Extrasistoli: cause, sintomi e terapia
Table of Contents
Definizione
Le extrasistoli costituiscono la forma più elementare e, l’elemento base di tutte le tachiaritmie. Si definisce extrasistole un battito originato da un punto del cuore diverso dal nodo sinusale, che interviene prematuramente rispetto al ciclo sinusale interrompendo la normale regolarità del ritmo cardiaco. In base alla sede di origine, le extrasistoli possono essere suddivise in atriali, giunzionali e ventricolari.
Extrasistoli atriali
Le extrasistoli atriali si possono osservare nel 60% degli adulti sani e non hanno rilevanza clinica. In pazienti con un tessuto di conduzione predisposto possono invece scatenare tachicardie parossistiche sopra-ventricolari. Nei soggetti sani esse sono favorite dallo stress (psichico e fisico), dall’abuso di sostanze eccitanti (tè, caffè, tabacco, droghe) e da disturbi gastroesofagei (reflusso, distensione gastrica).
All’ECG le extrasistoli atriali sono caratterizzate da onde P che hanno una morfologia diversa da quella dell’onda P del normale ritmo sinusale. L’onda P ectopica extrasistolica (onda P’) è inoltre prematura: presenta, cioè, un intervallo dall’onda P sinusale del complesso precedente inferiore all’ intervallo compreso fra due P sinusali del ritmo di base. La morfologia dell’onda P’ consente di individuare da quale zona degli altri l’ extrasistolia ha origine.
Terapia
Visto che la maggioranza delle extrasistoli atriali sono asintomatiche, non richiedono terapia. Devono essere trattate solo se danno sintomi e si devono eliminare i possibili fattori scatenanti (alcool, caffeina). In assenza di fattori scatenanti si possono trattare con un beta-bloccante o calcio-antagonista. Se nel paziente persiste il sintomo nonostante il trattamento medico, e si identifica un unico focus ectopico, allora si può procedere ad ablazione.
Extrasistoli giunzionali
Le extrasistoli giunzionali sono meno comuni di quelle atriali e ventricolari. Hanno origine nella giunzione AV (nodo AV e fascio di His) e possono diffondere sia verso gli atri sia verso i ventricoli. L’ordine con cui l’impulso ectopico diffonde verso gli atri e i ventricoli dipende anzitutto dalla sede di origine delle extrasistole. Se l’exrasistole ha origine nella parte media del nodo AV, l’impulso attiverà pressoché contemporaneamente gli atri e i ventricoli. Elettrocardiograficamente si manifestano come complessi QRS di morfologia normale, non preceduti da onda P. Quando vi è conduzione retrograda agli atri si può vedere un onda P’ negativa in II, III e aVF, che segue il complesso QRS. Abitualmente non danno sintomi, ma occasionalmente possono causare palpitazioni e onde a “cannone”. Se asintomatiche si trattano come le extrasistole atriali.
Extrasistoli ventricolari
Le extrasistoli ventricolari costituiscono la forma di aritmia più frequente. Anch’esse si possono manifestare sia in presenza sia in assenza di cardiopatia. In assenza di cardiopatia riconoscono gli stessi fattori favorenti descritti per le extrasistole atriali. In presenza di cardiopatia si manifestano molto frequentemente in corso di infarto miocardico e scompenso cardiaco.
All’ECG le extrasistoli ventricolari sono caratterizzate da complessi QRS prematuri più larghi di quelli del normale ritmo sinusale ( di solito la durata è superiore a 0,12 sec) non precedute da onde P. Nella maggior parte dei casi l’extrasistole ventricolare non riesce ad arrivare ad attivare gli atri e, quindi, a penetrare nel nodo del seno, in quanto l’impulso elettrico è in genere bloccato nel nodo AV; ne deriva che l’ extrasistole non interferisce con la formazione ritmica dell’impulso sinusale e la relativa attivazione sinusale degli atri. Abitualmente sono seguite da una pausa compensatoria, per cui la somma dell’intervallo pre e post-extrasistolico è uguale al doppio di un ciclo sinusale.
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