CARDIAC ARRHYTHMIA AND AMBULATORY MONITORING

1. CARDIAC ARRHYTHMIA AND AMBULATORY MONITORING DR RICHARD MANSFIELD, CONSULTANT CARDIOLOGIST

3. So what might be the cause of palpitation/syncope? SR Sinus Tachycardia Atrial Ectopics Atrial Tachycardia AF/Flutter AVNRT/AVRT Heart Block Ventricular Ectopics Ventricular Tachycardia

4. Contributory Factors for Palpitation Anxiety and depression Caffeine Smoking Chocolate Alcohol Medications – beta-agonists, theophylines etc Illicit drug use

5. Palpitation: What to look for in the patient’s history Exercise Syncope Prior MI Hypertension Cardiomyopathy Valve disease Family History If present……refer

6. Important! What to look for in the Family History Heart muscle diseases (Cardiomyopathy) Atrial Fibrillation Premature IHD ICD SCD <40years If present……….REFER!

7. All patients must have an ECG If the 12 lead ECG is normal and there is no history of syncope, risk factors or FH of SCD then ‘unlikely’ to be a significant (life-threatening) arrhythmia

8. But….ECG abnormalities! AF/Flutter Atrial Tachycardia/ SVT Previous MI LVH +/- Strain LBBB T Wave and ST segment changes Pre-excitation (WPW) Second/Third Degree AV Block Brugada pattern Long QTc If you see these ECG abnormalities with a history of palpitation or syncope consider referral!

9. Just when you thought it was OK to have RBBB ……..Brugada syndrome

10. Long QT syndrome Jervell and Lange-Nielson Romano-Ward ECG prolonged repolarisation Not always evident at rest QTc ? < 440-450ms QTc ? < 460-470ms Risk increased > 500ms Lots of drugs cause QT prolongation http://www.c-r-y.org.uk/lqtsdrugs.htm

11. Provocation of the QT interval

12. And….you guessed it….Short QT too!! A QT interval of < 350ms at a heart rate of around 60 bpm is a very rare finding in a normal person

13. RISK STRATIFICATION for Palpitation and syncope

14. SYNCOPE (tLOC) Dr Richard Mansfield Consultant Cardiologist RUH Bath

15. Guidelines ….There are times when I despair!....

16. Classification Neurally-mediated Cardiac Arrhythmia Structural heart disease HOCM AS MI Cerebrovascular Syncope like conditions

17. Syncope – who to refer Recurrent neuro-cardiogenic syncope Cardiac Syncope – urgent NICE Guidelines 2010

18. Ambulatory ECG Monitoring

19. Who needs ambulatory monitoring? Frequent palpitation Questionable role in infrequent syncope Link the tape duration or device to the frequency of symptoms 24 hrs 48 hrs 72 hrs 7 days Diary card important! Use the clock on the device!

20. What devices are there?

21. Ambulatory ECG monitoring For open access tests serious arrhythmias will usually have been filtered out if analysed at RUH Heart Block VT etc Tapes are still formally reported at BMI Bath Clinic or CircleBath

22. For open access what reports do you get? Tomcat summary report You should get the full disclosure of the analysis

23. Tape reports

24. ………but is this normal?

25. ‘Felt uneven heart beat’…. this is abnormal

26. Full disclosure 1

27. Full disclosure 2

28. Full disclosure 3

29. Key points on tapes Determine the rhythm Consider what is normal Review the symptoms Do the ECG abnormalities correlate with symptoms? Are there high risk features that need referral? Be mindful of artefact and confirm findings on both channels

30. Q1. What is the underlying rhythm? Is it sinus or AF? If the underlying rhythm is sinus are there any periods of bradycardia or tachycardia Bradycardia < 60bpm Tachycardia > 100bpm Is it appropriate? (drugs/exercise) Nocturnal bradycardia is normal Sinus arrhythmia is normal in young patients

31. Q2. Are there ectopics? Do they correlate with symptoms? Are they atrial? pacs = premature atrial contractions = atrial ectopics! Common as short runs – can be normal Are they ventricular? pvcs = premature ventricular contractions = ventricular ectopics! – also referred to as aberrant premature normal Unifocal, Bifocal, multifocal, bigemminy, trigemminy, couplets and triplets

32. Ventricular ectopics – when do I need to worry? Rare < 15 per hour Occasional 15-29 per hour Frequent > 30 per hour When does this become significant? Frequency > 60 per hour AND/OR Risk factors History of MI HTN Cardiomyopathy FH of SCD

33. So what do you do about ectopics? Consider if referral needed Lifestyle Caffeine Alcohol Chocolate Try and avoid BB unless associated RFs and onward referral

