Acute Arrhythmias in the Hospitalized Patient Gregory M Marcus, MD, - - PowerPoint PPT Presentation

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Acute Arrhythmias in the Hospitalized Patient Gregory M Marcus, MD, - - PowerPoint PPT Presentation

Jan 18, 2023 99 likes •688 views

Acute Arrhythmias in the Hospitalized Patient Gregory M Marcus, MD, MAS Associate Professor of Medicine Division of Cardiology University of California, San Francisc Disclosures Medtronic: Research Support SentreHeart: Reserch

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Acute Arrhythmias in the Hospitalized Patient

Gregory M Marcus, MD, MAS Associate Professor of Medicine Division of Cardiology University of California, San Francisc

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Disclosures

  • Medtronic: Research Support
  • SentreHeart: Reserch Support
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SLIDE 3

Don’t Forget the Basics

  • 79 yo man with a history of CHF s/p

remote ICD presents with progressive, severe dyspnea at rest

  • Compliant with his medicines; described

some diarrhea after a recent trip to Mexico

  • Sitting up, diaphoretic, tachypneic, oxygen

saturation ~87%, blood pressure ~88/40

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Don’t Forget the Basics

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Don’t Forget the Basics

When you have a questionable ECG: IF you can, always…

  • 1. Compare it to a previous ECG
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Current: 2 months prior:

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Don’t Forget the Basics

When you have a questionable ECG: IF you can, always…

  • 1. Compare it to a previous ECG
  • 2. Think about electrolytes (K+, Mg2+, Ca2+)
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SLIDE 8

Tachyarrhythmias- Unstable

SVT Atrial fibrillation AF with WPW VT/ VF

  • Unconscious, altered mental status,
  • ngoing chest pain
  • “Hypotension” is a clinical judgment
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Tachyarrhythmias-quasi-stable

SVT Atrial fibrillation AF with WPW VT/ VF

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Tachyarrhythmias-quasi-stable

SVT

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Tachyarrhythmias-quasi-stable

SVT

Vagal Manuevers

WAIT! AIT! GE GET A 12 LE T A 12 LEAD AD ECG! CG!

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Tachyarrhythmias-quasi-stable

SVT

Vagal Manuevers

  • Carotid sinus massage
  • Valsava
  • Will terminate ~20%1
  • 1. Lim SH et al. Ann Emerg Med 1998;31:30-35
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Tachyarrhythmias-quasi-stable

SVT

Adenosine

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The primary method of adenosine clearance is

  • 1. Liver metabolism
  • 2. Renal excretion
  • 3. Red blood cell metabolism
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Tachyarrhythmias-quasi-stable

SVT

Adenosine

  • Metabolized by red blood

cells and endothelium

  • Give 6 mg IV with 20 cc flush
  • Repeat with 12 mg IV X 2
  • How do I know if I’ve given

enough?

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SLIDE 16

SVT can be cured with ablation

  • 1. >95 % of the time
  • 2. 85-95% of the time
  • 3. 75-85% of the time
  • 4. 65-75% of the time
  • 5. 55-65% of the time
  • 6. 45-55% of the time
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SVT can be cured with ablation

Hazard Ratio for Emergency Department Visits (95% CI) Multivariable adjusted Cox proportional hazard ratios for predictors of recurrent Emergency Department visits for SVT taking clustering of individuals into

  • account. The vertical line represents a hazard ratio of 1 (no difference), and the

error bars denote 95% confidence intervals. Filled circles denote baseline (static) variables, and open circles represent variables that were time-updated throughout the study period.

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Tachyarrhythmias-quasi-stable

Atrial Fibrillation

Nondihydropyrdine Calcium channel blockers Diltiazem Verapamil Beta-blockers Metoprolol Atenolol Carvedilol Labetolol Propanolol

Blood Pressure

  • 1. Address underlying condition
  • 2. Esmolol
  • 3. Digoxin
  • 4. Amiodarone
  • 5. ?Dronaderone?
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Tachyarrhythmias-quasi-stable

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The most likely diagnosis is:

  • 1. Ventricular Tachycardia
  • 2. Atrial fibrillation with WPW
  • 3. SVT with aberrancy
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Tachyarrhythmias-quasi-stable

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Tachyarrhythmias-quasi-stable

Atrial Fibrillation with preexcitation

AV nodal blockers

Give:

Procainamide Ibutilide

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A Patient with WPW Syndrome Should Be Referred to an EP Because

  • 1. Genetic testing will be helpful for family

counseling

  • 2. An implantable defibrillator may be

indicated to prevent sudden death

  • 3. An ablation may be indicated to prevent

sudden death

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Tachyarrhythmias-quasi-stable

Ventricular Tachycardia

  • Scarcity of data
  • Amiodarone probably the most

effective1,2

  • - Can cause bradycardia
  • - Can hinder EP studies/ ablation

Extrapolate from cardiac pulseless VT/ VF versus placebo:

  • 1. Kudenchuck PJ et al. N Engl

J Med 1999;341:871-878 versus lidocaine:

  • 2. Dorian P et al. N Engl J Med

2002;346:884-890

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Tachyarrhythmias-quasi-stable

