Download Synopsis of Management on Ventricular arrhythmias

Synopsis of Management on
Ventricular arrhythmias
M. Soni MD
Interventional Cardiologist
No financial disclosure
Premature Ventricular Contraction (PVC)
Ventricular Bigeminy
Ventricular Trigeminy
Multifocal PVC’s
Ventricular Couplet or Paired PVC’s
Unifocal
Multifocal
Ventricular Tachycardia:
Non Sustained
Ventricular Tachycardia to V Fib
(Torsades de pointes)
“Twists of points”
Comment: The QRS changes from negative to positive polarity and appears to twist
around the isoelectric line.
Ventricular Fibrillation
Clinical presentation
Ventricular arrhythmias
• Asymptomatic ventricular arrhythmias in the absence
of identifiable heart disease predicted a small
increase in risk (Ann Intern Med 1992;117:990–6) , while another study
suggested no increased risk.(J Intern Med 1999;246:363–72)
• PVCs and runs of NSVT in subjects with structural
heart disease contribute to an increased mortality
risk.
• Suppression of PVCs – Severe and disabling symptoms.
• Beta blocker – Antiarrhythmic
• Refractory cases: Radiofrequency catheter ablation.
Ventricular arrhythmias
• SCD is leading cause of death in USA. estimates in
the range of 300,000 to 350,000 SCDs annually.
• At least 50% of all SCDs due to CHD occur as a first
clinical event or among subgroups of patients thought
to be at relatively low risk for SCD.
• The rhythm most often recorded at the time of
sudden cardiac arrest is ventricular tachyarrhythmia
(VF>>VT).
Automated external defibrillator
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Approximately 80% of cardiac
arrests occur out-of hospital.
AED saves lives when external
defibrillation can be rendered
within minutes of onset of VF.
Its use by both traditional and
nontraditional first responders
appears to be safe and
effective.
Federal, state and community
efforts have been effective in
placing AEDs in schools, sporting
events, high-density residential
sites and airports as well as on
airplanes and in police and fire
department vehicles.
EVALUATION OF PATIENTS WITH DOCUMENTED
OR SUSPECTED VENTRICULAR ARRHYTHMIAS
Resting Electrocardiogram
Exercise Testing
Ambulatory Electrocardiography
Left Ventricular Function and Imaging –
Echocardiogram, Cardiac CT/MRI, Myocardial
perfusion SPECT, Coronary angiogram
• Electrophysiological Testing
• EP testing for the evaluation of VT was
introduced in 1972 by Wellens et al.
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Ventricular arrhythmias
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Beta blocker
Antiarrhythmic till 1980 (Class I III)
ICD (First ICD placed in feb 1980)
Ischemia
Electrolytes (K and Mg)
Drugs
Ablation
Surgery
Therapies For
Ventricular Arrhythmia
• Beta blockers are effective in suppressing
ventricular ectopic beats and arrhythmias as well
as in reducing SCD in a spectrum of cardiac
disorders in patients with and without HF.
• With the exception of beta blockers, the
currently available antiarrhythmic drugs have not
been shown in randomized clinical trials to be
effective in the primary management of patients
with life-threatening ventricular arrhythmias or
in the prevention of SCD.
Special Considerations Where
Antiarrhythmic Drugs May Be Indicated
• Patients With Ventricular Tachyarrhythmias Who Do
Not Meet Criteria for an Implantable CardioverterDefibrillator
• Patients With ICD Who Have Recurrent Ventricular
Tachycardia/Ventricular Fibrillation With Frequent
Appropriate ICD Firing.
• Patients With ICD Who Have Paroxysmal or Chronic
Atrial Fibrillation With Rapid Rates and
Inappropriate ICD Firing.
Conclusions:
Among survivors of ventricular fibrillation
or sustained ventricular tachycardia causing
severe symptoms, the implantable cardioverter–
defibrillator is superior to antiarrhythmic drugs for
increasing overall survival.
(N Engl J Med 1997;337:1576-83.)
Conclusions::
In patients with a prior myocardial infarction
who are at high risk for ventricular tachyarrhythmia,
prophylactic therapy with an implanted defibrillator
leads to improved survival as compared
with conventional medical therapy.
(N Engl J Med 1996;335:1933-40.)
Conclusions
In patients with a prior myocardial infarction
and advanced left ventricular dysfunction,
prophylactic implantation of a defibrillator improves
survival and should be considered as a recommended
therapy.
(N Engl J Med 2002;346:877-83.)
Conclusions::
In patients with NYHA class II or III CHF and LVEF of 35 percent or
less, amiodarone has no favorable effect on survival, whereas single-lead,
shock-only ICD therapy reduces overall mortality by 23 percent.
NEJM 352;3 January 20, 2005
Implantable Cardioverter Defibrillator
ICD therapy, compared with conventional or traditional antiarrhythmic
drug therapy, has been associated with mortality reductions
from 23% to 55% depending on the risk group participating
in the trial, with the improvement in survival due almost
exclusively to a reduction in SCD.
ACC/AHA/ESC 2006
Catheter Ablation Therapy
• Used for more than 25 years.
• Success rate; Normal heart >
90%, Structural heart
disease 50-75%
• Initially used in the
treatment of patients with
multiple ICD shocks for VT
(VT storm), it is now used
more frequently and earlier
in the management of VT.
• Excellent choice for patients
when medications are not
effective, tolerated, or
preferred.
Mapping of VT
Surgical therapy
• EP mapping and surgical resection of an
arrhythmogenic focus.
• Left cervicothoracic sympathetic ganglionectomy in
LQTS
• Large myocardial aneurysms secondary to MI are
associated with hemodynamic compromise and are
frequently accompanied by major ventricular
arrhythmias.
• In selected patient aneurysm resection can improve
cardiac function and may reduce or eliminate the
accompanying ventricular arrhythmia.