Download Rhythm Disturbances

Arrhythmia Management
17 Sept 2008
Dr John Bayliss
FRCP
Consultant Cardiologist
West Herts Cardiology
Arrhythmia Guidelines
2006
NICE CG36 AF
www.nice.org
2005
NSF CHD Arrhythmias
2006
Beds&Herts
Cardiac Network
Arrhythmia guidelines
www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm
www.westhertscardiology.com Documents/Local
www.starpace.co.uk Clinical Specialty/Cardiovascular
West Herts Cardiology
p 64
Palpitations: Importance
Common
 Often benign
 Often troublesome ++
 Occasionally fatal

Need careful assessment – some/most in 1y Care
Need for Rapid Access Arrhythmia services
Early involvement of specialist clinician
Ablation / Device therapy increasingly effective
West Herts Cardiology
p 55
Assessment of “Palpitations”/Arrhythmias

Full History = most important
Clinical Examination
 Heart rate response (during & after exercise)
 12 lead ECG (esp during symptoms)
 Blood tests
U&E, Glucose, Thyroid FT, Liver FT, FBC

West Herts Cardiology
p 56-7
Palpitations: Detailed History
 Age of patient
 Type and Duration of symptoms?






 Individual “thumps”, “misses”, etc
 Runs of tachycardia: ?Regular, ?Irregular
 Duration, Frequency
Onset: ? Sudden/Gradual, ? Circumstances
Cessation: ? Sudden/Gradual, ? Circumstances
Associated symptoms
 ? Polyuria (due to Atrial Natriuretic Peptide release in Atrial tachyarrhythmias)
 ? Collapse/Dizzy/Breathless, etc
Concurrent illness
Family History (Sudden Death, Cardiomyopathy, CHD)
Drug History (incl OTC)
West Herts Cardiology
p 58
Palpitations: Low risk features
= Manage in Primary Care
 History:
Not known to have heart disease
No family history of collapse or sudden death
at age < 40 years
No previous collapse/blackouts
Only infrequent attacks

Symptoms:
Palpitations last < 30 minutes
“Missed” beats (= ectopics) or brief rhythm
irregularity only
West Herts Cardiology
p 57
Palpitations: High risk features
= Refer to Heart Rhythm Specialist
 Pre-existing heart disease:
Previous angina, MI, angioplasty,heart surgery
Clinical heart failure, or LV systolic dysfunction
(ejection fraction < 40%)
Structural heart disease: valve disease,
cardiomyopathy, congenital heart disease

Family history of collapse or sudden death at
age < 40 years

Previous or recurrent collapse/blackouts.
West Herts Cardiology
p 57
Should GPs report 12 lead ECGs ?!

24yr old woman, occasional brief “flutters”
West Herts Cardiology
Long QT and Brugada syndrome

“Ion channelopathies”
QTc >450-500ms = high risk of VT/SCD
West Herts Cardiology
Investigation of Arrhythmias
May be useful
 Ambulatory ECG (24hr – 7 days)
 Echocardiogram
 Exercise ECG – if exercise related or ?CHD
Tilt Test – if postural or vagal symptoms
 Cardiac MRI - esp in young patient
 Implantable ECG Loop Recorder (ILR, “Reveal”)
if infrequent but serious events
 Electrophysiological Study (EPS)
 Catheter Ablation therapy

West Herts Cardiology
Implantable Loop Recorder (ILR, “Reveal” device)






15 mins daycase procedure
Local anaesthetic
implant in upper L chest
Battery lasts 18 months
High quality downloadable
ECG before+during attack
Most cost-effective test
Yield 43% 1
Cost 26% less than usual Ix 2
1Krahn
West Herts Cardiology
AD, et al. Circ. 2001;104:46-51. 2Krahn AD, et al. JACC. 2003;42:495-501.
Arrhythmias: Treatment
Depends on (ECG) diagnosis !
 S Tachy
: ? Cause (POTS ! “heartsink”)
 A Tachy
: β blocker
 AVNRT / AVRT : Ablation (Flecainide/Propafenone)
 A Flutter
: Ablation (Verapamil,Dig,Amio)
 Paroxysmal AF : Sotalol, Propafenone, Flecainide
 Permanent AF
: Rate v Rhythm...
 VT
: ICD (β blocker, Amio, Ablation)
 Bradycardias
: Pacing
West Herts Cardiology
p 59
Catheter Ablation

for arrhythmias with localised anatomical substrate
 often curative (no need to continue anti-arrhythmic Rx)
West Herts Cardiology
Device Therapy

Pacemakers
 Cardiac Resynchronisation Therapy
(CRT, Biventricular pacing)

