表現(xiàn)）：Symptoms,suchasdizziness、amaurosisandsyncope,associatedwithinsufficientblood-supplyofheartandbrainduetobradycardia(與心動(dòng)過緩有關(guān)的心、腦等臟器供血不足的癥狀，如頭昏、黑蒙、暈厥等）?！馝lectrocardiography（心電圖）：○Persistentandnotablesinusbradycardianotcausedbydrugs（HR＜50beats/min）非藥物引起的持續(xù)顯著的竇性心動(dòng)過緩（50次/分以下）；○Sinusarrestandsinoatrialexitblock（竇性停搏與竇房傳導(dǎo)阻滯）○B(yǎng)radycardia-tachycardiasyndrome:Alternationofperiodsofbradycardiaandpaxoxysmalrapidatrialtachyarrhythmiasencompassingatrialflutter,atrialfibrillationoratrialtachycardia（心動(dòng)過緩-心動(dòng)過速綜合征：心動(dòng)過緩與房性快速性心律失常交替發(fā)作，后者包括心房撲動(dòng)、心房顫動(dòng)或房性心動(dòng)過速）。●Management（治療）：○Whensymptomsaremanifested,treatmentgenerallyinvolvespermanentpacemakerimplantation(有癥狀的病竇患者，應(yīng)接受起搏器治療)；○Pacingforthebradycardiacombinedwithdrugtherapytotreatthetachycardiaisrequiredinpatientswithbradycardia-tachycardiasyndromePrematurebeats（過早搏動(dòng)）●Siteofprematureimpulse（早搏起源部位）：Atrial，junctionandventricularpremature（房、結(jié)、室性早搏，結(jié)早少見）?！馛ouplinginterval（配對(duì)間期）：Fullycompensatory、notfullycompensatorypause（代償完全、代償不完全）?！馦onofocal、multifocal（單源和多源）。Atriaprematurebeats（房性過早搏動(dòng)）●Electrocardiography（心電圖檢查）○PrematureP’wavedifferentfromsinusPwave(提前出現(xiàn)與竇性P波不同P’波)；○P-Rintrvalexceeding0.12s(P-R間期≥0.12s)；○SupraventricularQRScomplex(QRS通常為室上性)；○Notfullycompensatorypause(代償間隙不完全)。Clinicalsignificance（臨床意義）○Occursin60%ofhealthyadults(正常成人60%可發(fā)生房性早搏)；○Occursineverykindoforganicheartdiseases;presagetheoccurrenceofsupraventriculartachyarrhythmias(各種器質(zhì)性心臟病均可發(fā)生房性早搏，可能為快速性房性心律失常的先兆)。Management（治療）:○Atrialprematurebeatsgenerallydonotrequiretreatment(房性早搏通常無需治療)；○Insymptomaticpatients,treatmentwithaβ-blocker,acalciumantagonistordigitaliscanbetried（癥狀明顯或觸發(fā)快速性房性心律失常時(shí)，可試用β受體阻滯劑,鈣阻滯劑或洋地黃治療）。