Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC - - PowerPoint PPT Presentation

Arrhythmias in Cardiac Rehab

Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted Medical Center

Disclosures: None

Arrhythmias can be promoted by exercise

• Sympathetic nervous system
• Circulating catecholamines
• Automaticity enhanced triggered activity
• Electrolyte shifts
• Baroreceptor activation
• Myocardial stretch and ischemia

Objectives

• Review common abnormal rhythms noted in cardiac rehab – in a case

based presentation

• Identify common abnormal rhythms
• Discuss management of common abnormal rhythms
• Discuss significance of rhythm abnormalities

Case 1: Atrial Fibrillation

Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?

• A. Patient has excellent heart

rate variability finish exercise and discharge home routine follow-up

• B. Patient has excellent heart

rate variability finish exercise but call MD for treatment of Heart failure

• C. Don’t exercise patient

Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?

• A. Patient has excellent heart

rate variability finish exercise and discharge home routine follow-up

• B. Patient has excellent heart

rate variability finish exercise but call MD for treatment of Heart failure

• C. Don’t exercise patient

73 year-old male with known paroxysmal atrial fibrillation

• Cardiac rehab session

normal heart rate variability

• SYMPTOMATIC
• Heart failure symptoms
• Discuss with MD and plan

for treatment of CHF.

Atrial fibrillation

• New atrial fibrillation: notify MD as discussion for anticoagulation and

rhythm/rate control may be necessary

• Known atrial fibrillation: evaluate for symptoms and heart rate

variability

• No symptoms and good heart rate variability: routine follow-up
• Symptoms notify MD
• Heart rate suppression and or tachy/brady syndrome -> further clinical

evaluation

Stroke Prevention in AF

• wading in the deep

Case 2: 48 year old female s/p AV canal repair and mitral valve replacement, Tricuspid repair with a pacemaker

Case 2

What do you do?

• A. This is VT stop patient and start

CPR

• B. The rate of 245 is incorrect

recalculate rate. Importantly patient is asymptomatic and you see pacing marks

• C. Pacemaker is not functioning

well and should not track at this

• rate. Certainly an arrhythmia call

the physician

Case 2

What do you do?

• A. This is VT stop patient and start

CPR

• B. The rate of 245 is incorrect

recalculate rate importantly patient is asymptomatic you see pacing marks

• C. Pacemaker is not functioning

well and should not track at this

• rate. Certainly an arrhythmia call

the physician

Case 2

What do you do?

• A. This is VT stop patient and start

CPR

• B. The rate of 245 is incorrect

recalculate rate importantly patient is asymptomatic you see pacing marks

• C. Pacemaker is not functioning

well and should not track at this

• rate. Certainly an arrhythmia call

the physician

Device settings are DDDR 60-140 bpm

Pacemaker patient

• Please determine settings on pacemaker and if they are pacemaker
• dependent. (DDDR 60-130)
• Determine if intrinsic rate or pacemaker rate
• Symptoms important
• Questions - call MD or pacemaker nurse

What about Patients with a Defibrillator

• Settings are different as usually they don’t need

pacing and usually single chamber unless pacing is needed (VVIR 40)

• With defibrillators it is important to see what the

VT/VF Zones programmed for shock. (you don’t want the patient’s heart rate at that zone).

• Common VT zones (monitor zone above 180 bpm, VF

rate 200bpm)

Case 3: 63 year-old with defibrillator

Case 3: panel to the right 63 year-old with defibrillator What is happening in panel 4?

DDDR 85-130

• A. Patient is in VT
• B. Patient is paced
• C. Patient will be shocked

shortly and should be cooled down

1 2 3 4 5

63 year-old patient with Defibrillator for out of hospital arrest is in the middle of session 88 what do you do?

• A. Call 911 and transfer to ED
• B. If patient is asymptomatic

let him go home

• A. Call 911 and transfer to ED
• B. If patient is asymptomatic let him go

home

63 year-old patient with Defibrillator for

• ut of hospital arrest is in the middle of

session 88 what do you do?

Case 4: 72 year-old mal s/p bypass surgery

• A. Start CPR
• B. Asymptomatic you have time

to determine rhythm as SVT with Aberrancy vs. VT

• C. VT in light of history of

coronary artery disease until proven otherwise

• D. Don’t exercise – check

electrolytes, meds, notify MD

• E. No symptoms go ahead and

exercise

• F. More than one answer is

correct

Case 4: 72 year-old mal s/p bypass surgery

• A. Start CPR
• B. Asymptomatic you have time

to determine rhythm as SVT with Aberrancy vs. VT

• C. VT in light of history of

coronary artery disease until proven otherwise

• D. Don’t exercise – check

electrolytes, meds, notify MD

• E. No symptoms go ahead and

exercise

• F. More than one answer is

correct

How to distinguish SVT from VT

• Rate
• Regularity: warm up

phenomenon in VT

• AV dissociation
• Morphology
• QRS duration >140 in RBBB

is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)

• Concordance

How to distinguish SVT from VT

• Rate
• Regularity: warm up

phenomenon in VT

• AV dissociation
• Morphology
• QRS duration >140 in RBBB

is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)

• Concordance

Rare PVCs

• Rare single PVCs
• Asymptomatic
• Usually clinically

insignificant unless increase with frequency during exercise

Case 5: 63 year-old male with history of AA repair and coronary re- implantation

• Patient has frequent PVCs

during rest and exercise

• Holter shows a 30% burden
• Patient has no symptoms of

chest pain

• Cardiac rehab obtains a 12

lead ECG

• PVCs localized to Right

coronary cusp

• CT shows impingement of re-

implanted right coronary artery

• Patient gets Right coronary

artery stent

Case 6: 33 year-old s/p mitral valve repair

• A. Conduction system disease

recommend he sees physician and gets a pacemaker

• B. Wenckebach may not be

significant wait and see how he does with exercise

Case 6: 33 year-old s/p mitral valve repair

• A. Conduction system disease

recommend he sees physician and gets a pacemaker

• B. Wenckebach may not be

significant wait and see how he does with exercise

Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?

• A. Normal sinus rhythm
• B. Junctional escape
• C. Complete heart block
• D. Atrial flutter

Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?

• A. Normal sinus rhythm
• B. Junctional escape
• C. Complete heart block
• D. Atrial flutter

82 year-old female with CAD and RV failure – what is the rhythm?

• A. Normal sinus rhythm
• B. Junctional escape
• C. Complete heart block
• D. Atrial flutter

Any Questions?