Download – E R F

ELECTROPHYSIOLOGY ROTATION – FELLOW CURRICULUM
EDUCATIONAL GOALS
THE EDUCATION GOALS FOR THIS ROTATION ARE SPECIFICALLY DESIGNED FOR THE GENERAL
CARDIOLOGIST, BUT CAN BE MODIFIED (INCLUDING MODIFYING THE SCHEDULE) FOR THOSE INTERESTED
IN PURSUING AN ELECTROPHYSIOLOGY FELLOWSHIP.
1.
2.
3.
4.
5.
Gain experience in the clinical management of outpatients with arrhythmias and devices.
Gain experience in the selection of patients for EP procedures including devices.
Gain exposure to electrophysiology procedures.
Gain experience with antiarrhythmic medications.
Develop competence in EKG and Holter interpretation.
SCHEDULE
Monday AM: Clinic with Dr. Crawford (UM)
Monday PM: VA EP Lab
Tuesday AM: EP Clinic (VA)
Tuesday PM: EP Clinic (VA)
Wednesday AM: Clinic with Dr. Jongnarangsin (UM)
Wednesday PM: VA EP Lab or EP Review with Dr. Jongnarangsin
Thursday (alternating weekly)
Thursday AM/PM: EP Procedures (UM Floor 2A)
Thursday AM/PM: Clinic with Dr. Latchamsetty (Brighton Clinic) --- EP Procedures if done early
Friday: Device Interrogation with EP Fellow or Holter Monitor reading
GUIDELINES
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2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation.
2013 European Heart Rhythm Association Practical Guide on the use of NOACs.
2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities.
REVIEW ARTICLES, REFERENCES, & OTHER STUDIES
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Non-pharmacologic Approaches to Stroke Prevention in Atrial Fibrillation (LAA closure)
Congenital Long and Short QT Syndromes
New Algorithm using only lead AVR for differential diagnosis of wide QRS complex tachycardia
Clinical Management of Ventricular Tachycardia
Optimal Programming of Implantable Cardiac-Defibrillators
Dual-Chamber Pacing or ventricular backup pacing in patients with an ICD (DAVID Trial)
Pacemaker or Defibrillator Surgery without Interruption of Anticoagulation (BRUISE
CONTROL)
2014 Subcutaneous ICD Review Article
PRIMARY PREVENTION TRIALS
Study
Multicenter
Automatic
MADIT (1996) Defibrillator
Implantation
Trial
CABG-Patch
(1997)
Patients (n)
Inclusion
criteria
Therapy
Hazard ratio
196
NYHA I–III, prior
MI, LVEF ≤0.35,
NSVT, and
positive EPS
ICD vs.
standard
medical
therapy
0.46
Scheduled for
CABG, LVEF
≤0.35, positive
SAECG
ICD vs.
standard
medical
therapy
1.07
Coronary Artery
Bypass Graft
900
Patch trail
Multicenter
Unsustained
MUSTT (1999)
Tachycardia
Trial
351
c
a
a
a
ICD vs.
CAD, LVEF
0.40
conventional
≤0.40, NSVT,
antiarrhythmic
d
and positive EPS
0.24
therapy
95% CI
P value
0.26–0.82
0.009
0.81–1.42
NS
0.27–0.59
<0.001
0.13–0.45
<0.001
CAT (2002)
Cardiomyopathy
104
Trial
ICD vs.
NYHA II or III,
standard
DCM≤9 months,
medical
LVEF ≤0.30
therapy
0.83
0.45–1.82
NS
AMIOVIRT
(2003)
Amiodarone
versus
Implantable
CardioverterDefibrillator
NYHA I-III, DCM,
asymptomatic ICD vs.
NSVT, LVEF
amiodarone
≤0.35
0.87
0.31–2.42
NS
0.40–1.06
0.08
DEFINITE
(2004)
Defibrillators in
Nonischemic
Cardiomyopathy 458
Treatment
Evaluation
0.06–0.71
0.006
103
ICD vs.