Ventricular Tachycardia

  • Scarcity of data
  • Consider
  • - Lidocaine gtt
  • - Procainamide
  • watch for hypotension and

prolonged QT

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Tachyarrhythmias-quasi-stable

Ventricular Tachycardia

  • Get EP involved
  • May respond to beta-blockers or

calcium channel blockers

  • May be amenable to ablation
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Tachyarrhythmias

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Tachyarrhythmias

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Tachyarrhythmias

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Tachyarrhythmias

1.Electrolytes

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Tachyarrhythmias

1.Electrolytes

Hypokalemia

Hypo-Mg

T U

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Tachyarrhythmias

1.Electrolytes

Hypokalemia Hypo-Mg2+

Hypo-Ca2+

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Tachyarrhythmias

1.Electrolytes

Hypokalemia Hypo-Mg2+

Hypo-Ca2+

  • 2. DRUGS
  • 3. Congenital
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Tachyarrhythmias

  • 1. IV magnesium
  • 2. Isoproterenol
  • 3. Transvenous pacing
  • 4. Unstable DC shock
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Bradyarrhythmias + +

Blood Flow

+

SYMPATHETIC NERVOUS SYSTEM PARA- SYMPATHETIC NERVOUS SYSTEM

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Bradyarrhythmias + +

Blood Flow

+

SYMPATHETIC NERVOUS SYSTEM PARA- SYMPATHETIC NERVOUS SYSTEM

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Bradyarrhythmias + +

Blood Flow

+

SYMPATHETIC NERVOUS SYSTEM PARA- SYMPATHETIC NERVOUS SYSTEM

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Bradyarrhythmias + +

Blood Flow

+

SYMPATHETIC NERVOUS SYSTEM PARA- SYMPATHETIC NERVOUS SYSTEM

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Bradyarrhythmias + +

Blood Flow

+

SYMPATHETIC NERVOUS SYSTEM PARA- SYMPATHETIC NERVOUS SYSTEM

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Bradyarrhythmias

Blood Flow

  • Important questions:

– Is this dynamic/ reversible/ vagal?

  • IE, more likely benign
  • IE, less likely respond to pacing
  • IE, more likely transiet

– Or is this structural

  • IE, more likely dangerous
  • IE, more likely needs pacing
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Bradyarrhythmias + +

Vagal tone

Lengthening P-P interval before pause Lengthening PR before a pause

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Bradyarrhythmias + +

  • 1. Atropine
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Bradyarrhythmias

+ +

  • 1. Atropine
  • 2. Dopamine
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Bradyarrhythmias

+ +

  • 1. Atropine
  • 2. Dopamine
  • 3. Epinephrine
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Bradyarrhythmias

+ +

  • 1. Atropine1
  • 2. Dopamine1
  • 3. Epinephrine1
  • 4. Isoproterenol

(vasodilating)

  • 1. AHA Guidelines. Circulation 2005;112:67-77
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Bradyarrhythmias + +

Beta- blocker Calcium channel blocker

Glucagon Calcium

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Bradyarrhythmias + +

Conduction disease Lev’s disease/ fibrosis

  • r an MI
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Bradyarrhythmias

+

+

  • 1. Atropine
  • 2. Dopamine
  • 3. Epinephrine
  • 4. Isoproterenol
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Bradyarrhythmias

+

+

  • 1. Atropine
  • 2. Place external pacing

pads

  • 3. Pace if atropine fails
  • 4. Dopamine
  • 5. Epinephrine
  • 6. Isoproterenol
  • 7. Transvenous pacer

AHA Guidelines. Circulation 2005;112:67-77

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Bradyarrhythmias

+ +

  • 1. Atropine1
  • 2. Transcutaneous1

pacing OR Dopamine OR Epinephrine (then mention isoproterenol)

  • 3. Consider

consultation ± transvenous pacing

  • 1. AHA Guidelines. Circulation 2010;18:S749
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Bradyarrhythmias

Transcutaneous Pacing

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  • Pt. comes in with multiple,

recurrent shocks from his ICD

1.PUTS DEVICE IN “MAGNET MODE” 2.FOR AN ICD: INHIBITS THERAPY DETECTION 3.FOR A PACEMAKER: INHIBITS SENSING

  • 1. Place external pads
  • 2. Place magnet on chest
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  • Pt. comes in with catastrophic

bleeding on warfarin…but needs warfarin for atrial fibrillation and a high CHADS2 score (>2) Or Patient comes in with apparent embolic stroke in atrial fibrillation with an INR of 2.5

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Devices for stroke prevention

  • All anticoagulants by nature will be

associated with an increased risk of bleeding

  • In AF patients with thrombus/

thromboembolism, the left atrial appendage is thought to be the site of thrombus formation in more than 90%

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Devices for stroke prevention

  • Consider referral for a percutaneous left

atrial appendage occlusion:

– Watchman (occlusion device) – Lariat (epicardial suture)

  • No guidelines for now
  • Reimbursement may be an issue
  • Likely indicated for:

– If CHADS2 score warrants warfarin or a novel anticoagulant and there are contraindications (mainly bleeding) – If patient has a stroke on therapuetic anticoagulation

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Thank You