Ventricularprematurebeats（室性過早搏動(dòng)）●Electrocardiography（心電圖）：○AprematureQRScomplexwhichisbizarreinshapeandhasadurationexceeding0.12s,withalargeandoppositeTwave（提前出現(xiàn)寬大畸形的QRS波，QRS波時(shí)限>0.12s，Ｔ波倒置);○NoprematurePwaveprecedingQRScomplex（QRS波前面無提前的Ｐ波）?！餏ullycompensatorypause(代償完全)?！馛linicalsignificance（臨床意義）：○Mostcommonarrhythmia（最常見的心律失常）；○Mayoccurinhealthypersonsandpatientswitheverykindofheartdisease（正常人和各種心臟病均可出現(xiàn)室性早搏）；○Digitalisintoxication、hypokalemia（洋地黃中毒、低血鉀）。●Management（治療）:○Forpatientswithnoorganicheartdisease，noneedtoreceivedugtherapy（無器質(zhì)性心臟病者，予解釋，無需藥物治療）；○Forpatientswithacutemyocardialinfarction，notadvisabletousedrugsforpreventingventricularfibrillation，butβblockerisadvisable（急性心肌梗死患者，不主張預(yù)防用藥，可β受體阻滯劑）；○Chronicheartdiseases：amiodarone，βblocker（慢性心臟病變：胺碘酮，β受體阻滯劑）。Junctionalprematurebeats（結(jié)性過早搏動(dòng)）●Electrocardiography（心電圖）：○PrematureQRScomplexwhichissupraventricular（提前出現(xiàn)QRS波，形態(tài)為室上性）○NegativeＰ`wave：PrecedingQRScomplex—Ｐ`-Ｒ<0.11s，amidQRScomplexorfollowingQRScomplex—Ｒ-Ｐ`<0.20s（逆行Ｐ`波：可出現(xiàn)在QRS前，則逆Ｐ`-Ｒ<0.11s，可在QRS中，也可在QRS后，則Ｒ-Ｐ`<0.20s）；○Fullycompensatorypause（代償完全）?！馦anagement（治療）：Seeatrialprematurebeats（見房性早搏）。Paroxysmalsupraventriculartachycardia（陣發(fā)性室上性心動(dòng)過速）●Etiology（病因）：○Usuallynostructuralheartdisease（通常無器質(zhì)性心臟?。弧餗ainlycausedbypreexcitationsyndromeandAVnodalreentrytachycardia（最常見由預(yù)激綜合征和房室結(jié)雙徑路引起）。●Clinicalfeatures（臨床表現(xiàn)）：○Suddenonsetandtermination（突發(fā)、突止）;○Palpitation,chestdistress,occasionalsyncopeorshock(心悸、胸悶，偶有暈厥、休克)；○Absolutelyregularrhythmandregularintensityofthefirstheartsound（心音絕對(duì)整齊，心音強(qiáng)弱一致）。Electrocardiography（心電圖）：○NonoticeablePwave（P波不易辨認(rèn)）；○SupraventricularQRScomplexwitharegularrhythmandatratesbetween160-250beats/min（QRS為室上性、節(jié)律整齊，頻率160-250次/分）。Management（治療）:○Terminatingtheattack（終止發(fā)作）：◆Vagalmaneuvers（興奮迷走神經(jīng)）：

