What every cardiac rehab staffer should know Jae Patton, MSN, CRNP Nurse Practitioner Supervisor Saint Agnes Heart Failure Center Types of cardiac rhythm management devices Single, dual or triple chamber – this refers to how many chambers of the heart are paced Pacemaker or AICD - pacemakers treat Brady arrhythmias, AICDs treat tachyarrythmias **All AICDs are pacemakers, but not all pacemakers are AICDs** Wearable defibrillators Implantable loop recorders How many chambers? Dual chamber pacemaker Pacemakers – treat brady arrhythmias Automatic Implantable Cardiodefibrillators (AICDs) treat tachy-arrhythmias What’s involved in an implant? Post-Implant Recovery If new implant – 10 lb weight restriction on affected side Keep affected arm in front plane of the body If new implant OR generator change Keep dressing in place until removed by clinic/office Watch incision for signs of infection once dressing removed Indications : Who needs a pacemaker? Think symptoms Sinus node dysfunction Sick sinus syndrome – includes symptomatic sinus pauses Chronotropic incompetence, even iatrogenic Certain brady mediated tachy-arrhythmias (Pause dependent VT) Indications: Who needs a pacemaker? Think symptoms AV Nodal dysfunction • Complete heart block or any symptomatic high grade AV block (2nd degree Type II) • S/P AV node ablation for tachy-brady syndrome Indications: Who needs an AICD? Cardiac arrest Cardiac dysrhythmias such as VT or VF not r/t reversible causes Ischemic or non-ischemic cardiomyopathy with an EF <35% and Class II- III symptoms Ischemic cardiomyopathy with EF< 30% and Class I symptoms Familial cardiomyopathies or arrhythmias such as Brugada syndrome, Hypertrophic Cardiomyopathy, long QT syndrome AICDs: The waiting game… Once cardiomyopathy has been diagnosed, there is a waiting period before a reassessment of EF and the decision to implant an AICD – Ischemic cardiomyopathy s/p revascularization (PTCA, stent, CABG)– 40 days Non-ischemic cardiomyopathy – 90 days – 9 months, with optimal medical therapy in place (beta blockers, ACE-I, Spironolactone) ***An option for patients in the “waiting window” who are higher risk is an external, wearable defibrillator or “Life Vest” Lifevest Wearable Defibrillators Indications: Who needs Cardiac Resynchronization Therapy? Similar to AICD indications – treats Dysynchrony EF < or= 35% Class II, III, ambulatory Class IV LBBB with QRS at least 120 ms (also patients who are V paced most of the time) Indications for CRT Therapy—Algorithm Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or with implantation of pacing or defibrillation device for special indications LVEF <35% Evaluate general health status Comorbidities and/or frailty limit survival with good functional capacity to <1 y Continue GDMT without implanted device Acceptable noncardiac health Evaluate NYHA clinical status NYHA class I symptoms NYHA class II, III, and ambulatory class IV symptoms Class I LBBB pattern, sinus rhythm, QRS duration ≥150 ms Class IIa LBBB pattern, QRS 120-149 ms NYHA class IV (stage D) Refractory symptoms or dependence on intravenous inotropes Device not indicated except in selected patients listed for transplantation or with LV assist devices If device already in place, consider deactivation of defibrillation OR Non-LBBB pattern, QRS >150 ms OR Class IIb Anticipated to require frequent ventricular pacing (>40%) OR • LVEF <30% • QRS >150 ms • LBBB pattern • Ischemic cardiomyopathy Atrial fibrillation, if ventricular pacing is required or QRS criteria above are met and rate control will result in near 100% ventricular pacing with CRT Class IIb Non-LBBB pattern, QRS 120-149 ms Benefit for NYHA class I and II patients has been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival. Biventricular Pacing/ CRT – How does it work? CRT-D vs. CRT pacers Most Cardiac resynchronization devices are also AICDs – CRT-D devices. Think about the indications. On rare occasion, a BiVentricular pacer only is used to improve symptoms, but not prolong life All AICDs are pacemakers, but not all pacemakers are AICDs! What should I know about my patient’s device? What type of device is it? (PPM, AICD, CRT-D etc) The brand name – Medtronic, Saint Jude, Boston Scientific , Biotronick Do they have appropriate follow up? (q3-4 months for AICDs, q6-12 for pacemakers). Who with? What should I know about my patient’s device? How is it programmed? What’s their brady programming? VVI 40 DDDR 60-120 What’s their tachy programming? VF rate? How many zones? Do they have a VT rate? AICDs – How are they programmed? AICDs treat potentially deadly arrhythmias – VT or VF in one of two ways: 1. Overdrive pacing(pain free) 2. Shocks Devices have the capability to be “zoned” – they can have multiple “levels” of therapy. All AICDs have pacemaker capability and are programmed at minimum in a back up mode AICDs – Programming is rate based Single zone programming Single zone devices are programmed to deliver therapy when the “VF” rate is reached (whether the patient is in VF or not). They may deliver overdrive pacing first, but will still charge up to shock the patient if the pacing is unsuccessful. This is the safest programming for treating VT/VF, but it can lead to more inappropriate shocks – usually in the setting of poorly controlled Afib. AICDs – Two or three zone programming The VF zone is the same as in a single zoned device The VT zone is less aggressive, and is triggered when the patient hits a lower programmed rate – it looks for “discriminators” to proved that the rhythm is VT - is it regular? Is it wide? Did it have a sudden onset? It will withhold therapy if these criteria are met, but continue to monitor The third zone, if programmed, is often for monitoring for atrial arrhythmias. What do I do if my patient receives a shock? One shock is not an emergency – make sure the patient is safe and comfortable and page the cardiologist to discuss Save any strips you have! Your tele strip may help determine what type of arrhythmia your patient had. More than one? 911! (or a METS call if patient is conscious, code if patient is unconscious) This might be due to -Ischemia and resulting VT - VT due to