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Transcript
Arrhythmias: Tests, Devices, Physiologists Jane Eldridge BSc(Hons) Dunelm, ACP, BSc(Hons) Clin. Phys., MRCCP Lead Cardiac Physiologist Cardiac Catheter Labs West Herts NHS Trust Tests for Arrhythmias ECG, with rhythm strip Carotid sinus massage (Hypersensitive carotid sinus syndrome) 24 hour ECG holter (a.k.a. tape analysis) 48 hour to 7 day ECG holter (for less frequent symtoms) Implanted ECG Loop Recording Device (Reveal™ for very infrequent symptoms) Treadmill test for HR response (chronotropic incompetence) and exercise-induced arrhythmia Echocardiography (structural causes for arrhythmia) Tilt-testing (pre-syncope / syncope) Electrophysiology Study (EPS) for accessory pathways and circular or re-entry arrhythmias potentially suitable for ablation ECGs Excellent diagnostic tool Non-invasive, quick, easy and cheap! Recommend rhythm strip also Beware of auto-reporting! Good skin prep and electrode contact for clear & clean ECG Essential to have good electrode positioning to be useful as a diagnostic tool Carotid sinus massage (CSM) to provoke arrhythmia eg asystole ECG Holters / Tape analysis Del-Mar Reynolds “Lifecards” Symptoms button ± diary Each card loaded into specialist tape analyser software Each 24hr tape takes approx 30 mins to analyse by experienced Cardiac Physiologist All recorded ECG is examined Correlation of symptoms very important Report generated by Cardiac Physiologist Significant arrhythmias reported immediately to Cardiologist Implantable ECG Loop Recording Devices (ILRs): Reveals Implanted left pectoral region Programmable criteria for auto recording eg brady @ 30bpm Activator given to patient to press if symptomatic Pt comes into clinic for regular (usually 3 monthly) downloads of device by Cardiac Physiologist Can only be downloaded with specialist programmer Pt advised to contact dept ASAP if they have an event so the device can be downloaded Devices cost approx £1250 Battery lasts for approx 2-3 yrs Exercise testing for arrhythmia & chronotropic response Looking for appropriate HR response to exercise (and any exercise induced arrhythmia) Conducted by 2 Cardiac Physiologists (who should have ILS or ALS certificate) using treadmill Terminated for observed arrhythmia, symptoms or poor HR response Report generated and printouts of arrhythmias observed Head-up Tilt Testing for Neurally Mediated Syncope Warm, quiet, low lighting room Attempt to provoke event. BP and HR closely monitored by Cardiac Physiologist (who should have ILS or ALS certificate) Significant HR drop / sinus pause / asystole (cardioinhibitory response) may be suitable for pacemaker implant For sudden heart rate drops we may use specialised algorithms on the pacemaker known as “accelerations” Loss of vascular tone with blood pressure drop (vasodepressor response); Pacemaker may be unsuitable Echocardiography to identify structural causes for arrhythmia Non-invasive test that gives vast array of information Cardiac dimensions Cardiac function Valve structures Valve functions Shunts & abnormalities Cardiomyopathies Dysynchrony Approx 40 mins per test Highly Specialist Cardiac Physiologist required Electrophysiology study (EPS) Several specialised catheters inserted into different areas of the heart Electrical activation pattern mapped Accessory pathways, circular routes or re-entry circuits identified Carefully controlled radiofrequency ablation across faulty pathways administered by Cardiac Physiologist Expensive, very specialised equipment and staff, timeconsuming procedure (2-4hrs) Can be curative Indications for device implant Pacemakers – SSS, AVB, CHB, CI, Chronic AF with bradycardia, Symptomatic Bifasicular block / Trifasicular block, Neurally mediated syncope (CSS, VVS, situational syncope) Biventricular pacemakers (CRT-P) – CHF with LBBB & low EF(<35%), dysynchrony on echo, long PR with poor haemodynamics, NYHA class IV Implantable Cardiac Defibrillators (ICDs) – Primary indication; significant risk of life threatening arrhythmia eg Long QT, Brugada, DCM, Post MI with NSVT & poor EF – Secondary indication; survival of a VT or VF arrest Biventricular ICD (CRT-D) – CHF with LBBB & low EF(<35%), dysynchrony on echo, long PR with poor haemodynamics, NYHA class III or IV, prior MI with risk of SCD Pacemakers Single (atrial or ventricular) or dual chambered Pacemakers now store lots of information that can be reviewed at follow-up eg % time spent in AF Now extremely programmable with many features & algorithms eg (a few examples) – Rate responsiveness (HR in response to activity) – AF suppression (pacing the atria) – Rate drop acceleration response Must be regularly followed up in clinic (at least once a year) to assess function and battery Requires highly specialist equipment and Cardiac Physiologists for implant and follow-up Device costs vary from approx £1500 to £3500 Biventricular pacemakers Also known as Cardiac Resynchronisation Therapy (CRT) May be patients for whom chronic RV pacing is becoming problematic 3 leads usually (atria, RV and LV) Pacing both ventricles in a timed manner allowing resynchronisation Optimises cardiac output by allowing appropriate ventricular filling and coordinated contraction CRT devices cost about £4000 to £8000 Implantable Cardiac Defibrillators ICDs Ability to DC shock for ventricular tachyarrhythmias eg VF and VT 700-800 Volts or 30-40 Joules Most now can also deliver ATP (antitachy pacing) to attempt to reduce need for shock therapy Extremely complex devices that have many programmable features Set-up and management is often quite tricky eg in the presence of AF Most devices are also able to pace although most patients do not have a primary pacing indication ICD systems cost approx £8,000 to £15,000 Biventricular ICDs! Also known as “CRT-D” 2 ventricular leads for cardiac resynchronisation Shock leads for defibrillation Highly complex, very programmable devices Highly specialist equipment and Cardiac Physiologists required Devices cost up to £15,000 Specialist Cardiac Staff Cardiographers – Basic qualifications / certification – ECGs, application and removal of tapes and monitors Cardiac Physiologists – Qualified to BSc (Hons) Clinical Physiology (4 yrs) or equivalent – Registered with RCCP (voluntary, soon compulsory) – ECG analysis & interpretation, tape analysis, exercise treadmill testing, RACPC, tilt testing, cardiac catheterisation & intervention Highly Specialist Cardiac Physiologists – Post registration specialisation in echo or devices and / or electrophysiology (a further 2-4 yrs) – Higher qualifications eg BSE, NASPE or HRUK accreditation – Independent echo reporting, device management (implant and follow-up) and or electrophysiology study interpretation and treatment Guidelines for practice National standards for practice: – National Institute of Clinical Excellence (NICE) – British Cardiovascular Society (BCS) publishes guidelines for national standards of practice and has affiliations of the following groups: – The Society for Cardiological Science and Technology (SCST) – Registration Council of Clinical Physiologists (RCCP) – British Society of Echocardiography (BSE) – Heart Rhythm UK (HRUK) for Devices and EP – Arrhythmia Alliance (AA) – for info leaflets – British Heart Foundation (BHF) – for info booklets Local guidelines and competancies in Cardiology Dept Any questions? Old method for taking an ECG!