DCM, LVEF
standard
≤0.35, PVCs, or
medical
NSVT
therapy
0.65
0.20
a
b
DINAMIT
(2004)
Defibrillator in
Acute
Myocardial
Infarction Trial
Recent MI, LVEF
≤0.35, impaired
cardiac
autonomic
function
674
ICD vs.
standard
medical
therapy
SCD-HeFT
(2005)
Sudden Cardiac
e
Death in Heart 1676
Failure Trial
ICD plus
standard
NYHA II or III,
medical
LVEF ≤0.35,
therapy vs.
ischaemic and
placebo plus
nonischaemic
standard
cardiomyopathy
medical
therapy
IRIS (2009)
Immediate Risk
Stratification
898
Improves
Survival
ICD vs.
Recent MI, LVEF standard
≤0.40, or NSVT medical
therapy
•
•
•
•
•
•
1.08
0.42
0.77
1.04
a
b
a
0.76–1.55
NS
0.22–0.83
0.009
0.62–0.96
0.007
0.81–1.35
NS
a
Overall mortality.
Death from arrhythmia.
Group randomized to EPS-guided therapy with antiarrhythmic medications or ICDs (out of 704 patients in total).
d
Cardiac arrest or death from arrhythmia.
e
ICD and placebo arms only (excluding amiodarone arm).
CI, confidence interval; DCM, dilated cardiomyopathy; NSVT, non-sustained ventricular tachycardia; NS, non-significant (P> 0.05); SAECG, signal-averaged
electrocardiogram; PVC, premature ventricular complex.
b
c
SECONDARY PREVENTION TRIALS
Patients
(n)
Study
Inclusion
criteria
Therapy
Hazard
ratio
Antiarrhythmics
versus
Implantable
1016
Defibrillator
trail
ICD vs.
VF or
antiarrhythmic
a
symptomatic
0.62
medical
sustained VT
therapy
CASH
(2000)
Cardiac Arrest
288
Study Hamburg
Cardiac
arrest
survivors
CIDS
(2000)
Canadian
Implantable
Defibrillator
Study
Cardiac
arrest, VF or ICD vs.
symptomatic amiodarone
VT
AVID
(1997)
a
659
ICD vs.
0.77
antiarrhythmic
b
medical
0.42
therapy
a
0.82
95% CI
P value
0.43–0.82 <0.02
1.112
0.721
c
c
0.081
0.005
0.60–1.10 NS
d
d
Defibrillator
versus BetaBlockers for
Unexplained
Death in
Thailand
DEBUT
(2003)
86
Cardiac
arrest
survivors
ICD vs. βblocker
therapy
NA (0 vs.
NA
4 deaths)
0.02
Major implantable cardioverter defibrillator trials for secondary prevention of sudden cardiac death
•
•
•
•
•
•
a
Overall mortality.
Sudden death.
Upper bound of 97.5% confidence interval.
d
One-tailed.
e
Death, recurrent cardiac arrest, cardiac transplantation.
CI, confidence interval; NA, not available; NS, non-significant (P> 0.05).
b
c
CRT TRIALS
Study
Topic
MUSTIC-SR
(2001)
CRT in
HFrEF
(ischemic
and nonischemic)
MIRACLE
(2002)
CRT in
HFrEF
(ischemic
and nonischemic)
CRT and
ICD in
MIRACLE ICD HFrEF
(ischemic
(2003)
and nonischemic)
CRT and
CONTAK CD
ICD in
(2003)
HFrEF
Patients Inclusion
(n)
criteria
Therapy
Primary End
Point
Hazard 95% P
ratio CI
value
58
LVEF < 35%,
LVIDd > 60,
QRS > 150,
NYHA III; no
indication for
PPM
Active vs.
Inactive BIV
pacing in the
same patients
after implant
6 min walk
N/A
453
NYHA III or IV,
LVEF ≤ 35%,
LVIDd ≥ 55,
QRS ≥ 130, 6
min walk ≤
450
Active vs.
Inactive BIV
(randomized)
pacing after
implant
NYHA class,
QOL score, 6
min walk
369
NYHA III or IV,
LVEF ≤ 35%,
QRS ≥ 130,
LVIDd ≥ 55,
stable drug
regimen ≥ 1
month
Active vs.
