Tachydysrhythmias

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Tachydysrhythmias

• Adam Davidson
• Bryan Young
• Thanks to McCrossin for donating his previous
  blood, sweat and tears!

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I think this is where I insert something funny..
I was drawing a blank, until
Kipper (as of Oct 15th) GAA 5.00 Sav 0.826
Thats Funny!!!
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Tachydsyrhythmias

• Outline
• Introduction Approach to tachydysrhythmias
• Narrow Complex
• AVNRT vs AVRT
• A fib Ottawa Protocol
• Wide Complex
• If we have time practice ECGs

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Tachydysrhythmias

• Outline
• Predominant focus on
• ECG recognition (just recognize the rhythms)
• Rhythm Management
• Some pathophysiology
• Easy approach to remembering diagnosis and
  treatment without killing anyone in the attempt
  for simplicity
• Special attention to RTs, A fib, and WCTs

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Tachydysrhythmias

• Introduction
• 5 Step Approach to dysrhythmia management
• IV, O2, Monitor, Advanced airway and
  defibrillator to the bedside
• Are they stable or unstable?
• Is the QRS narrow or wide?
• Is the rhythm regular or irregular?
• Are there p-waves? Are they normal?

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ACLS Guidelines
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Tachydysrhythmias

• Narrow Complex, regular rhythm
• Sinus Tach
• AVNRT
• Orthodromic AVRT (WPW)
• Atrial Flutter with consistent AV block
• Narrow Complex, Irregular rhythm
• Atrial fibrillation
• Atrial flutter with variable block
• Multi-focal atrial tachycardia

• Wide Complex, Regular Rhythm
• Ventricular tachycarida
• SVT with BBB
• Antidromic AVRT
• Wide Complex, Irregular Rhythm
• Polymorphic ventricular tachycardia
• Torsades
• Atrial fibrillation with BBB
• WPW with atrial fibrillation
• Atrial flutter with variable AV block and BBB

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Tachydsyrhythmias

• Introduction
• Stable vs Unstable
• Chest pain may not always indicate instability
  in young patients without CV risk factors. A
  consideration but a relatively unreliable
  predictor of CV stability
• Altered mental status look for other causes of
  AMS (e.g. pt with septic shock and a compensatory
  rapid Afib or sinus tach)
• Hypotension Beware of young female with a normal
  SBP of 90
• Pulmonary Edema May be acute and secondary to
  decreased CO with tachyarrhythmia, or may be
  chronic
• Think of stability as a spectrum (not
  dichotomous)

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Narrow, Regular

• Sinus Tach
• AVNRT
• OAVRT
• A flutter

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P waves

• Whats normal?

• Best seen in V1
• Upright in II
• Negative in AVR

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Regular NCT

• Sinus Tachycardia
• Can be confused with SVT and A Flutter with 21
  block
• Pearl
• Maximal tachy response 220 - patients age

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Monitor 1
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Adenosine 6mg IV push
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Flutter!

• Atrial re-entrant circuit surrounding tri-cuspid
  valve
• Very distinct pathway with little variation among
  individuals
• Time to complete circuit is 200msec
• Leads to atrial rate of 300/min
• Ventricular rate based on degree of AV block
• 21-150, 31-100, 41-75, 51-60

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Treatment

• 60 occurs w/ some acute disease process
• Harder to chemically convert than A fib
• ACC recommend rate control followed by electrical
  cardioversion
• Cardioversion improved with incr AV block
• Require very low joules
• 10-20 joules often sufficient
• While poor evidence, follow same anti-coagulation
  rules as A fib

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Monitor 2
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AVNRT AVRT

• Accessory pathways w/in or outside of AV node
• Symptoms similar
• Palpitations 98
• Dizziness 78
• Dyspnea 48
• CHEST PAIN 38 (structurally normal hearts)
• STD/TWI in 25 and 57 respectively
• Still need to take seriously if RF for CAD or
  elderly

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AVNRT

• Etiology
• Idiopathic
• Often no precipitating cause
• Circus pathway w/in AV node
• Differ in conduction velocity and refractory
  period
• Usually triggered by a PAC

