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Atrial Fibrillation and Flutter
Current Approaches to Management
Mohamed H. Kanj, MD
Associate Director, EP Labs
Department of Cardiovascular Medicine
Cleveland Clinic
Narrow Complex Tachycardias
.
Mr. X is a 45-year-old man with sudden onset of a "fluttering
sensation in the chest.”. He went to the local ED and he was told he
has atrial flutter. The fluttering sensation was gone in 4 hours. No
prior history of palpitation.He was discharged and was asked to
follow up with his physician.
There is no history of other cardiovascular or pulmonary disease.
His review of systems is benign except for irritable bowel syndrome.
He does not take any medications. His physical examination is
normal. An electrocardiogram (ECG) done at your clinic shows
normal sinus rhythm with normal ECG.
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ED Workup
CBC
nl
Basic panel nl
TSH nl
CXR no pathology noted
Cardiac enzymes negative
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ED rhythm strip
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What is the diagnosis?
A.
B.
C.
D.
E.
Atrial flutter
Paroxysmal supraventricular tachycardia
New onset AF
Sinus tachycardia
Paroxysmal AF
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What is the diagnosis?
A.
B.
C.
D.
E.
Atrial flutter
Paroxysmal supraventricular tachycardia
New onset Atrial fibrillation
Sinus tachycardia
Paroxysmal atrial fibrillation
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Oscillatory waves in AFL and AF
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Types of Atrial Fibrillation
New Onset: First episode of atrial fibrillation
of any duration.
Paroxysmal:> 1 Episode,<1 wk duration,
self terminate.
Persistent: > 1 Episode,> 1wk duration or
history of cardioversion
Permanent: Episodes lasting for more than 1
week for which cardioversion has failed or
has not been attempted.
Lone: Any type in a patient with structurally
normal heart and younger than 60 yrs
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What would you do next?
A.
B.
C.
D.
E.
Amiodarone 400 TID 1 wk then 200
QD
Warfarin 5 mg and follow INR
Aspirin 81 mg QD
2-D echo and a Holter monitor
Refer to Electrophysiology
Narrow Complex Tachycardias
.
What would you do next?
A.
B.
C.
D.
E.
Amiodarone 400 TID 1 wk then 200
QD
Frequency of further
Warfarin 5 mg and follow INR
episodes is unpredictable
Aspirin 81 mg QD
2-D echo and a Holter monitor
Risk factors?
Refer to Electrophysiology
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Minimal Work up for AF
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Our patient Workup
2 D echo No structural heart dx
Holter: 1 episode of AF lasted 3 hours:
resting HR around 110 and up to 190 with
exercise
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What would you do next?
A.
B.
C.
D.
E.
Amiodarone 400 TID for 1 week then 200 QD
Warfarin 5 mg and follow INR
Aspirin 325 QD
Metoprolol 50QD and ASA 81 QD
EP Consult
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.
What would you do next?
A.
B.
C.
D.
E.
Amiodarone 400 TID for 1 week then 200 QD
Warfarin 5 mg and follow INR
Aspirin 325 QD
Metoprolol 50QD and ASA 81 QD
EP Consult
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.
AF THERAPY
ANTITHROMBOTIC RX
AND
RHYTHM
CONTROL
OR ?
RATE
CONTROL
Symptoms
if irregular and high heart rate
and most symptoms can be controlled by
rate control
Combination
Ensure
good heart rate control to decrease
risk of tachy-induced cardiomyopathy
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Rate Control
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Rate Control
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Anticoagulation
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Special Groups
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Our Patient
Fast HR BB
CHADS score is 0 ASA or nothing
Follow up visit – 8 months
Remains
symptomatic despite metoprolol 200
QD
Frequency: 1 per week lasting 6-9 hours
One
required DC cardioversion at his local
hospital. An exercise stress test was
performed and was negative for ischemia.
The hospitalist wanted to put him on
Amiodarone, but he was reluctant to take it
pending further discussions with you.
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What is your next recommendation?
A.
B.
C.
D.
