What is ventricular extrasystole: treatment and consequences

What it is

Sudden contractions of the left or right ventricles of the heart are associated with the appearance of foci of excitation in the Purkinje fibers or in the distal areas after the branching of the His bundle branches. This phenomenon can be observed in severe diseases of the heart muscle caused by intoxication, overexcitation, and congenital characteristics of the conduction system of the heart.

Single ventricular extrasystoles are observed normally in completely healthy people. They usually do not manifest themselves clinically and do not require special treatment. With age, their number increases.

Causes

To understand the etiology of the appearance of such arrhythmia, it is most convenient to present all the factors in the form of a table:

For any disease, the only examination that will clearly show the presence of additional ventricular contractions is electrocardiography. If it is not possible to register a deviation during an ECG, then a special device is used that records heart activity over a given time.

Description

Ventricular extrasystole is an earlier (in relation to the main contractile rhythm) excitation of the ventricles of the heart, accompanied by corresponding changes in the electrocardiogram and the appearance of the clinical picture of the disease.
Ventricular extrasystole develops against the background of many diseases and causes, the main of which are:

• various diseases of the cardiovascular system (myocarditis, cardiomyopathy, coronary heart disease, arterial hypertension, pulmonary hypertension and others);
• postoperative phenomena due to surgical interventions on the heart, as well as after injuries to the chest in the heart area;
• the use of certain medications (for example, cardiac glycosides);
• metabolic disorders (acute and chronic renal failure, alcohol poisoning and chronic alcoholism, decreased levels of potassium and magnesium in the blood);
• hypoxic phenomena that are observed in anemia, acute and chronic heart failure, lung diseases (bronchial asthma, COPD);
• endocrine disorders (hyperfunction of the thyroid gland, diabetes mellitus type 1 and 2);
• idiopathic (in cases where the cause cannot be determined).

The prognosis of ventricular extrasystole depends on its form, the presence of pathology in the cardiovascular system, and disturbances in hemodynamic parameters. Functional ventricular extrasystoles do not pose a threat to life, in most cases they have absolutely no effect on the general condition of a person. However, if there is an organic lesion of the heart, on the basis of which ventricular extrasystole has developed, the prognosis is significantly worse. This is associated with the risk of developing ventricular tachycardia and ventricular fibrillation, which without qualified medical care can be fatal.

Symptoms and manifestations

Most often, single extrasystoles appear without clinical symptoms. According to statistics, interruptions in this case develop in 30% of patients, and approximately 7% believe that this phenomenon significantly worsens their well-being. The patient’s complaints at the time of the onset of arrhythmia are as follows:

• heart sinking, tremors and interruptions;
• dizziness and general weakness;
• shortness of breath, lack of air;
• volley and frequent ventricular extrasystoles can cause pain against the background of an ischemic attack and impaired consciousness.

I have often noticed that additional myocardial contractions of functional origin often cause significant symptoms. But disturbances against the background of organic changes of a chronic nature are not perceived, as if a person is getting used to them.

Classification and types

There are several types of classifications to determine the type of a given arrhythmia. They are important for establishing the cause of the pathology, accurate diagnosis, treatment approach and further prognosis.

According to the frequency of occurrence, the following ventricular extrasystoles are distinguished:

• rare (less than 5 per minute);
• medium frequency (up to 16/min);
• frequent (16 or more).

By density:

• single;
• pairs;
• group.

By localization:

• right ventricular;
• left ventricular.

By localization of excitation:

• monomorphic (arise from one focus, have the same appearance on the ECG);
• polymorphic (different places of origin, complexes differ markedly when registered).

According to the rhythm of appearance:

• bigeminy (every second contraction is an extrasystole);
• trigeminy (every third);
• quadrigeminy (fourth);
• sporadic (excitations without a clear sequence).

According to the degree of danger, there are the following classes:

1. Benign ventricular extrasystoles. They occur in the absence of myocardial damage or hypertrophy, their frequency does not exceed 10 per hour, and are not accompanied by impaired consciousness.
2. Potentially malignant. Against the background of left ventricular dysfunction, with a frequency of 10 or more per minute. No fainting or cardiac arrest.
3. Malignant. Frequent, polymorphic and polytopic, against the background of significant deviations (ejection fraction of 40% or less), turn into stable ventricular tachycardia. The medical history contains a description of impaired consciousness and (or) cardiac arrest.

Ryan gradation

My colleagues and I still use the classification of ventricular extrasystole (VC), proposed by M. Ryan in 1975; it is intended for patients who have a history of myocardial infarction. According to this gradation, the following degrees of arrhythmia development are distinguished:

Early ventricular extrasystoles have especially severe consequences for the patient’s life. They occur while the active phase of depolarization occurs, preventing the heart from relaxing for the next contraction.

Medicines

Photo: fitohome.ru

To reduce the number of ventricular contractions and reduce post-extrasystolic force, β-blockers (bisoprolol, carvedilol) are used. Since β-blockers lead to a decrease in blood pressure and heart rate, it is important to monitor your blood pressure and pulse while taking this group of drugs. Reducing the dosage of the drug or discontinuing it (using the minimum therapeutic dose) is carried out when the heart rate is less than 55 beats per minute or lower and with hypotension. It is also important to note that contraindications to taking β-blockers are diseases of the respiratory system, occurring with broncho-obstructive syndrome, AV blockade of the 2nd degree and higher.

Sedatives are also used in the treatment of ventricular extrasystole. These are drugs of plant or synthetic origin that cause a decrease in emotional stress. It is important to note that sedatives do not have a hypnotic effect, but can facilitate the onset of sleep and increase its depth. Sedatives are well tolerated by patients of various age groups, including elderly and senile patients; there are practically no side effects.

