Management of common arrhythmias Dr. Fawzia Al-Kandari - - PowerPoint PPT Presentation

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Management of common arrhythmias Dr. Fawzia Al-Kandari - - PowerPoint PPT Presentation

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Management of common arrhythmias Dr. Fawzia Al-Kandari Cardiologist, cardiac Electrophysiologist Chest Diseases Hospital Head of cardiology unit- Jaber Al Ahmed Hospital Common Arrhythmias SVT ( supra-ventricular Tachycardia) AF (

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Management of common arrhythmias

  • Dr. Fawzia Al-Kandari

Cardiologist, cardiac Electrophysiologist Chest Diseases Hospital Head of cardiology unit- Jaber Al Ahmed Hospital

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  • SVT ( supra-ventricular Tachycardia)
  • AF ( Atrial Fibrillation )
  • PAC’s ( Premature Atrial Contractions)
  • PVC’s ( Premature Ventricular contractions )
  • VT ( Ventricular Tachycardia )

Common Arrhythmias

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Basic principles for the management of all types of arrhythmias:

  • Instability = DC
  • Documentation is paramount = 12 lead ECG or Rhythm strip
  • Future Risks

Basic Principles

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1- Supra-Ventricular Tachycardia ( SVT )

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1- Supra-Ventricular Tachycardia ( SVT )

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Prevalence is 2.29 per 1000 persons Usually young with no structural heart disease. Women twice the Men ≥ 65 of age has higher risk of developing PSVT

SVT

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Approach to Dx of SVT

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

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Approach to Dx of SVT

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

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Common Regular SVT causes

  • Narrow QRS tachycardia
  • Can be wide if BBB ( Aberrancy)

AVNRT 60% AVRT 30% AT 10%

Short RP ( P fused in QRS) Short RP ( VA>80) Long RP ( P wave different from sinus)

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ACC/HRS 2015 SVT Guidelines (Acute)

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

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ACC/HRS 2015 SVT Guidelines (Acute)

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

1 2 3 4 5

Options in Pregnancy

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In the Emergency Room

  • Stability.
  • Document with 12 leads ECG.
  • Cardiovert ( medical or electrical).
  • Observe for few hours in ER .
  • Discharge with referral to Cardiology clinic.
  • Verapamil/diltiazem or BB is optional until Cardiology clinic.
  • NO antiarrhythmics
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ACC/HRS 2015 SVT Guidelines (Ongoing)

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

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ACC/HRS 2015 SVT Guidelines (Ongoing)

2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

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First episode = Either wait and see or Ablation if the patient prefers. Multiple episodes = Strongly advise for ablation. Failed Ablation or Patient’s Preference = Medical Therapy :

  • CCB or BB as first option
  • Flecainide or Propofol
  • Sotalol or Dofetilide
  • amiodarone

In The Cardiology Clinic

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2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

If wide QRS tachycardia

  • If in doubt, always Treat as VT = synchronized cardioversion.
  • If patient is stable , one could try Adenosine for diagnostic purposes.
  • NO Verapamil
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Symptomatic WPW ( narrow or wide SVT)

  • Catheter Ablation is recommended ( class I )

Asymptomatic WPW

  • Observation or Ablation are reasonable ( Both options can be
  • ffered for the patient ( class IIa) )

WPW

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2- Atrial Fibrillation ( AF )

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2- Atrial Fibrillation ( AF )

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Irregular heart beats due to chaotic and disorganized atrial conduction. With loss of organized atrial contractions ( loss of P wave ).

2- Atrial Fibrillation ( AF )

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Prevalence (1% < 60 yrs of age), (12% in > 75 yrs of age ) Life time risk of developing AF in Europe is ( 23% to 26 %) after the age of 40 yrs. Risks :

  • 5 Folds risk of Stroke
  • 3 Folds risk of HF
  • 2 Folds risk of Dementia and Mortality

Atrial Fibrillation

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AF Definitions

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC VOL. 64, NO. 21, 2014.

  • Valvular AF = Moderate to Severe MS or Mechanical Valve prosthesis

2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019.

  • ‘Lone AF’ and ‘Chronic AF’ terms are Obsolete.
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AF management

Management of AF includes:

  • Determining the Aetiology.
  • Decide about stroke risk and need for Anticoagulation.
  • Rate control for all patients.
  • Decide whether Rhythm control strategy is required
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AF Anticoagulation

: ( Includes Men = 2 and Women =3 )

For patients with AF and CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended.

2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019. 2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719–2747

CHA2DS2VASc = 2

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AF Anticoagulation

:( Includes Men = 0 and Women = 1)

Both the 2014 ACC/HRS guidelines and 2012 European (ESC) guidelines agree that patients with (Score 0) Receive NO therapy.

2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019.