Increase metoprolol to 150 BID
"pill-in-the-pocket” with propafenone 450
mg PRN
Amiodarone 400 TID for 1 week then
200 QD
Flecainide 100 BID
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.
What is your next recommendation?
A.
B.
C.
D.
Increase metoprolol to 150 BID
"pill-in-the-pocket” with propafenone 450
mg PRN
Amiodarone 400 TID for 1 week then
200 QD
Flecainide 100 BID
Rate control management have failed Rhythm Control
Frequent episodes Daily
Less frequent, long episodes Pill in the pocket
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Antiarrhythmics
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Pt admitted last night with palpitation
You are seeing next day. Episode started 18 hours
ago. Patient is well aware of his symptoms.
Resting HR 90 bpm
A.
B.
C.
D.
E.
Heparin, DCCV , and warfarin for 4 weeks
Warfarin and see in 3 weeks for DCCV
Cardioversion: Ibutilide/flecainideor DCCV
TEE, DCCV, and coumadinfor 4 weeks
Amiodarone at 1 mg/min for 6 hrs and reassess.
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Pt admitted with palpitation for 8 hrs
A.
B.
C.
D.
E.
Heparin, DCCV , and warfarin for 4 weeks
Warfarin and see in 3 weeks for DCCV
Cardioversion: Ibutilide/flecainideor DCCV
TEE, DCCV, and coumadinfor 4 weeks
Amiodarone at 1 mg/min for 6 hrs and reassess.
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Cardioversion
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Hospital care
Immediately after DC cardioversion, he has a 3.5
seconds pause. The nurse brought to your
attention that he had a 3.8 second pause last
night at 3 AM while asleep. He denies any
symptoms of lightheadedness, syncope or
exertional shortness of breath.
A.
B.
C.
D.
E.
Schedule for a DDD pacer
Schedule for VVI pacer
Stop flecainide and start Amiodarone
Decrease metoprolol to 25 BID
None of the above
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Hospital care
A.
B.
C.
D.
E.
Schedule for a DDD pacer
Schedule for VVI pacer
Stop flecainide and start Amiodarone
Decrease metoprolol to 25 BID
None of the above
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Clinic Follow up
He comes back 8 months later and says that he
continues to have AF once 2 months lasting 10
min. However, he is happy with the current
therapy. What would you recommend?
A. Stop
flecainide and start Sotalol
B. Stop flecainide and metoprolol and start Sotalol
C. Discontinue flecainide and start amiodarone
D.Continue same regimen
E. Proceed with AF ablation
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Hospital Follow up
A. Stop
flecainide and start Sotalol
B. Stop
flecainide and metoprolol and start Sotalol
C. Discontinue
D. Continue
E. Proceed
flecainide and start amiodarone
same regimen
with AF ablation
Treatment should be tailored
to symptoms NOT to
recurrence
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Another hospital visit
Mr. X presents 3 months later to the ED with palpitations.
This occurred shortly after playing basketball with his
friends. When he checked his pulse, it was fast. Sitting
down for 10 minutes didn't relieve his symptoms or
control his heart rate.
Bp: 130/70 and HR 180 bpm. He is lying in bed
comfortably in no distress. Lungs are clear to auscultation
and heart sounds are rapid.
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What is the most likely diagnosis?
A.
B.
C.
D.
Ventricular tachycardia
Dual tachycardia: AF and VT
Atrial flutter
Ventricular flutter
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What would you do next to diagnose and
treat this arrhythmia?
A.
B.
C.
Carotid sinus massage; metoprolol 5 mg
IV
Administer 6 mg of intravenous
adenosine; Amiodarone 300 mg IV
Electrophysiology study; emergency
cardioversion
Narrow Complex Tachycardias
.
What is the most likely diagnosis?
A.
B.
C.
D.
Ventricular tachycardia
Dual tachycardia: AF and VT
Atrial flutter
Ventricular flutter
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Class IC agents
IC agents (Na blockers), slows conduction and may result in
slowing and regularization of the fibrillatory wavelets into flutter.
If there was significant prolongation in the flutter wave CL, 1:1 AV
conduction across the AV node may occur, resulting in a
paradoxical increase in ventricular rate.
