EKG Review and Arrhythmia Management. Walter Coats D.O., FACC Interventional Cardiology Jefferson City, Missouri

Transcription

1 EKG Review and Arrhythmia Management Walter Coats D.O., FACC Interventional Cardiology Jefferson City, Missouri

2 Disclosures I have no relationships to disclose.

3 Goals and Objectives Use a systematic approach to interpret interesting EKG findings. Review key features of common arrhythmias Review management of common arrhythmias

4 Outline EKG Session #1 (Arrhythmias and Heart Block) Supraventricular Arrhythmias EKG Session #2 (Ischemia/Infarction) Ventricular Arrhythmias EKG Session #3 (Miscellaneous) Bradyarrhythmias

5 EKGs

6 EKG #1

7 EKG #1 This EKG represents: A. Normal sinus rhythm B. No ischemic changes C. Normal EKG D. All of the above

8 EKG #2

9 EKG #2 A feature commonly associated with this arrhythmia may include: A. Ischemia B. Retrograde P-waves C. Degeneration to ventricular fibrillation D. None of the above

10 EKG #3

11 EKG #3 The disease state commonly associated with the above arrhythmia: A. Dialysis dependent renal disease B. Hepatic cirrhosis C. Central nervous system event D. Chronic obstructive pulmonary disease

12 EKG #4

13 EKG #4 The above EKG represents: A. Sinus tachycardia B. Ectopic atrial tachycardia C. Atrial flutter D. 2:1 atrioventricular conduction E. Two of the above

14 EKG #5

15 EKG #5 Appropriate management of this arrhythmia includes A. Permanent pacing B. Permanent pacing only in symptomatic individuals C. Therapeutic trial of isoproterenol D. Electrical cardioversion

16 Supraventricular Arrhythmias

17 Supraventricular Arrhythmias Premature atrial contractions Inappropriate sinus tachycardia Supraventricular tachycardia (SVT) Atrial flutter Atrial fibrillation

18 Premature Atrial Contractions Generally considered to be benign Extremely common Are associated with a small increase in risk of Atrial fibrillation Stroke Death

19 Premature Atrial Contractions Management Reassurance Hydration Tolerance of symptoms Avoidance of stimulants (caffeine) Beta blockade for refractory symptoms

20 Inappropriate Sinus Tachycardia Persistent increase in resting heart rate or sinus rate unrelated to, or out of proportion with, the level of physical, emotional, pathological, or pharmacologic stress. Enhanced automaticity of SA node Excessive sympathetic tone

21 Inappropriate Sinus Tachycardia 90% are female Mean age 38 +/- 12 years Rule out secondary cause Infection, hormonal, anemia, hypovolemia, etc.

22 Inappropriate Sinus Tachycardia Persistent tachycardia > 100 bpm, during the day with excessive rate response to exercise Document with Holter monitoring P wave morphology is sinus

23 Inappropriate Sinus Tachycardia Treatment with beta blockade or calcium channel blockers Sinus node ablation for the most refractory cases

24 Supraventricular Tachycardia Most commonly due to re-entry AV nodal reentrant tachycardia (AVNRT) Occurs within AV node Slow Pathway Fast Pathway

25 Supraventricular Tachycardia AV reentrant tachycardia (AVRT) Wolff-Parkinson-White Accessory pathway (Pre-excitation)

26 Supraventricular Tachycardia Ambulatory cardiac monitoring 24 hour Holter Monitoring Event monitoring (usually 4 weeks) Implantable loop recorders

27 Supraventricular Tachycardia Acute management (Narrow complex) Valsalva, carotid massage, cold water, etc. Adenosine 6 mg to 12 mg IV push Calcium channel blockers Beta blockers DC cardioversion for unstable patients Synchronized, Biphasic, J

28 Supraventricular Tachycardia Catheter Based Ablation Performed by an electrophysiologist Slow pathway ablation is preferred 96% success rate Decreased risk of AV block (1%) Potential for cure

29 Atrial Flutter Macro reentrant circuit in the atria ( bpm) AV node slows conduction Thrombogenic arrhythmia

30 Atrial Flutter Adenosine to make the diagnosis Calcium Channel Blockade and Beta blockade Amiodarone Digoxin

31 Atrial Flutter Ibutilide (Corvert) IV infusion of 1 mg over 10 minutes Premedicate with Potassium and Magnesium Sotalol, Flecainide, Propafenone, etc. Very limited role acutely