Inactive BIV
(randomized)
pacing after
implant
NYHA class,
QOL score, 6
min walk
490
NYHA II-IV,
LVEF ≤ 35%,
QRS ≥ 120
N/A
<
0.001a
N/A
<
0.001b,
0.001c,
0.005a
N/A
N/A
0.07b,
0.02c,
0.36a
Active vs. Inactive Mortality or
BIV (randomized) Hospitalization N/A
pacing
for HF
N/A
0.35
N/A
CRT and
MIRACLE ICD
ICD in
II (2004)
HFrEF
CRT with
COMPANION
PPM vs.
(2004)
with ICD
CARE HF
(2005)
REVERSE
(2008)
CRT with
ICD in
HFrEF
CRT with
ICD in
HFrEF
CRT with
MADIT-CRT
ICD in
(2009)
HFrEF
186
Active vs.
NYHA II, LVEF Inactive BIV
≤ 35%, QRS ≥ (randomized)
pacing after
130
implant
1520
NYHA III or IV,
LVEF ≤ 35%,
QRS ≥ 120, PR
interval > 150
814
NYHA III or IV,
BIV pacing with
LVEF ≤ 35%,
Death or
ICD vs. Medical
0.63
QRS ≥ 120,
hospitalization
Rx
LVIDd ≥ 30
610
NYHA I or II,
LVEF ≤ 40%,
QRS ≥ 120,
LVIDd ≥ 55
Active vs.
Inactive BIV
(randomized)
pacing after
implant
1820
NYHA I or II,
LVEF ≤ 30%,
QRS ≥ 130,
LVIDd ≥ 55
Death or nonCRT with ICD vs.
fatal heart
0.66
ICD alone
failure event
[0.52,
0.001
0.84]
NYHA II or III,
Death,
CRT with ICD vs.
LVEF ≤ 30%,
hospitalization 0.75
ICD alone
QRS ≥ 120
for CHF
[0.62,
0.003
0.91]
Heart block
needing PPM, BIV pace vs. RV
EF ≤ 50%,
pace in heart
NYHA I, II, or block
III Sx
[0.60,
0.90]
CRT with
RAFT (2010) ICD in
HFrEF
BLOCK-HF
(2013)
a
CHF due to
691
RV pacing
6-minute walk improvement
NYHA class improvement
c
QOL score improvement
d
Companion, BIV pacing without ICD
e
Companion, BIV pacing with ICD
f
Reverse, hospitalization
b
Change in
peak VO2
N/A
Medical Rx vs.
0.80d
BIV pacing vs
Death or
BIV pacing with hospitalization 0.81e
ICD
N/A
[0.68,
0.95]d 0.010d
[0.69, 0.015e
0.96]e
[0.51, <
0.77] 0.001
HF clinical
composite
0.47f
response,
hospitalization
Death, heart
failure
needing IV Tx, 0.75
15% increase
in LVIDs
0.87
0.10
0.03f
BOOKS
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THE COMPLETE GUIDE TO ECGS – JAMES E. O’KEEFE
OXFORD SPECIALIST HANDBOOKS IN CARDIOLOGY
o PACEMAKERS AND ICDS
o CARDIAC ELECTROPHYSIOLOGY AND CATHETER ABLATION
CHOU'S ELECTROCARDIOGRAPHY IN CLINICAL PRACTICE: ADULT AND PEDIATRIC, 6E (FAR MORE
DETAIL IN THIS COMPARED TO O’KEEFE)
CARDIAC ELECTROPHYSIOLOGY: FROM CELL TO BEDSIDE, 6TH ED
2012 ACC BOARD REVIEW LECTURES (WILL NEED LOGIN)
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Chapter 3 - Electrophysiology
MAYO BOARD REVIEW LECTURES
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Video #19 – Intracardiac Tracings
Video #20 – Atrial Fibrillation
Video #22 – ICDs
Video #23 – SVTs
Video #24 – Ventricular Arrhythmias
Video #25 – Pacemakers
Video #26 – Antiarrhythmic Agents
Video #37 – Cardiac Channelopathies
Video #40 – ECGs
Video #27 – EP Mock Test