Due to the use-dependency nature of these drugs, significant
infranodal conduction delay (in the ventricular tissue) may occur at
high ventricular rates, resulting in ECG morphology similar to
ventricular tachycardia. Thus, the development of wide QRS
complex tachycardia in patients with atrial arrhythmias being
treated with sodium channel blockers should raise the suspicion of
atrial flutter with 1:1 conduction
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What would you do next to diagnose and
treat this arrhythmia?
A.
B.
C.
Carotid sinus massage; metoprolol 5 mg
IV
Administer 6 mg of intravenous
adenosine; Amiodarone 300 mg IV
Electrophysiology study; emergency
cardioversion
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Grnadma’s visit
Grandma is a 78 yo lady with history of permanent
AF for the past 15 years. She had a DDD pacer.
Other medical problems include DM. She takes
warfarin and metoprolol 25 mg BID. Her Bp
120/60. Device interrogation revealed that
permanent AF with occasional VP (4%) and good
heart rate histogram. She seems to be in NYHA
FCII. EF 50%
What would you do next?
Narrow Complex Tachycardias
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What would you do next?
A.
B.
C.
D.
DC cardioversion followed by flecainide
50 BID
DC cardioversion followed by
Amiodarone 200 daily
Start Amiodarone 400 TID for one week
then arrange for DC cardioversion to be
followed by Amiodarone 200 mg PO
daily
None of the above.
Narrow Complex Tachycardias
.
What would you do next?
A.
B.
C.
D.
DC cardioversion followed by flecainide
50 BID
DC cardioversion followed by
Amiodarone 200 daily
Start Amiodarone 400 TID for one week
then arrange for DC cardioversion to be
followed by Amiodarone 200 mg PO
daily
None of the above.
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Atrial Fibrillation Follow-up Investigation of
Rhythm Management (AFFIRM)
HYPOTHESIS: Rhythm management is as safe
as rate control management
N=4060 pts (>65 yr or risk factor for stroke)
Primary endpoint: Total mortality
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AFFIRM
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AFFIRM: Adverse Events
RATE
CONTROL
RHYTHM
CONTROL
p-value
306 (27%)
356 (28%)
0.058
TdP VT
2 (0.2%)
13 (0.8%)
0.004
Sustained VT/VF Arrest
24 (1.7%)
18 (1.2%)
0.355
Bradycardic Cardiac Arrest
2 (0.1%)
13 (0.8%)
0.004
Hospitalization after baseline
1218 (70%)
1375 (78%)
<0.001
Ischemic Stroke *
79 (5.7%)
84 (7.3%)
0.680
Death
* 78% of RHYTHM CONTROL and 68% of RATE CONTROL pts with
ischemic stroke were off warfarin or had PT/INR <2.0
Narrow Complex
Tachycardias
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AFFIRM: Conclusion
Sinus Rhythm is equivalent to atrial fibrillation as
regard to mortality: FALSE
TRUE: Intension to control rate is non-inferior to
a strategy intended to control rhythm.
Reason: More than expected SR in control arm,
inefficacy of AAD and side effect of AAD.
Lessons from AFFIRM
If you need to correct AF, look else where
. We need a treatment that restores sinus
rhythm without the risk of proarrhythmias
(brady and tachy)
Anticoagulate if needed
3 yrs later
During
the past 3 years, he has changed
jobs and, consequently, medical insurance.
In the meantime, he saw another physician
who put him on amiodarone 200 mg daily
because he was having frequent
symptomatic episodes (4-5/week). Despite
amiodarone he continues to have at least 12 episodes per week that are fairly
symptomatic. He is concerned about side
effects of Amiodarone
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What would you recommend?
A.
B.
C.
D.
Reassure the patient
Refer to a cardiothoracic surgeon for a
surgical Maze procedure
Refer to an interventional
electrophysiologist for PVAI
Discontinue amiodarone and refer to
an interventional electrophysiologist
for AV node ablation with pacemaker
Narrow Complex Tachycardias
.
What would you recommend?
A.
B.
C.
D.
