Disclosures Research Support: NIH, PCORI, TRDRP, Medtronic, - PDF document

10/12/2018 Common Rhythm Problems in Hospital Medicine Gregory M Marcus, MD, MAS Professor of Medicine Division of Cardiology University of California, San Francisc Disclosures • Research Support: NIH, PCORI, TRDRP, Medtronic, Jawbone, Eight Sleep • Consulting: InCarda • Equity: InCarda 1

10/12/2018 Goals of the Talk • What to do when encountering an arrhythmia • Leveraging the encounter to maximize benefit to the patient long-term Tachyarrhythmias- Unstable • Unconscious, altered mental status, SVT ongoing chest pain • “Hypotension” is a clinical judgment Atrial fibrillation AF with WPW SHOCK THE VT/ VF PATIENT 2

10/12/2018 SHOCK THE PATIENT Anything other than VF  MAKE SURE IT IS ON “SYNCH” “Is the Unstable defibrillator SVT, AF, on synch?” VT “Is the STILL in SHOCK THE unstable defibrillator PATIENT SVT, AF, on synch?” VT SHOCK THE PATIENT 3

10/12/2018 Tachyarrhythmias-quasi-stable Atrial fibrillation SVT AF with WPW VT Tachyarrhythmias-quasi-stable Nondihydropyrdine Calcium channel blockers Atrial Fibrillation Diltiazem Verapamil Beta-blockers Metoprolol Atenolol Carvedilol Labetolol Propanolol Blood Pressure 1. Address underlying condition 2. Esmolol 3. Digoxin 4. Amiodarone 5. ?Dronaderone? 4

10/12/2018 How about cardioversion? Elective Cardioversion • DC cardioversion is the most efficacious but requires sedation • If the patient has no structural heart disease (no CAD, normal EF, not severe LVH)  200-300 mg of flecainide or 600 mg of propafenone (MUST BE GIVEN WITH AV NODAL BLOCKER DUE RISK OF 1:1 ATRIAL FLUTTER) • Ibutilide IV- Torsades risk, requires 4 hours of monitoring • Tikosyn (dofetilide) can work, but usually in 1-2 days and generally in setting of careful QT monitoring over 3 days 46 year old man without cardiovascular risk factors and symptomatic AF on propafenone 5

10/12/2018 46 year old man without cardiovascular risk factors and symptomatic AF on propafenone • A SLOWER FLUTTER PARADOXICALLY CAN RESULT IN A FASTER RHYTHM BECAUSE THE AV NODE CAN ACCOMMODATE A GREATER PROPORTION OF DEPOLARIZATIONS • PATIENTS ON FLECAINIDE OR PROPAFENONE REALLY SHOULD BE ON AN AV NODAL BLOCKER How about cardioversion? Elective Cardioversion • Most thrombi in atrial fibrillation arise from the left atrial appendage • Cardioversion can reduce left atrial appendage function – Even from AF to sinus • The pericardioversion period is a particularly pro- thrombotic time – Regardless of mode: DC/ electrical, pharmacologic, spontaneous 6

10/12/2018 I decide to go with Elective Cardioversion • Prior to cardioversion: 1, 2 – Can exclude preexisitng thrombus by TEE – Can anticoagulate (therapeutic/ for at least 3 weeks) prior to cardioversion 1. JACC 2006;48:e149-246 2. Chest 2004;126:429S-456 I decide to go with Elective Cardioversion • During and after cardioversion: 1, 2 – Anticoagulation for at least 4 weeks – Applies even to those who would otherwise not require anticoagulation • Generally does not make sense to cardiovert AF in order to avoid anticoagulation 1. JACC 2006;48:e149-246 2. Chest 2004;126:429S-456 7

10/12/2018 I decide to go with Elective Cardioversion • The magic 48 hours – Must be documented! – Reason to consider starting anticoagulation NOW in the hospital as it may “stop the clock” – There are cases of stroke even within this time window, so only do this if you need to and start anticoagulation if you can Primary goal in treating atrial fibrillation: to prevent THROMBOEMBOLISM 1. Atrial fibrillation increases the risk of stroke 5 times 2. 23.5% of all strokes in those age 80-89 are attributed to AF Wolf et al. Stroke 1991 8

10/12/2018 ATRIAL FIBRILLATION IS OFTEN ASYMPTOMAIC Page et al. Circulation 1994 Audience Response Question Among Cryptogenic Stroke Patients, AF can be found in: • 0-3% • 3-10% • 10-20% • 20-30% 9

10/12/2018 AF is common if you look hard enough among cryptogenic stroke patients Brachman et al. Circ A&E 2016 We want to prevent THROMBOEMBOLISM 10

10/12/2018 How is This Relevant to Hospital Medicine? • That patient who develops atrial fibrillation in the setting of cellulitis or pneumonia • ASSUME YOU WERE LUCKY TO CATCH IT BECAUSE THE PATIENT WAS BEING MONITORED • ANTICOAGULTE UNLESS THERE IS A COMPELLING REASON NOT TO –Examples: »CHADSVASC of 0 or perhaps 1 »History of hemorrhagic stroke 11

