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Názvem arytmie se označuje široká skupina stavů projevujících se poruchou pravidelnosti a/nebo frekvence srdečního rytmu. Rytmus při arytmii je tedy buď zrychlený (tachykardie, obvykle nad 120/min), nebo zpomalený (bradykardie, obvykle pod 50/min), nebo nepravidelný. Z prostorových důvodů se zde zaměříme jen na nejzávažnější, život ohrožující arytmie, které vyžadují terapii již v prehospitalizační fázi.

 Sinusová bradykardie, zástava sinu:

Zpomalení sinusového rytmu pod 50/min (u přirozených vagotoniků pod 40/min), event. zástava sinusového rytmu (obvykle s náhradním junkčním — či komorovým rytmem), bývá nejčastěji v důsledku vagové reakce nebo sick sinus syndromu. Terapie: atropin 0,5-2,0 mg i.v.

 Extrasystoly supraventrikulární, komorové: Ojedinělé extrasystoly v prehospitalizační fázi nevyžadují  léčbu.  Léčit  je  nutné  pouze  tzv.  maligní komorové extrasystoly (tj. páry či salvy extrasystol, polytopní četné extrasystoly, typ R na ,T). Terapie: Mesocain 100 mg i.v., event. opakovat v dávce 50 mg i. v.

 Tachykardie se štíhlými QRS komplexy:

Při pravidelné tachykardii se štíhlými QRS komplexy se může jednat o přibližně 7 druhů supraventrikulárních tachykardií. Pokud není klinický obraz hrozivý (hypotenze, srdeční selhání nebo stenokardie), je lépe s léčbou vyčkat do nemocnice, po natočení kvalitního EKG (event. s jícnovým svodem). Pokud je klinický obraz hrozivý (což nastává u těchto tachykardií vzácně), vyzkoušíme masáž karotického sinu a při neúspěchu tohoto jednoduchého manévru je nutno se pokusit o farmakologickou léčbu jedním z následujících léků: β-blokátor, ajmalin. adenozin, event. verapamil (v uvedeném pořadí).

 Tachyfibrilace síní:

Pokud není spojena s klinicky závažným stavem, je opět lépe léčbu odložit až na nemocniční lůžko či ambulanci. V prehospitálizační fázi lze podat digoxin nebo β-blokátor, event. verapamil (nekombinovat však verapamil s β -blokátorem).

 Tachykardie se širokými QRS komplexy:

Může se jednat o komorovou tachykardii nebo o supraventrikulární tachykardii s aberací QRS komplexu (tj. s »funkčním« raménkovým blokem). V odlišení někdy pomůže masáž karotického sinu (při supraventrikulární tachykardii se rytmus zpomalí, komorová tachykardie na masáž  nereaguje). Komorovou tachykardii léčíme mezokainem (100 mg i.v., event. druhá dávka 50 mg i.v.) nebo ajmalinem. Při klinicky hrozivém stavu (hypotenze, event. bezvědomí) provádíme okamžitou elektrickou kardioverzi. Komorová tachykardie může bez léčby kdykoli přejít do fibrilace komor!

 Torsade de pointes

Jedná se o zvláštní druh komorové tachykardie vznikající často při prodloužení intervalu Q-T (vedlejší účinek řady antiarytmik!) a při hypokalémii či hypomagnezémii. Léčba spočívá v korekci hladin minerálů (K, Mg), vysazení event. provokujícího antiarytmika. Efekt jiných léků (β-blokátory nebo naopak β -mimetika – např. izoprenalin, amiodaron) není spolehlivě prokázán. Klasická antiarytmika jsou obvykle kontraindikována Při dlouhotrvajícím paroxyzmu torsade de pointes, provázeném ztrátou vědomí, je samozřejmě indikována elektrická defibrilace.

 Fibrilace komor

Je to nejzávažnější arytmie: při jejím vzniku je nemocný de facto ve stavu klinické smrtí. Je charakterizována chaotickou elektrickou aktivitou vedoucí k rychle se opakujícímnekoordinovaným a hemodynamicky neúčinným kontrakcím svalových vláken a komor a tím kzástavě oběhu. Minutový výdej srdeční rychle klesá k nulovým hodnotám a během několika minutnastává smrt. Objektivně se manifestuje fibrilace komor kardiální synkopou s bezvědomím, nehmatným pulsem,neslyšitelnými ozvami a neměřitelným tlakem. Na EKG jsou zcela nepravidelné a deformované komorové komplexy, v nichž nelze rozeznatjednotlivé kmity. Amplituda jednotlivých výkyvů (aberantních komorových komplexů) je různá, často na počátku relativně vysoká, později se výkyvy oplošťují, popř. vzniká asystolie.

Patogeneze: fibrilace komor vzniká vždy na hrubě porušeném srdečním svalu, kde se vytvořilyčetné oblasti s různou refrakterností a kde je tendence lokálně tvořit rychlé sledy impulsů. Kromějednoduché, unifokální tvorby impulsů se může uplatnit i multifokální tvorba impulsů nebomechanismů reentry, popř. kombinace těchto mechanismů.

Výskyt:

-akutní fáze IM – fibrilace komor je hlavní příčinou smrti v předhospitalizační fázi na srdeční infarkt. Asi v polovině případů IM jde o primární fibrilaci komor, druhou polovinu tvoří sekundární fibrilace  komor.-zasažení elektrickým proudem-otravy, např. digitálisem, chinidinem, procainamidem apod.-iatrogenně při kardiochirurgických operacích, zejména v hypotermii-při léčbě komorových tachykardií elektrickým impulsem (kardioverze) nebo při stimulaci, jestliže  impuls přišel do vulnerabilní fáze (fenomén R na T)

Rozdělení fibrilací komor:

1. Primární – je poměrné dohře terapeuticky ovlivnitelná, neboť u ní jde pouze o elektrickou instabilitu srdce a nikoliv o mechanické postižení. Tzn. není zde srdeční selháni ani hypotenze.