Reassure the patient
Refer to a cardiothoracic surgeon for
a surgical Maze procedure
Refer to an interventional
electrophysiologist for PVAI
Discontinue amiodarone and refer
to an interventional
electrophysiologist for AV node
ablation with pacemaker
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Foci Triggering Atrial
Fibrillation
25%
9%
45%
16%
94%
Haissaguerre
Haissaguerre New
New Engl
Engl JJ Med
Med 1998
1998
Narrow Complex Tachycardias
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Atrial Flutter
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Atrial Futter
Atrial rhythm regular
Atrial F waves similar
Atrial rates: 250-350
Ventricular rate variable
Clinical senarios: valve disease, cardiac
surgery( valvular,congenital), enlarged
atria (systolic or diastolic dysfunction, pulm
disease)
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Atrial flutter: irregular
Group beating!
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Atrial flutter- regular
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Atrial Flutter
•Typical types: cavotricuspid isthmus dependent
• Atypical types: usually dependent on scars, surgical
incisions, other veins and mitral annulus
• Frequently triggered by atrial fibrillation
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Atrial Flutter: Typical
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Atrial Flutter Circuit
Atrial Flutter Circuit
Atrial Flutter Ablation
Atrial Flutter RFA
Atrial Flutter Ablation
Approximately 15% of AF patients treated with an AA
will develop AFL
Advantages:
95% efficacy
As primary Tx RFA more effective than AARx
AF Update
Anticoagulation
ASA Plavix
Dabigatran
LAA closure device
Rhythm Control
Dronedarone
HF
Ablation
Rate control
AVN ablation and pacing
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Anticoagulation Results
Hart, Ann Intern Med 1999;131:492
Intensity of Anticoagulation
Fuster, Ryden, Cannom, JACC 2006 ACC/AHA/ESC Guidelines
Non-Valvular Atrial Fibrillation Stroke Prevention
Medical Rx
• Warfarin cornerstone of therapy
• Assuming 51 ischemic strokes/1000 pt-yr
• Adjusted standard dose warfarin prevented 28
strokes at expense of 11 fatal bleeds
• Aspirin prevented 16 strokes at expense
of 6 fatal bleeds
• Warfarin
• 60-70% risk reduction vs no treatment
• 30-45% risk reduction vs aspirin
• (30% decrease in cardiovascualr events then
no aspirin if taking coumadin)
Cooper: Arch Int Med 166, 2006
Lip: Thromb Res 118, 2006
3000838-10
Challenges in Treating AF
• However warfarin is not always well-tolerated
• Narrow therapeutic range (INR between 2.0 – 3.0)
• Effectiveness is impacted by interactions with
•
some foods and medications
Requires frequent monitoring and dose adjustments
• Published reports indicate that less than 50% of patients eligible are being
treated with warfarin due to tolerance or non-compliance issues
• SPORTIF trials suggest only 60% of patients treated are within a therapeutic INR
range, while 29% have INR levels below 2.0 and 15% have levels above 3.0
Vitamin K antagonists
Problems with Warfarin
Food and drug interactions
Genetic variation in metabolism
narrow therapeutic window
dosage adjustments & freq.
monitor with INR
overlap with parenteral drugs
slow onset of action
New Anticoagulants
ORAL
PARENTERAL
TF/VIIa
TTP889
TFPI (tifacogin)
X
Rivaroxaban
Apixaban
LY517717
YM150
DU-176b
Betrixaban
TAK 442
IX
VIIIa
Va
Xa
APC (drotrecogin alfa)
sTM (ART-123)
IXa
AT
II
Dabigatran
Fondaparinux
Idraparinux
DX-9065a
IIa
Fibrinogen
Fibrin
Adapted from Weitz& Bates, J ThrombHaemost2007
Dabigatran
Potent, direct, competitive inhibitor of
thrombin.
80% of the given dose is excreted by the
kidneys.
Peaks in an 1 hr and t1/2 15 hours
Dose: 110 mg BID and 150 mg BID.