34. Q3. Is there Atrial Fibrillation? Is it the underlying rhythm or is it paroxysmal? Depends on symptoms but is a common incidental finding – ‘5 to 12 beats’…correlate to symptoms Pauses of 2-3 seconds when in AF are normal (in the absence of syncope) Look at rate control in persistent/permanent AF (New ESC Guidelines) Lenient rate control < 110bpm Strict rate control <80 bpm

35. Atrial tachycardia/SVT Fast and regular 120-180+ bpm Narrow complex usually Sudden onset and offset Short bursts not uncommon – correlate to symptoms

36. Q4. Are there any pauses? Pauses > 3 seconds are significant Pauses of 2-3 secs in rate controlled AF are normal in the absence of symptoms

37. Q5. Is there Ventricular Tachycardia? BCT > 3 beats Non sustained < 30s and Sustained >30s If there is VT then refer……urgently!

38. Q6. Is there AV Block? First degree AV block (PR> 0.2ms) and 2nd degree AV block (Mobitz I- Wenkebach) – do not need referral unless symptoms especially syncope 2nd degree (Mobitz Type II) or CHB – refer urgently Look for rate limiting drugs ….and stop them!

39. Key points on tapes Determine the rhythm Review the symptoms Do the ECG abnormalities correlate with symptoms? Are there high risk features that need referral? Be mindful of artefact and confirm findings on both channels

40. Arrhythmia management SVT Atrial Fibrillation Atrial Flutter

41. SVT – How would you treat this?

42. How to treat SVT Acute Vagal manoeuvres Refer for cardioversion Chronic Beta Blocker or Verapamil first line and refer DO NOT give Verapamil or Digoxin in known WPW Catheter ablation is the definitive therapy

43. Atrial Fibrillation

44. Atrial Fibrillation

45. Case History 65 male NIDDM, HTN – mild - Bendroflumethiazide DC CV 2009 after incidental finding of AF at pre-admission for hand surgery SOB playing squash! Last 2/52. Not with other activities AF 120bpm on ECG at the surgery What would you do?

46. Different forms of AF

47. AF Treatment Strategy

48. AF Treatment algorhithm

49. NICE Guidance 2006 Rhythm control Symptomatic Younger First episode of AF Secondary to treated or corrected precipitant With CCF (debatable) Rate control Over 65 CHD Contra-indications to anti-arrhythmic therapy Unsuitable for CV

50. AF Treatment algorhithm

51. Rate control for AF – new targets

52. Rate control for AF -which agents?

53. AF Treatment algorhithm

54. Who should be cardioverted? AGWS Network Guidance 2010

55. PAF Drug Therapy – which agents if the heart is normal?

56. PAF Drug Therapy – which agents if the heart is not normal?

57. Dronedarone – False promise? Maybe! ‘Amiodarone without the side-effects!’...or so we thought……. Sanofi Aventis – advisory on LFTs Prior to treatment Every month for 6/12 9 and 12 months If ALT >3x N repeat 48-72 hours if still >3xN STOP

58. Catheter Ablation for AF Pulmonary Vein Isolation AV Node Ablation Catheter Maze Surgical ablation with other procedures

59. Who should be referred for Catheter Ablation? Young (<65?) PAF not responding to 1or 2 drugs Persistent attacks requiring cardioversion AV node ablation for rate control (less common)

60. Catheter Ablation to isolate the Pulmonary Veins

61. Does it work? Yes! Paroxysmal better than a history of persistent episodes Success rates 85% but not first time! Operator dependent Still need to be on Warfarin as per DC CV pre and post procedure Not unusual to have ectopics and short runs of AF for 4 weeks post procedure NICE Statement due Spring 2011

62. Thromboembolic risk: CHADS2

63. Thromboembolic Risk: CHA2DS2-Vasc

64. So ASA or Warfarin?

65. Bleeding Risk

66. Dabigatran - direct thrombin inhibitor RELY Study Licence due June/July 2011 Unanswered questions DC CV Valves

67. LAA occluder in prevention of thromboembolism NICE approved Availability Bleeding risk on oral anti-coagulants

68. AF – who to refer AF with Syncope PAF resistant to beta-blocker Hard to rate control Young (!) with AF Consideration of ablation

69. Case History 66 male NIDDM, HTN – mild - Bendroflumethiazide DC CV 2009 after incidental finding of AF at pre-admission for hand surgery Echo N but LAA 5.5cm SOB playing squash! Last 2/52. Not with other activities AF 120bpm on ECG at the surgery What would you do? Rate control and warfarin (CHA2DS2-Vasc = 3) Consider repeat DC CV

70. Atrial Flutter Everything you do for AF - do the same for Atrial Flutter If there is a tachycardia 150bpm think of atrial flutter Effectively treated by DC CV and ablation

71. Thank you!