32 Atrial Flutter DC cardioversion 50 J of synchronized energy Indicated acutely for hypotension Onset < 48 hours: Cardioversion Onset > 48 hours: TEE with cardioversion

33 Atrial Flutter Catheter ablation Cavo tricuspid isthmus % successful initially, 80% at 2 years

34 Atrial Fibrillation Chaotic atrial activation Ineffective atrial contraction

35 Atrial Fibrillation First priority: slow the rate Anticoagulation?

36 Atrial Fibrillation Rate control (<80 bpm) Beta blockers Calcium channel blockers Digoxin (no hypotension) Anticoagulation? Rhythm control Cardioversion Anti arrhythmics Sotalol Amiodarone Etc. Anticoagulation?

37 Atrial Fibrillation

38 Atrial Fibrillation

39 Atrial Fibrillation Cardioversion Afib onset < 48 hours Anticoagulate and shock Afib onset > 48 hours Transesophageal Echo and shock OR Anticoagulate for 3 weeks and shock

40 Atrial Fibrillation Anticoagulation should be continued for 4 weeks post shock regardless of strategy Maintenance with an antiarrhythmic is usually necessary

41 Atrial Fibrillation CHA2DS2VASc Congestive Heart Failure (1) Hypertension (1) Age 75 (2) Diabetes Mellitus (1) Stroke/TIA (2) PVD (1) Age (1) Female gender (1) Annual risk of stroke 0 0% 1 1.3% 2 2.2% 3 3.2% 4 4.0% 5 6.7% 6 9.8% 7 9.6% 8 6.7% %

42 Newer Anticoagulants Rivaroxaban Apixiban Dabigatran

43 Atrial Fibrillation Catheter ablation Best for symptomatic paroxysmal afib refractory to at least one anti arrhythmic

44 Atrial Fibrillation Coming soon Watchman Device

45 Atrial Fibrillation Coming soon Lariat Procedure

46 EKG #6

47 EKG #6 The infarction represented in this EKG involves the: A. Right coronary artery B. Left anterior descending coronary artery C. Left circumflex coronary artery D. Left main coronary artery

48 EKG #7

49 EKG#7 The infarction represented most likely involves the: A. Right coronary artery B. Left anterior descending coronary artery C. Left circumflex coronary artery D. Left main coronary artery

50 EKG #8

51 EKG #8 Territories involved in the above infarction include all of the following except: A. Inferior B. Lateral C. Posterior D. Anterior

52 EKG #9

53 EKG #9 The above EKG demonstrates: A. Right bundle branch block B. Anterior ST elevation myocardial infarction C. Culprit LAD lesion D. All of the above

54 EKG #10

55 EKG #10 The above EKG represents A. Infarction of the left main coronary artery B. Global ischemia C. Biventricular heart failure D. None of the above

56 Ventricular Arrhythmias Premature Ventricular Contractions Ventricular Tachycardia

57 Premature Ventricular Contractions Very Common 50% of people have them < 5% have more than 50 in 24 hours Small, but increased risk of mortality and SCD

58 Premature Ventricular Contractions Early depolarization due to automaticity Ischemia Electrolyte abnormalities Increased autonomic tone Primary Cardiomyopathy Tachycardia Mediated Cardiomyopathy

59

60 Premature Ventricular Contractions Goals of Therapy Symptom relief Suppress the arrhythmia Identification of underlying cardiomyopathy Prevention of cardiomyopathy

61 Premature Ventricular Contractions Hydration Magnesium/Potassium supplementation Stress Reduction

62 Premature Ventricular Contractions Beta blockade Modestly decrease the frequency of PVCs Modestly improve symptoms Amiodarone May be effective in suppressing PVCs.

