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Transcript
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.patton@stagnes.org
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