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Transcript
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