Antiarrhythmic drugs include procainamide or amiodarone. These drugs should be used under ECG or Holter monitoring, as they can cause various side effects. For example, taking procainamide can lead to the development of hallucinations, depression, myasthenia gravis, and suppression of bone marrow hematopoiesis (leukopenia, thrombocytopenia, neutropenia, agranulocytosis, hypoplastic anemia). With rapid intravenous administration of the drug, collapse, disruption of atrial or intraventricular conduction, and asystole are possible. While taking amiodarone, a metallic taste in the mouth, a feeling of heaviness in the epigastric region, nausea, vomiting, bronchospasm in patients with severe respiratory failure, tremor, sleep disturbance, and headache may occur.

Diagnostics

Diagnostics that determine rhythm disturbances are based on standard methods. First, a cardiologist or therapist conducts a survey, identifying the patient’s main complaints. Examination and auscultation help to detect signs of heart failure and suspect a valve problem.

ECG and Holter monitoring

The most effective method for accurately determining heart rhythm disturbances such as ventricular extrasystole is an electrocardiographic study. But it cannot 100% identify the problem, since additional stimulation does not always occur at the time of taking an ECG.

If it is necessary to establish a diagnosis, 24-hour monitoring is used, which is called Holter monitoring. It helps in determining any type of arrhythmia, especially if the deviation is transient. After recording the electrical activity of the heart, it becomes possible to:

• clarify the number and morphology of ventricular complexes;
• dependence of their appearance on physical activity or other factors;
• record changes depending on sleep or wakefulness;
• draw a conclusion about the effectiveness of drug therapy.

Electrocardiographic signs

On an ECG, ventricular extrasystole manifests itself as follows:

1. The occurrence of an extraordinary QRS complex. It is characterized by the absence of an atrial wave, expansion and deformation. In this case, T has the opposite (discordant) direction. Most often, it is followed by a complete compensatory pause (isoline).
2. Extrasystoles from the left ventricle are characterized by a tall and wide R wave, as well as a subsequent deep negative T wave in leads III, aVF, V1 and V2, as shown in the photo. At the same time, there is a deep and wide S, high T in I, II, aVL, V5 and V

1. Complexes from the right ventricle present the opposite picture, +R and –T will be in I, II and left precordial leads. Negative R and positive T are in the right leads and aVF, the changes are clearly visible in the photo.

1. There are interpolated (inserted) extrasystoles. On the cardiogram they appear as a deformed QRS complex, which is inserted between two normal contractions and does not have a compensatory pause. Often this phenomenon accompanies bradycardia, as can be seen in the photo.

More details on the electrocardiographic signs of extrasystoles can be found here.

Treatment

Treatment tactics after detection of ventricular extrasystoles depend on the presence of other diseases, symptoms, and threatening types of rhythm disturbances. If there are no complaints and rare emerging complexes are identified, no special therapy is required. A person is advised to give up caffeinated drinks, avoid alcohol and smoking.

If attacks are accompanied by clinical symptoms, but are benign and do not interfere with hemodynamics, beta blockers become the drugs of choice. Sometimes Valocordin or Corvalol helps stop an attack. In some cases, the problem can be eliminated with the help of Phenazepam.

Some specialists use class I antiarrhythmics in this case. But recent research confirms the inconsistency of this choice. It is especially dangerous to give these drugs in the presence of cardiac ischemia or during active myocarditis. The mortality rate of patients with the use of these drugs increases by 2.5 times.

In case of malignant extrasystole, the patient is placed in a hospital, where the following means are used:

1. Amiodarone – used alone or in combination with beta blockers (Concor). This can significantly reduce the likelihood of death in patients with impaired cardiac blood flow. Treatment is carried out under the control of the QT interval.
2. If Amiodarone is ineffective, Sotalol is used.
3. If the problem is caused by an electrolyte imbalance, the patient receives potassium chloride or magnesium sulfate.

Treatment for a benign course continues for several months under ECG monitoring, then gradual withdrawal of antiarrhythmic drugs is recommended. Malignant pathology requires longer therapy.

How to relieve an attack

Frequent ventricular extrasystole is often observed in the first hours and days of acute myocardial infarction. It is dangerous due to the development of fibrillation and requires immediate relief. To do this, the following algorithm of actions is used:

1. Intravenous administration of Lidocaine in a stream followed by a transition to a drip.
2. If there is no result, switch to Novocainamide or Etatsizin.
3. If palpitations are noted, beta blockers and Cordarone are used.
4. For extrasystoles against the background of bradycardia, it is better to use Ethmozin or Ritmilen.
5. Combining antiarrhythmic drugs is undesirable. This should only be done if absolutely necessary.

A detailed description of the use of drugs to relieve extrasystole is here.

When is surgery necessary?

The indication for surgery for this arrhythmia is the detection during daily monitoring of at least 8,000 extraordinary contractions throughout the year. In this case, the patient is recommended to undergo radiofrequency ablation (RFA).

The essence of this technique is that a catheter is inserted into the patient into a large-caliber vessel (this can be a vein under the collarbone or in the thigh area), which is guided under the control of equipment to the very heart. Then a radiofrequency pulse is applied to the site of pathological excitation (burning). I would like to note that such manipulation is usually successful, its effectiveness is 90%.

