Managing Arrhythmias. Dr Phil Boreham, Consultant Cardiologist Southmead Hospital

Transcription

1 Managing Arrhythmias Dr Phil Boreham, Consultant Cardiologist Southmead Hospital

2 The Normal ECG Rate:- Normal resting Rate : bpm (usually 60-90) Tachycardia is >100 bpm Bradycardia is <50 bpm Rhythm:- Sinus Rhythm, regular with a P wave preceding every QRS complex Atrial Fibrillation is always irregularly irregular: no P waves Atrial Flutter is regular (150) or regularly irregular if variable block: P waves present. Atrial Tachycardia is regular, speeds up and slows down, usually ~ 130 bpm SVT: is regular QRS narrow no visible P waves rates usually > 150 bpm VT: is regular QRS wide no visible P waves rates usually >150 maybe minimally symptomatic

3 Sinus Rhythm

4 The Normal ECG

5 The Normal ECG

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7 Atrial Fibrillation irregularly irregular

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9 Atrial Flutter

10 SVT:- 2 main mechanisms

11 SVT be calm

12 Supra Ventricular Tachycardia

13 SVT starts

14 SVT stops

15 The Normal ECG

16 Palpitation patient

17 More W-P-W

18 W-P-W in SR

19 W-P-W in Sinus Rhythm

20 Orthodromic SVT

21 W-P-W in AFib

22 Regularly irregular

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24 Tachycardias Regular Ventricular Tachycardia: wide QRS ( >120 msec) rate usually >140 bpm Supra Ventricular Tachycardia: narrow QRS rate usually >150 bpm Atrial Flutter: narrow QRS rate usually = 150 bpm Irregular Atrial Fibrillation: narrow QRS rates vary Multiple Ectopic beats superimposed on Sinus Rhythm

25 Ventricular Tachycardia

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28 VT do something!

29 SVT - be calm

30 Atrial Flutter

31 Atrial Flutter

32 Atrial Fibrillation

33 The Treatment of all TachyArrhythmias is:- Beta Blockers - NICE guidance Which Beta Blockers BISOPROLOL and NEBIVOLOL Atrial Fibrillation Beta blockers and rarely-catheter Ablation Atrial Flutter Beta blockers and occasionally-catheter Ablation Atrial Tachycardia Beta blockers and Catheter Ablation SVT Catheter Ablation and Beta Blockers VT and VF Beta blockers and Implantable Cardiovertor Defibrillators (ICD) and occasionally Amiodarone Those pts who can t take BB there is Catheter Ablation or Ca2+ blockers

34 AFib? Rate or Rhythm? NICE guidance, AFFIRM trial, RACE trial 1 st priority RATE CONTROL 2 nd priority Anticoagulation Risk assessment using CHADS 2 score (or CHA 2 DS 2 -VASc) C Congestive Cardiac Failure eg impaired LV function 1point H Hypertension, uncontrolled 1pt A Age>65 yrs 1pt D Diabetes Mellitus 1pt S Stroke or TIA - 2 pts VASc vascular disease 1 point A age>75 yrs 2 pt S sex - female 1 pt 1 Point = nil or consider offer OAC 2 points = recommend OAC

35 Answer:- Rate control Rate control: - for the vast majority of AFib pts - Pts over 65 yrs - NICE Rhythm control:- for <15% of AFib pts Young pts under 65 yrs, with NO other cardiac conditions eg valves or hypertension Echo routinely for pts <65yrs or with murmur

36 Rate & Rhythm drugs for AFib Rate control:- Aim for resting heart rate of <70 bpm in AFib 1 st Beta Blocker or Calcium antagonist (Diltiazem) 2 nd Digoxin + BBlocker or Digoxin + Diltiazem(Slozem) NOT Amiodarone Rhythm control:- Aim for Sinus Rhythm most of time 1 st Standard Beta blocker eg Bisoprolol 2 nd Sotalol or Amiodarone both class III AARx 3 rd Dronedarone monthly LFTs for 6 months then at 9, 12 4 th Flecainide ONLY in norm LV; Cardiologist use ONLY NB Dronedarone is not compatible with Dabigatran

