Download Ventricular tachycardia

Tachycardias
Štěpán Havránek
Summary
1) Supraventricular (supraventricular rhythms)
Atrial fibrillation and flutter
Atrial ectopic tachycardia / extrabeats
AV nodal reentrant a AV reentrant tachycardia
2) Ventricular (ventricular rhythms)
Ventricular ectopia / extrabeats
Accelerated idioventricular rythm
Ventricular tachycardia – mono a polymorfic
– sustained and unsustained
Ventricular fibrillation
Diagnosis is based on ECG
HR > 100 BPM
Management is based on symptoms
or clinical significance of arrhytmia
Supraventricular
Tachycardias
„narrow QRS complex tachycardia“
Atrial fibrillation and flutter
Atrial fibrillation
- Very fast and uncoordinated activity. „Multiple reentry“.
PS
LS
LK
PK
Atrial fibrillation and flutter
Type I – cavo-tricuspidal
istmus dependency.
Right atrium
PS
LS
LK
PK
Type II – the others atrial
macroreentrant arrhythmias
PS
LS
LK
PK
Atrial fibrillation and flutter
Prevalence:
1% total adult population
3,8% over 60 y
9,0% over 80 y
Prognosis:
Mortality is 2x higher
→ Tromboembolic complications (stroke)
→ Higher incidence heart failure
AFIB classification
First documented: Only one episode, reccurent
Paroxysmal: Self-terminating
Perzistent: Required cardioversion
Permanent: No termination, arrhythmia left sustained
LONE (non-valvular) AFIB: No primary disease
SECONDARY AFIB: AFIB is complication of i.e. CAD,
valvular disease, heart failure, arterial hypertension,
cardiomyopaties, hyperyreosis, metabolic condition
Clinical manifestation
AFIB/ AF
Asymptomatic
Symptomatic
Palpitations - irregular and fast
Heart failure symptoms – dyspnoea, edema
Chest pain
Dizziness, syncope
Diagnosis based on ECG
→
PS
→
PK
LS
LK
→
→
PS
LS
LK
PK
→
→
→
Management
ECG – diagnosis + underline condition
Holter ECG 24 hrs, 7 days, 4 weeks – diagnosis
Lab tests – TSH, fT4, mineralogram – underline condition
ECHO – looking for aethiology, left atrial size
Transesophageal ECHO – trombi in left atrial appendage –
screening of compliacation
Treatment
Antitrombotic treatment
Anticoagulation
Warfarin - INR 2-3.0
Dabigatran 110/150mg 2 x d
Rivaroxaban 15/20mg 1 x d
Apixaban 2.5/5mg 2 x d
None
CHA2DS2VASc score
CHA2DS2VASc score
Rhythm and rate control
1) Sinus rhythm is target of treatment– Rythm control
2) Ventricular response is target of treatment– Rate control
Therapy according to symptoms, structural heart disease,
tolerance and side effects of drugs
Rate control
Target heart rate:
1) 60-80 bpm in rest
2) 90-115 bpm during stress
Meidicaments:
1) β blockators (metoprolol, bisoprolol, betaxolol)
2) Non-dihydropyridinové Ca blockators (verapamil, diltiazem)
3) Digoxin
Combination
Rhythm control
Medicaments:
1) Ic class
Propafenon 300 – 900 mg
2) III class
Amiodaron 100 – 400 mg
Sotalol 160 – 320 mg
Dronedaron 800 mg
DC cardioverizion
Biphasic synchronized discharge 200J
85 – 90 % accute effect.
1 – 2 % risk of stroke
→ > 4 weeks before and after antikoagulation / TEE
Catheter ablation
Indication: symptoms, no effect of drugs, absence of severe
structural heart disease.
Disavantages:
→ Time consuming procedure
→ 75% succes rate at best
→ Complications
Avantages:
→ Prevent of AFIB recurrence
→ Reduction of drug treatement
Type I AF
Morady F. N Engl J Med.
1999;340:534-544.
Courtesy of Dr. Brian Olshansky.