Archives

O. Y. Zharinov, V. O. Kuts National Medical Academy of Postgraduate Education. P. L. Shupika Ministry of Health of Ukraine

Extrasystole (ES) is the most widespread disturbance of the heart rhythm, which can significantly influence the life quality of patients, being a marker of structural and functional changes in the myocardium and indicate the unsafety of life unsafe You have heart arrhythmia. A more refined strategy for the management of ill patients is directly linked to the development of the concept of “stratification of risk”, so that patients are divided into groups according to the level of risk of death from all causes and, among other things, cancers. about cardiac death (CCD). In addition, day-to-day instrumental methods for diagnosing cardiac arrhythmias are being actively promoted, including ambulatory ECG monitoring. In clinical practice, there is an obvious need for the creation of favorable recommendations for the management of cervical diseases, specific diagnostic and therapeutic approaches.

ETIOLOGY

When SHE appears, they can call out any structural illness of the heart. They are especially common in patients with acute myocardial infarction (MI) and chronic ICH. However, extrasystoles can also occur with other myocardial stresses, including subclinical ones. In many patients with extrasystole, no available instrumental methods of investigation can be used to detect any signs of a weakened heart.

Wider causes and factors associated with SE:

• Ailments of the myocardium, endocardium and cerebrovascular arteries: ICH, myocarditis, myocardiofibrosis, cardiomyopathy, blood vessels, arterial hypertension or hypotension, heart failure (HF);
• Electrolyte imbalance (hypokalemia, hyperkalemia, hypomagnesemia, hypocalcemia), impaired acid-salinity;
• Hypoxia: sick leg, pulmonary hypoventilation (for example, during surgery);
• Traumatic injuries: chest injury, heart surgery, empty heart catheterization, brain and spinal cord injuries;
• Impaired autonomic regulation: neurocirculatory dystonia, neuroses, diencephalitis, sympathetic ganglionitis and truncitis, psychoemotional stress;
• Pathological reflexes, diseases of the organs and poisoning (virazkova disease, gum disease, pancreatitis, diaphragmatic clubina, colitis and enterocolitis, especially if they are accompanied by flatulence, constipation or electrolyte disturbances balance); dystrophic changes in the cervical and thoracic lobes of the ridge (osteochondrosis, spondyloarthrosis); bronchial diseases and illnesses, especially those accompanied by a persistent cough; prostate adenoma;
• Diagnostic procedures: endoscopy (bronchoscopy, gastroscopy, laparoscopy, cystoscopy, colposcopy, rectoscopy), puncture, carotid sinus massage, pressure on the apple of the eye, breathing while holding a deep breath;
• Allergies: food, medicinal, microbial, occupational, household;
• Pharmacodynamic and toxic effects of medications such as cardiac glycosides, quinidine, novocainamide, anesthetic agents, morphine, glucocorticoids, potassium, calcium preparations, tricyclic antidepressants, related phenotiases in other words, adrenomimetics.

The main electrophysiological mechanisms of extrasystole are re-entry (return input of awakening) and post-depolarization. The basis for extrasystoles may also be the mechanisms of asynchronous renewal of myocardial alertness and pathological automatism.

COLLABORATION OF THE SICK

Treatment of patients with cervical heart disease includes methods to ensure the diagnosis of cardiac rhythm disturbances, determination of the clinical and prognostic significance of arrhythmia, choice of treatment and assessment of its effectiveness.

Anamnesis.

When examining a patient, provide the following information: subjective manifestations of arrhythmias (heart palpitations, interruptions in the functioning of the heart, problems or a “frozen” heart, discomfort in the chest, due to insufficient wind, shortness of breath, confusion, syn digging camps), ancient history of destruction of the rhythm; factors that provoke arrhythmia (physical stress, psycho-emotional stress, late hour of prey, body position, food intake, alcohol, chicken); endured the remaining hours of illness; background cardiac pathology; advance use of antiarrhythmic drugs (AAP).

Clinically quilted.

Identification of arrhythmias during auscultation of the heart or during palpation of peripheral arteries; presence of clinical signs of HF.

Laboratory methods of investigation.

Valued instead of potassium, sodium, creatinine in blood serum, thyroid-stimulating hormone activity.

EKG.

Main ECG signs of extrasystoles (ES):

1. It is preceded by the appearance of a widened and deformed intrabasic rhythm of the QRS complex without the P wave transmitted to it, after late extrasystoles, before which the P wave is registered, which does not impair the electrophysiological connection with the neck;
2. Most often, a new compensatory pause is evident.

The shape of SH is not only due to the localization of the extrasystole, but also due to the fluidity and direction of the expansion of the impulse in the shanks. Therefore, the ECG makes it possible to determine the location of the ectopic cavity behind the morphology of the extrasystolic complex. It appears that there is a blockade of the right leg and the left anterior bundle of His, and it should be located in the system of the left posterior bundle of His, or in the posterior wall of the left bundle; It appears that there is a blockade of the right leg and the posterior inferior ganglion of the His bundle, which is located in the left anterior ganglion of the His bundle; If there appears to be a complete blockade of the left branch of the His bundle, then there is a blockage in the right branch of the His bundle. The QRS complex of the left ventral extrasystole in the right thoracic abductions has a mono- or biphasic form: R, qR, RR', RS, Rs and in the left ones - rS or QS. The QRS complex of the right ventricular extrasystole in the right thoracic adducts takes the form rS or QS, and in the left - R (Table 1). This is due to the dilation of the interstitial septum, as, of course, its length and shape slightly vary in relation to the QRS complex of the main rhythm. The QRS shape of the rSR' type in V1 is typical for extrasystoles from the left half of the interseptal septum, and the R or qR type in V6 is typical for extrasystoles from the right half of the septum. The directness of the QRS complex of the extrasystolic complex in all thoracic abductors allows localization of the cerebral muscle in the basal lobes of the heart, and the directness of the QRS complex in the lower abdomen allows for localization of the thoracic abductor in the basal lobes of the heart. In cases that are difficult for topical diagnostics, it is more precise that extrasystoles are not indicated, surrounded by a warning about the presence of E.

