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TREATMENT OF VENTRICULAR ARRHYTHMIAS-A CASE STUDY TREATMENT OF VENTRICULAR ARRHYTHMIAS-A CASE STUDY The life expectancy of An Australian, is about 79.9 years for the males and 84.3 years for the female. One of the causes of death is a number of chronic diseases, the definition a chronic disease is a serious disease that may or may not be spread directly from one person to the other may result from several factors that include someone’s genetic make-up, their lifestyle and environment. Heart disease is one of the chronic diseases that cannot be spread directly from one person to another and is one of the major causes of deaths in Australia. Cardiac arrest is the abrupt loss of heart function that someone may or may not be diagnosed with a heart disease. Death occurs shortly after the symptoms appear. Cardiac arrest occurs when there are arrhythmias caused when the heart’s electrical system does not function properly. An attempt to reverse cardiac arrest is the performance of cardiopulmonary resuscitation (CPR) to the person and a defibrillator is used to shock the person under cardiac arrest in order to restore normal heart rhythm within a few minutes. A sudden cardiac arrest may be caused by any heart or related condition. Among the determinants of someone’s vulnerability to heart diseases, include tobacco use and excessive consumption of alcohol among other risk factors. In Australia, there is a high number of smokers with the more disadvantaged areas having more daily smokers1,2. In 20112012, around 1 in 5 adults indulged in harmful alcohol use that exposed them to lifetime harm. 1 ABS 2013e. Australian Health Survey updated results, 2011-2012 Canberra ABS. 2 ABS 2013f. Austalian Health Survey. Updated results , 2011-2012 Canberra. ABS The case of patient AC, is an 85 year old female diagnosed with chronic cardiac failure, she has smoked and consumed alcohol for around 35 years. Preventive measures that patient AC could have taken include non- indulgence in tobacco use and consumption of alcohol. Before I prescribe patient AC is any kind of palliative care, I ensure that her diagnosis is confirmed by the measurement of ventricular function by transthoracic echocardiography. Transthoracic echocardiography involves an ultrasound for the heart in addition to the clinical signs and symptoms recommended by the National Heart Foundation and the Cardiac Society of Australia and New Zealand Chronic Heart Failure Clinical Practice Guidelines Writing Panel. These guidelines are aimed at strengthening the quality of remaining life for the patient by ensuring that the condition does not deteriorate. The guidelines are achieved by drug, non-drug and surgical procedures. The severity of her condition will be based on the symptoms shown by her condition, with 20-30% one-year mortality probability indicating mild to moderate heart failure and 50% one-year mortality in severe heart failure3. The patient confirms the age statistic of those with a high risk of diagnosis with Chronic cardiac Arrest due to their exposure to heart or related diseases. I note her age as one of the probable contributors to the diagnosis. A majority of patients diagnosed with heart related diseases were 75 years and over4. 90% of deaths caused by heart related diseases occurred in people aged 75 years and over. Older age has been associated with the risk of heart diseases. The patients that are diagnosed, however often have other accompanying conditions. I therefore test 3 Watson RDS, Gibbs CR & Lip (2000). ABC of heart failure: clinical features and complications. British Medical Journal 320:236-9 4 AIHW: Senes S & Britt H (2001). A general practice view of cardiovascular disease and diabetes in Australia. Cardiovascular Disease Series No. 18. Cat no. CVD 17. Canberra: AIHW. the patient to find if she has any of the other accompanying conditions, which may also have been among the contributors to her chronic cardiac failure condition. The accompanying conditions include high blood pressure that results in cardiomyopathy, which is a thickened heart muscle and diabetes, that are common with the diagnosis of patients with the accompanying condition of diabetes found to be higher. The tests shoe the patient has high blood pressure. Before giving my prescription I put into consideration that the medication I give her might also result in a sudden cardiac arrest and as her diagnosis is chronic it might be fatal. Some heart medications that have increased the risk of the patient include antiarrhythmitic drugs used to treat arrhythmias, which may result in fatal ventricular arrhythmias and may cause sudden cardiac arrest. Common causes of cardiac arrest that may have resulted in diagnosis of the patient’s condition, diagnosis also include, scarring resulting from a previous heart condition, this can be eliminated as they are no previous records of any previous heart condition. Another cause is drug use for purposes of pleasure purposes for those without organic heart disease. After inquiry the patient confirms that they are not involved in such activity. According to the Sudden Cardiac Arrest Foundation5, the regulation of the numbers of those that die from cardiac arrest depends on care taken at the different levels. One is preventive measures taken for those at risk. Another is the ability of someone to provide immediate care for someone under cardiac arrest this will depend on the availability of defibrillators at the scene and 5 Sudden