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Regular NCT

• AVNRT
• Diagnosis
• Trial of
• Adenosine
• ECG Findings
• Rate 120-220
• P waves may be retrograde or may be buried in QRS
• Initiation of rhythm demonstrates a prolonged PR
• Negative T waves after AVNRT termination is very
  common (does not mean IHD)

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AVNRT
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Regular NCT

• AVNRT
• Management
• Vagal Maneuvers
• Adenosine
• Very short 1/2 life
• Rarely produces hypotension
• CCB (verapamil, diltiazem)
• If adenosine isnt effective
• Negative inotropes
• Cause vasodilatation

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AVRT

• WPW is the common form
• Characterized by accessory pathways that conduct
  without the refractory period characterized by
  the AV node (conduction impulses are not limited)
• Accessory pathways can conduct anterograde (most
  common), retrograde, or both
• Triggered by a PAC or PVC

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AVRT

• Orthodromic WPW
• First beat is sinus rhythm with a short PR and
  wide QRS
• Second beat shows an atrial premature beat which
  is blocked by the AP and therefore travels down
  the AV node
• After myocardial depolarization impulse is now
  conducted retrograde up the AP

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AVRT

• Management (orthodromic)
• Vagal Maneuvers
• Adenosine
• As effective as verapamil _at_ terminating OAVRT
• Ultra-short acting so preferred if rhythm is to
  be restored with DC cardioversion
• Caution!
• Rate Control CCB or BB
• Procainamide
• Safest drug if OAVRT presenting as a wide complex
  tachycardia (ie if any chance rhythm is VT)

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Adenosine

• Adenosine
• MOA
• Hyperpolarization of the AV node thereby
  decreasing frequency of depolarization
• Dosing
• 6 mg IV over 1-2 seconds if not effective in 1-2
  minutes may repeat with 12 mg
• Extremely short 1/2 life

Decrease dose with Central Line, Tegretol, Heart
Transplant 3mg starting dose!
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ACC Adensosine Recommendations
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Adenosine Side Effects

• Various side effects occur 40-60
• Facial flushing (18)
• Palpitations/Chest Pain
• Dyspnea (12)
• Sense of impending doom
• Usually very short lived (5-10sec)

BUT..
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Beware!!

• Adenosine incr atrial ectopy.
• Can induce atrial fibrillation in 12-15 of
  AVRTs
• Can have severe consequences, especially if
  already given an AV nodal blocker
• Very high ventricular rates and possibility of V
  fib
• Need to be ready to defibrillate
• Studies show 0 in AVNRT

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AVRT vs AVNRT

• Invisible p waves 100 specific AVNRT
• RV1 or SII 100 predictive of AVNRT
• Isolated retrograde p waves, RP interval gt
  100msec, STE in aVR highly predictive of AVRT
• Pre-excitation on sinus ECG likely AVRT

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AVRT vs AVNRT
RP gt100msec
SII
STE aVR
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Regular NCT

• Differential Diagnosis
• Sinus Tach
• A Flutter
• AVNRT
• OAVNRT

• Summary
• Trial of adenosine
• Help to make diagnosis
• Help to break the rhythm
• Warn pt of S/E
• Max sinus rate 220 - pts age
• Cardiovert unstable patients (assuming not sinus
  tach)
• V1 is best lead to see p-waves
• Risk of A fib w/ Adenosine and AVRT

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Monitor 3
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Narrow, Irregular
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Irregular NCT

• Multifocal Atrial Tachycardia
• Commonly Misdiagnosed as A Fib
• More than two foci of impulse formation
• Etiology
• Often associated with pulmonary disease and
  hypoxemia
• Management
• Often resolves when hypoxemia is corrected
• Fluids if hypotensive
• Caution
• Important distinction to make from A Fib because
  you do not cardiovert these patients
• Most of these pts have reactive airways (dont
  give BB)

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A Fib

• Management
• Three part approach to management
• Appropriate control of ventricular rate
• Need for, proper timing of, and appropriate
  method for restoration of sinus rhythm
• Need for anticoagulation to prevent
  thrombo-embolism