Table 1. Characteristic forms of NEC complexes in thoracic ECG leads with basal, perineal and superior localization

The intervals of aggregation of monotopic HE are, however, regardless of the fact that their form may be different (in this type the stench is polymorphic). The intervals for the accumulation of monotopic extrasystoles should not exceed 0.06–0.10 s. Floods may vary over the course of the consolidation interval and, as a rule, have different shapes of QRS complexes. Two extrasystoles are called guy (Fig. 1), and three to five are called group, “volley” (Fig. 2), or runs of ventral tachycardia - PC. You can also see early and even early SH („R to T”) (Fig. 3). Extrasystoles may be irregular (monotopic or polytopic), and their appearance with regularity is designated as an arrhythmia (bigeminia, trigeminia, quadrigeminia, etc.). Interpolations are registered between two normal QRS complexes, especially against the background of bradycardia.

Picture 1.

Alone and paired polytopic extrasystole.

Figure 2.

Group polytopic shlunochkova extrasystole.

Figure 3.

Early shlunochkova extrasystole “R to T”.

Scholochkovy extrasystole against the background of anterior fibrillation must be differentiated from aberant sluchkovy complexes. The shortening of the cardiocycle during atrial fibrillation, which ends with an aberrant scapular complex, is not accompanied by a compensatory pause, and is transferred to an extended RR interval. Aberrant QRS complexes, as a rule, take the form of blockade of the right leg of the His bundle of varying degrees of severity in the output V1 (rSR', rSr'), and left ventricular extrasystoles - the form R, RS, Rs, qR, RR' or Rr' (Table 2 ).

Table 2. Differential diagnosis of supraventricular extrasystoles with aberation of the internal sac conductivity and sac extrasystoles

OTHER METHODS OF INSTRUMENTAL DIAGNOSTICS

Holter monitoring (HM) of the ECG allows recording of the ECG without compromising the patient's roach mode for 24 years or more with the subsequent automated analysis of the recording. The number of extrasystoles per hour of exercise is assessed, their distribution of activity, connections with physical or emotional stress, heart rate, body intake, changes in body position, transitional episodes, etc. ii myocardium.

HM ECG is a “standard” method for diagnosing apparently infrequent extrasystoles, as well as assessing the severity of ECG detected during ECG registration. CM ECG allows more precise, shorter-term ECG recording to provide a clear and comprehensive assessment of the disturbance of heart rhythm due to a significantly larger number of assessed ectopic complexes. Alone, it is common to find ECG with CM in apparently healthy individuals.

The equalization of circadian changes in the number of extrasystoles and the frequency of heart rate (HR) allows for the increase in fluid intensity of such and bradyseal forms of extrasystoles. One of the broadest types of extrasystoles is the “vagal” (vagal, or “low”), when the frontal complexes are registered 1.5 times less often in the passive period of dob, against the background of sleep Synchronous with sinus rhythm. Vagozalezhnaya is more often diagnosed in young people without signs of heart pathology, it often has an episodic sign and is not considered sick. This form of extrasystole importantly does not require antiarrhythmic therapy. With the “adrenergic” (sympathostatic or “day” type), the average number of extrasystoles per year is 1.5 times greater during the active period of stimulation, and extrasystoles are often associated with accelerated sinus rhythm. The “adrenergic” type is more typical for summer people, especially those with IHD, hypertensive illness, heart disease, dilated and hypertrophic cardiomyopathies, myocardial fibrosis. In contrast to the “vagal” type, such extrasystole is not benign and often requires the use of AAP, beta-blockers and amiodarone. Even often, the daily connection between the number of extrasystoles and the period of increase and heart rate. You can also watch out for the “hectic” type of subdivision of extrasystoles with significant fluctuations from year to year. Such high ectopic activity over a short period of time may be associated with recurrent myocardial ischemia. The use of the HM ECG has significantly increased the possibility of detecting extrasystole and parasystole, establishing the variability of their forms and options.

The HM ECG method allows you to evaluate changes in heart rate variability per day. Zocrema, a decrease in the standard indicator of heart rate variability - standard variation of RR intervals by stretching (SDNN) - below 50 ms indicate an imbalance in the autonomic regulation of heart rate and one of the predictors of guilt RSS in patients with post-infarction cardiosclerosis, left systolic dysfunction (LS) and heart failure and save sinus rhythm. The strongest predictor of the risk of life-threatening arrhythmia was the result of low heart rate variability due to decreased heart rate fraction (EF) and impaired baroreflex sensitivity (follow-up). ATRAMI, 1998). It is clear that measurements are often used to assess hourly and spectral indicators of heart rate variability.

With CM ECG, attention is also paid to the variability and variability of the consolidation interval, as well as the variability of the QT interval. It is important to evaluate the additional fluctuations of the adjusted QT interval, and even with this significant increase, the severity of the “discharge” period of the cardiac cycle and the delay before the onset of paroxysms may increase „pirates-tachycardia”.