Cardiac Arrest Foundation. Retrieved from http://www.sca-aware.org accessed on may 13 2015 whether they have been trained on its use6. Also, is the care given to those successfully resuscitated from sudden cardiac arrest? Since the condition of the patient was not prevented. She should be with someone able to administer a CPR to her and were in a place with such equipment in case she is discharged at all times. The prompt response to emergency cases by CPR has resulted in saving of a lot of lives. Studies suggest that 75% to 80% cases of sudden cardiac arrest are attributed to Ventricular Fibrillation (VF) which is recorded at the time of sudden cardiac arrest and pulseless ventricular tachycardia (VT). The other 15% to 20% are attributed to bradyarrhythmias, advanced atrioventricular (AV) block and asytole7. EP mechanisms investigated for the onset of VF/VT its continuation has demonstrated no class I or III antiarrhythmitic agent resulting in reduction of Sudden Cardiac Death (SDC) mortality for patients at risk. Investigations reveal that instead drugs without direct EP action on cardiac muscles or specialized conducting tissue have been effective for prevention of SCD. The drugs include beta blockers, ACE inhibitors, angiotensin receptor blocking agents, lipid-lowering agents spironalactone and fibrionolytic and antithrombotic agents. The following drugs therefore help in narrowing down my prescription to her. Evaluation of patients with documented or suspected ventricular arrhythmias 6 Drezner J.(2007). Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic program: A consensus statement. Heart Rhythm 4:549-565 7 Cummings R.(1991). Improving survival from sudden cardiac arrest: The “chain of survival” concept: A statement for health professionals from the Advanced Cardiac Life Support subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation.83 The severity of her cardiac disease increases her risk of Sudden Cardiac Death than even the frequency or classification of ventricular arrhythmia. The patient was established to have ventricular arrhythmia after undergoing a number of evaluations that include, Checking her for palpitations, presynscope and syncope were one of the initial indications of the patient having ventricular arrhythmias. A thorough drug history was also carried out for the patient. Her family history of SCD also showed vulnerability of her to ventricular arrhythmias and SCD. High intake of nicotine from tobacco use was also an indicator. The patient underwent echocardiograph in order to accurately diagnose myocardial, valvular, and congenital heart disorders associated with ventricular arrhythmias. Echocardiography was also used to evaluate the patients Left Ventricular systolic function and wall regional motion. The combination of echocardiography and pharmacological stress was applied in order to determine whether the patient’s ventricular arrhythmias was caused by ischaemia as she has no resting ECG abnormalities which then limited the accuracy of ECG for ischemia detection. A background, economic check for my patient reveals that she is not very able economically. I therefore recommend health care, government programs for her that may be able to help. This is because economic constraints play a role in the incidence of Sudden Cardiac Arrest. This is because of skipping of the cardiac medications due to lack of money for the purchase of the prescribed medication. Therapies for ventricular arrhythmias The management of the patient’s condition was carried out in a number ways that include. One is drug therapy. She is given beta blockers as opposed to antiarrhythmitic drugs because of their potential lethal effects. Beta blockers were effective in suppressing ventricular arrhythmias. They are safe and effective antiarrhythmic agents. The drugs work by competitive adrenergic receptor blockade of sympathetically mediated triggering mechanisms and slowing down the sinus rate. Special Considerations Where Antiarrhythmic Drugs are indicated The patient was also diagnosed with ICD, therefore prescription of an the antiarrythmic drug amiodarone. The combination of beta-blockers and amiodarone is effective in suppressing ventricular arrhythmias due to the patients low EF and poor renal function. Nonantiarrhythmic drugs Alternatively, the patient would be prescribed to administration of potassium and magnesium that can favourably influence the EP substrate involved in ventricular arrhythmias. Another alternative is surgical therapy, this may involve ablation or surgical resection of an arrhythmogenic focus, cardiac sympathectomy or aneurysm resection. Surgical also has revascularization also has favourable effects which include reduction in myocardial ischaemia. Management of Cardiac Arrest The patient is at higher risk as survival of patients with VF is greater with the exception of patients with pathophysiological conditions such as her that favour the potential of partial arrhythmia. The probability of survival decreases drastically within 1 to 2mins after the onset of cardiac arrest, a brief period of CPR to provide oxygen for the patient increase the probability of VF. Review of Related Literature Amiodarone is highly effective in suppression of ventricular arrhythmias and in maintaining sinus rhythm in patients. It is used after ventricular arrhythmias has not responded to the other antiarrhythmics. Amiodarone is available in tablets of 200 and 400mg an also available in a solution for intravenous administration8. The