2. Sekundární – tento typ fibrilace přichází u těžce postiženého srdce s mechanickou insuficiencí, která vede k současnému srdečnímu selhání nebo je přítomna hypotenze až kardiogenní šok. Terapeuticky je špatně ovlivnitelná.

3. Terminální – agonální, předsmrtná

Terapie: elektrická deftbrilace (200-200-360 J). Při defibrilaci je nutné její technicky dokonalé provedení: dobré potření elektrod EKG gelem, správné přiložení a pevné přitlačení elektrod na kůži, nedotýkat se pacienta ani podložky jinak než přes elektrody. Neodkladná resuscitace.

A-V blok III. stupně

V prehospitalizační fázi lze podat atropin 0,5-2,0 mg i.v. a při hrozivém klinickém obrazu  na  dobu transportu event. Izoprenalin v infúzi. Lépe je zavést zevní elektrostimulaci. Při progresi do asystolie komor zahájit neodkladnou resuscitaci.

Terminální EKG

Terminální (konečné, předsmrtné) stahy jsou charakterizovány bizarními tvary. Zpočátkuse zpomaluje frekvence, prodlužuje se PQ interval (síňokomorové vedení), objevuje se tzv. vlna J(„Asbornova vlna“), která následuje po R kmitu a vede k rozšíření komplexu QRS. Vlna Tse oplošťuje:

Postupně se mění tento EKG obraz ve sporadicky se vyskytující komorové komplexy nízké voltážetvaru monofázické vlny, na niž nelze rozeznat jednotlivé části QRS komplexu. Tyto změny jsou refrakterní na terapii.

Komorová tachykardie

Je to sled 3 (případně 5) nebo více po sobě následujících komorových extrasystol v rychlém sledu,tedy salvy extrasystol. Ektopický komorový fokus aktivuje komory rychlostí 140-220/min.Komorovou tachykardii předcházejí často četné komorové extrasystoly. Síně jsou na komorách nezávislé a obvykle zůstávají pod kontrolou sinusového uzlu. Komorová tachykardie je podstatně vzácnější, prognosticky daleko závažnější a terapeutickyodolnější než supraventrikulární tachykardie. Na EKG je nález širokých komplexů QRS (nad 0,12 s) aberantního tvaru, který může připomínat obraz blokády některého z Tawarových ramének. Vlny P jsou skryty v aberantních komorovýchkomplexech, a proto je lze těžko diferencovat. Frekvence vln P (síňových stahů) je obvyklenormální a tedy výrazně nižší než komorových komplexů.

Po skončení paroxysmu komorové tachykardie bývá na EKG někdy deprese ST až obraz IM.Tento obraz se označuje jako posttachykardický syndrom.

Diferenciální diagnóza: největším problémem je odlišení od supraventrikulární tachykardiese současnou blokádou raménka, většinou pravého. Pokud se podaří identifikovat vlny P, majíu komorové tachykardie zřetelně pomalejší frekvenci nezávislou na frekvenci komor. Vlny P se dají dobře registrovat pomocí jícnových svodů. Klinické rozlišení je zejména v tom, že komorovátachykardie nereaguje na masáž karotického sinu (dráždění vagu), kdežto supraventrikulárnítachykardie na masáž karotického sinusu reaguje. Z hlediska terapie je klinická závažnost komorové tachykardie tak urgentní, že při diagnostickýchrozpacích je nutno tachykardii považovat za komorovou a také ji tak léčit.

Rozdělení podle závažnosti:

1. Benigní forma – přichází často jako krátkodobý paroxysmus u mladých lidí se zdravým srdcem.

2. Maligní forma – vzniká na těžce poškozeném srdečním svalu a má velmi špatnou prognózu.

Výskyt:

-jako časná či pozdní komplikace akutního infarktu myokardu

-pokročilá ischemická choroba srdeční

-předávkování léky – digitalis, chinidin, procainamid

-vzácněji u myokarditid (zejména revmatického původu) a u kardiomyopatií

-u vrozených syndromů prodlouženého QT (viz kapitola „Interval QT“)

-zcela ojediněle jsou krátkodobé paroxysmy i u jedinců se zdravým srdcem

 Zvláštní typy komorových tachykardií:

1. Torsade de points – tento typ je charakterizován frekvencí QRS komplexů kolem 200/min., přičemž amplitudy bizarních QRS komplexů při této tachykardii pomalu narůstají a poklesají:

Vysvětluje se to periodickou změnou hlavního vektoru QRS. Ataky tachykardie bývají kratší, mohou spontánně vymizet, ale mohou přejít též ve fibrilaci komor.

Výskyt:-předávkováni léky (chinidin, mesocain, procainamid)

-poruchy elektrolytové rovnováhy (hypokalémie, hypomagnezémie)

-u vrozených syndromů prodlouženého QT

2. Bidirektionální komorová tachykardie:

– komorová tachykardie se dvěma střídajícími se typy QRS komplexů. Je často projevem digitálisové intoxikace.

 3. Repetitivni monomorfní komorová tachykardie

– nepravidelně se střídají krátké úseky komorové tachykardie (většinou 3-15 aberantních komplexů) a normální sinusové komplexy s P vlnou. Má dobrou prognózu, vyskytuje se u mladých zdravých lidí.

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