Dabigatran versus Warfarin in Patients
with Atrial Fibrillation
N Engl J Med 2009;361
Dabigatran
Rates of the primary outcome were 1.69% per year in
the warfarin group, as compared with 1.53% per year
in the group that received 110 mg of dabigatran
(P<0.001 for noninferiority) and 1.11% per year in the
group that received 150 mg of dabigatran (P<0.001
for superiority).
The rate of major bleeding was 3.36% per year in the
warfarin group, as compared with 2.71% per year in
the group receiving 110 mg of dabigatran (P = 0.003)
and 3.11% per year in the group receiving 150 mg of
dabigatran (P = 0.31).
Potential Risks
No increase hepatotoxicity ( fear
from ximelagatran)
Increased risk of GI bleeding (?
tartaric acid) but not total bleeding
risk
No beneficial effect on MI risk ( ASA
in CAD)
Summary
•
The lower dose of dabigatran, when
compared with warfarin, was associated
with similar rates of stroke and
systemic embolism as well as lower
rates of major hemorrhage
•
The higher dose of dabigatran was
associated with lower rates of stroke
and systemic embolism but with a
similar rate of major hemorrhage.
Practice Implications
Patients already taking warfarin with
excellent INR control have little to gain
in switching to dabigatran due to it’s
twice daily dosing and greater risk of
nonhemorrhagic side effects
Patients who have atrial fibrillation and
at least one additional risk factor for
stroke could potentially benefit from
dabigatran.
ASA+ PLAVIX: ACTIVE
Documented AF + ≥1 risk factor
for Stroke
Unsuitable for VKA
ACTIVE A
C&A versus ASA
ACTIVE W
C&A versus VKA
No Exclusion Criteria for ACTIVE
I
ACTIVE I
Irbesartan versus Placebo
Partial Factorial Design
0.10
0.15
HR=0.72 (0.62-0.83) p=0.00002
0.05
Placebo+Aspirin
Clopidogrel+Aspirin
0.0
Cumulative Hazard Rates
Stroke
0
No. at Risk
C+A 3772
ASA 3782
1
2
3
4
3491
3458
3229
3155
2570
2517
1203
1186
Years
Conclusions
Addition of clopidogrel to aspirin in high risk
AF patients, unsuitable for VKA:
Reduces major vascular events
Primarily due to a reduction in stroke
With an increase in major bleeding
ACTIVE A and W:
Stroke Rates and Risk Reductions
Treatment
VKA
C+A
Aspirin
ACTIVE W
(Rate per year)
1.4
2.4
--
ACTIVE A
(Rate per year)
--
2.4
3.3
RRR versus Aspirin
-58%
-28%
--
RRR versus
C+A
-42%
--
--
LA Appendage Occlusion
PLAATO
Atritech
Watchman
Sievert, Circ 2002;105:1887
Intent-to-Treat
Primary Efficacy Results
Randomization
Randomization allocation
allocation (2
(2 device
device :: 11 control)
control)
Device
Device
Events
Events
Cohort
Cohort
Control
Control
Total
Total
(no.)
(no.)
Rate
Rate
pt-yr
pt-yr
Events
Events
(95%
(95% CI)
CI)
Total
Total
(no.)
(no.)
Rate
Rate
pt-yr
pt-yr
Rel.
Rel. Risk
Risk
(95%
(95% CI)
CI)
NonNon(95%
(95% CI)
CI)
20
20
582.3
582.3
3.4
3.4
(2.1,
(2.1, 5.2)
5.2)
16
16
318.0
318.0
5.0
5.0
(2.8,
(2.8, 7.6)
7.6)
0.68
0.68
(0.37,
(0.37, 1.41)
1.41)
Event-free
Event-free
probability
probability
900
900 pt-yr
pt-yr
Posterior
Posterior
Probabilities
Probabilities
inferiority
inferiority
Superiority
Superiority
0.998
0.998
0.837
0.837
ITT
ITT Cohort:
Cohort:
Non-inferiority
Non-inferiority criteria
criteria
met
met
WATCHMAN
WATCHMAN
Control
Control
Days
Days
244
244
463
463
147
147
270
270
52
52
92
92
12
12
22
22
3001664-2
Intent-to-Treat
All Stroke
Device
Control
Posterior probabilities
Events
eve
Total
pt-yr
Rate
Events Total
Rate
(95% CI) (no.)