37 Rate & Rhythm drugs for AFib Rhythm control:- Pill in the Pocket For Paroxysmal / Persistent AFib Usually in younger pts <60yrs with structurally normal hearts Flecainide, Sotalol or Dronedarone started at onset of symptoms and stopped when AFib stops Flecainide is NOT for use in pts with ANY structural heart disease apart from mild Mitral Regurg

38 Admission Criteria AFib with angina at rest AFib with heart failure AFib with ventricular rate > 150 bpm Otherwise Primary care with initial:- Rate control + Anticoagulation eg Bisoprolol + Nothing OR Bisoprolol + Dabigatran/Warfarin see CHA 2 DS 2 -VASc score Refer to Cardiology OPD if appropriate for Rhythm control and DC Cardioversion

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41 Catheter ablation of WPW pathway

42 CryoAblation of W-P-W

43 W-P-W patients with AFib Any Tachy or Brady arrhythmia & syncope is an emergency admission ALL W-P-W patients with palps should be referred for Ablation Highest risk Tachy arrhythmias :- W-P-W with AFib & Ventricular Tachycardia Attach Automatic External Defibrillator

44 Electrical DC Cardioversion of AFib Patients unsuitable for DC Cardioversion:- - Elderly patients >65-70 yrs (NICE) - Pts with contraindication to anticoagulation - Unfavourable cardiac features eg Lt Atrium> 5.5cm, Mitral Valve - Long duration of AFib eg >12 months - Multiple relapses while on AntiArrhythmic treatment (AARx) - Thyrotoxicosis untreated After successful DC Cardioversion:- 60% of pts will have relapsed into AFib by 1 year despite appropriate AARx

45 Catheter Ablation for AFib 1- Ablation of AVNode causing Heart Block (Pts>70yrs) & Permanent Pacemaker - (usually reserved for elderly - drug intolerant pts) 2- Pulmonary Vein Isolation, PVI (Pts <50/55yrs) Low success rate 33% - 1 procedure; most need 2 procs Long term success poor - 4 years post PVI < 40% in SR High recurrence rate of AFib > 10% pa Procedures are high risk 6% SERIOUS complications % of patients have asymptomatic Cerebral Infarcts 4-6 mm in size Very few Cardiologists would have this procedure straw poll at AHA / ESC

46 PVI Ablation Pt selection is key Age <55yrs :: if older > very high recurrence rate (vhrr) eg 70% Paroxysmal AFib only :: if permanent/chronic vhrr Normal :: if Hypertension, Thyroid, Alcohol, vhrr Normal Heart :: if any Valves or Cardiomyopathy vhrr 1 procedure 12 months success 33%, 5 yr -20% are still in SR 2 procedures 12 month success 60-65%, 4yr <40% are still in SR Procedural risks are high 4-6% SERIOUS incl Death, % silent cerebral infarcts for EACH procedure

47 Brady Arrhythmias

48 1 st Degree Heart Block

49 Wenkebach Block

50 2:1 Second degree Heart Block

51 Complete Heart Block

52 Nodal Rhythm

53 Sinus Rhythm

54 Sinus Node disease Is fairly uncommon 1in1000 pts >55yrs mean 65yrs Clinical features: fatigue, SoB on Ex, getting old, pre&syncope 30% Findings: inappropriate sinus brady (drug free, thyroid OK) Increased sensitivity to β blocker, diltiazem, digoxin amiodarone Loss of chronotropic response to exercise

55 Sinus Node disease I

56 Sinus Node disease II

57 Sinus Node disease III

58 Sinus Node disease IV

59 Sinus Node disease V

60 Sinus Node disease VI

61 Treatment Check Thyroid hypothyroidism Identify and remove drugs eg Beta blockers, Diltiazem/Verapamil, Amiodarone Treatment symptomatic Pacemaker

62 END

63 New oral Anticoagulants Dabigatran RE-LY pts 2yr fup reduction in mortality 12%, rel. risk reduction 35% reduction in ischaemic AND haemorrhagic stroke Apixaban Aristotle pts 1.8 yr fup reduction in mortality 11%, rel. risk reduction 22% reduction in haemorrhagic stroke only Rivaroxaban Rocket-AF pts 1.9yr fup No reduction in mortality or stroke vs. warfarin