How to deal with suspected arrhythmia CCG Educational Evening 17.7.14

1. How to deal with suspected arrhythmiaCCG Educational Evening 17.7.14 Dr Sanjay Kumar Lead Consultant Cardiologist Dr Ravi Kamdar Consultant Cardiologist in Devices and Arrhythmia Croydon Health Services NHS Trust

2. Objectives • Brief overview of new suspected arrhythmia pathway • Things to do before referral • Case studies • Questions

4. Suspected Arrhythmia – diagnosis & management * In all adult age groups , use traffic lights system to guide further action ( slides 2 & 3) Immediate transfer to hospital for specialist assessment/treatment treatment Patient presents with symptoms, palpitations, chest pain, dyspnoea, syncope/pre syncope, asymptomatic Assessment – history & examination. Onset of symptoms (duration) – palpitations, dyspnoea, and impact of activities of daily living or at night. Past medical history & family history. Examination: General appearance, respiratory rate, pulse, BP, chest auscultation. Full blood count, urea & electrolytes, glucose, TFTs & LFTs and chest X ray if appropriate • Red Flag signs: • Patient looks unwell e.g. signs of heart failure • Exercise – induced dizziness/syncope • Syncope with injury • Syncope with angina • Syncope with known structural/ischaemic heart disease • 2nd or 3rd Degree Heart Block • Other ECG abnormality – evidence of previous MI,LV hypertrophy ,short PR interval, long QT,LBBB, significant t-wave inversion Steps that are based in primary care Steps that are based in acute Steps that are taken in community services Decision making point Shared decision making with patient 12 lead ECG with accurate interpretation and reporting. Consider echocardiogram Red flag signs Review of results to determine if single episode. Normal ECG and no evidence of structural heart disease. Consider other diagnosis and further investigation if appropriate. Management in primary care. Consider virtual Cardiac advise Service Normal results – changes required e.g. reduce caffeine intake Abnormal results with recurrent symptoms LIFESTYLE Incidental finding of Atrial fibrillation e.g. pulse check Atrial fibrillation Complete CHADS₂ - Vasc risk score Impact of exercise and advise regarding management to maintain an active lifestyle without fear See slide 4 Recurrent palpitations, recurrent pre-syncope/syncope/symptomatic bradycardia Initiate Anticoagulant therapy if appropriate with Primary care management with annual review to monitor rate and rhythm in line with Croydon guidelines. http://nhscroydonintranet.croydonpct.nhs.uk/TeamsAndDepartments/primarycarecommissioning/prescribing/Pages/Documents.aspx • Referral to Community Arrhythmia clinic if : • Age <65yrs • Adequate heart rate or rhythm control not achieved • Symptomatic despite good rate/rhythm control • Paroxysmal AF • AF with other ECG abnormality, structural heart disease or heart failure • Lone AF e.g. no history or echo evidence of cardiovascular disease Community Arrhythmia clinic – Consultant –led with Arrhythmia Nurse Specialist Smoking cessation course Family history of inherited cardiac condition Alcohol advice and guidance on healthy eating Inherited Cardiac Condition Clinic Discharge to primary care as appropriate Work – driving or flying issues. Sensitive issues regarding sexual activity Community Anti Coagulant Clinic

6. Identify specific patients….high risk of adverse outcomes? Can intervention improve QoL? What does the patient mean? ‘Abnormally perceived heartbeat’ – tachycardia, bradycardia, irregularity, pounding, ‘missed beats’, ‘extra beats’, ‘fluttering’ Do they mean chest discomfort? Duration, frequency, Onset/offset, Precipitating factors – nocturnal? exertional? Emotional? Mode of termination – vagal? What else happens? Pre-syncope or syncope, acute-onset sustained SOB, chest pain What’s making it worse? Mental health – anxiety, depression, somatisation disorders Caffeine, alcohol Recreational drugs – amphetamines, cocaine Medications – β agonist, theophylline, T4, calcium antagonists, class I anti-arrhythmics (e.g. flecainide), drugs prolonging QTc Family history? Evidence of early-onset AF, heart failure or premature CAD in close relative? Sudden cardiac or unexplained death <40yrs old? RTA? Drowning? Potential misdiagnosis of epilepsy? Sudden death? Palpitations - What to do before referral (1)

