EKG Review and Arrhythmia Management Walter Coats D.O., FACC Interventional Cardiology Jefferson City, Missouri
Disclosures I have no relationships to disclose.
Goals and Objectives Use a systematic approach to interpret interesting EKG findings. Review key features of common arrhythmias Review management of common arrhythmias
Outline EKG Session #1 (Arrhythmias and Heart Block) Supraventricular Arrhythmias EKG Session #2 (Ischemia/Infarction) Ventricular Arrhythmias EKG Session #3 (Miscellaneous) Bradyarrhythmias
EKGs
EKG #1
EKG #1 This EKG represents: A. Normal sinus rhythm B. No ischemic changes C. Normal EKG D. All of the above
EKG #2
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
EKG #3
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
EKG #4
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
EKG #5
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
Supraventricular Arrhythmias
Supraventricular Arrhythmias Premature atrial contractions Inappropriate sinus tachycardia Supraventricular tachycardia (SVT) Atrial flutter Atrial fibrillation
Premature Atrial Contractions Generally considered to be benign Extremely common Are associated with a small increase in risk of Atrial fibrillation Stroke Death
Premature Atrial Contractions Management Reassurance Hydration Tolerance of symptoms Avoidance of stimulants (caffeine) Beta blockade for refractory symptoms
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
Inappropriate Sinus Tachycardia 90% are female Mean age 38 +/- 12 years Rule out secondary cause Infection, hormonal, anemia, hypovolemia, etc.
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
Inappropriate Sinus Tachycardia Treatment with beta blockade or calcium channel blockers Sinus node ablation for the most refractory cases
Supraventricular Tachycardia Most commonly due to re-entry AV nodal reentrant tachycardia (AVNRT) Occurs within AV node Slow Pathway Fast Pathway
Supraventricular Tachycardia AV reentrant tachycardia (AVRT) Wolff-Parkinson-White Accessory pathway (Pre-excitation)
Supraventricular Tachycardia Ambulatory cardiac monitoring 24 hour Holter Monitoring Event monitoring (usually 4 weeks) Implantable loop recorders
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, 50 200 J
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
Atrial Flutter Macro reentrant circuit in the atria (250-300 bpm) AV node slows conduction Thrombogenic arrhythmia
Atrial Flutter Adenosine to make the diagnosis Calcium Channel Blockade and Beta blockade Amiodarone Digoxin
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
Atrial Flutter DC cardioversion 50 J of synchronized energy Indicated acutely for hypotension Onset < 48 hours: Cardioversion Onset > 48 hours: TEE with cardioversion
Atrial Flutter Catheter ablation Cavo tricuspid isthmus 90-100% successful initially, 80% at 2 years
Atrial Fibrillation Chaotic atrial activation Ineffective atrial contraction www.cpmc.org
Atrial Fibrillation First priority: slow the rate Anticoagulation? www.cpmc.org
Atrial Fibrillation Rate control (<80 bpm) Beta blockers Calcium channel blockers Digoxin (no hypotension) Anticoagulation? Rhythm control Cardioversion Anti arrhythmics Sotalol Amiodarone Etc. Anticoagulation?
Atrial Fibrillation
Atrial Fibrillation
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
Atrial Fibrillation Anticoagulation should be continued for 4 weeks post shock regardless of strategy Maintenance with an antiarrhythmic is usually necessary
Atrial Fibrillation CHA2DS2VASc Congestive Heart Failure (1) Hypertension (1) Age 75 (2) Diabetes Mellitus (1) Stroke/TIA (2) PVD (1) Age 65-74 (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% 9 15.2%
Newer Anticoagulants Rivaroxaban Apixiban Dabigatran
Atrial Fibrillation Catheter ablation Best for symptomatic paroxysmal afib refractory to at least one anti arrhythmic www.aafp.org
Atrial Fibrillation Coming soon Watchman Device www.dicardiology.com www.ubergizmo.com
Atrial Fibrillation Coming soon Lariat Procedure www.clevelandakroncanton.mdnews.com
EKG #6
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
EKG #7
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
EKG #8
EKG #8 Territories involved in the above infarction include all of the following except: A. Inferior B. Lateral C. Posterior D. Anterior
EKG #9
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
EKG #10
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
Ventricular Arrhythmias Premature Ventricular Contractions Ventricular Tachycardia
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
Premature Ventricular Contractions Early depolarization due to automaticity Ischemia Electrolyte abnormalities Increased autonomic tone Primary Cardiomyopathy Tachycardia Mediated Cardiomyopathy
Premature Ventricular Contractions Goals of Therapy Symptom relief Suppress the arrhythmia Identification of underlying cardiomyopathy Prevention of cardiomyopathy
Premature Ventricular Contractions Hydration Magnesium/Potassium supplementation Stress Reduction
Premature Ventricular Contractions Beta blockade Modestly decrease the frequency of PVCs Modestly improve symptoms Amiodarone May be effective in suppressing PVCs.
Premature Ventricular Contractions Radiofrequency ablation Frequent, symptomatic PVCs refractory to medical therapy Treatment or prevention of tachycardia mediated cardiomyopathy
Ventricular Tachycardia Any wide complex tachycardia is VT until proven otherwise Unstable = cardioversion Revascularization in ischemia Correct electrolytes
Ventricular Tachycardia Initial anti arrhythmic therapy IV Procainamide IV Lidocaine (esp. with ischemia) IV Amiodarone IV Beta Blocker NOT Calcium Channel Blockers
Ventricular Tachycardia Antiarrhythmic suppression Beta blockers Sotalol Amiodarone
Ventricular Tachycardia Electrophysiology Testing To distinguish BBB from VT Patients with syncope, palpitations, and non ischemic cardiomyopathy
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
EKG #11
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
EKG #12
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
EKG #13
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
EKG #14
EKG #14 The above EKG demonstrates: A. Normal pacemaker function B. Failure to sense C. Failure to capture D. Both B and C
EKG #15
EKG #15 The above EKG represents: A. Atrial flutter B. Atrial fibrillation C. Ectopic atrial tachycardia D. Heart transplantation
EKG #16
EKG #16 Treatment for the above patient may include: A. Pericardiocentesis B. Electrical cardioversion C. Transesophageal echocardiogram D. Thoracentesis
EKG #17
EKG #17 The above EKG demonstrates: A. Pre excitation B. Shortened PR interval C. Delta wave D. All of the above
EKG #18
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
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
Sinus Bradycardia Frequently a normal finding Some consider HRs in the 50s as normal Evaluate for sleep apnea, hypothyroidism, medication related bradycardia
Sinus Bradycardia Pacing for: Symptomatic with heart rate 40 bpm Absence of underlying cause Documented Pauses 3 seconds
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
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
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 www.practicalclinicalskills.com
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 www.asda.net.au
Sick Sinus Syndrome Tachy Brady syndrome Usually Progressive Attempt to keep patients in NSR www.ajcc.aacnjournals.org
Sick Sinus Syndrome Pacing indicated for symptomatic bradycardia Pacing in patients intolerant to rate control drugs Pacing MAY improve maintenance of NSR www.ajcc.aacnjournals.org
References Rimmerman and Jain. Interactive Electrocardiography. Lippincot, Williams, and Wilkins. 2007. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias Executive Summary. Circulation. 2003;108:1871-1909. 2014 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.
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 :1064 1108. ACC/AHA/HRS Practice Guidelines for Device Based Therapy of Cardiac Rhythm Abnormalities. Circulation. 2008;117:e350- e408.