Repeated HM ECG against the background of treatment makes it possible to assess the effectiveness of the prescribed therapy. Based on the changes in the spontaneous fluctuations in the frequency of culprit arrhythmias of the heart, the following criteria for the effectiveness of antiarrhythmic therapy in patients with cerebral hypertension have been developed: a) a change in the number of cervical arrhythmias for an additional 50– 75%; b) a change in the number of young and early children by 90% or more; c) externally suspended episodes of ST; d) with polymorphic cerebral neck - a change in the number of morphological types of extrasystoles to 1–2. Assessing the adequacy of treatment with an antiarrhythmic drug, in addition to exceeding the criteria, also requires taking into account the specificity of its effect on sinus rhythm, conductivity, and the frequency of ischemic episodes.

Interpretation of HM ECG data to assess the effectiveness of antiarrhythmic therapy in case of high blood pressure. When the AAP is assigned to the 1st class under classification V. Williams, the effectiveness of the specified clinical criteria does not allow for an improvement in the prognosis of survival of patients with treatment. Moreover, the use of certain drugs (flecainide, encainide) in controlled studies was associated with significant increases in the prevalence of PCC. It is important that the treatment of patients with severe structural disorders of the myocardium (dysfunction of the myocardium after myocardial infarction or dilated cardiomyopathy, with/without heart failure) begins with the therapy of etiopathogenetic Direction: correct ischemia and hemodynamic disturbances. For evidence of LS dysfunction and partial symptomatic ES, amiodarone or sotalol should be added before basic preventive therapy (angiotensin-converting enzyme (ACE) inhibitors, β-blockers, aspirin, statins) - methods with proven effectiveness This is for the prevention of malignant sac arrhythmias. It is significant that beta-blockers and amiodarone can be used empirically, based on the established availability of these drugs, to predict the survival of patients and, regardless of changes in heart rhythm disturbances. In these situations, the HM ECG is completely dynamic to assess the interruption of heart rhythm disturbances against the background of antiarrhythmic therapy. And in situations where the stagnation of AAP is determined by the clinical manifestations of the rhythm disturbance, and not by their prognostic values, the initial criterion for the effectiveness of the drug is a change in symptoms causing arrhythmia. It is also agreed that the most effective way to prevent RSS in patients with high risk criteria is implantation of an internal cardioverter-defibrillator.

Trying out physical skills

(Master's test, step test, veloergometry, treadmill test) can provoke the appearance of WHILE under the hour of desire and in the early adolescence period due to increased activity of the sympathoadrenal system, an increase in catecholamines , development of tissue hypoxia, acidosis. In patients with chronic ICH, bicycle ergometry under one hour reveals HI in 60% of patients, and its frequency often correlates with displacements of the ST segment (Fig. 4). Under the infusion of physical exercise, the number and gradation of extrasystoles may change: an increase in the number of extrasystoles during the hour of exercise at high heart rate or in the first half after the end of the exercise Consider this possible connection with IHS; “Good” extrasystoles usually appear at the hour of exercise and renew 3–5 hours after its completion. It is necessary to call for diagnostic tests due to the following reasons: in some patients it is not possible to provoke an extrasystole that was previously diagnosed; in 11–40% of patients with a healthy heart, during physical exercise there is a single extrasystole, and in 5% - a pardy; In some patients, with physical stimulation, group and early extrasystoles may occur.

Figure 4.

Right-sided extrasystole against the background of horizontal depression of the ST segment.

Orthoclinostatic test

allows you to clarify the nature of extrasystolic arrhythmia: stable extrasystole occurs at rest during functional tests; Labile extrasystole of voltage appears or becomes stronger during an orthostatic test and a standard applied pressure of 50 W; Labile extrasystole calmly appears during an orthostatic test and physical exertion with a pressure of 50 W and appears after the transition to a horizontal position. It is important that labile extrasystole of stress and stable extrasystole are more likely to be associated with the presence of heart disease and/or a stable substrate of arrhythmia, and labile extrasystole of calm, as a rule, є functional (vagal).

Echocardiography

It is necessary to clarify the infusion of both SE and AAP on the hemodynamic stage. The method allows you to estimate the size of the empty heart in systole and diastole, the vascular fraction, the thickness of the heart walls, the mass of the myocardium of the heart, the relationship between the end-diastolic volume and the mass of the myocardium of the heart, and zones of hypo- and akinesia, local hypertrophy, valvular valves, the phenomenon of “post-systolic “strengthening”, myocardial dysplasia of the right shank. A change in LVEF of less than 40% in patients with IHS is associated with an increased risk of RSS. Cardiac dysfunction can be more accurately determined using radioisotope ventriculography or coronary ventriculography.

Inner-Heart EED

It is a routine method for diagnosing disturbances in cardiac rhythm and conductivity, an important indication for cardiac pacing, radiofrequency catheter ablation and implantation of a cardioverter-defibrillator. The investigation is carried out in specially equipped laboratories. There are no absolute indications for performing intracardiac EPD in patients with SHE. This investigation may be even more useful if it is necessary to establish a connection between the heart rhythm and syncope and presyncope. If you are ill with asymptomatic excess of extrasystole, EPD is not indicated.

CLINICAL AND PROGNOSTIC VALUE

The clinical significance of IE is mainly determined by its type and gradation, the severity of symptoms, the nature of the underlying illness, the stage of heart disease and the functional state of the myocardium.

Schlunoch's extrasystoles, especially without a structural disturbance of the heart, are not dangerous for life. They are detected during ECG HM in most practically healthy individuals of all age groups, and in 10% the stench is polytopic and rarely group. Zagalom SH does not necessarily indicate a concomitant cardiac pathology, and in the absence of cardiac disease is not a predictor of progression of illness and mortality. On the other hand, in patients with severe structural disorders of the heart and myocardial dysfunction, especially against the backdrop of post-infarction cardiosclerosis or heart failure, frequent heart failure is detected and is an additional prognostic factor.

