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Arrhythmias: The Good, the Bad and the Ugly

Arrhythmias: The Good, the Bad and the Ugly. Soori Sivakumaran MD, FRCPC Clinical Associate Professor of Medicine University of Alberta October 4, 2014. What is this rhythm?. Ventricular Tachycardia. History of previous MI or cardiomyopathy Abnormal cardiac exam

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Arrhythmias: The Good, the Bad and the Ugly

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  1. Arrhythmias: The Good, the Bad and the Ugly Soori Sivakumaran MD, FRCPC Clinical Associate Professor of Medicine University of Alberta October 4, 2014

  2. What is this rhythm?

  3. Ventricular Tachycardia • History of previous MI or cardiomyopathy • Abnormal cardiac exam • Family history of sudden/premature cardiac death • A slow rate doesn’t mean its not VT

  4. Supraventricular Tachycardias • Atrial fibrillation • Atrial flutter • Atrial tachycardia • Multifocal atrial tach • Junctional tachycardia • AV nodal re-entry • AV re-entry tachycardia Murgatroyd, Krahn Yee Skanes and Klein

  5. History • Previous heart disease • Onset • Associated symptoms • Regular or irregular • Chest discomfort, SOB, lightheaded, syncope • Termination • Spontaneous or by patient maneuvers

  6. ECG Criteria • What is the heart rate? • Are there P waves? • Is the rhythm regular or irregular? • What is the relationship of P waves to QRS complexes? • Are the QRS complexes wide or narrow?

  7. Sinus Tachycardia • Most common fast rhythm • Response to another condition • Treat primary problem (sepsis, pain etc.) • Do not treat tachycardia! Murgatroyd, Krahn Yee Skanes and Klein

  8. AVRT vs AVNRT Murgatroyd, Krahn Yee Skanes and Klein

  9. Atrial fibrillation can keep bad company • Hypertension • Pulmonary embolus • Cardiomyopathy • Valvular heart disease • Ischemia • Thyrotoxicosis • Pericarditis Murgatroyd, Krahn Yee Skanes and Klein

  10. Anticoagulation prevents strokes Valvular AF Stroke Risk Factors (Non Valvular AF) • Age over 65 • Hypertension • Diabetes • Previous Stroke or TIA • Structural Heart Disease

  11. Anticoagulation prevents strokes • Warfarin reduces the risk of stroke by 2/3 • ASA reduces the risk of stroke 30% • Recommended in non valvular AF with no stroke risk factors but arterial vascular disease • INR target 2.0 to 3.0 • Newer oral anticoagulants an alternative

  12. Electrical and chemical cardioversion have the same risk of stroke • CV safe within 48 hours of the onset of atrial fibrillation • Do not start anti-arrhythmic drugs that may cardiovert the patient beyond this window • After 3 weeks of anticoagulation with the INR between 2.0 and 3.0 • CV safe following a TEE to rule out LA thrombus

  13. Rate Control • Usually safest strategy in ER • Digoxin is a poor rate control agent unless patient is at rest • Beta blocker and calcium channel blockers much more effective for rate control • Digoxin can be used in combination with above and in patients in acute CHF

  14. Rate control = Rhythm control Misconceptions • People live longer if sinus rhythm is maintained • The risk of stroke is less if sinus rhythm is maintained

  15. 30 25 Rhythm Rate 20 15 Mortality (%) 10 p = 0.058 5 0 3 2 5 0 1 4 Time (Years) Atrial Fibrillation: Follow-up Investigation of Rhythm Management (AFFIRM) Primary Endpoint - Total Mortality Rhythm: 2033 1932 1807 1316 780 255 Rate: 2027 1925 1825 1328 774 236 AFFIRM Investigators N Engl J Med 347:1825-33, 2002

  16. Symptoms determine whether to pursue a rhythm control strategy • Patients with atrial fibrillation have a wide range of symptoms • Patients are more likely to have symptoms: • Younger • Female • Paroxysmal AF • LVH • CHF

  17. Symptoms determine whether to pursue a rhythm control strategy Common Symptoms • Palpitations • Dyspnea • Fatigue • Decreased exercise tolerance The degree of symptoms may not be clear until the patient is back in sinus rhythm

  18. Antiarrhythmic drugs can be pro-arrhythmic • Class I and III antiarrhythmic drugs are potentially proarrhythmic • VF is worse than AF • Contraindicated in patients with structural heart disease • Need to rule out structural heart disease and ischemia and other factors before using

  19. Asymptomatic PAF is common • Many patients have who have symptomatic episodes of atrial fibrillation also have asymptomatic episodes of atrial fibrillation • Cannot use symptoms to determine that AF is not recurring • Probably safest to continue anticoagulation indefinitley in most cases • For stroke risk, PAF = CAF

  20. Anti-arrhythmic Rx should be stopped in chronic atrial fibrillation • Risks with no benefit • Rate control agents • Continue anticoagulation with monitoring (maybe affected by discontinuation)

  21. AF with Pre-Excitation Murgatroyd, Krahn Yee Skanes and Klein

  22. Conclusions • Record the rhythm on 12 lead ECG • Consider running 12 lead rhythm strip with CSM or adenosine • The presence of structural heart disease greatly increases the risk of ventricular arrhythmias • Don’t use amiodarone IV for everything

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