Other supraventricular
tachycardia
•
•
•
AV reentrant tachycardia
AV nodal reentrant tachycardia
Ectopic atrial tachycardia
Symptoms:
•
•
•
Palpitations – typically regular, fast
START in second, sustained arrhythmia, STOP in second
Rare: Chest pain, syncope, dizziness
Typical SVT
AV nodal reentrant tachy
AV node constitutes reentr. circuit: Slow and Fast pathway
ASíně
A Síně
AVN
AV uzel
AVN
AV uzel
V
V
Komory
Komory
Síně
Síně
A
A
AV uzel
AVN
AV uzel
AVN
V
V
Komory
Komory
AV reentrant tachycardia
Accessory pathway
LA
Two subtypes (figures)
RA
RV
LV
ortodromic
antidromic
LA
WPW syndrome
preexcitation
RA
RV
LV
LA
LA
RA
RA
RA
RV
RV
LA
LV
LV
RV
LV
Atrial ectopy
Presence of focus
*
LA
RA
RV
LV
Atrial ectopic tachycardia
Atrial ectopic tachycardia
Atrial ectopic tachycardia
Supraventricular tachycardia
Diagnosis: ECG, electrophysiology
Therapy of narrow complex tachycardia
Acute:
Vagal maneouvers
Adenosin iv 6-18mg bolus
Beta blocker, verapamil
DC version
Long – prevention of reccurence:
Beta blocker, verapamil
Catheter ablation
Adenosin 12 mg i.v.
Catheter ablation
Ventricular rhythms
„wide QRS complex tachycardia“
Classification
1) Ventricular premature beats
2) Accelerated idioventricular rhythm
3) Ventricular tachycardia
4) Ventricular fibrillation
Ventricular premature beats
Ventricular premature beats
Frequent finding in cardiological practice
Symptoms:
Asymptomatic, symptomatic
Palpitations (irregular and slow)
VPB → exclude structural heart disease
Therapy:
Underline disease
Symptoms
β-blockers
Antiarhythmics – propafenone, amiodaron
Catheter ablation
Accelerated idioventricular rhythm
Accelerated idioventricular rhythm
Reperfusion
HR < 100 bpm
Benign
Ventricular tachycardia
Organised ventricular activity > 3 beats > 100 bpm.
ECG: wide compex (QRS > 120 ms).
Classification:
ECG: Monomorphic, polymorphic
Hemodynamic impact: Sustained: > 30 s or cardiac arrest
Nonsustained: < 30 s
Ventricular tachycardia
!!!!!!!!!!! Clinical and prognostic view !!!!!!!!:
1. Idiopatic VT – no structural heart disease – BENIGN
2. VT with structural heart disease – MALIGNANT
→ Idiopatic VT – treated when symptoms are present
→ Malignant – must be treated
VT with structural heart disease / malignant
potential
Coronary artery disease – acute or chronic forms
Dilatative cardiomyopathy
Hypertrofic cardiomyopathy
Arhythmogenic right / left ventricle dysplasia
Postmyocarditic scarring
Long QT syndrome
Short QT syndrome
Brugada syndrome
Monomorphic VT
PS
PS
LS
LS
LK
LK
*
PK
PK
Focus
Reentry
150 ms
100 ms
200 ms
300 ms
140 ms
400 ms
500 ms
570 ms
0 ms
130 ms
Polymprphic VT
Polymprphic VT
Polymprphic VT
Clinical manifestation of VT
Dependent on:
Systolic function
Heart rate
Situation (standing or lying)
Manifestation:
Sudden cardiac death – pulsless VT, progression to VF
Syncope – non-sustained, self-terminating
Dyspnea, chest pain
Asymptomatic
Asymptomatic VT
Ventricular fibrillation
Everytime malignant
Manifestation:
Sudden cardiac death, cardiac arrest
VF
VT progression to VF
Therapy VT or VF
Acute and initial therapy according to clinical status:
1. Cardiac arrest – VF or pulsless VT
- CPR + urgent defibrillation
2. Tolerated VT
Antiarythmics iv. – prokainamid, amiodaron, sotalol
DC cardioversion
Next step:
Exclusion of all conditions leading to VT or VF
Management of VT / VF - I
If patient has manifested VT – looking for:
Family history of sudden cardiac death
- chanelopathies – long / short QT
- ARVC / D
- Brugada syndrome
Personal history
- CAD, AMI, cardiomyopathies
Warning symptoms
- syncope
Management of VT / VF - II
12 – lead ECG
- evidence of acute / old MI
- LBBB (DCMP)
- left ventricular hypertrophy
- repolarization changes
- long QT
Evidence of structural heart disease:
- ECHO
- MRI
- Coronary angiography
Idiopathic VT
Occurence: 10% of all VT
Prognosis: Benign
!!Absence of structural heart disease and warnig
symptoms!!
Therapy: According to symptoms
Drugs - β-blockers
Antiarhythmics – propafenone, amiodaron
Catheter ablation in case of intolerance or resistence
Therapy malignant VT or VF
Definitive treatement:
1. Implantation of ICD
2. A. Drugs – amiodarone
B. Catheter ablation
Catheter ablation
ICD
Primary prevention:
Patient without manifestaion of VT/VR yet
BUT who are in severe risk of VT/VF
Risk:
Structural heart disease
Secondary prevention:
Patient who survived episode of VT/VF