2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719–2747

CHA2DS2VASc = 0

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AF Anticoagulation

( Men = 1 and Women = 2)

2019 focused update of 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC

2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719–2747

CHA2DS2VASc = 1

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AF Anticoagulation- European

2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719–2747

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Warfarin or NOAC

NOACs are Recommended over warfarin in NOAC-eligible patients with AF (i.e. all except with moderate-to-severe mitral stenosis or a mechanical heart valve)

2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019.

Guidelines approved NOACs include :

  • Dabigatran (PRADAXA) -

Approved Reversal Agent ( Idarucizumab )

  • Rivaroxaban ( XARELTO) -

Approved Reversal Agent ( Adexanet alfa)

  • Apixaban (ELIQUIS) -

Approved Reversal Agent ( Adexanet alfa)

  • Edoxaban ( SAVAYSA)

Betrixaban = Waiting FDA approval

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AF patients on anticoagulant who develop bleeding require multidisciplinary team decision. Risk of stroke versus Risks of the bleeding ? Options of Management :

  • Hold anticoagulant
  • Stop bleeding source
  • Reversal agents
  • Supportive measures ( FFP, PPC, VIIa, RBC Transfusion …..etc)

* An important question always rises after the bleeding episode ? when to resume anticoagulant and is there alternative? ( Future Risks )

Anticoagulation But Bleeding ?

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Evidence suggests that LAA is the main site of thrombus formation (90%) and subsequent cardioembolic stroke in AF patients.

Ann Thorac Surg. 1996;61:755–759. Acta Med Scand. 1969;185:373–379. J Am Coll Cardiol. 1995;25:452–459. Circulation 2002;105:1887–1889. J Am Coll Cardiol. 2007;49:1490–1495.

Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation (class IIb recommendation)

2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019.

Anticoagulation But Bleeding ?

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AF cardioversion

AF for Cardioversion YES Onset < 48 hr No Long Term Anticoagulant NO CHA2DS2Vasc Score 0 Cardioversion score 1 Cardioversion SR AF 4 Weeks Anticoagulant Consider if Long Term OAC indicated CHA2DS2Vasc Opt for rate control if LAA thrombus still present Therapeutic OAC for 3 weeks Heparin No LAA Thrombus LAA Thrombus 3 Weeks Anticoagulant TEE Strategy No Conventional OAC or TEE YES Long Term Anticoagulant Heparin SR AF

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AF cardioversion

AF for Cardioversion YES Onset < 48 hr No Long Term Anticoagulant NO CHA2DS2Vasc Score 0 Cardioversion score 1 Cardioversion SR AF 4 Weeks Anticoagulant Consider if Long Term OAC indicated CHA2DS2Vasc Opt for rate control if LAA thrombus still present Therapeutic OAC for 3 weeks Heparin No LAA Thrombus LAA Thrombus 3 Weeks Anticoagulant TEE Strategy No Conventional OAC or TEE YES Long Term Anticoagulant Heparin SR AF

< 48 hours

( IIb Recommendation) (IIb Recommendation)

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AF cardioversion

AF for Cardioversion YES Onset < 48 hr No Long Term Anticoagulant NO CHA2DS2Vasc Score 0 Cardioversion score 1 Cardioversion SR AF 4 Weeks Anticoagulant Consider if Long Term OAC indicated CHA2DS2Vasc Opt for rate control if LAA thrombus still present Therapeutic OAC for 3 weeks Heparin No LAA Thrombus LAA Thrombus 3 Weeks Anticoagulant TEE Strategy No Conventional OAC or TEE YES Long Term Anticoagulant Heparin SR AF

> 48 hours- conventional

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AF cardioversion

AF for Cardioversion YES Onset < 48 hr No Long Term Anticoagulant NO CHA2DS2Vasc Score 0 Cardioversion score 1 Cardioversion SR AF 4 Weeks Anticoagulant Consider if Long Term OAC indicated CHA2DS2Vasc Opt for rate control if LAA thrombus still present Therapeutic OAC for 3 weeks Heparin No LAA Thrombus LAA Thrombus 3 Weeks Anticoagulant TEE Strategy No Conventional OAC or TEE YES Long Term Anticoagulant Heparin SR AF

> 48 hrs - TEE

For patients with AF or atrial flutter of 48 hours’ duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardioversion and proceed with cardioversion if no left atrial thrombus is identified, including in the LAA, provided that anticoagulation is achieved before transesophageal echocardiography and maintained after cardioversion for at least 4 weeks ( IIa Recommendation)
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AF Rate Control

Control of ventricular rate : Comorbidity to pick drug Ideal in : Beta blockers (eg, atenolol, Ideal in metoprolol, propranolol, • Hyperthyroidism carvedilol)

  • Postoperative patients
  • In acute MI
  • Chronic CHF

Calcium channel blockers

  • Nifedipine, amlodipine, and Felodipine

(verapamil, diltiazem) do not slow AV conduction

  • Useful in COPD

Digoxin

  • Useful in heart failure
  • Not useful alone in PAF
  • IV with Amiodarone for HF if no WPW
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AF Rate Control in HF

Digoxin

  • Limited efficacy alone
  • Optimal levels (0.5-0.8)
  • Heart rate at rest may not reflect level of control

Beta blockers

  • Slow AV conduction
  • Indicated for treatment of CHF
  • Cannot be used in decompensated CHF

Amiodarone

  • Effective for rate control
  • Used in acute setting for rate control
  • Chronically, only used for rhythm control due to

less toxic alternatives

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AF Rate control

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC VOL. 64, NO. 21, 2014.