pt-yr (95% CI)
600
pt-yr
14
409.3
3.4
(1.9, 5.5)
8
223.6
3.6
0.96
0.927
(1.5, 6.3) (0.43, 2.57)
0.488
900
pt-yr
15
582.9
2.6
(1.5, 4.1)
11
318.1
3.5
0.74
0.998
(1.7, 5.7) (0.36, 1.76)
0.731
Event-free probability
Cohort
WATCHMAN
RR
NonSuperiority
(95% CI) inferiority
Randomization allocation
(2 device:1 control)
Control
ITT cohort: Non-inferiority
criteria met
900 patientpatient-year analysis
244
463
147
270
Days
52
92
12
22
3000838-101
PROTECT AF Trial
What are the Analysis Issues
1.
2.
3.
4.
How do you deal with safety endpoints which are
also primary efficacy endpoints?
How do you deal with early procedural safety risks
(seen with all invasive interventional procedures) vs
late primary efficacy endpoints?
How do you deal with a strategy of warfarin started
immediately and indefinitely versus an invasive
approach that also requires 45 days of warfarin
(?double jeopardy)
How do you factor in procedural learning curve?
Ablation and anticoagulation
Freedom from hemorrhagic and nonhemorrhagic strokes
Rhythm Control
Medications
Catheter
Surgical
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Rhtyhm Control: Surgical
Surgical ablation and LAA clipping/excision
in all undergoing cardiothoracic surgery
with history of AF irrespective to response
to AADs
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.
Rhythm Control: Catheter
Second line treatment
May be first line option in:
Nl heart with normal size LA
SVT induced AF
Tachycardia induced cardiomyopathy
Family history of SCD
Patient doesn’t want to take AADs
Narrow Complex Tachycardias
.
Rhythm Control: Newer AADs
Dronedarone:
devoid of iodine.
no thyroid toxicity, no pulmonary toxicity,
no TdP
Vernakalant( atrial specific Ina, Ikur,
Ikach, Ito):
AF conversion (intravenous) without TdP,
and, so far, in its oral trials, No ventricular
proarrhythmia so far.
Narrow Complex Tachycardias
.
EURIDIS and ADONIS
Primary Endpoint: Pts with First Recurrence of AF/AFL
EURIDIS
ADONIS
0.8
Cumulative Incidence
Cumulative Incidence
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Log-rank test results: p=0.0138
0.6
0.5
0.4
0.3
0.2
0.1
Log-rank test results: p=0.0017
0.0
0.0
Time
(days)
0.7
0
60
120
180
240
300
Placebo
360
Time
(days)
0
60
120
180
240
300
360
Dronedarone 400 mg bid
A Significant and Consistent Reduction in First Recurrence of Atrial Fibrillation / Atrial Flutter
Narrow
Complex
JCVEP 2006
12: suppl
Tachycardias
.
Cumulative Incidence (%)
ATHENA Study
Primary Outcome: Cumulative Incidence of First
Cardiovascular Hospitalization or Death
100
75
Hazard ratio: 0.76 (0.69-0.84)
P<0.001
50
Placebo
Dronedarone
25
0
0
No. at Risk
Placebo
Dronedarone
2327
2301
6
1858
1963
12
18
Months
24
30
1625
1776
385
403
3
2
1072
1177
Hohnloser SH et al. N Engl J Med. 2009;360:668-678.
ANDROMEDA
Time From Randomization to Death From Any Cause
Placebo
0.8
Analysis up to study discontinuation
Placebo Dronedarone
(n=317)
(n=310)
0.7
Cumulative incidence
Dronedarone
0.6
# of patients who died
Relative risk (vs placebo)
95% CI
Log rank P value
0.5
0.4
0.3
12
25
2.3
1.071; 4.247
0.027
0.2
0.1
0.0
Time
(days)
0
30
60
90
120
150
180
210
Placebo
317
256
181
103
50
18
6
1
Dronedarone
310
257
174
104
59
22
5
1
240
Number at risk:
Kober L, et al. N Engl J Med 2008:358:2678-87.