combination of Amiodarone and beta blockers has the ability to prevent shocks in the patients receiving ICD therapy for secondary prevention of ventricular arrhythmias. ICD shocks are life threatening to patients. ICD shocks also led to reduced physical and mental functioning. Studies reported that patients that received no ICD shocks led a more quality life than those patients that received ICD shocks as it even resulted in anxiety over when the next ICD shock experience would occur. Combination of amiodarone and beta-blockers also resulted in myocardial antiarrythmitic effects as it has direct on the sinus node, reducing heart rate which also helped to prevent inappropriate shocks. Common side effects include fatigue, tremor, poor coordination, nausea, vomiting, constipation, visual disturbances, skin discoloration, rash and the worst result may be worsening of arrhythmias. Uncommon side effects of amiodarone include, liver injury that has a higher probability to occur with higher doses and prolonged therapy9. The liver injury caused may be direct damage to lipid bilayers and disturbance of lysosomal and mitochondrial function. Amiodarone may also cause A different form of liver injury when administered intravenously in high doses to elderly patients. Injury caused by amiodarone may be fatal, resulting in liver failure 8 Vasallo P, Trohman.(2007). Prescribing amiodarone:an evidence based review of clinical indications. JAMA. 298 9 Varma R, Troup P, Komorowski, Sarna T.( 1985).Clinical and Morphological effects of amiodarone on the liver. Gastreonterology.88 1091-3 and that will result in death10. However, in situations where amiodarone is considered totally necessary, liver biopsy should be used in monitoring the occurrence and extent of liver injury, if any, and guide whether medication should be stopped or the patient should continue taking the required dose. Palliative Care Palliative care is aimed at improving the value of life and providing of support to patients and close relatives of the patients that is their family for patients that have been diagnosed with serious or chronic illness. Palliative care takes a holistic approach and aims to meet not only the patients different needs that are physical, emotional, spiritual and even logistical but also meet the needs of their caregivers11. Palliative consultations result in earlier referrals to hospice. Earlier referrals are associated with higher family satisfaction brought about by awareness of what the family should expect at the time of death and higher participation in the care of patients at home. Later referrals often result in the families’ dissatisfaction with the hospice services as they have a relatively short time to comprehend the situation. This is may be in terms of understanding that a hospice is for patients diagnosed with chronic illness and therefore it is there to ensure that their last moments of their life are as good as it can possibly be under their circumstances. The family should therefore be able to keep in mind that the patient's condition will deteriorate. Palliative care is categorized in hospice palliative care and non-hospice palliative care. During a patient's illness palliative care would have to move from non-hospice palliative care to 10 Lwaktere J. Morris , Knight EJ.(1990) Fatal Fulminating Liver Failure Possibly Related to amiodarone treatment. Br. J Hosp Med44:60-1 11 Lynn J, Teno, Philips.(1997). Perceptions by family members of dying experience of older and seriously ill patients. ANN Intern Med 126:97-106 hospice palliative care. This decision should be made by all concerned parties which will probably include the patient and their loved ones. A decision to take that action may also be influenced by the assessments of the patient’s condition and determination that they have a few months to live. Another determinant would be the increase in frequency of hospitalization of the patient. Instead of movement of the patient in and out of the hospital, it is recommended that his patient be taken to a hospice to provide ‘comfort’ as the patient can be with family and as well be able to receive the necessary medical attention12. Palliative care for patients has been found to increase the quality of life for patients diagnosed with heart disease chronic cardiac arrest being one among many. Palliative care increases the patients' quality of life by improving patient satisfaction and it also reduces the cost of care. This should then reduce the patient’s expenditure as the other forms of treatment are quite costly. It is has also been recommended for the end stage in heart diseases. Patients living with serious illness identified some of their needs as appropriate pain and symptom management. The patients would like for their conditions should be managed in a way that results in the least pain for them. Patients would also like palliative care to take care of unnecessary prolongation of dying. Patients would like to relieve their loved ones the burden of deciding whether the life support system should be cut off even when there probability of their survival is quite low. Patients would therefore like for them to be let to rest when the nurses have done all they can but their body's response to it has been very minimal and is deteriorating13. 12 Conor SR.