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A fib

• Management Rate control
• Initial management in stable patients, regardless
  of duration, is rate control
• Rates in A Fib
• Mean resting rate in AF of recent onset is
  between 110-130
• Rates may exceed 250 in WPW
• Rates greater than 150 in absence of WPW should
  raise suspicion of a hyperadrenergic state
• Goal
• A controlled rate is between 60-80 bpm at rest,
  90-115 during moderate exercise

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Atrial Fibrillation Rate Control
DRUG Loading Dose Onset Maintenance
Diltiazem 0.25 mg/kg over 2 minutes Repeat 15 min later at 0.35 mg/kg IV bolus 2-7 min 5-15 mg/hour by infusion
Metoprolol 2.5-5 mg IV up to max 15mg 5 min N/A
Verapamil (avoid combining with BB risk of asystole) 5-10 mg IV 3-5 min N/A
Propranolol 1 mg IV over 2 min q5 min to max 5 mg 5 min
Esmolol 0.5 mg/kg IV over 1 min 5 min 50-200mcg/kg/min
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A fib Rate Control
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A fib

• Management Rate Control
• Options for rate control
• Beta-Blockers (metoprolol, propranolol, esmolol)
• CCB (verapamil, diltiazem)
• Beta-Blockers
• Good for sympathetic states (thyrotoxicosis,
  postop)
• Caution in patients with asthma, COPD
• Diltiazem
• Faster onset than BB
• Caution with CHF (can give with parenteral
  calcium to decrease risk of hypotension)
• An oral rate control agent should be used if AF
  persists and discharge is considered

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The Biggies!!
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A fib

• Management Rate vs Rhythm
• Major Trials
• RACE
• NEJM 2002 347(23)
• AFFIRM
• NEJM 2002 347(23)1825-33

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A fib

• RACE
• Management Rate vs Rhythm
• RACE
• Comparison b/w rate control and rhythm control in
  chronic AFib
• Outcome Measures
• Death, HF, embolism, bleeding
• Inclusion
• 522 patients with previous failure to convert
  following electrical cardioversion (average age
  69)
• Methods
• Rhythm control with sotalol, if failure after 6
  months flecainide, if recurrence in 6 months
  amiodarone

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A fib

• Management Rate vs Rhythm
• AFFIRM
• Comparison between rate vs rhythm control
• Outcome Measures
• Primary Mortality
• Secondary Death, disabling stroke, anoxic
  encephalopathy, major bleeding, or cardiac arrest
• Inclusion Criteria
• gt/ 65 yrs old
• Other RF of stroke or death
• Previous history of A Fib for at least 6 hours in
  the past 6 months

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A fib

• Management Rate vs Rhythm
• RACE and AFFIRM Results
• Equal rates of embolization (primarily in
  patients who stopped warfarin or with
  subtherapeutic INR)
• Recurrent episodes of AF detected in 90 of
  patients with rhythm control
• 90 or recurrences asymptomatic
• 17 or asymptomatic recurrences last up to 48
  hours
• More drug S/E in rhythm control arm

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A fib

• Management Rate vs Rhythm
• What do we take away from RACE and AFFIRM
  results?
• Results show slightly better outcomes with rate
  control in a specific patient population
• Rate control and rhythm control with appropriate
  anticoagulation are acceptable approaches to
  management depending on clinical scenario
• Side effects of antiarrhythmics are not benign

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A fib

• Management Rate vs Rhythm
• Major Trials to date have not included
• Younger patients with lone AF (15 of patients
  with AF)
• Pts with highly symptomatic AF
• Pts with significant CHF
• Pts with contraindications for anticoagulation or
  rate control
• Pts with new onset AF
• Rates of recurrence of AF will vary depending on
  patient risk factors

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NCT AF Rate vs Rhythm

• Favours Rate Control
• Persistent AF
• Recurrent AF
• Less Symptomatic
• gt 65 yrs
• HTN
• No Hx of CHF
• Structural disease on echo (LAE)
• Previous antiarrhythmic drug failure
• Patient preference

• Favours Rhythm Control
• Paroxysmal AF
• First episode of AF
• More symptomatic
• lt 65 yrs
• No HTN
• Hx of CHF
• No previous antiarrhythmic drug failure
• Patient preference

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Afib and CHF
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A fib and CHF