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AF Rate control

Target HR: If can not achieve rate control :

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC VOL. 64, NO. 21, 2014.

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AF Rhythm control

Some patients with AF might benefit from rhythm control:

  • Persistent symptoms associated with AF
  • Difficulty in achieving adequate rate control
  • Younger patient age
  • Tachycardia-mediated cardiomyopathy
  • multiple episodes of AF requiring ER visits
  • AF precipitated by an acute illness
  • To prevent progression from paroxysmal to persistent AF
  • Patient preference.
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AF Rhythm Control Medications

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC VOL. 64, NO. 21, 2014.

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Pulmonary vein Isolation

For most patients rhythm control is started with antiarrhythmics then Ablation if failed medications. However AF ablation is becoming more and more favourable as first line.

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Paroxysmal AF

1. Symptoms Refractory or Intolerant to at least 1 antiarrhythmic ( class I Recommendation) 2. Before therapeutic trials of antiarrhythmics ( class IIa Recommendation)

Persistent AF

1. Symptoms refractory or Intolerant to at least 1 antiarrhythmic ( class IIa Recommendation) 2. Before initiation of antiarrhythmics ( class IIb Recommendation)

Long- standing persistent

1. Symptoms Refractory or Intolerant to at least 1 antiarrhythmics( class IIb Recommendation)

2014 AHA/ACC/HRS GuidelineJACC VOL. 64, NO. 21, 2014

AF Ablation

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3-Ventricular Arrhythmias

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In a study of middle-aged men, both with and without known heart disease, a 6-h monitor sampling technique identified a 62% incidence of asymptomatic ventricular arrhythmias.

Am J Cardiol 1969;24:629–50.

Studies on the Risks of Asymptomatic PVCs in normal heart showed conflicting results. Associated with Increased risk in :

  • Structural heart disease
  • Frequent ( > 10 per hour)
  • Multifocal and complex morphology of PVCs
  • PVCs during exercise especially if in the recovery phase
  • NSVT

PVCs & NSVT

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Antiarrhythmics was commonly used, However ;

  • No trial showed any mortality reduction.
  • Increase mortality ( CAST Trial and many other studies)

2014 EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias.Heart Rhythm, Vol 11, No 10.

PVCs & NSVT

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PVCs & NSVT

2014 EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias.Heart Rhythm, Vol 11, No 10, October 2014 ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. Heart Rhythm, Vol 5, No 6, June 2008

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Management of PVCs

2014 EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias.Heart Rhythm, Vol 11, No 10, October 2014

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Ventricular Tachycardias

Monomorphic VT Polymorphic VT Bidirectional VT Torsades de pointes Ventricular Flutter VF

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In the Acute presentation : Unstable Document ( ECG or Rhythm Strip ) and DC shock Stable:

  • Can try medications
  • If failed then synchronized Cardioversion

Then Baseline 12 lead ECG after cardioversion to sinus rhythm.

Sustained VT

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In the Acute presentation : If VT recurs

  • Replace Electrolytes: K+ ( keep level 3.5 - 5 mmol/l)

Magnesium ( keep level ≈1.0 mmol/l)

  • Sedate ( anesthesia/Ventilation)
  • Antiarrhythmic infusion
  • Repeat DC Cardioversion ( check the Energy+ patches

placement)

  • Check any treatable Causes

Sustained VT

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  • Symptoms
  • Known heart disease?
  • Precipitating Medications
  • Other comorbidities ( Lung, Liver, Kidneys, Thyroid….etc)
  • Family history

Sustained VT- History

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In the cardiology Service:

  • Review ECG
  • Echocardiography ( structural Heart Abnormalities)
  • Exercise test ( for ischemic symptoms, exercise related VA…etc)
  • CTA or Coronary Angiography
  • Cardiac MRI ( for Certain Dx eg. ARVD)
  • Genetic testing ( inherited Arrhythmias)

Sustained VT- Evaluation

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2015 ESC VA and SCD Guidelines.European Heart Journal/ ehv316

Sustained VT- Evaluation

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Manage any reversible causes If LV Dysfunction = Optimize Therapy Consider :

  • Beta Blockers
  • Antiarrhythmics
  • ICD Indications
  • VT ablation

Sustained VT- Chronic Management

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Points to remember :

  • History
  • hemodynamic stability
  • documentation of arrhythmia
  • Future Risk assessment
  • Multidisciplinary approach

Conclusion

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Thanks

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