Implantable Cardioverter Defibrillators (ICD)
West Herts Cardiology
Pacemakers : 1958 – 2008 : 50 years
1st "Permanent" Implantable Pacemaker
& Bipolar Hunter-Roth Lead (1958)
West Herts Cardiology
ICD function

VF terminated by single 34J shock
VF = Dead
SR = Alive
West Herts Cardiology
West Herts Cardiology
AF: Types
Aetiology
“Lone” AF
First Episode
(New onset)
vs
OR
Alcohol
Acute infection
Hypertension
Ischaemia / CHD
Sick Sinus Syndrome
Heart Failure
Cardiomyopathy
Valve disease
Hyperthyroid, etc


Timing
Paroxysmal
(PAF)
Persistent
Permanent
22% of PAF progress to permanent AF within 2 years
50-60% of patients are back in AF 1 year after cardioversion
Circulation 2001;104:2118–2150
West Herts Cardiology
p 58
AF: Management

? Rate or Rhythm Control
Rate control
Control of Ventricular Rate at rest + on exercise
Rhythm control
Restoration of SR + Maintenance of SR

? Anticoagulation
Risk of thromboembolism
Risk of Warfarin=1-2% yearly risk of serious bleed
West Herts Cardiology
p 60
p 64
AF: Rate v Rhythm control

Choose Rhythm Control:
Symptomatic, Younger
Uncontrolled Heart Failure
First episode (?), or now corrected precipitant

DC Cardioversion
≥3 weeks anticoagulation before + 4 weeks after

Try to Maintain SR (50% revert to AF in 1 yr)
? Need for Amiodarone / Sotalol
Propafenone / Flecainide
West Herts Cardiology
p 60
p 64
AF: Rate v Rhythm control - AFFIRM
The Atrial Fibrillation Follow-up Investigation of Rhythm Management
n=4060, age >65, AF
Mean age = 69.7
Hypertension in 71%
Rate control =
<80 at rest
<110 on walk
+ Warfarin (INR 2-3)
Rhythm control =
Drugs ± Cardioversion(s)
+ Warfarin (INR 2-3)
unless SR for 4(-12) weeks
AFFIRM NEJM 2002;347:1825-33
West Herts Cardiology
p 62
AF: Rate v Rhythm control

Choose Rate Control: if patient stable and if
Age >65
Underlying CHD, Hypertension, Valve Disease
 Anti-arrhyhtmic Rx not tolerated / contraindicated
Cardioversion inappropriate

Use β Blocker first:
Atenolol, Bisoprolol, Metoprolol
or rate controlling Ca++ blocker: Verapamil, Diltiazem
Add Digoxin if necessary, or if CHF
West Herts Cardiology
p 60
p 64
IMPORTANT
Digoxin : a drug of
nd
rd
2 -3
choice !
West Herts Cardiology
AF: Digoxin = Increased Mortality

SPORTIF III+V (Warfarin v Ximelagatran)

n=7329 in AF
Mod-high stroke risk


53% on Digoxin
Mortality = 6.5%

47% not on Digoxin
Mortality = 4.1%

Hazard ratio
(adjusted for risks)
1.53

? ↑ Platelet activation
Gjesdal, K et al. Heart 2008;94:191-196
West Herts Cardiology
AF: Thromboprophylaxis
≥5% / year
Warfarin
NICE CG36 June 2006 www.nice.org.uk
<3% / year
?
Aspirin
West Herts Cardiology
p 61
p 64
AF: Warfarin or Aspirin
In AF, compared to placebo
 Aspirin ↓ relative risk of stroke by 20%
 Warfarin ↓ relative risk of stroke by 60%

Warfarin increases absolute annual risk of
serious haemorrhage by 2+ %

Benefit

Echo is usually unnecessary for decision
Risk
West Herts Cardiology
CHADS2 risk score in AF
Predicts annual risk of stroke in non-rheumatic AF
CHF
Hypertension
Age 75 or older
Diabetes
Stroke or TIA
RISK SCORE
Points
Risk Score
Stroke rate* %
(95%CI)
1
0
1
2
3
4
5
6
1.9 (1.2-3.0)
2.8 (2.0-3.8)
4.0 (3.1-5.1)
5.9 (4.6-7.3)
8.5 (6.3-11.1)
12.5 (8.2-17.5)
18.2 (10.5-27.4)
1
1
1
2
0-6
* Assuming no Aspirin taken
Warfarin indicated if
CHADS2 Score = 2 or more
Gage BF et al JAMA 2001;285:2864-2870
West Herts Cardiology
p 60-1
West Herts Cardiology