electrolyte imbalances, med non-adherence, or worsening heart failure - Afib RVR or other atrial arrhythmia at the VF rate (this is VERY common) My AICD patient is coding! You know what to do! High quality CPR is key! If your patient has an AICD and you’re performing CPR - you may feel a tingling sensation if they receive a shock – it won’t hurt you My AICD patient is coding! In a code, you may need to defibrillate your patient Anterior-posterior lead placement is ideal but… If your paddles or defib pads are at least 5 inches/ 12 cm away from the device, you can defibrillate Most devices will be in the left upper chest – occasionally in right upper chest or abdomen. Traditional pectoral/ apical paddle placement is ok Anterior/ Posterior Paddle Placement My patient is being shocked repeatedly – but he’s awake! Up to 30% of patients receive inappropriate shocks from their AICDs – usually for Afib RVR This is NOT benign – has a negative impact on mortality If the heart rhythm on the monitor is narrow but fast – at the patient’s VT or VF rate – and they are getting shocked… Don’t be afraid to use the magnet! The magnet temporarily “blinds” the device to your patient, stopping therapy. (Does NOT turn off pacer function!) ***Useful if your patient is being shocked inappropriately for Afib RVR or other SVT NASPE/BPEG Code for Antibradycardiac Pacing I Chamber paced II Chamber sensed V - ventricle A – atrial D – dual (a&v) O - none V –ventricle A – atrial D – dual (a&v) O-none III Mode of Response IV Rate Response T - triggered R - on I – inhibited D – dual (t&i) O - none Pacemaker programming NASPE/NBG code First letter is chamber paced, second letter is chamber sensed, third is the response (triggered or inhibited) Fourth letter – (not always used) is rate response VOO VVI AAI DDD DDI DDD in a nutshell Ventricular Pacing Atrial pacing Dual chamber pacing DDD vs VVI programming VVI rate – one number DDD rate – lower rate – max tracking rate for example 60-120 V pacing – is it good or bad? Depends … BiV pacing is good! Better forward flow, good remodeling Patients with CRT and CRT-D devices should be paced 100% of the time – or as close to 100% as possible V pacing – is it good or bad? RV pacing is bad! Negative remodeling, ventricular dilatation Decreased cardiac output Increased cardiac filling pressures Functional mitral regurgitation Patients who aren’t pacer dependent will have algorithms programmed in to decrease RV pacing, but keep patients safe. What is rate response? Rate response allows the patient to have a more physiologic response to exercise. Rate response senses when the patient is exercising and increases the heart rate to accommodate. Fourth position of the NASPE/NBG code “R” VVIR DDDR How does rate response work? Accelerometers - Medtronic, St Jude Minute ventilation – Boston Scientific Myocardial contractility – Biotronick And finally – because you’ve always wanted to know - What does a magnet do? In pacemaker – paces the ventricle at a set rate without sensing (VOO) – this can also interrupt a pacemaker mediated tachycardia, or allow for safe pacing during cautery In a defibrillator, blinds the device to the patient – this can be used if a patient is receiving multiple inappropriate shocks for Afib or SVT Trouble shooting - How to evaluate weirdness on the monitor I see no pacer spikes and my patient has a pacemaker? Is that bad? I see pacer spikes all over the place! My patient’s pacing above his pacer settings, especially when he’s exercising – shouldn’t he be inhibiting? My patient is pacing at the same rate all the time, even when he’s all-out exercising. Is that right? My patient is pacing at her max tracking rate even though she stopped exercising 20 minutes ago. CRT Case Study 67 year old man ICM, EF 25%, PM dependent after AV node ablation, Class III HF symptoms at presentation, upgraded to a CRT-D device. 3 weeks post implantation he reports feeling well, now class I-II symptoms – starts cardiac rehab. CRT Case Study Presents for rehab one morning feeling poorly, more SOB, fatigued Fluid overload? Weight stable, no LE edema, no recall of sodium indiscretion The new intern points out his QRS wave form looks “funny” compared to last week You get the following ECG (A) and compare it to his baseline (B) - Questions? Feel free to contact me with questions at Jill.firstname.lastname@example.org Cardiovascular Team Professionals: Join the American College of Cardiology Today! The ACC mission is to transform cardiovascular care and improve heart health. The work you do every day! Let ACC become your professional home. Cardiovascular Team Professionals: Join the American College of Cardiology Today! By becoming a member of the American College of Cardiology (ACC), you join a network of over 50,000 cardiovascular professionals dedicated to providing the highest standards of cardiovascular care. The ACC puts tools, resources and education at your fingertips to help you stay up-to-date on the latest in cardiovascular medicine, and connects you with leading colleagues in the field. Eligible professionals include: Nurses, Advanced Practice Nurses, Pharmacists, Technologists, Physician Assistants, Genetic Counselors, Occupational Therapists, Physical Therapists, Dieticians, Exercise Physiologists, Psychologists, & Clinical Social Workers. Membership fee is discounted for today’s attendees - $100. What will you gain when you join the ACC? • A global network of over 50,000 cardiovascular professional peers • Professional development opportunities • Access to publications including the JACC journals: Journal of the American College of Cardiology, JACC: Imaging, JACC: Interventions and JACC: Heart Failure • Full access to CardioSource.org and CardioSource mobile, putting ACC/AHA guidelines, FREE education, clinical content and more in the palm of your hand • Reduced registration fees for educational courses and educational products • Information updates based on your preferences, including clinical information in the Cardiovascular Team Section Newsletter (created by and just for CV team professionals), advocacy updates and more. Visit www.acc.org/CVT to download an application today!