(2007)Development of hospice and Palliative Care in the United States. Omega 56:89-99 13 ibid Palliative care improves the overall outcome of the situation. Patients who receive nonhospice palliative care have a high probability to die at home. This should be so if the patient and his/her family have decided that this is what they would wish. It may also result due to economic constraints facing the family. The patient and family would then prefer to implement nonhospice palliative care in order to prevent accumulation of massive hospital debts which they are unable to cater for this kind of palliative care may also be preferred due to the recent studies that have shown an improvement in survival by 81days as compared to those that were not in the hospice. This can be attributed to avoidance of hospital stays. Palliative care also impacts on health care use and costs. Palliative care decreases the number of procedures undertaken towards the end of life, the length of stay of patients in inpatient wards and intensive care unit and also reduced pharmaceutical costs. This results in an overall decrease of total costs under palliative care. It also results in hospice savings, where hospice programs save about 40% at the end of life stage and about 17% in the last six months of a patient's life. Difficulty has however been encountered on the determinants of when it is recommended for a patient to be transferred to a hospice. In an attempt to solve this it was recommended that prognostic factors be used to determine whether the patient is at the end of life stage. Goals of care should then be established for all patients diagnosed with a chronic illness. Pain should be addressed at every visit to ensure that the patient does not experience unbearable pain that reduces their quality of life14. 14 Schockett E, Teno J, Miller s. (2005). Late referral to hospice and bereaved family member perception of quality of end of life care. J Pain Symptom manage. 30:400-407 Advance care planning also includes communication. The palliative approach advocates for shared decision making between the patient, caretakers and the medical team. Discussion of specific interventions such as CPR helps the patient to discuss conditions that might create fear and confusion for them. Palliative care is also concerned with evidence-based approaches to the symptoms. Some of the suffering that patients go through is pain. Opioids may be used as a pain reliever although here is a risk of addiction of the patent to it15. Patients may also go through depression that may result in increased number of hospitalization events. To manage depression other underlying factors such as pain should be addressed. Psychotherapy and cognitive behavioural therapy may also be helpful in reducing depression in patients. Fatigue is also another difficulty which the patients experience and can be reduced by stimulants. At the end of stage of heart diseases for instance, chronic cardiac arrest discontinuation of medical therapy may result in the quality of life. This may be due to the development of other conditions that may be as a result of the medications. To ensure the quality of life these drugs may have to be withdrawn. 15 Ibid References ABS 2013e. Australian Health Survey updated results, 2011-2012 Canberra ABS. ABS 2013f. Austalian Health Survey. Updated results , 2011-2012 Canberra. ABS. AIHW: Marthers C&Penn R. (1999). Health Sytem Costs of cardiovascular diseases and diabetes Australia 1993-1994. Health and Welfare Expenditure Series no. 5cat n. HWE 11 Canberra: AIHW. AIHW: Senes S & Britt H (2001). A general practice view of cardiovascular disease and diabetes in Australia. Cardiovascular Disease Series No. 18. Cat no. CVD 17. Canberra: AIHW. Boutitie F, Boissel I, Connolly S, EMIAT(European Mocardial Infarct Amiodarone Trial) and CAMIAT(Canadian Amiodarone Myocardial Infarction Trial) investigators. Amiodrane interaction with beta blockers:analuysis of merged EMIAT and CAMIAT databases. Connolly SJ. Evidence based analysisof amiodrane efficacy and safety. Conor SR.(2007)Development of hospice and Palliative Care in the United States. Omega 56:8999 Cummings R.(1991). Improving survival from sudden cardiac arrest: The “chain of survival” concept: A statement for health professionals from the Advanced Cardiac Life Support subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation.83 Drezner J.(2007). Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic program: A consensus statement. Heart Rhythm 4:549-565 Lwaktere J. Morris , Knight EJ.(1990) Fatal Fulminating Liver Failure Possibly Related to amiodarone treatment. Br. J Hosp Med44:60-1 Lynn J, Teno, Philips.(1997). Perceptions by family members of dying experience of older and seriously ill patients. ANN Intern Med 126:97-106 Schockett E, Teno J, Miller s. (2005). Late referral to hospice and bereaved family member perception of quality of end of life care. J Pain Symptom manage. 30:400-407 Stuart J. Connoly, DoriAN, Roberts R, Gent M, Bailin S, Talajic for the Optimal Pharmacological Therapy in Cardioveter Defibrillator Patients(optic) investigator.(2006) Comparison of Amiodrane plus B-Blockers for prevention of shocks from implantable cardioveter defibrillators. JAMAvol 295(2). Sudden Cardiac Arrest Foundation. Retrieved from http://www.sca-aware.org accessed on may 13 2015 Varma R, Troup P, Komorowski, Sarna T.( 1985).Clinical and Morphological effects of amiodarone on the liver. Gastreonterology.88 1091-3 Vasallo P, Trohman.(2007). Prescribing amiodrane:an evidence based review of clinical indications. JAMA. 298 Watson RDS, Gibbs CR & Lip (2000). ABC of heart failure: clinical features and complications. British Medical Journal 320:236-9