63 Premature Ventricular Contractions Radiofrequency ablation Frequent, symptomatic PVCs refractory to medical therapy Treatment or prevention of tachycardia mediated cardiomyopathy

64 Ventricular Tachycardia Any wide complex tachycardia is VT until proven otherwise Unstable = cardioversion Revascularization in ischemia Correct electrolytes

65 Ventricular Tachycardia Initial anti arrhythmic therapy IV Procainamide IV Lidocaine (esp. with ischemia) IV Amiodarone IV Beta Blocker NOT Calcium Channel Blockers

66 Ventricular Tachycardia Antiarrhythmic suppression Beta blockers Sotalol Amiodarone

67 Ventricular Tachycardia Electrophysiology Testing To distinguish BBB from VT Patients with syncope, palpitations, and non ischemic cardiomyopathy

68 Ventricular Tachycardia ICD therapy for: HOCM Arrhythmogenic Right Ventricular Cardiomyopathy EF 40% who have survive V-fib or unstable VT EF 35% who are on optimal medical therapy for 3 months without recovery of EF

69 EKG #11

70 EKG #11 A disease state frequently associated with this EKG finding: A. Hepatic Cirrhosis B. End Stage Renal Disease C. Central Nervous System Event D. Malignant neoplasm

71 EKG #12

72 EKG #12 A disease state frequently associated with this EKG finding: A. Hepatic Cirrhosis B. End Stage Renal Disease C. Central Nervous System Event D. Malignant neoplasm

73 EKG #13

74 EKG #13 The EKG changes above are most consistent with: A. Left ventricular hypertrophy B. Right ventricular hypertrophy C. Both of the above D. Neither of the above

75 EKG #14

76 EKG #14 The above EKG demonstrates: A. Normal pacemaker function B. Failure to sense C. Failure to capture D. Both B and C

77 EKG #15

78 EKG #15 The above EKG represents: A. Atrial flutter B. Atrial fibrillation C. Ectopic atrial tachycardia D. Heart transplantation

79 EKG #16

80 EKG #16 Treatment for the above patient may include: A. Pericardiocentesis B. Electrical cardioversion C. Transesophageal echocardiogram D. Thoracentesis

81 EKG #17

82 EKG #17 The above EKG demonstrates: A. Pre excitation B. Shortened PR interval C. Delta wave D. All of the above

83 EKG #18

84 EKG #18 In patient with the above rhythm, which agent would NOT be recommended for rate slowing or cardioversion A. Verapamil B. IV Lidocaine C. IV Amiodarone D. IV Procainamide

85 Brady arrhythmias Sinus bradycardia First degree AV block Second degree AV block Type 1 (Wenckebach) Second degree AV block Type 2 Complete heart block Sick Sinus Syndrome

86 Sinus Bradycardia Frequently a normal finding Some consider HRs in the 50s as normal Evaluate for sleep apnea, hypothyroidism, medication related bradycardia

87 Sinus Bradycardia Pacing for: Symptomatic with heart rate 40 bpm Absence of underlying cause Documented Pauses 3 seconds

88 First Degree AV Block PR interval 200 ms Due to delay in the AV node Extremely common Generally benign, progression is uncommon PR 300 ms can cause symptoms

89 Second Degree AV Block Type 1 Wenckebach Due to delay in the AV node Generally benign, progress is uncommon Indications for pacing same as sinus bradycardia

90 Second Degree AV Block Type 2 More advanced infranodal AV block Progression to Third Degree AV block is common and sudden Pacing indicated event in the absence of symptoms

91 Third Degree AV Block Advanced AV block, usually infranodal Can be induced by ischemia, electrolyte abnormalities, valve surgery, catheter ablation Permanent pacing indicated after reversible causes are ruled out

92 Sick Sinus Syndrome Tachy Brady syndrome Usually Progressive Attempt to keep patients in NSR

93 Sick Sinus Syndrome Pacing indicated for symptomatic bradycardia Pacing in patients intolerant to rate control drugs Pacing MAY improve maintenance of NSR

94 References Rimmerman and Jain. Interactive Electrocardiography. Lippincot, Williams, and Wilkins ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias Executive Summary. Circulation. 2003;108: AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2014;130:e199-e267. A Comparison Of Rate Control And Rhythm Control In Patients With Atrial Fibrillation. NEJM 2002, Vol. 347, No. 23.

95 References ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death Executive Summary. JACC Vol. 48, No. 5, 2006 : ACC/AHA/HRS Practice Guidelines for Device Based Therapy of Cardiac Rhythm Abnormalities. Circulation. 2008;117:e350- e408.