arrhythmias: typical manifestations and their management

1. Arrhythmias: typical manifestations and their management 24th September 2008 Victoria Watson BHF Arrhythmia Nurse Specialist Imperial College Healthcare NHS Trust London

2. The arrhythmia chapter does not set out treatment targets like some of the other chapters but represents an important document which will help direct the development of EP services over the next five years.The arrhythmia chapter does not set out treatment targets like some of the other chapters but represents an important document which will help direct the development of EP services over the next five years.

3. National Service Framework for Arrhythmias Assessment by Arrhythmia Specialist Sudden Cardiac Death Screening for at risk patients Rapid assessment of syncope Implantable Defibrillators by NICE guidelines Patient Support and Family screening Atrial Fibrillation-NICE GUIDELINES Stroke Prevention Therapy for symptoms Biventricular devices for Heart Failure NSF lay out specific conditions which ought to be seen by an arrhythmia specialist within an acceptable time scale which and treated within waiting list targets. It underpins the aims of the the NHS Plan to ‘Universalise the Best’ and achieve similar levels of practice around the the country with particular reference to Sudden Cardiac Death, Biventricular Pacing and Atrial Fibrillation. I want to address some of the specific issues with respect to these area.NSF lay out specific conditions which ought to be seen by an arrhythmia specialist within an acceptable time scale which and treated within waiting list targets. It underpins the aims of the the NHS Plan to ‘Universalise the Best’ and achieve similar levels of practice around the the country with particular reference to Sudden Cardiac Death, Biventricular Pacing and Atrial Fibrillation. I want to address some of the specific issues with respect to these area.

4. Symptoms Irregularly irregular pulse Syncope Pre-syncope, dizziness Shortness of breath Fatigue CVA Palpitations NONE

5. Assessment Duration,frequency, Rate/rhythm-tap out Onset/offset Associated symptoms Cardiac history

7. Premature atrial ectopic beats

8. The diagnostic process History Examination ECG Blood results Cardiac assessment (echo, exercise test, prolonged ECG monitoring, angiogram, cardiac MRI etc.)

9. TREATMENT DRUG THERAPY CARDIOVERSION ELECTROPHYSIOLOGY STUDIES ABLATION ICD’s BRADY/ TACHY PACING

10. Atrial Fibrillation-irregular,no definite p waves

11. Demographics

12. Causes of AF Hyperthyroidism Intercurrent Illness Especially LRTI, UTI in elderly Perioperative AF Alcohol- probably genetic predisposition

13. Causes continued Any STRUCTURAL heart disease- especially those associated with LA enlargement LVH Reduced systolic function Valvular (especially mitral) heart disease Hypertensive Heart disease Cardiomyopathy of any cause (up to 30%) Hypertrophic cardiomyopathy

14. Rate vs Rhythm Control Consider both in all patients Rhythm control the preferred strategy in Young patients (<65yrs) Highly symptomatic patients Patients who develop heart failure with AF Newly diagnosed AF or AF with clear precipitant

15. Safest Drug in the Management of Atrial Fibrillation Electricity! Cardioversion- Must have 4 INRS >2 pre-procedure BUT- less successful the longer duration of AF with dilated left atrium 50% of patients will have reverted within a year

16. Drugs –rate control NICE recommend:- Beta blocker/ calcium channel blocker for rate control Digoxin only for sedentary patients

17. Drugs to chemically cardiovert Flecanide/propafenone - NOT in structural heart disease Best drug to chemically cardiovert But electrical cardioversion is more effective and safer Sotalol Otherwise less effective and less well tolerated than standard beta blocker Amiodarone -last resort

18. Risk factors for stroke in Atrial Fibrillation NICE 2006 Anticoagulation guidelines warfarin vs aspirin High risk Ischaemic stroke/TIA Age =75 Hypertension Diabetes Vascular disease Valve disease Heart failure Moderate risk Age =65 with no high risk factors Age <75 with hypertension, diabetes or vascular disease Low risk Age <65 with no moderate or high risk factors

19. Anticoagulation All studies show superiority of standard dose warfarin (INR 2-3) over any other strategy in all groups The beneficial effect is even more marked in the elderly (>75) where the risk of embolic stroke climbs significantly But clinicians remain circumspect about using warfarin in the real world (especially in the elderly)

21. Supra ventricular tachycardia-narrow complex, rapid, p waves may/may not be present

22. AVNRT

23. Most common SVT There is no disease predisposition More prevelant in Women Narrow complex, 120-250 bpm Typically 3rd and 4th Decade Recurrent palpitations RAPID onset and RAPID offset vagal maneuvers to terminate the arrhythmia

24. Cardiac Catheter Ablation Safe low risk procedure, Complication rate of 1-2%, mortality 1-2/1000 Effective, a CURE Ablation Therapy for Arrhythmias AVNRT / AVRT / Atrial Flutter >98% Success Rate Atrial Tachycardia / VT >90% Success Rate Atrial Fibrillation ~70% Success Rate

26. Atrial Flutter ECG – regular saw tooth ‘flutter waves’ Ventricular rate will be a 300bpm, 150bpm, 75bpm and regular due to pathway Possible will predispose to A fib Flutter ablation – ablate pathway 98% success

27. Bradycardia Drugs Age Hypothyroidism Ischaemia Excess vagal tone Negative chronotropes Hyperkalaemia

29. At Risk Patients Heart failure- reduced systolic function Ischaemic Heart disease Post myocardial infarction Cardiomyopathy of any cause (Hypertrophic cardiomyopathy,dilated cardiomyopathy)

30. Ventricular Tachycardia (Monomorphic)

32. ICD-Key device system components

33. Implantable cardioverter-defibrillators (ICDs) Current NICE guidance

34. Rapid Access Arrhythmia Clinic Arrhythmia Nurses- 0207 8862378 Victoria Watson Victoria.watson@imperial.nhs.uk 07768953414 Andrea Grieger Andrea.grieger@imperial.nhs.uk 07768980832