Dronadarone
Contraindication: Patients with NYHA Class IV heart failure or
NYHA Class II – III heart failure with a recent decompensation
requiring hospitalization or referral to a specialized heart
failure clinic.
AVN ablation
Elderly
When AF ablation fails
Contraindications to anticoagulation
Narrow Complex Tachycardias
.
Catheter Ablation of the AV
Junction
Advantages
Improved rate control
Improved QOL
Improved LVEF
No AADs
Less hospitalizations
Disadvantages
Pacemaker dependence
Procedure
complications
Continued embolic risk
Loss of AV synchrony
AVJ & BiV Pace (PAVE)
Doshi et al., J Cardiovasc
Electrophysiol 2005; 16:1160
PACE: EF >45 % requiring RV pacing
P=0.76
LV ejection fraction (%)
65.0
*
60.0
55.0
P<0.001
50.0
Baseline
1 yr
*P<0.001 vs RVA pacing
Absolute difference of EF by 7%
RVA pacing
end--systolic volume (ml)
LV end
BiV pacing
P<0.001
40.0
35.0
30.0
*
25.0
P=0.42
20.0
Baseline
1 yr
*P<0.001 vs RVA pacing
Absolute difference of LVESV by 8.1ml
Thank You
Narrow Complex Tachycardias
.
Case 2
33 yo gentleman presenting with
palpitation. He has had episodes since he
was a kid.
Rx: No meds
HR 150 Bp 130/85
PE: NAD, Lungs clear, Heart tach
Narrow Complex Tachycardias
.
Case 2
* ***
Narrow Complex Tachycardias
.
Case 2
What would you do now?
Verapamil 5 mg IV then PO
Adenosine 6 mg IV
Digoxin 0.25 mg IV then 0.25 in 5 hours
IV procainamide
Narrow Complex Tachycardias
.
AF with WPW
IV
procainamide (Class Ic, Ib, or III)
DC
Cardioversion
DONOT
give
Digoxin (directly and indirectly)
Verapamil
They may accelerate ventricular rate (VF)
Narrow Complex Tachycardias
.
Case 3
76 yo gentleman with history ischemic
cardiomyopathy presenting with acute sudden
onset of SOB at rest of 2 hours duration. This has
been accompagnied with a chest pressure. PE:
GA: breathing heavily. Heart tach. JVD 7 cm.
Lungs crackles on bases. Ext no edema but cold
and sweaty.
Bp 80/55 HR 150
Narrow Complex Tachycardias
.
ECG: AFib
Narrow Complex Tachycardias
.
Case 3 ECG
What would you do next?
A. Start
Cardizem drip
B. Start IV NTG followed by IV dopamine if
Bp decreased
C. DC Cardioversion
D. Start IV Amiodarone
Narrow Complex Tachycardias
.
AF RVR with hemodynamic instability
Tx DC cardioversion
Symptomatic hypotension
Heart failure
Chest pain
Narrow Complex Tachycardias
.
Case 4
82 yo gentleman with history of AF, DM, HF
and CRI was admitted with diarrhea, blurred
vision and hallos around lights. Rx: coumadin 4
QD, digoxin 0.125 QD, Insulin, metoprolol 25
QD. Bp 110/50 BUN/Cr 70/4.3. His ECG:
Narrow Complex Tachycardias
.
Beside hydration, what are you going
to do next?
A. Check Mg, Phosphorus
B. Check digoxin level
C. Send for a pacer
Narrow Complex Tachycardias
.
Case 4
Digoxin level was 5.1
What are you going to do next?
A. Stop
digoxin, Dialyse
B. Decrease Digoxin to QOD
C. Stop digoxin, start Dopamine drip
D. None of the above
Narrow Complex Tachycardias
.
AT with AV block
Atrial arrhythmia with regular rhythm
think dig toxicity!
Treatment: digibind
Narrow Complex Tachycardias
.