7. Examination & simple tests Physical evidence of structural heart disease(HF, abnormal HS, murmurs)? Thyrotoxicosis? Anaemia? 12 lead ECG – AF, high-grade heart block, old MI, LVH, LBBB, ischaemic ST/t-wave change, short PR, long QTc Sources of advice for patients CUH arrhythmia nurse / clinic Charities: Arrhythmia Alliance: www.heartrhythmcharity.org.uk Atrial Fibrillation Association: www.atrialfibrillation.org.uk Sudden Adult Death Trust: www.sadsuk.org Cardiac Risk in the Young: www.c-r-y.org.uk Occupation / driving: DVLA rules If arrhythmia identified that causes (or is likely to cause) incapacity, stop driving Doctors’ responsibility to inform patient If no diagnosis (or awaiting specialist assessment), but disabling symptoms, advise patient to stop driving Working at height? Control of potentially dangerous machinery? Palpitations - What to do before referral (2)

11. How would you manage these patients? Case Study 1 64yr old lady Irregular pulse on recent pulse check 12-lead ECG: Atrial fibrillation, heart rate 120bpm, otherwise NAD Many years’ minor (NYHA class 2) exertional breathlessness, otherwise no symptoms Hypertension, type 2 diabetes, 30U alcohol/week o/e Looks well, BP 150/90, RR 12, no cardiac murmurs FBC, U&E, TFT normal CXR – no parenchymal lung abnormality, borderline cardiomegaly Action Advice? Reduce alcohol intake. Avoid vigorous effort until rate-controlled. Treat co-morbidity e.g. salt/BP Drugs? Rate control with β blocker (exercise-induced tachycardia) or rate-limiting CCB (BP); anti-coagulate with warfarin Investigation? Echo (LV function, LA size, valves, evidence of CAD); 24hr Holter after initiating rate-limiters (HR control) Onward referral? Suspected arrhythmia clinic – <65, rate or rhythm control? Diagnose underlying cause?

12. The CHADS2 index has been routinely used as an initial, rapid, and easy-to-remember means of assessing stroke risk1–4 Sum 33.6% withCHADS20 or 1 *Adjusted stroke rate = expected stroke rate per 100 patient-years from exponential survival model, assuming ASA not taken 1. Gage et al. JAMA 2001;285:2864–2870 2. Gage et al. Circulation 2004;110:2287–2292 3. Camm et al. Eur Heart J 2010;31:2369–2429 4. Nieuwlaat et al. Eur Heart J 2006;27:3018–3026

13. The CHA2DS2-VASc scheme was adopted by the ESCto complement the CHADS2 scoring system CHA2DS2-VASc: • In patients with a CHADS2 score of 0–1, or • When a more detailed stroke risk assessment is indicated Camm et al. Eur Heart J 2010;31:2369–429.

14. The 2010/2012 ESC guidelines recommenduseof a simple bleeding risk score: HAS-BLED HAS-BLED ≥3: • Indicates ”high risk”, and • Some caution and regular review of the patient is needed following the initiation of antithrombotic therapy, whether with OAC or aspirin Camm et al. Eur Heart J 2010;31:2369–429. Camm et al. Eur Heart J 2012;e-published August 2012, doi:10.1093/eurheartj/ehs253. Pisters et al. Chest 2010;138:1093–100.

15. How would you manage these patients? Case Study 2 27yr old female medico-legal solicitor c/o 1 episode of severe dizziness while standing in a long post-office queue, nearly lost consciousness No chest pain, SOB No recurrent symptoms PMH: 2 previous similar episodes aged 16 and 18, while studying for exams No medication, no alcohol, occasional cannabis use FH: mother died suddenly aged 35, cause unknown o/e normal – no cardiac murmurs FBC, U&E, TFT normal 12-lead ECG: sinus rhythm 70bpm, no heart block, normal QTc Action Advice? Identify & avoid triggers e.g. prolonged standing, pain/cough/laugh, review/minimisework stresses; keep well-hydrated; curtail cannabis use Drugs? Water Investigation? Echocardiogram (subclinical cardiomyopathy, severe valvular heart disease) Onward referral? One-stop arrhythmia clinic, GP advice service What if no FHx? Re-assure likely vasovagal – advice, referral only if symptoms not controlled by conservative means

16. How would you manage these patients? Case Study 3 79yr old man c/o 4 episodes of self-terminating palpitation, over a period of 6 weeks Each episode approximately 1-minute long, associated with minor SOB Minor (NYHA class 2) exertional SOB, no angina pectoris, no syncope MI 10 years ago, hypertension, hypercholesterolaemia, current smoker Rx: Aspirin, lisinopril, simvastatin (beta blocker not tolerated – dizziness) o/e normal – no cardiac murmurs FBC, U&E, TFT normal 12-lead ECG: sinus rhythm 60bpm, first degree heart block, LBBB Similar ECG appearances 3 years ago Action Advice? Stop smoking (IHD) Drugs? Avoid rate-limiting medication Investigation? CXR (HF), echo (LVSD, LVH, scar, substrate for AF/VT) Onward referral? A&E (red flag)