• Multicentre RCT w/ 1376 pts
• EF lt35, Sx of CHF, Hx of A fib
• Primary Endpoint Time to death from CV causes
• Pts in A fib for longer than 12mo excluded
• Rhythm Control medical /- D/C cardioversion
  with long term med (usually amio)
• Rate Control BB/CCB /- Dig

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A fib and CHF
Rhythm Control group had more hospitalizations. Ot
herwise no differences in primary and all
secondary endpoints Overall annual mortality for
pts w/ CHF and hx of A fib 10 !!! Study
changes common held belief that A fib is an
independent predictor of worse outcome in CHF
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A fib

• Management Rhythm Control
• Who are you more likely to want to cardiovert?
• First Episode of AF
• Low risk for recurrence
• Persistent symptoms with rate control
• Unstable patients

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A fib

• Management Rhythm Control
• When would we expect trouble or less success with
  cardioversion?
• AF duration gt 1 year
• Increased LA dimension on echo (gt5cm)
• Paroxysmal AF of short duration which tends to
  resolve spontaneously and always recurs
• Patients with underlying medical conditions
• CHF
• Hyperthyroidism
• COPD
• Electrolyte changes/ dig toxicity
• Of note Age alone is NOT a predictor or
  cardioversion success or higher complication rate
• Exercise caution in cardioverting patients with
  AV node dysfunction

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A fib

• Management Rhythm Control
• Chemical Cardioversion
• Lower Success rate
• Slower conversion
• Proarrhythmic (may be following discharge)
• Longer ED stay
• Indications
• Failed Electrical
• Patient Preference

• Electrical Cardioversion
• Higher success rate (75-93)
• Faster conversion
• No risk of drugs
• Better ED flow
• Painful
• Narcotics /- sedatives

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A fib

• Management Rhythm control
• Electrical Cardioversion
• Safe if patient in AF for less than 48 hours
• Syncronized, AP position is better
• Monophasic 200 J Biphasic 50-150 J (biphasic
  better)
• May need to do it more than once
• Propofol for sedation may actually increase
  success of conversion
• NPO Guidelines
• 6 hrs for solids 2hrs for fluids (Am Soc Anesth)
• NPO is a consideration for depth but not a
  contraindication (ACEP Can Consensus Guidelines)

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Atrial Fibrillation

• Recurrence post DC cardioversion
• Majority in first week, up to 50 first month
• J Am Coll Cardiol 98 31(1)167

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A fib

• Management Rhythm control
• Chemical Cardioversion
• Ibutilide (Level A evidence)
• Flecainide (Level A evidence)
• Propafenone (Level A evidence)
• Procainamide (Level B evidence)
• Sotalol (Level B evidence)
• Chronic oral Amiodarone (Level B evidence)
• Can be used to pretreat patients prior to
  electrical CV
• NOT used for unstable patients
• How long does it take?
• Are patients safe for D/C?

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A fib Rhythm Control
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A fib

• Management Rhythm Control
• Ibutilide (Class III)
• Conversion time 1 hour
• Dose 1 mg IV over 10 min
• Success rate 32-51
• Side effects Prolonged QT w/ arrythmias 3.2
• Propafenone (Class Ic)
• Conversion time 2 hours
• Dose 600mg PO (no IV form)
• Success rate 50-55
• Side effects Arrhythmia 5, lung effects similar
  to BB

• Management Rhythm Control
• Procainamide (Class Ia)
• Conversion time less than 1 hr
• Dose 1g IV infusion over 1 hour
• Success fewer studies but Ottawa Protocol showed
  52
• Side Effects hypotension, incr QTc, useful for
  acute onset
• Amiodarone (Class III)
• Conversion time long
• Dose 400mg PO tid
• Success 35
• Side Effects bradycardia, incr QTc (less than
  Ibutilide), Vtach

IA-Recommendations
II-Recommendations
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Ottawa Procainamide Protocol
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Procainamide 1g in 250cc D5W Infused over 1hr
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Procainamide /- Cardioversion
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A fib

• Management Anticoagulation peri-cardioversion
• Risk Factors for thromboembolism
• AF gt 48h
• Valvular heart disease
• Significant LV dysfunction
• Previous thromboembolism
• Hyperthyroidism
• ASD (even if repaired)
• One series of patients with symptomatic AF lt 48
  demonstrated 0.8 incidence of embolism 12-24 hrs
  post CV. All were elderly F with no prior hx of
  AF
• Ann Int Med 1997 126(8) 615-620