Stimulatingthroat（刺激咽喉部）；

Valsalvamaneuvers（Valsalva氏動(dòng)作）；

Carotidsinusmassage（頸動(dòng)脈竇按摩）；

Pressingeyeball（壓迫眼球）?！鬌rugtherapy（藥物治療）：

Verapamil（維拉帕米）;

Propafenone（心律平）；

Adenosine（A.T.P）;

Cedilanid（西地蘭）；

Amidarone（胺碘酮）?！羰车勒{(diào)搏超速抑制.◆DCcardioversion（直流電復(fù)律）?！餚reventionofrecurrences（預(yù)防發(fā)作）：◆Amidarone（胺碘酮）；◆Radiofrequencyablation—radicaloperation（射頻消融—根治性手術(shù)）。Paroxysmalventriculartachycardia（室性心動(dòng)過速）Etiology（病因）：○Occursinpatientswitheverykindofstructuralheartdisease（見于各種器質(zhì)性心臟病患者）；○Occasionallyoccursinpersonswithoutstructuralheartdisease（偶見于無器質(zhì)性心臟病者）?！餌rugintoxication--digitalis（藥物中毒：如洋地黃）?！餎lectrolyteimbalance:hypokalemia(電解質(zhì)紊亂：如低血鉀)?！餝timulant：heartoperation，anesthesia，heartcatheterization(刺激:心臟手術(shù),麻醉,心導(dǎo)管檢查等)。Clinicalfeatures（臨床表現(xiàn)）：○Maycauseserioushemodynamicsresponses，suchashypotension，syncope，dyspnea，anginapectoris，shockorAdams-Strokesyndrome（室速可引起嚴(yán)重血流動(dòng)力學(xué)反應(yīng)：低血壓、暈厥、呼吸困難、心絞痛、休克、阿－斯綜合征）?！餏eaturesonauscultation（聽診特點(diǎn)）：◆Mayhaveirregularrhythm（心律可不規(guī)則）；◆Atratesbetween100-250beats/min（頻率100-250次／分）；◆Mayvaryintheintensityofthefirstsound（第一音強(qiáng)弱有變化）?！馝lectrocardiography（心電圖）：○Occurrenceofaseriesofthreeormoreconsecutiveprematureventricularcomplexes（3個(gè)或以上室性早搏連續(xù)出現(xiàn)）；○B(yǎng)izarrelyshapedQRScomplexwhosedurationexceeds0.12s，withTwavepointingoppositetothemajorQRS（QRS波群形態(tài)畸形，時(shí)限超過0.12s,T波與主波反向）；○Atratesbetween100-250beats/min（心室率100-250次/分,可略不規(guī)則）;○AtrioventriculardissociationwhichmeansPwaveisnotrelatedtoQRScomplex（P波與QRS無關(guān)系,稱室房分離）;○Capturebeatsandfusionbeats（心室奪獲與室性融合波）.●Management（治療）:○Terminatingonset（終止發(fā)作）：◆Lidocaine（利多卡因）；◆Amiodarone（胺碘酮）DCcardioversion（直流電復(fù)律）。Atrialflutter（心房撲動(dòng)）●Etiology(病因):○Mayoccurinpatientswithoutstructuralheartdisease（可發(fā)生在無器質(zhì)性心臟病患者）；○Usuallyoccursinpatientswithrheumaticheartdisease、coronaryheartdiseaseorcardiomyopathy（可見于心臟病如風(fēng)濕性心臟病、冠心病、擴(kuò)張性心肌病等）；○Occursasaresultofatrialdilationsuchasmitralstenosisandmitralinsufficiency（也見于引起左房擴(kuò)大的情況如二尖瓣狹窄與關(guān)閉不全）；○Inothercauses：hyperthyroidism，alcoholismorpericarditis（其他：甲狀腺機(jī)能亢進(jìn)、酒精中毒、心包炎等）?！馛linicalmanifestation(臨床表現(xiàn)):○Lesscommonthanatrialfibrillation（不如心房顫動(dòng)多見）；○Tendstobeunstable：revertingtosinusrhythmordegeneratingintoatrialfibrillation（有不穩(wěn)定傾向，可恢復(fù)為竇性或進(jìn)展為心房顫動(dòng)）○Nosymptomifventricularresponseisnotfast（心室率不快時(shí)可無癥狀）；○Mayinduceanginaorheartfailure（心室率快時(shí)可誘發(fā)心絞痛或心力衰竭）；○MayhavevariedintensityofS1iftheratioofA-Vconductionvaries（當(dāng)房室傳導(dǎo)比例發(fā)生變動(dòng)時(shí)，第一心音強(qiáng)度亦變化）●Electrocardiography(心電圖):○RegularflutterwavecalledF：samecontour，sizeandamplitude（形態(tài)、大小、振幅均規(guī)則的鋸齒形撲動(dòng)波，稱F波）；○FrequencyofFwave：250-300beats/min（F波頻率250-300次/分）；○RateofA-VconductionisthedeterminantforregularorirregularR-Rintervals（心室率規(guī)則與否取決于房室傳導(dǎo)比例）。