Arrhythmias: typical manifestations and their management

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Arrhythmias typical manifestations and their
management

• 24th September 2008
• Victoria Watson
• BHF Arrhythmia Nurse Specialist
• Imperial College Healthcare NHS Trust
• London

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National Service Framework
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National Service Framework for Arrhythmias

• Assessment by Arrhythmia Specialist
• Sudden Cardiac Death
• Screening for at risk patients
• Rapid assessment of syncope
• Implantable Defibrillators by NICE guidelines
• Patient Support and Family screening
• Atrial Fibrillation-NICE GUIDELINES
• Stroke Prevention
• Therapy for symptoms
• Biventricular devices for Heart Failure

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Symptoms

• Irregularly irregular pulse
• Syncope
• Pre-syncope, dizziness
• Shortness of breath
• Fatigue
• CVA
• Palpitations
• NONE

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Assessment

• Duration,frequency,
• Rate/rhythm-tap out
• Onset/offset
• Associated symptoms
• Cardiac history

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Ventricular Beats- Ectopy

• Characteristics of PVC's (Huff, 9-3, 6, 10)
• PVCs dont have P-waves unless they are
  retrograde (may be buried in T-Wave)
• T-waves for PVCs are usually large and opposite
  in polarity to terminal QRS
• Wide (gt .16 sec) notched PVCs may indicate a
  dilated hypokinetic left ventricle
• Every other beat being a PVC (bigeminy) may
  indicate coronary artery disease
• Some PVCs come between 2 normal sinus beats and
  are called interpolated PVCs

The classic PVC note the compensatory pause
Interpolated PVC note the sinus rhythm is
undisturbed
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Premature atrial ectopic beats
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The diagnostic process

• History
• Examination
• ECG
• Blood results
• Cardiac assessment (echo, exercise test,
  prolonged ECG monitoring, angiogram, cardiac MRI
  etc.)

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• TREATMENT
• DRUG THERAPY
• CARDIOVERSION
• ELECTROPHYSIOLOGY STUDIES
• ABLATION
• ICDs
• BRADY/ TACHY PACING

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Atrial Fibrillation-irregular,no definite p waves
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Demographics
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Causes of AF

• Hyperthyroidism
• Intercurrent Illness
• Especially LRTI, UTI in elderly
• Perioperative AF
• Alcohol- probably genetic predisposition

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Causes continued

• Any STRUCTURAL heart disease- especially those
  associated with
• LA enlargement
• LVH
• Reduced systolic function
• Valvular (especially mitral) heart disease
• Hypertensive Heart disease
• Cardiomyopathy of any cause (up to 30)
• Hypertrophic cardiomyopathy

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Rate vs Rhythm Control

• Consider both in all patients
• Rhythm control the preferred strategy in
• Young patients (lt65yrs)
• Highly symptomatic patients
• Patients who develop heart failure with AF
• Newly diagnosed AF or AF with clear precipitant

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Safest Drug in the Management of Atrial
Fibrillation

• Electricity!
• Cardioversion- Must have 4 INRS gt2 pre-procedure
• BUT-
• less successful the longer duration of AF with
  dilated left atrium
• 50 of patients will have reverted within a year

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Drugs rate control

• NICE recommend-
• Beta blocker/ calcium channel blocker for rate
  control
• Digoxin only for sedentary patients

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Drugs to chemically cardiovert

• Flecanide/propafenone - NOT in structural heart
  disease
• Best drug to chemically cardiovert
• But electrical cardioversion is more effective
  and safer
• Sotalol
• Otherwise less effective and less well tolerated
  than standard beta blocker
• Amiodarone -last resort

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Risk factors for stroke in Atrial Fibrillation

• NICE 2006
• Anticoagulation guidelines warfarin vs
  aspirin
• High risk
• Ischaemic stroke/TIA
• Age 75
• Hypertension
• Diabetes
• Vascular disease
• Valve disease
• Heart failure
• Moderate risk Age 65 with no high risk factors
• Age lt75 with hypertension, diabetes or
  vascular disease
• Low risk Age lt65 with no moderate or high risk
  factors

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Anticoagulation

• All studies show superiority of standard dose
  warfarin (INR 2-3) over any other strategy in all
  groups
• The beneficial effect is even more marked in the
  elderly (gt75) where the risk of embolic stroke
  climbs significantly
• But clinicians remain circumspect about using
  warfarin in the real world (especially in the
  elderly)

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Effects of anticoagulation rates on stroke rates
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Supra ventricular tachycardia-narrow complex,
rapid, p waves may/may not be present
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AVNRT
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Atrioventricular nodal re-entry
tachycardia

• Most common SVT
• There is no disease predisposition
• More prevelant in Women
• Narrow complex, 120-250 bpm
• Typically 3rd and 4th Decade
• Recurrent palpitations
• RAPID onset and RAPID offset
• vagal maneuvers to terminate the arrhythmia

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Cardiac Catheter Ablation

• Safe low risk procedure, Complication rate of
  1-2, mortality 1-2/1000
• Effective, a CURE
• Ablation Therapy for Arrhythmias
• AVNRT / AVRT / Atrial Flutter gt98 Success Rate
• Atrial Tachycardia / VT gt90 Success Rate
• Atrial Fibrillation 70 Success Rate

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Atrial Flutter

• ECG regular saw tooth flutter waves
• Ventricular rate will be a 300bpm, 150bpm, 75bpm
  and regular due to pathway
• Possible will predispose to A fib
• Flutter ablation ablate pathway 98 success

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Bradycardia

• Drugs
• Age
• Hypothyroidism
• Ischaemia
• Excess vagal tone
• Negative chronotropes
• Hyperkalaemia

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At Risk Patients

• Heart failure- reduced systolic function
• Ischaemic Heart disease
• Post myocardial infarction
• Cardiomyopathy of any cause
• (Hypertrophic cardiomyopathy,dilated
  cardiomyopathy)

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Ventricular Tachycardia (Monomorphic)
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Rhythm Strip During Episode of Sudden Death
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ICD-Key device system components
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Implantable cardioverter-defibrillators
(ICDs) Current NICE guidance
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Rapid Access Arrhythmia Clinic

• Arrhythmia Nurses- 0207 8862378
• Victoria Watson
• Victoria.watson_at_imperial.nhs.uk
• 07768953414
• Andrea Grieger
• Andrea.grieger_at_imperial.nhs.uk
• 07768980832