Ectopic activity of the scutulae is detected in 75–90% of patients with acute myocardial infarction in the first 72 years of illness and results in a high frequency of RSS at this time, but does not correlate with mortality over time. u. The presence of illness at a later stage indicates an unfavorable prognosis. Thus, the frequency of IE less than 1 per year is observed in 50% of patients upon discharge from the hospital and indicates a mortality rate of approximately 5%. In most cases (1–10 per year), which occurs in 20% of patients, the mortality rate reaches 20%. Short paroxysms of ST occur in 12% of patients, and mortality from all causes falls to 30% during the first period after suffering MI. The emergence of serious cardiac arrhythmias after MI is associated with the presence of recurrent ischemia with metabolic and electrolyte disorders. Important factors that contribute to arrhythmogenesis are HF and stenosing coronary atherosclerosis.

Children and polytopes are affected in 70–90% of patients with HF, and short episodes of HF – in 40–80%. In this type of heart failure, heart rhythm disturbance is an unfavorable prognostic factor, and 33–47% of all deaths in patients with HF occur in RSS. Arrhythmogenic factors in HF include dysfunction of the left ventricle (EF < 45%), myocardial ischemia, hypoxia, electrolyte disorders, as well as arrhythmogenic effects of congested therapeutic drugs, especially cardiac glycosides, etc. Iuretics and peripheral vasodilators.

The frequency of SE in patients with dilated cardiomyopathy is very high. Thus, frequent and polytopic SH are observed in 80–90% of patients, short episodes of SH are observed in 20–60%. The frequency of RCC is 10% per year and accounts for half of all deaths. In approximately 50% of patients, anterior extrasystoles are detected. The formation of arrhythmias is associated with the presence of severe dysfunction of LS and HF.

Scholastic extrasystoles are recorded in 50–65% of patients with hypertrophic cardiomyopathy with obstruction of the outflow tract of the left cord, including in 32% of patients, and in 14–25% of paroxysms of pharyngitis. The frequency of RCC in these patients is 2.5–9% per river. The atrial extrasystole occurs earlier, lower than the cardiac rhythm. Causes and factors that contribute to arrhythmogenesis: cellular disorganization in different sections of the myocardium, hypoxia, hypokalemia, obstruction of the outflow tract of the left ventricle, diastolic dysfunction of the left ventricle, heart failure, arrhythmogen no infusion of drugs, intense physical exercise.

The risk of RSS due to sulcus rhythm disturbances especially increases in patients with arrhythmogenic dysplasia of the right sac, congenital or inborn QT syndrome, valvular heart disease (including mitral valve prolapse), arterial hypertension єyu.

The level of concern associated with the ECG can be seen in the following specific features of the ECG. As a matter of fact, there are no dangerous extrasystoles with the configuration of the blockade of the left leg of the His bundle and the vertical position of the electrical axis transmitted to the QRS complex (Rosenbaum type) or if the QRS complex of extrasystoles in all thoracic abductions is superior and predicts the graphic for Wolff-Parkinson-White syndrome type A (type Wolf). The QRS complex of such extrasystoles does not have additional splitting, its amplitude becomes 20 mm or more, duration can be up to 0.12 s, and the ST segment and asymmetrical T wave are straightened discordantly to the main tooth of the socket complex. Septal cords with narrow QRS complexes are more often seen in young people due to structural heart disease and are rarely symptomatic. Potziyno groomed, the marshmallow vinike on the fountains of the structural Uzhennnya Cherzi, the form of the block of law of the bunch of Gis, the amplitudu is not the amplitud complex of the QRS (often up to 10 mm) Сdodatki rodsheshchelni, and the triviality of the yogo is more than 0.12–0.14 s. Anomalies of repolarization may be observed: horizontal depression of the ST segment and concordant straightening of the symmetrical, constricted T wave.

CLASSIFICATIONS OF SLUNOCHKOV'S EXTRASYSTOLES

According to the recommendations of the Association of Cardiologists of Ukraine, created on the basis of the International Classification of Diseases X review, the following types of extrasystoles are seen: atrial, atrioventricular, scapular (one by one - up to 30 per year, often - 30 or more per year, arrhythmia, polymorphic, paired, early - type “R to T”).

In Ukraine, when interpreting HM ECG data in patients with sutular rhythm disorders, the classification of B. Lown and M. Wolf (1971) is traditionally used. Based on this classification, there are 5 classes of extrasystoles: 1) monomorphic, < 30 per year; 2) monomorphic, > 30 per year; 3) polymorphic; 4) pairing (4a) and running of ventral tachycardia (4b); 5) early (“R to T”). This classification was developed to systematize heart rhythm disturbances in patients with acute myocardial infarction, but does not meet the needs of stratification of risk and choice of tactics for differential treatment in post-infarction patients ientiv. The reported variants of sulcular disturbances in the cardiac rhythm of the image according to the classification of R. Myerburg (1984), which can be easily recognized when interpreting the results of the ECG HM (Table 3). It is clear that when stratifying the risk in post-infarction patients, it is already about 10 per year. Before arrhythmias of “high gradations”, protect against paroxysms of any kind. Moreover, persistent CT, regardless of the clinical symptoms and the nature of structural heart disease, is seen as a malignant disruption of the rhythm, so the prognostic value of unstable CT lies heavily behind the underlying disease of the heart and function central state of the myocardium. The morphological type of CT also signifies the essential features of the mechanisms of guilt and tactics for managing the sick, sedation, stagnation of AAP and catheter methods of debridement.