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A fib

• Management Anticoagulation peri-cardioversion
• ACUTE trial 13.8 of patients who had AF gt 48 h
  were found to have thrombus on TEE
• JACC 2001 37(3) 691-702
• Can use TEE in patients you dont want to wait on
  for 3 weeks

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A fib

• Management Anticoagulation Pericardioversion
• AF lt 48 h
• Consider LMWH single dose in patients without RF
• Consider long-term anticoagulation in pts with RF
• AF gt 48 patients with RF for thromboembolism
• TEE negative UFH or LMWH then warfarin x 1
  month
• TEE positive LMWH Warfarin 3/52,
  cardioversion, then warfarin x 1 month post
  cardioversion

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A fib

• Management Anticoagulation
• CHADS2
• CHF
• Hypertension
• Age gt75
• DM
• Previous Stroke or TIA (2 points)
• Patients with intermittant AF have same risk as
  patients with persistent AF

JAMA, 2001
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CHADS2
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CHADS2

• Anti-Coagulation
• Score
• 0 ASA
• 1 ASA or Warfarin (take individual factors into
  account
• 2-6 Warfarin unless contra-indicated

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A fib

• Disposition
• Admit if
• Structural heart disease
• Embolic event
• Those at high risk for thromboembolism
• Those with failure of rate control in ED
• Patients in heart failure
• Low risk
• No comorbid disease
• No ischemic changes
• lt 60 years old
• No chest pain

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Irregular NCT

• Atrial Fibrillation and Pregnancy
• Etiology
• Structural Heart Disease
• Hyperthyroidism
• Management
• Rate Control
• BB, CCB, Digoxin
• Rhythm Control
• DC cardioversion if unstable
• Anticoagulation
• UFH or LMWH during 1st trimester and after 36 wks
• Warfarin or heparin during second trimester

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Irregular NCT

• Atrial Fibrillation and MI
• BB should be given whenever possible
• If BB contraindicated then give digoxin or
  amiodarone to slow the rate
• DC cardioversion if unstable
• Avoid class procainamide
• Give heparin

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Irregular NCT

• Atrial Flutter with variable AV block
• Similar treatment as with atrial fibrillation

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Irregular NCT

• Differential Diagnosis
• A Fib
• A Flutter with variable AV block
• MAT

• Summary
• Unstable A Fib cardioversion
• AV nodal blockers are first therapy in A fib
• Unstable chronic A Fib is a B to deal with in
  elderly patients
• MAT is not a destabilizing rhythm
• Be cautious attributing symptoms to Afib in rates
  lt150

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My brain is seriously killing me.
On a lighter note. Choose One!
Malibu Gets Owned
Fat Kid Amusement Park
Halloween Prank Gone Bad
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Monitor 4
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Wide, Regular
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Regular WCT

• Antidromic AVRT
• First sinus beat has a short PR and a wide QRS
  (normal)
• When an atrial premature beat is triggered the AV
  node is refractory and therefore the impulse is
  blocked
• The path of least resistance in this case
  becomes the AP and a wide complex tachycardia
  ensues
• High risk of Vfib, may be difficult to
  differentiate from VTach

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Anti Dromic AVRT

• Management (antidromic)
• IV Procainamide
• Even if it doesnt acutely terminate the
  tachycardia, it often helps slow the rate and
  improve hemodynamic stability
• Second line (consider only if absolutely certain
  of diagnosis)
• IV Beta Blockers (Sotalol, Propranolol,
  Metoprolol)
• IV Ca Channel Blockers
• IV Adenosine

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Antiarrhythmics

• AVRT
• Treatment Amiodarone
• ACLS Guidelines for management of WPW recommend
  Amiodarone
• Extreme caution for amiodarone in many other
  articles
• AJEM 200725576-583
• JAMA 2007 298(11)312-22
• CJEM 2005 7(4)262-5
• Risk of accelerated ventricular rates

