Arrhythmia Management

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Arrhythmia Management
17 Sept 2008

• Dr John Bayliss FRCP
• Consultant Cardiologist

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Arrhythmia Guidelines
2006 NICE CG36 AF 2005 NSF CHD Arrhythmias 2006 BedsHertsCardiac Network Arrhythmia guidelines
www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm w
ww.westhertscardiology.com Documents/Local www.st
arpace.co.uk Clinical Specialty/Cardiovascular
www.nice.org
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Palpitations Importance

• Common
• Often benign
• Often troublesome
• Occasionally fatal
• Need careful assessment some/most in 1y Care
• Need for Rapid Access Arrhythmia services
• Early involvement of specialist clinician
• Ablation / Device therapy increasingly effective

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Assessment of Palpitations/Arrhythmias

• Full History most important
• Clinical Examination
• Heart rate response (during after exercise)
• 12 lead ECG (esp during symptoms)
• Blood testsUE, Glucose, Thyroid FT, Liver FT,
  FBC

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Palpitations Detailed History

• Age of patient
• Type and Duration of symptoms?
• Individual thumps, misses, etc
• Runs of tachycardia ?Regular, ?Irregular
• Duration, Frequency
• Onset ? Sudden/Gradual, ? Circumstances
• Cessation ? Sudden/Gradual, ? Circumstances
• Associated symptoms
• ? Polyuria (due to Atrial Natriuretic Peptide
  release in Atrial tachyarrhythmias)
• ? Collapse/Dizzy/Breathless, etc
• Concurrent illness
• Family History (Sudden Death, Cardiomyopathy,
  CHD)
• Drug History (incl OTC)

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Palpitations Low risk features

• Manage in Primary Care
• History
• Not known to have heart disease
• No family history of collapse or sudden death at
  age lt 40 years
• No previous collapse/blackouts
• Only infrequent attacks
• Symptoms
• Palpitations last lt 30 minutes
• Missed beats ( ectopics) or brief rhythm
  irregularity only

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Palpitations High risk features

• Refer to Heart Rhythm Specialist
• Pre-existing heart disease
• Previous angina, MI, angioplasty,heart surgery
• Clinical heart failure, or LV systolic
  dysfunction (ejection fraction lt 40)
• Structural heart disease valve disease,
  cardiomyopathy, congenital heart disease
• Family history of collapse or sudden death at age
  lt 40 years
• Previous or recurrent collapse/blackouts.

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Should GPs report 12 lead ECGs ?!

• 24yr old woman, occasional brief flutters

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Long QT and Brugada syndrome

• Ion channelopathies

QTc gt450-500ms high risk of VT/SCD
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Investigation of Arrhythmias

• May be useful
• Ambulatory ECG (24hr 7 days)
• Echocardiogram
• Exercise ECG if exercise related or ?CHD
• Tilt Test if postural or vagal symptoms
• Cardiac MRI - esp in young patient
• Implantable ECG Loop Recorder (ILR, Reveal) if
  infrequent but serious events
• Electrophysiological Study (EPS) Catheter
  Ablation therapy

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Implantable Loop Recorder (ILR, Reveal device)

• 15 mins daycase procedure
• Local anaesthetic
• implant in upper L chest
• Battery lasts 18 months
• High quality downloadable ECG beforeduring
  attack
• Most cost-effective test
• Yield 43 1
• Cost 26 less than usual Ix 2

1Krahn AD, et al. Circ. 200110446-51. 2Krahn
AD, et al. JACC. 200342495-501.
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Arrhythmias Treatment

• Depends on (ECG) diagnosis !
• S Tachy ? Cause (POTS ! heartsink)
• A Tachy ß blocker
• AVNRT / AVRT Ablation (Flecainide/Propafenone)
• A Flutter Ablation (Verapamil,Dig,Amio)
• Paroxysmal AF Sotalol, Propafenone, Flecainide
• Permanent AF Rate v Rhythm...
• VT ICD (ß blocker, Amio, Ablation)
• Bradycardias Pacing