Case 5
Mr Jones is a 75 yo gentleman with history
of symptomatic parxysmal atrial fibrillation
who was admitted with AF RVR. His
medical regimen include Warfarin 6 mg
daily and digoxin 0.25 daily. Cardiology
were consulted and recommended starting
him on Amiodarone 200 QD?
Narrow Complex Tachycardias
.
Case 5
What would you do?
A. Decrease Warfarin to 4 QD, decrease
Digoxin to 0.125 QD
B. Increase Warfarin to 8 mg, decrease
digoxin to 0.125 QD
C. no need to adjust warfarin, decrease
digoxin to 0.125 QD
D. Decrease Warfarin to 4 QD, No need to
change digoxin
Narrow Complex Tachycardias
.
Case 5
What would you do?
A. Decrease Warfarin to 4 QD, decrease
Digoxin to 0.125 QD
B. Increase Warfarin to 8 mg, decrease
digoxin to 0.125 QD
C. no need to adjust warfarin, decrease
digoxin to 0.125 QD
D. Decrease Warfarin to 4 QD, No need to
change digoxin
Narrow Complex Tachycardias
.
Drugs interaction
Increase INR or bleeding risk
Acetaminophen
Alcohol
Amiodarone
Anabolic Steroid
Antibiotics (except PCN
and rifampin) including
antifungal
Thyroid Hormone
Decrease INR
American Ginseng
Barbiturates
Carbamazepine
Oral C ontraceptive
Penicillin
Rifampin
St. John's Wort
Multivit containing Vit K
Narrow Complex Tachycardias
.
Other drug interaction
Digoxin and Verapamil
Digoxin and Amiodarone
Decrease Dig by half
Decrease Dig by half
Dig Toxicity: abdominal pain, anorexia, bizarre mental
symptoms in the elderly, blurred vision, bradycardia,
confusion, delirium, depression, diarrhea, disorientation,
drowsiness, fatigue, hallucinations, halos around lights,
reduction in visual acuity, mydriasis nausea, neuralgia,
nightmares, personality changes, photophobia,
restlessness, vertigo, vomiting, and weakness
Narrow Complex Tachycardias
.
Case 6
68 yo lady with history of AF for the past 6 years.
PSH: None
PMH: admitted with black toe- resolved after 1 days. No
DM, No HTN, No stroke
EKG: AF, Echo Normal LV function
A. Aspirin
B. Coumadin
C. Aspirin or Coumadin
Narrow Complex Tachycardias
.
Case 6
68 yo lady with history of AF for the past 6 years.
PSH: None
PMH: admitted with black toe- resolved after 1 days. No
DM, No HTN, No stroke
EKG: AF, Echo Normal LV function
A. Aspirin
B. Coumadin
C. Aspirin or Coumadin
Narrow Complex Tachycardias
.
Case 7
43 yo gentleman with history of PAF on aspirin 81 and
metoprolol 50 QD. He has been in AF for 3 days. What
would you do?
A.
Heparin, DCCV , and warfarin for 4 weeks
Cardioversion: Ibutilide/flecainide or DCCV
Heparin,TEE, DCCV, and coumadin for 4 weeks
Amiodarone at 1 mg/min for 6 hrs and reassess.
B.
C.
D.
Narrow Complex Tachycardias
.
A.
B.
C.
D.
Heparin, DCCV , and warfarin for 4 weeks
Cardioversion: Ibutilide/flecainide or
DCCV
Heparin,TEE, DCCV, and coumadin for 4
weeks
Amiodarone at 1 mg/min for 6 hrs and
reassess.
Narrow Complex Tachycardias
.
Case 7
62 yo gentleman s/p CABG POD #5. He
has been in and out of AF for the past 3
days. He is quite symptomatic. His CHADS
score is 2.
A. Amiodarone and Coumadin for ever
B. Amiodarone for 3 months and Coumadin
for 4-6 months and then reassess
C. Aspirin 325 mg
Narrow Complex Tachycardias
.
Case 7
A.
Amiodarone and Coumadin for ever
B.
Amiodarone for 3 months and Coumadin
for 4-6 months and then reassess
C.
Aspirin 325 mg
Narrow Complex Tachycardias
.