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Arrhythmia Management

Arrhythmia Management. Dr John Bayliss FRCP Consultant Cardiologist. 17 Sept 2008. Arrhythmia Guidelines. www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm www.westhertscardiology.com Documents/Local www.starpace.co.uk Clinical Specialty/Cardiovascular . www.nice.org. p 64.

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Arrhythmia Management

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  1. Arrhythmia Management Dr John Bayliss FRCP Consultant Cardiologist 17 Sept 2008

  2. Arrhythmia Guidelines www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm www.westhertscardiology.com Documents/Local www.starpace.co.uk Clinical Specialty/Cardiovascular www.nice.org p 64

  3. Palpitations: Importance • Common • Often benign • Often troublesome ++ • Occasionally fatal • Need careful assessment – some/most in 1y Care • Need for Rapid Access Arrhythmia services • Early involvement of specialist clinician • Ablation / Device therapy increasingly effective p 55

  4. Assessment of “Palpitations”/Arrhythmias • Full History = most important • Clinical Examination • Heart rate response (during & after exercise) • 12 lead ECG (esp during symptoms) • Blood testsU&E, Glucose, Thyroid FT, Liver FT, FBC p 56-7

  5. Palpitations: Detailed History • Age of patient • Type and Duration of symptoms? • Individual “thumps”, “misses”, etc • Runs of tachycardia: ?Regular, ?Irregular • Duration, Frequency • Onset: ? Sudden/Gradual, ? Circumstances • Cessation: ? Sudden/Gradual, ? Circumstances • Associated symptoms • ? Polyuria (due to Atrial Natriuretic Peptide release in Atrial tachyarrhythmias) • ? Collapse/Dizzy/Breathless, etc • Concurrent illness • Family History (Sudden Death, Cardiomyopathy, CHD) • Drug History (incl OTC) p 58

  6. Palpitations: Low risk features = Manage in Primary Care • History: • Not known to have heart disease • No family history of collapse or sudden death at age < 40 years • No previous collapse/blackouts • Only infrequent attacks • Symptoms: • Palpitations last < 30 minutes • “Missed” beats (= ectopics) or brief rhythm irregularity only p 57

  7. Palpitations: High risk features = Refer to Heart Rhythm Specialist • Pre-existing heart disease: • Previous angina, MI, angioplasty,heart surgery • Clinical heart failure, or LV systolic dysfunction (ejection fraction < 40%) • Structural heart disease: valve disease, cardiomyopathy, congenital heart disease • Family history of collapse or sudden death at age < 40 years • Previous or recurrent collapse/blackouts. p 57

  8. Should GPs report 12 lead ECGs ?! • 24yr old woman, occasional brief “flutters”

  9. Long QT and Brugada syndrome • “Ion channelopathies” QTc >450-500ms = high risk of VT/SCD

  10. Investigation of Arrhythmias May be useful • Ambulatory ECG (24hr – 7 days) • Echocardiogram • Exercise ECG – if exercise related or ?CHD • Tilt Test – if postural or vagal symptoms • Cardiac MRI - esp in young patient • Implantable ECG Loop Recorder (ILR, “Reveal”) if infrequent but serious events • Electrophysiological Study (EPS)® Catheter Ablation therapy

  11. Implantable Loop Recorder (ILR, “Reveal” device) • 15 mins daycase procedure • Local anaesthetic • implant in upper L chest • Battery lasts 18 months • High quality downloadable ECG before+during attack • Most cost-effective test • Yield 43% 1 • Cost 26% less than usual Ix 2 1Krahn AD, et al. Circ. 2001;104:46-51. 2Krahn AD, et al. JACC. 2003;42:495-501.