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Antiarrhythmics

• Treatment Procainamide
• Blocks fast inward Na current and outward K
  current
• Shown to prolong refractory period of atrial,
  ventricular, and AP tissue as well as slow
  antegrade and retrograde conduction in the
  accessory pathway
• Strong potential for hypotension with rapid
  administration therefore requires a slow rate of
  infusion and slow onset of action (40-60 minutes)
• Dose 20 mg/min until arrhythmia is suppressed,
  hypotension ensues, QRS prolonged gt 50, or a
  total of 17 mg/kg has been given (1.2 g for a 70
  kg patient)
• Maintenance 1-4 mg/min diluted in NS (reduce if
  patient is in renal failure)
• Other Indications
• Stable VT, Afib rate control, AVNRT, Afib and WPW

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Monitor 5
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Regular WCT

• Ventricular Tachycardia
• Monomorphic VT
• Treatment
• Unstable Cardioversion
• Stable Procainamide is first choice, if they
  drop their pressure then cardioversion
• Safer in pregnancy
• Safer if diagnosis is wrong (ie WPW)
• Amiodarone
• Falling out of favour
• 30-50 effective
• Better evidence for Procainamide
• Go to Amio if procainamide doesnt work
• Circ 2006 Ventricular Arrhythmia Guidelines

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Regular WCT

• Ventricular Tachycardia
• Diagnosis
• Fusion Beats
• AV Dissociation
• Capture Beats
• Extreme RAD

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Regular WCT

• Ventricular Tachycardia
• Diagnosis
• Fusion Beats
• AV Dissociation
• Capture Beats

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Regular WCT

• Ventricular Tachycardia
• Diagnosis
• Fusion Beats
• AV Dissociation
• Capture Beats

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Regular WCT

• Ventricular Tachycardia
• PVC is the most common inciting event
• R on T phenomenon high risk of VT
• Approach
• Pulse absent treat as VF
• Stable or Unstable Cardioversion
• Differentiate between Mono vs Polymorphic

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Regular WCT

• Unknown WCT
• Brugada Criteria
• Proposed to distinguish between regular,
  monomorphic WCT caused by SVT and VT

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Regular WCT

• Unknown WCT
• Brugada Criteria
• Original Study
• Sn 99, Sp 97
• Other studies
• Sn 79-92
• Sp 43-70
• Follow up studies have not duplicated the
  sensitivity and specificity claimed in the
  original study
• Non-agreement between EM physicians in 22 of
  cases

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Regular WCT

• Unknown WCT
• Brugada Criteria
• Morphology associated with the fourth criterion
  with RBBB appearing complex

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Regular WCT

• Unknown WCT
• Brugada Criteria
• Morphology associated with the fourth criterion
  with LBBB appearing complex

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WCT
R
R
P
Regular RR and RP intervals, STE in aVR, RPgt
100msec
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Baseline
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Regular WCT

• Differential Diagnosis
• VT
• SVT with BBB
• Antidromic WPW

• Summary
• Assume VT when in doubt
• Cardiovert early
• Stable patients can still have VT
• Procainamide is probably best antiarrhythmic in
  this group
• Brugada is unreliable
• Rx of SVT with VT Tx is safe and often effective
• Most likely VT if underlying heart disease

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Monitor 6
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Irregular, Wide
98
Irregular WCT

• Torsades
• Etiology (prolonged QT)
• Antiarrhythmics
• Ibutilide
• Procainamide
• Sotalol
• Amiodarone
• Antimicrobials
• Macrolides
• Fluroquinolones

• Psychotropics
• Diuretics
• K and Mg disturbances
• Hypothermia
• Congenital prolonged QT
• Jervell and Lange Nielsen
• Romano-Ward
• Idopathic
• Electrolyte abnormalities
• Anorexia

99
Irregular WCT

• Polymorphic VT
• Management
• Shock, then check the QT
• Prolonged QT - MgSO4 (any other antiarrhythmic
  may be harmful)
• QT normal - Any antiarrhythmic you want (keep in
  mind these rhythms may be a consequence of
  ischemia)
• Hemodynamically Stable
• MgSO4
• 2-4g IV bolus repeated in 2-4 minutes (careful in
  renal failure)

100
Irregular WCT

• Differential Diagnosis
• PMVT
• Torsades
• WPW with AF
• AF with BBB

• Summary
• The most tricky of the 4 groups
• Using antiarrhythmics (amio, procainamide, and
  lidocaine) may cause harm in patients with
  torsades
• Using AV nodal agents in WPW with AF may cause
  harm (risk V Fib)
• If in doubt Electricity and check QT after
  rhythm converted
• Old ECGs very helpful!!

