arrhythmias the good the bad and the ugly
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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

Arrhythmias: The Good, the Bad and the Ugly

Soori Sivakumaran MD, FRCPC

Clinical Associate Professor of Medicine

University of Alberta

October 4, 2014

ventricular tachycardia
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
supraventricular tachycardias
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

history
History
  • Previous heart disease
  • Onset
  • Associated symptoms
    • Regular or irregular
    • Chest discomfort, SOB, lightheaded, syncope
  • Termination
    • Spontaneous or by patient maneuvers
ecg criteria
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?
sinus tachycardia
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

avrt vs avnrt
AVRT vs AVNRT

Murgatroyd, Krahn Yee Skanes and Klein

atrial fibrillation can keep bad company
Atrial fibrillation can keep bad company
  • Hypertension
  • Pulmonary embolus
  • Cardiomyopathy
  • Valvular heart disease
  • Ischemia
  • Thyrotoxicosis
  • Pericarditis

Murgatroyd, Krahn Yee Skanes and Klein

anticoagulation prevents strokes
Anticoagulation prevents strokes

Valvular AF

Stroke Risk Factors (Non Valvular AF)

  • Age over 65
  • Hypertension
  • Diabetes
  • Previous Stroke or TIA
  • Structural Heart Disease
anticoagulation prevents strokes1
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
electrical and chemical cardioversion have the same risk of stroke
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
rate control
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
rate control rhythm control
Rate control = Rhythm control

Misconceptions

  • People live longer if sinus rhythm is maintained
  • The risk of stroke is less if sinus rhythm is maintained
slide27

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

symptoms determine whether to pursue a rhythm control strategy
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
symptoms determine whether to pursue a rhythm control strategy1
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

antiarrhythmic drugs can be pro arrhythmic
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
asymptomatic paf is common
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
anti arrhythmic rx should be stopped in chronic atrial fibrillation
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)
af with pre excitation
AF with Pre-Excitation

Murgatroyd, Krahn Yee Skanes and Klein

conclusions
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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