  12. Arrhythmias: Treatment Depends on (ECG) diagnosis ! • S Tachy : ? Cause (POTS ! “heartsink”) • A Tachy : β blocker • AVNRT / AVRT : Ablation (Flecainide/Propafenone) • A Flutter : Ablation (Verapamil,Dig,Amio) • Paroxysmal AF : Sotalol, Propafenone, Flecainide • Permanent AF : Rate v Rhythm... • VT : ICD (β blocker, Amio, Ablation) • Bradycardias : Pacing p 59

  13. Catheter Ablation • for arrhythmias with localised anatomical substrate • often curative (no need to continue anti-arrhythmic Rx)

  14. Device Therapy • Pacemakers • Cardiac Resynchronisation Therapy(CRT, Biventricular pacing) • Implantable Cardioverter Defibrillators (ICD)

  15. Pacemakers : 1958 – 2008 : 50 years 1st "Permanent" Implantable Pacemaker & Bipolar Hunter-Roth Lead (1958)

  16. ICD function • VF terminated by single 34J shock VF = Dead SR = Alive

  17. First Episode (New onset) OR Alcohol Acute infection Hypertension Ischaemia / CHD Sick Sinus Syndrome Heart Failure Cardiomyopathy Valve disease Hyperthyroid, etc Paroxysmal (PAF) Persistent Permanent AF: Types Aetiology Timing • 22% of PAF progress to permanent AF within 2 years • 50-60% of patients are back in AF 1 year after cardioversion “Lone” AF vs Circulation 2001;104:2118–2150 p 58

  18. AF: Management • ? Rate or Rhythm Control • Rate controlControl of Ventricular Rate at rest + on exercise • Rhythm controlRestoration of SR + Maintenance of SR • ? Anticoagulation • Risk of thromboembolism • Risk of Warfarin=1-2% yearly risk of serious bleed p 60 p 64

  19. AF: Rate v Rhythm control • Choose Rhythm Control: • Symptomatic, Younger • Uncontrolled Heart Failure • First episode (?), or now corrected precipitant • DC Cardioversion • ≥3 weeks anticoagulation before + 4 weeks after • Try to Maintain SR (50% revert to AF in 1 yr) • ? Need for Amiodarone / Sotalol Propafenone / Flecainide p 60 p 64

  20. AF: Rate v Rhythm control - AFFIRM The Atrial Fibrillation Follow-up Investigation of Rhythm Management n=4060, age >65, AF Mean age = 69.7 Hypertension in 71% Rate control = <80 at rest <110 on walk + Warfarin (INR 2-3) Rhythm control = Drugs ± Cardioversion(s) + Warfarin (INR 2-3)unless SR for 4(-12) weeks AFFIRM NEJM 2002;347:1825-33 p 62

  21. AF: Rate v Rhythm control • Choose Rate Control: if patient stable and if • Age >65 • Underlying CHD, Hypertension, Valve Disease • Anti-arrhyhtmic Rx not tolerated / contraindicated • Cardioversion inappropriate • Use β Blocker first:Atenolol, Bisoprolol, Metoprololor rate controlling Ca++ blocker: Verapamil, Diltiazem • Add Digoxin if necessary, or if CHF p 60 p 64

  22. IMPORTANT Digoxin : a drug of 2nd-3rd choice !

  23. AF: Digoxin = Increased Mortality • SPORTIF III+V (Warfarin v Ximelagatran) • n=7329 in AF • Mod-high stroke risk • 53% on DigoxinMortality = 6.5% • 47% not on DigoxinMortality = 4.1% • Hazard ratio(adjusted for risks)1.53 • ? ↑ Platelet activation Gjesdal, K et al. Heart 2008;94:191-196

  24. AF: Thromboprophylaxis ≥5% / year <3% / year Warfarin Aspirin ? p 61 p 64 NICE CG36 June 2006 www.nice.org.uk

  25. AF: Warfarin or Aspirin In AF, compared to placebo • Aspirin ↓relative risk of stroke by 20% • Warfarin ↓ relative risk of stroke by 60% • Warfarin increases absolute annual risk of serious haemorrhage by 2+ % • Benefit Risk • Echo is usually unnecessary for decision

  26. CHADS2 risk score in AF Predicts annual risk of stroke in non-rheumatic AF * Assuming no Aspirin taken Warfarin indicated if CHADS2 Score = 2 or more Gage BF et al JAMA 2001;285:2864-2870 p 60-1

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