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Catheter Ablation

• for arrhythmias with localised anatomical
  substrate
• often curative (no need to continue
  anti-arrhythmic Rx)

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Device Therapy

• Pacemakers
• Cardiac Resynchronisation Therapy(CRT,
  Biventricular pacing)
• Implantable Cardioverter Defibrillators (ICD)

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Pacemakers 1958 2008 50 years
1st "Permanent" Implantable Pacemaker Bipolar
Hunter-Roth Lead (1958)
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ICD function

• VF terminated by single 34J shock
• VF Dead SR
  Alive

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AF Types
Aetiology
Timing
Lone AF
vs

• 22 of PAF progress to permanent AF within 2
  years
• 50-60 of patients are back in AF 1 year after
  cardioversion

Circulation 200110421182150
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AF Management

• ? Rate or Rhythm Control
• Rate controlControl of Ventricular Rate at rest
  on exercise
• Rhythm controlRestoration of SR Maintenance of
  SR
• ? Anticoagulation
• Risk of thromboembolism
• Risk of Warfarin1-2 yearly risk of serious bleed

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AF Rate v Rhythm control

• Choose Rhythm Control
• Symptomatic, Younger
• Uncontrolled Heart Failure
• First episode (?), or now corrected precipitant
• DC Cardioversion
• 3 weeks anticoagulation before 4 weeks after
• Try to Maintain SR (50 revert to AF in 1 yr)
• ? Need for Amiodarone / Sotalol
  Propafenone / Flecainide

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AF Rate v Rhythm control - AFFIRM
The Atrial Fibrillation Follow-up Investigation
of Rhythm Management
n4060, age gt65, AF Mean age 69.7 Hypertension
in 71 Rate control lt80 at rest lt110 on
walk Warfarin (INR 2-3) Rhythm control
Drugs Cardioversion(s) Warfarin (INR 2-3)
unless SR for 4(-12) weeks
AFFIRM NEJM 20023471825-33
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AF Rate v Rhythm control

• Choose Rate Control if patient stable and if
• Age gt65
• Underlying CHD, Hypertension, Valve Disease
• Anti-arrhyhtmic Rx not tolerated /
  contraindicated
• Cardioversion inappropriate
• Use ß Blocker firstAtenolol, Bisoprolol,
  Metoprololor rate controlling Ca blocker
  Verapamil, Diltiazem
• Add Digoxin if necessary, or if CHF

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IMPORTANT

• Digoxin a drug of 2nd-3rd choice !

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AF Digoxin Increased Mortality

• SPORTIF IIIV (Warfarin v Ximelagatran)
• n7329 in AF
• Mod-high stroke risk
• 53 on DigoxinMortality 6.5
• 47 not on DigoxinMortality 4.1
• Hazard ratio(adjusted for risks)1.53
• ? ? Platelet activation

Gjesdal, K et al. Heart 200894191-196
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AF Thromboprophylaxis
5 / year
lt3 / year
Warfarin
Aspirin
?
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NICE CG36 June 2006 www.nice.org.uk
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AF Warfarin or Aspirin

• In AF, compared to placebo
• Aspirin ? relative risk of stroke by 20
• Warfarin ? relative risk of stroke by 60
• Warfarin increases absolute annual risk of
  serious haemorrhage by 2
• Benefit Risk
• Echo is usually unnecessary for decision

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CHADS2 risk score in AF
Predicts annual risk of stroke in non-rheumatic AF
Risk Score Stroke rate (95CI)
0 1.9 (1.2-3.0)
1 2.8 (2.0-3.8)
2 4.0 (3.1-5.1)
3 5.9 (4.6-7.3)
4 8.5 (6.3-11.1)
5 12.5 (8.2-17.5)
6 18.2 (10.5-27.4)
Points
CHF 1
Hypertension 1
Age 75 or older 1
Diabetes 1
Stroke or TIA 2
RISK SCORE 0 - 6
Assuming no Aspirin taken
Warfarin indicated if CHADS2 Score 2 or more
Gage BF et al JAMA 20012852864-2870
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