Management(治療):○Primarilybedirectedtotheunderlyingdisease（針對(duì)原發(fā)病）；○Slowventricularresponse：calciumantagonistsuchasverapamil、diltiazem、digitalis（減慢心室率：鈣阻滯劑如維拉帕米、硫氮卓酮，洋地黃）；○Revertrhythm:amiodarone，electricaldefibrillation(轉(zhuǎn)復(fù)竇律:胺碘酮、電復(fù)律）；○Radicalcure:Radiofrequencyablation（根治：射頻消融）。Atrialfibrillation（心房顫動(dòng)）●Etiology(病因):○Mayoccurinhealthypersonswhenexcited、post-operationoracutealcoholintoxication（可見于正常人激動(dòng)、手術(shù)后、急性酒精中毒時(shí)）；○Occurinavarietyofcardiovasculardiseasessuchasrheumaticheartdisease、coronaryheartdisease、hyperthyroidism、chronicpulmonarydisease、hypertensivedisease、cardiomyopathiesandconstrictivepericarditis（心血管疾病如風(fēng)濕性心臟病、冠心病、甲亢性心臟病、肺源性心臟病、高血壓性心臟病、心肌病、縮窄性心包炎等）；○Isolatedatrialfibrillation—nostructuralheartdisease（無心臟病時(shí)稱孤立性房顫）?！馛linicalmanifestation(臨床表現(xiàn)):○Canbedividedintoparoxysmal、continuousorpermanentatrialfibrillation（可分為陣發(fā)性、持續(xù)性、永久性）；○Thedegreeofsymptomisdeterminedbytheventricularresponse（心室率快慢決定癥狀程度）；○Causeabout30%lessstrokevolumebecauseofchaoticatrialcontraction（因失去心房有效收縮，故心排血量減少約30%）;○Systemicemboli（易發(fā)生體循環(huán)栓塞）。●Clinicalmanifestation(臨床表現(xiàn)):Threeobviousfeaturesonauscultation：variationintheintensityofthefirstheartsound，irregularventricularrhythm，pulsedeficit（心臟聽診“三不等”：第一心音強(qiáng)弱不等、心律絕對(duì)不齊、脈搏短絀）?！馝lectrocardiography(心電圖):○NoPwave，fibrillatorywaveswhicharedifferentincontours，sizeandamplitude，theirfrequenciesarebetween350-600beats/min（P波消失代以形態(tài)、大小、時(shí)距不等的f波(顫動(dòng)波)，頻率350-600次/分）；○Irregularventricularrhythm（心室率不規(guī)則）；○SupraventricularQRScomplex（QRS為室上性）。Management(治療):○Seeatrialflutter（參見心房撲動(dòng)）；○Anticoagulationandantiplatelettherapy（抗凝、抗血小板治療）；○Radiofrequencyablation（射頻消融術(shù)）。Atrioventricularblock，AVB（房室傳導(dǎo)阻滯）●Concepts（概念）：○Impulseisabnormallydelayedorblockedduringtheconductionbetweentheatriaandventricles（指沖動(dòng)在房室傳導(dǎo)過程中被異常的延遲或阻滯）；○TheblockcanoccurintheAVnode，Hisbundleorbundlebranches（阻滯可發(fā)現(xiàn)在房室結(jié)、希氏束或束支等不同部位）?！餞heconductiondisturbanceisclassifiedbyseverityinthreecategories：firstdegreeAVblock—conductionisdelayedbutallatrialimpulsesareconducted；SeconddegreeAVblock—partsofatrialimpulsesareconducted；ThirddegreeAVblock—atrialimpulsesarenotcounductedatalltotheventricles（根據(jù)阻滯程度不同，可分為I，II，III度：I度AVB：指?jìng)鲗?dǎo)時(shí)間延遲，心房激動(dòng)能全部傳導(dǎo)下來。II度AVB：部分下傳，部分阻滯形成脫漏。III度AVB：全部不能下傳，稱完全性AVB）。Etiology（病因）：○Increaseinvagaltone：FirstortypeIseconddegreeAVBinhealthypersonsorathletes（迷走張力過高：正常人、運(yùn)動(dòng)員可I-II度Ⅰ型AVB）；○Everykindofstructuralheartdiseases（各種器質(zhì)性心臟病）；○Intoxication：digitalis，β-blockerandotherantiarrhythmias（藥物中毒：洋地黃，β-阻滯劑及其他抗心律失常藥物）；○Electrolytedisturbance：hypokalemia（電解質(zhì)紊亂：高血鉀）；○Primaryconductionbundledegeneration（原發(fā)性傳導(dǎo)束退化癥）。FirstdegreeAVblock（I度房室傳導(dǎo)阻滯）●Electrocard