1 / 28

Arrhythmia Management

Arrhythmia Management. Dr John Bayliss FRCP Consultant Cardiologist. 17 Sept 2008. Arrhythmia Guidelines. www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm www.westhertscardiology.com Documents/Local www.starpace.co.uk Clinical Specialty/Cardiovascular . www.nice.org. p 64.

bernad
Download Presentation

Arrhythmia Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Arrhythmia Management Dr John Bayliss FRCP Consultant Cardiologist 17 Sept 2008

  2. Arrhythmia Guidelines www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm www.westhertscardiology.com Documents/Local www.starpace.co.uk Clinical Specialty/Cardiovascular www.nice.org p 64

  3. 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 p 55

  4. Assessment of “Palpitations”/Arrhythmias • Full History = most important • Clinical Examination • Heart rate response (during & after exercise) • 12 lead ECG (esp during symptoms) • Blood testsU&E, Glucose, Thyroid FT, Liver FT, FBC p 56-7

  5. 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) p 58

  6. 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 < 40 years • No previous collapse/blackouts • Only infrequent attacks • Symptoms: • Palpitations last < 30 minutes • “Missed” beats (= ectopics) or brief rhythm irregularity only p 57

  7. 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 < 40%) • Structural heart disease: valve disease, cardiomyopathy, congenital heart disease • Family history of collapse or sudden death at age < 40 years • Previous or recurrent collapse/blackouts. p 57

  8. Should GPs report 12 lead ECGs ?! • 24yr old woman, occasional brief “flutters”

  9. Long QT and Brugada syndrome • “Ion channelopathies” QTc >450-500ms = high risk of VT/SCD

  10. 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

  11. 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 before+during attack • Most cost-effective test • Yield 43% 1 • Cost 26% less than usual Ix 2 1Krahn AD, et al. Circ. 2001;104:46-51. 2Krahn AD, et al. JACC. 2003;42:495-501.

  12. Arrhythmias: Treatment Depends on (ECG) diagnosis ! • S Tachy : ? Cause (POTS ! “heartsink”) • A Tachy : β blocker • AVNRT / AVRT : Ablation (Flecainide/Propafenone) • A Flutter : Ablation (Verapamil,Dig,Amio) • Paroxysmal AF : Sotalol, Propafenone, Flecainide • Permanent AF : Rate v Rhythm... • VT : ICD (β blocker, Amio, Ablation) • Bradycardias : Pacing p 59

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

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

  15. Pacemakers : 1958 – 2008 : 50 years 1st "Permanent" Implantable Pacemaker & Bipolar Hunter-Roth Lead (1958)

  16. ICD function • VF terminated by single 34J shock VF = Dead SR = Alive

  17. First Episode (New onset) OR Alcohol Acute infection Hypertension Ischaemia / CHD Sick Sinus Syndrome Heart Failure Cardiomyopathy Valve disease Hyperthyroid, etc Paroxysmal (PAF) Persistent Permanent AF: Types Aetiology Timing • 22% of PAF progress to permanent AF within 2 years • 50-60% of patients are back in AF 1 year after cardioversion “Lone” AF vs Circulation 2001;104:2118–2150 p 58

  18. 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 Warfarin=1-2% yearly risk of serious bleed p 60 p 64

  19. 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 p 60 p 64

  20. AF: Rate v Rhythm control - AFFIRM The Atrial Fibrillation Follow-up Investigation of Rhythm Management n=4060, age >65, AF Mean age = 69.7 Hypertension in 71% Rate control = <80 at rest <110 on walk + Warfarin (INR 2-3) Rhythm control = Drugs ± Cardioversion(s) + Warfarin (INR 2-3)unless SR for 4(-12) weeks AFFIRM NEJM 2002;347:1825-33 p 62

  21. AF: Rate v Rhythm control • Choose Rate Control: if patient stable and if • Age >65 • Underlying CHD, Hypertension, Valve Disease • Anti-arrhyhtmic Rx not tolerated / contraindicated • Cardioversion inappropriate • Use β Blocker first:Atenolol, Bisoprolol, Metoprololor rate controlling Ca++ blocker: Verapamil, Diltiazem • Add Digoxin if necessary, or if CHF p 60 p 64

  22. IMPORTANT Digoxin : a drug of 2nd-3rd choice !

  23. AF: Digoxin = Increased Mortality • SPORTIF III+V (Warfarin v Ximelagatran) • n=7329 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 2008;94:191-196

  24. AF: Thromboprophylaxis ≥5% / year <3% / year Warfarin Aspirin ? p 61 p 64 NICE CG36 June 2006 www.nice.org.uk

  25. 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

  26. CHADS2 risk score in AF Predicts annual risk of stroke in non-rheumatic AF * Assuming no Aspirin taken Warfarin indicated if CHADS2 Score = 2 or more Gage BF et al JAMA 2001;285:2864-2870 p 60-1

More Related