101
Irregular WCT

• WPW AF
• Management
• Concern is that by giving these patients
  beta-blockers we could potentially promote
  conduction down the accessory pathway
• Increased conduction down the accessory pathway
  can put these patients at risk of developing V
  Tach and ultimately V Fib

102
Irregular WCT

• WPW AF
• Diagnosis
• AF occurs in up to 40 of patients with WPW
• Thought to be the most common cause of cardiac
  death in patients with WPW because the rhythm can
  degenerate in V Fib

103
Irregular WCT

• WPW AF
• Diagnosis
• Consider WPW AF in patients with
• Irregular rhythm
• Rapid ventricular response (one that is too fast
  to be conducted down AV node)
• Wide, bizarre QRS complex signifying conduction
  down an accessory pathway
• May see an occasional QRS representing conduction
  down the AV node
• Other clues patient is young (lt50), or has a
  history of palpitations, rapid heart rate, or
  syncope

104
Irregular WCT

• AF and WPW
• Treatment options
• Procainamide
• 30 mg/min max dose 17 mg/kg
• Ibutilide
• 1 mg over 10 min repeat once after 10 min
• Contraindicated
• AV nodal blocking agents (BB, CCB, Dig,
  Adenosine)
• Avoid
• Amiodarone?

105
ACLS Amiodarone Recommendations
But
106
Irregular WCT

• WPW AF
• Management
• Tijunelis and Herbert published a literature
  review on the use of amiodarone in WPW patients
  with AF
• No evidence showing benefit. Several case
  studies showing harm (pro-arrhythmic) therefore,
  best to use DC cardioversion or procainamide in
  these patients for rhythm control
• Can J Emerg Med 20057(4)262-5

107
Antiarrhythmics

• WPW AF- Drugs of Choice
• Procainamide
• Fewer effects on QTc
• First line for WCT of unknown rhythm
• Dose 15-18mg/kg infused over 25-30 minutes or
  200mg q5min up to 1 g
• Avoid if hypotense, incr QTc
• Ibutilide
• More hemodynamically stable than procainamide
• Short 1/2 life (4 hours) rapid onset (20 min)
• Doesnt interact with most of the meds used for
  rate control
• No dosing concerns for hepatic or renal function
• Considered relatively safe in elderly
• Dose 1 mg over 10 minutes (undiluted), if first
  dose is unsuccessful then a second dose can be
  administered after 10 minutes dose is 0.01 mg/kg
  if less than 60 kg
• Avoid if incr QTc, structural heart disease,
  sinus node disease

108
Summary

• AVNRT/AVRT
• Adenosine very useful but be wary of A fib w/
  accessory tracts
• Chest pain, dyspnea common sx even in young
  healthy people
• STD/TWI common, but still need to consider
  ischemia in elderly/at risk
• Afib/WPW
• Safest bet is always D/C cardioversion
• AV nodal blockers bad, bad, bad!
• Ibutilide or Procainamide are the drugs of choice
• WCT
• When in doubt treat as VT
• 1st line med for WCT- Procainamide

• Afib
• Consider rhythm control for young, new Afib with
  no underlying structural heart disease, or
  symptomatic with rate control
• CHF no longer means rhythm control
• Not every patient needs Warfarin
• Consider adding Ca when giving Diltiazem
• Ibutilide, Propafenone, Procainamide likely more
  effective than Amiodarone

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Thank You!
110
Case Examples

1. 45 y/o male with new onset A Fib, distinct onset
   8 hours ago.
2. 80 y/o F with CHF, Afib x 30 years with acute
   decompensation. In AF with ventricular rate of
   150, hypotensive
3. 72 y/o male with symptomatic A Fib and having and
   MI. How does your management plan differ?
4. 66 y/o male with unstable AF (HR 125)
5. 34 y/o F pregnant female, hemodynamically stable
   (HR 170)