10/12/2018 Gialdini et al. JAMA 2014 12

10/12/2018 “A patient never calls you in the middle of the night to thank you for not having a stroke.” -Michael Ezekowitz, M.B., Ch.B., D.Phil 13

10/12/2018 What if I have a suspicion for AF but we don’t catch it? • Can order a Zio patch (monitors for 1-2 weeks) Injectable Loop Recorder • In-person validation (n=51): c-statistic=0.97 (95% CI 0.94-1). • Ambulatory validation (n=617): c- statistic=0.72 (95% CI 0.64-0.78) %) 14

10/12/2018 Atrial fibrillation ablation • Elective, generally takes time to schedule • For SYMPTOMATIC AF- not stroke prevention • Empiric (target PV isolation) • Efficacy ~70% in PAF and ~50% in persistent AF at 1 year, attrition in many over time • Can have early recurrence with long-term success Audience Response Question The success of a typical atrial flutter ablation is: • 40-50% • 50-70% • 70-95% • 95-100% 15

10/12/2018 Atrial FLUTTER ablation • Quicker procedure, easier to schedule • We have a very clear target • Flutter tends to be more difficult to rate control • Antiarrhythmic drugs do not work so well for flutter • Ablation of atrial flutter is FIRST LINE • Success rate is ~97% Tachyarrhythmias-quasi-stable SVT 16

10/12/2018 Tachyarrhythmias-quasi-stable Vagal Manuevers SVT WA WAIT! GET A 12 LEAD ECG! GET A 12 LEAD ECG! Tachyarrhythmias-quasi-stable Vagal Manuevers SVT • Carotid sinus massage • Valsava • Will terminate ~20% 1 1. Lim SH et al. Ann Emerg Med 1998;31:30-35 17

10/12/2018 Tachyarrhythmias-quasi-stable Adenosine SVT • 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? 75% reduction in ED visits among those undergoing catheter ablation (p=0.003). 18

10/12/2018 Tachyarrhythmias-quasi-stable The most likely diagnosis is: 1. Ventricular Tachycardia 2. Atrial fibrillation with WPW 3. SVT with aberrancy 19

10/12/2018 Tachyarrhythmias-quasi-stable Tachyarrhythmias-quasi-stable Atrial Fibrillation AV nodal blockers with preexcitation Give: Procainamide Ibutilide Then refer to EP for ablation 20

10/12/2018 Tachyarrhythmias-quasi-stable Ventricular • Scarcity of data Tachycardia • Amiodarone probably the most effective 1,2 -- 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 Tachyarrhythmias-quasi-stable Ventricular • Scarcity of data Tachycardia • Consider -- Lidocaine gtt -- Procainamide - watch for hypotension and prolonged QT 21

10/12/2018 Tachyarrhythmias-quasi-stable Ventricular • Get EP involved Tachycardia • May respond to beta-blockers or calcium channel blockers • May be amenable to ablation 22

10/12/2018 Tachyarrhythmias- a long QT 1.Electrolytes Hypokalemia Hypo-Mg2+ Hypo-Ca2+ 2. DRUGS 3. Congenital Tachyarrhythmias THINK ABOUT TORSADES IF 1. IV magnesium AMIODARONE ISN’T 2. Isoproterenol WORKING FOR “VF” 3. Transvenous pacing OR PERHAPS MAKING THINGS WORSE 4. Unstable  DC shock 23

10/12/2018 Bradyarrhythmias • Important questions: – Is this dynamic/ reversible/ vagal? • IE, more likely benign • IE, less likely respond to pacing • IE, more likely transient – Or is this structural • IE, more likely dangerous • IE, more likely needs pacing • In the absence of SYMPTOMS, type II second degree AV block or third degree AV block  pacemaker Short term: 24

10/12/2018 Pacemakers • Should be interrogated/ checked every 6 months – Eg, doesn’t necessarily need to be checked while in the hospital • Generally CAN now do MRIs with certain restrictions regarding machine and personnel available • We want to avoid RV pacing – It’s an EP sin to RV pace frequently in anyone with a depressed EF Biventricular Pacemaker 25

10/12/2018 His Bundle Pacing Implantable Cardioverter- Defibrillators • Generally interrogated/ checked every 3 months • All ICDs can also pace • Anti-tachycardia pacing (ATP) is one way to break a VT circuit without pain – But can always accelerate VT or lead to VF • Generally ALSO CAN now do MRIs with certain restrictions regarding machine and personnel available • Trend towards longer delays in detection, allowing faster rates with reduction in inappropriate shocks and DECREASE mortality 26

10/12/2018 Pt. comes in with multiple, recurrent shocks from his ICD 1. Place external pads 2. Place magnet on chest 1.PUTS DEVICE IN “MAGNET MODE” 2.FOR AN ICD: INHIBITS THERAPY DETECTION 3.FOR A PACEMAKER: INHIBITS SENSING Thank You 27