Table 3. Systematization of heart rate disturbances according to R. Myerburg (1984)

A well-known prognostic classification of sac arrhythmias was established by JT Bigger (1993), which divides sac arrhythmias into harmless (benign) and unsafe for life (malignant, lethal) and potentially unsafe (potentially lethal).

1. Harmless (benign) arrhythmias - be it any kind (rare, frequent, polytopic, young), as well as short episodes of ST for the presence of cardiac pathology, which do not cause hemodynamic impairment . The prognosis for cirrhosis is the same as for a healthy population. There is no indication for antiarrhythmic therapy.
2. Unsafe for life (malignant) sculular arrhythmias are episodes of ST that lead to disruption of hemodynamics or fibrillation of the sacs (FS). These arrhythmias, as a rule, are avoided in patients with manifestations of structural disorders of the heart (ICS, persistent HF, cardiomyopathies, heart failure) and impaired speed of heart rate. In these patients, SHE is only part of the spectrum of shlunochkovyh disturbances to the rhythm. They often also show instability and stability.
3. Potentially unsafe (potentially malignant) ventricular arrhythmias - frequent, polytopic, partial, short episodes of cardiac arrest in patients with structural heart disorders (ICS, HF, cardiomyopathies, di heart), so as not to disrupt the rhythm until changes in hemodynamics occur. A marker of greater prevalence of life-threatening cardiac arrhythmias in these patients is systolic dysfunction of the heart valve (LV EF <45%).

PRINCIPLES OF ILLNESS MANAGEMENT

Tactics for treating sick people who are suffering from: a) structural heart disease; b) the frequency of extrasystoles, the presence of group extrasystoles or concomitant paroxysms of tachyarrhythmia; c) clinical symptoms associated with arrhythmia. Indications for the use of β-blockers and/or other AAPs are the following clinical situations: 1) progressive progression of heart disease with a significant increase in blood count; 2). 3) arrhythmia (bi-, tri-, quadrigeminia), short runs of ST, which are accompanied by signs of CH; 4) against the background of illness, which is accompanied by an increased risk of life-threatening arrhythmias (mitral valve prolapse, low QT syndrome, etc.); 5) guilt or increase in the frequency of attacks of angina or acute myocardial infarction; 6) saving the SH after an attack of ST and FS; 7) extrasystoles against the background of abnormal conduction patterns (Wolf-Parkinson-White and Clerk-Levy-Kristesko syndromes).

Patients with good health will not require special antiarrhythmic therapy, but dynamic caution is necessary, because in some of them, according to the Framingham investigation, they may be the onset of cardiac disease. In case of extrasystole in a young age without a structural stress of the heart, especially one that appears at the hour of physical exertion, AAP is absolutely not prescribed. In case of subjective intolerance to extrasystole, rational psychotherapy, sedatives, tranquilizers or antidepressants are indicated. The effectiveness of treatment depends on medical indications and varies over three days up to 2–3 months. When a persistent sedative and antiarrhythmic effect is achieved, the dose of the drug over a skin period of 6–7 days is changed by one third to the full dose. As extrasystole occurs against the background of autonomic dysfunction with signs of sympathoadrenal activation, indications of β-blockers, and with dominant vascular-insular symptoms - M-cholinergic drugs (atropine, beladonium preparations, etrop ). Sicknesses with diseases of the internal organs and extrasystole will first require adequate treatment of the underlying disease. In all types of colds, it is aimed at identifying and reducing potential provoking factors of extrasystoles (such as caffeine intake, life situations), as well as accompanying disorders (arterial hypertension).

In case of single monofocal cerebral palsy in patients with cardiac-vascular diseases without impairment of hemodynamics and coronary blood flow, there is no need to prescribe AAP. The approach to the recognition of AAP is that the risk of side effects with drug treatment of “benign” arrhythmias is greater, and the results of treatment are less positive. The management of such patients requires treatment for the underlying illness, as well as the use of sedatives and psychotherapy methods for subjective intolerance to arrhythmia.

Potentially malignant splanchnic arrhythmias often occur against the background of structural heart disease, for example, ICHS or after a history of myocardial infarction. In such patients, in different gradations, there is a danger of further paroxysms of pharyngitis, tremors or fibrillation of the sac. However, patients with potentially malignant splanchnic arrhythmias will require adequate treatment of the underlying illness. This involves the correction of standard risk factors for ICHS (arterial hypertension, chicken, hypercholesterolemia, celiac diabetes). irin, β-blockers, statins) and for heart failure (ACE inhibitors, β-blockers , aldosterone antagonists). In case of established cardiac pathology, often in high grades, obtain adequate antiarrhythmic therapy. The drugs of choice are most often β-blockers, especially for the presence of additional indications: IHS, arterial hypertension, sinus tachycardia. The high effectiveness of these drugs is associated with their antianginal, antiarrhythmic and bradycardic action. If necessary, beta-blockers can be used with class I AAPs (propafenone, ethmozin, etacizin, disopyramide) to ensure their effectiveness.

The hypothesis about the preventive effectiveness of class I AAP in ES in preventing rapto-related death was revised after the results of the CAST study (1989) were published. The use of flecainide and encainide in post-infarction patients with asymptomatic high grades was associated with a significant increase in the risk of raptic death compared with placebo. The phenomenon is believed to be associated with the arrhythmogenic and negative inotropic action of class I AAP. At the same time, the negative evidence from the CAST study and other studies on the effectiveness of the AAP class I do not exclude the possibility of their effective non-invasive treatment for the treatment of ICH in patients with ICD, as well as for other causes of stenosis. arrhythmia.

