* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Supplemental Content - Annals of Internal Medicine
Survey
Document related concepts
Cardiac contractility modulation wikipedia , lookup
Heart failure wikipedia , lookup
Saturated fat and cardiovascular disease wikipedia , lookup
Cardiovascular disease wikipedia , lookup
Management of acute coronary syndrome wikipedia , lookup
Jatene procedure wikipedia , lookup
Electrocardiography wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Cardiac surgery wikipedia , lookup
Heart arrhythmia wikipedia , lookup
Coronary artery disease wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Transcript
From the Publishers of Are Those Ventricular Premature Contractions Really Benign ? COPYRIGHT © 2016, ALL RIGHTS RESERVED Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2016 Copyright © 2016 Copyright © 2016 *Reproduced with Permission from Howard Weitz, MD Patient Frequent VPCs noted during evaluation of “awareness” of the heartbeat. Structurally normal heart Normal left ventricular function Normal valves No inducible ischemia, no scar A structurally normal heart VPCs decreased during stress test Copyright © 2016 73 asymptomatic healthy patients Harold L. Kennedy, M.D., M.P.H., James A. Whitlock, B.S., Michael K. Sprague, Lisa J. Kennedy, Thomas A. Buckingham, M.D., and Robert J. Goldberg, Ph.D. Long-Term Follow-up of Asymptomatic Healthy Subjects with Frequent and Complex Ventricular Ectopy N Engl J Med 1985; 312:193-197. DOI: 10.1056/NEJM198501243120401 VPCs Frequent VPCs More than 60 VPC / hour Range 78-1994 VPC / hour Complex ventricular ectopy (75%) Couplets Bigeminy Multifocal VPCs Non sustained Vtach (up to 16 beats) Copyright © 2016 No evidence heart disease Echo Maximal exercise treadmill test Coronary angio (31 patients) if suspicious for CAD Copyright © 2016 73 asymptomatic healthy patients Long term prognosis similar to the healthy population *From The New England Journal of Medicine, Harold L. Kennedy, James A. Whitlock, Michael K. Sprague, et al), Long-Term Follow-up of Asymptomatic Healthy Subjects with Frequent and Complex Ventricular Ectopy, 312, 193197 Copyright ©1985 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. • 15,000 patients • ECG rhythm strip 2 minutes • 11 year follow up • Presence of VPC indicated 2X risk of CHD event, fatal CHD, death in subjects without known CHD or CHD risk factors - No exhaustive investigation to rule out structural heart disease *Massing, Mark W. et al. Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease Events and Mortality (from the Atherosclerosis Risk In Communities Cohort). American Journal of Cardiology. 2006; 12:1609 – 1612. *Reprinted from American Journal of Cardiology, 98/12, Mark W. Massing,Ross J. Simpson,Pentti M. Rautaharju,Pamela J. Schreiner,Richard Crow,Gerardo Heiss, Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease Events and Mortality (from the Atherosclerosis Risk In Communities Cohort), 1609-1612, 2006, with permission from Elsevier. *Reprinted from American Journal of Cardiology, 98/12, Mark W. Massing,Ross J. Simpson,Pentti M. Rautaharju,Pamela J. Schreiner,Richard Crow,Gerardo Heiss, Usefulness of Ventricular Premature Complexes to Predict Coronary Heart Disease Events and Mortality (from the Atherosclerosis Risk In Communities Cohort), 1609-1612, 2006, with permission from Elsevier. *Lee V et al. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: a meta-analysis and systematic review. Heart. 2012;98:1290-1298. doi:10.1136/heartjnl-2012-302005. Meta analysis The studies are poor They probably included patients with heart disease Adverse outcome: VPCs and Advanced age Cardiac risk factors There is no robust study of the clinical significance of VPCs in the patient with a structurally normal heart Copyright © 2016 *Dello Russo, Antonio et al. Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy. Heart Rhythm. 2011;12:1915 – 1922. Heart Rhythm 13 competitive athletes Frequent VPCs Normal heart Exam Transthoracic echo Cardiac MRI Subsequently electrophysiologic testing and biopsy 12 of 13 with either focal cardiomyopathy or myocarditis Norman Jeff Holter © The European Society of Cardiology 2006 Reproduced with Permission from Oxford University Press. *This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. Our approach to the healthy patient with symptomatic VPCs Evaluate the patient Document and quantitate the VPCs Copyright © 2016 Our approach to the healthy patient with symptomatic VPCs Evaluate the patient Document and quantitate the VPCs Look for structural heart disease Transthoracic echo Look for myocardial ischemia (stress test) Coronary artery disease risk factors VPCs with exercise Advanced imaging (CT, MRI) if indicated Copyright © 2016 *Cha YM et al. Premature Ventricular Contraction-Induced Cardiomyopathy A Treatable Condition. Circulation: Arrhythmia and Electrophysiology. 2012; 5: 229-236 doi: 10.1161/CIRCEP.111.963348 VPC Mediated Cardiomyopathy High VPC burden (15-20% of all beats) No obvious cause VPC ablation? Let’s call an expert! Reginald Ho, MD Copyright © 2016 Summary Studies that have looked at the prognosis of VPCs with structurally normal hearts are flawed and incomplete No exhaustive search for structural heart disease Document and quantitate the VPCs Search for causes for VPCs Echocardiogram to search for structural abnormality Treadmill stress test if at risk for CAD or vpcs increase with activity Be aware of VPC induced cardiomyopathy – it is reversible Copyright © 2016 Produced by and Copyright © 2016 COPYRIGHT © 2016, ALL RIGHTS RESERVED