If β-blockers and class I AAPs are insufficiently effective, amiodarone is prescribed - the most potent antiarrhythmic agent with the lowest level of arrhythmogenic effects. Amiodarone stagnates in case of resistance to other AAPs; In addition, it is the drug of choice in patients with life-threatening and clinically manifested arrhythmias against the background of severe structural heart disease. Encouraging results were obtained with amiodarone in patients with frequent cervical cancer after suffering from myocardial infarction in a meta-analysis of ATMA (1997). In groups of patients who were treated with amiodarone, the prevalence of RCC did not change significantly, but there was no significant change in overall mortality. Amiodarone is the drug of choice for the treatment of ventricular arrhythmias and their use in patients with systolic myocardial dysfunction and HF. Vicristan amiodarone in small doses (200 mg per dose) allows you to minimize the number of non-cardiac side effects. An alternative way to treat patients with splanchnic arrhythmias against the background of IHS is sotalol, a class III AAP with β-blocking agents.

The high effectiveness of amiodarone and sotalol in the treatment of patients with malignant splanchnic arrhythmias does not indicate the existence of safety problems for these patients. Class III AAP will correct the QT interval, and it is safe to set the interval to 440–460 ms. If indicators of the Q-T interval exceed the indicated limits, prolonged QT interval syndrome is diagnosed. A characteristic and specific manifestation of this is the polymorphic CT (pyrating tachycardia), which can be transformed in FS. The risk of developing arrhythmogenic effects with sotalol is greatest in the first three days of taking the drug. The arrhythmogenic effects of sotalol are avoided more often than with amiodarone.

BAGS

Slunochkova extrasystole is the most widespread in clinical practice of heart rhythm disturbances. You may suffer from a large number of cardiac and extracardial illnesses, which can be a common finding in otherwise healthy individuals. A set of current instrumental and laboratory methods for treating patients with directives to identify the causes and mechanisms, quantity and gradation, clinical and prognostic significance, and stratification. this riziku. A comprehensive strategy for the management of sick patients from the neck, sedation, and the effectiveness of arrhythmias with additional anti-arrhythmias are indicated in advance as a result of the development of the potential cortex, treatment for the reduction of arrhythmias, an improvement in the prognosis. annuity and the risk of arrhythmogenic and other side effects of therapy.

RECOMMENDED LITERATURE

1. Outpatient ECG monitoring. Current technologies, diagnostic capabilities, indications: Method. Pos_bnik / Bobrov V. O., Zharinov O. Y., Kuts V. O. and spivat. - Lviv: Medicine of the World, 2004. - 68 p.
2. Bobrov V. O., Zharinov O. I. Schlunchar arrhythmias (mechanisms of development, influx of myocardial dysfunction, prognostic assessment, differential therapy). - Lviv, 1995. - 122 p.
3. Dabrowski A., Dabrowski B., Piotrovich R. Daily ECG monitoring. - M.: Medpraktika, 2000. - 208 p.
4. Investigation of heart rate variability in cardiological practice: Method. rec. / Bobrov V. O., Chubuchny V. M., Zharinov O. Y. and spivat. - K: Ukrmedpatentinform, 1999. - 25 p.
5. Kushakovsky M. S. Cardiac arrhythmias. - St. Petersburg: IKF “Foliant”, 1998. - 640 p.
6. Orlov V.N. Guide to electrocardiography. - M.: Medical Information Agency, 2003. - 526 p.
7. Risk stratification and prevention of cardiac death: Method. rec. / Bobrov V. O., Zharinov O. Y., Sichov O. S. and spivat. - K: Ukrmedpatentinform, 2002. — 39 p.
8. Functional diagnostics in cardiology / Ed. L. A. Bockeria, E. Z. Golukhova, A. V. Ivanitsky. - M.: Publishing house NTsSSKh im. A. N. Bakuleva RAMS, 2002. - T. 1 - 427 p., t. 2 - 296 p.

Case from practice

A patient came to see me with a feeling of interruptions in the heart; during the attack, the extremities became cold, the pressure increased to 150/95 mm Hg. Art. There is no history of cardiac pathology. Indicates a worsening of arrhythmia with physical activity and alcohol intake. The ECG showed no deviation; after Holter monitoring, episodes of volley extrasystoles from the right ventricle were detected. After prescribing sedatives and a beta blocker (Bisoprolol), the patient was discharged after two weeks with improvement.

Expert advice

Detection of ventricular extrasystoles on an ECG is not yet a sign of a serious problem and does not require special treatment.
Functional rhythm disturbances are often accompanied by symptoms that do not correspond to the severity of the condition. To eliminate them, it is enough to remove alcohol from your diet, quit smoking and drink caffeinated drinks. Among the drugs you can drink valerian tincture, Corvalol. When extrasystole is accompanied by coronary disease or other disorders, you must immediately contact a cardiologist and undergo a full examination. All medications should be taken as scheduled and should never be discontinued on your own.

How to treat ventricular extrasystole

When treating ventricular extrasystole, classical drug therapy or surgery is used. The treatment regimen is always determined by a cardiologist.

In our center of the Federal Scientific and Clinical Center of the Federal Medical and Biological Agency there is a therapeutic department in which the patient can undergo all the necessary heart examinations and tests under the supervision of specialists.

The surgical department employs doctors with many years of experience who perform heart surgeries of any complexity. In the case of ventricular extrasystole, radiofrequency catheter ablation may be proposed - a targeted effect of the electrode on areas with impaired conductivity.