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3/8/2011
INTRINSIC RATE
SA NODE- 60-100
JUNCTION- 40
JUNCTION
40-60
60
VENTRICULAR- 20-40
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• Symptoms
Palpitation
Syncope- 15% of SVT patient.
Polyuria after Palpitation
• Baseline EKG- Evaluate for MI, delta
wave, QT interval etc.
• Try to Catch Arrhythmia on EKG
Holter Monitor, Event Moniter
Loop Recorder- Less frequent symptoms ( <2 episode/month)
• During Tachycardia
Adenosine and Vagal Maneuver might help in identifying mechanism.
FURTHER INVESTIGATION BASED
ON CLINICAL JUDGEMENT
•
•
•
•
24 48hr Holter
24-48hr
Event recorder – 1-2 month recording
ETT – if suspicious for ischemia
ECHO - structural heart disease, Systolic
function, PA pressure, Cardiac Tumor
• Tilt Table – POTS
• Electrophysiological Study- Severe Episode, WPW,
Mechanism Unclear, Recurrent Sustain SVT.
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DIAGNOSTIC APPROACH TO TACHYCARDIA
Wide Complex
Narrow Complex
VT
SVT with Aberrancy
Preexited tachycardia
Electrolyte or Drug effect
Irregular
Atrial fibrillation
A- Flutter with Variable Conduction
MAT
Regular
Short RP
Long RP
AVNRT
AVRT
A-Tachycardia
Sinus Tachycardia
Atypical AVNRT
PJRT
12 Lead EKG and Adenosine
will Help in majority of cases
R
R
P
Short RP
R
P
R
Long RP
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• Adenosine
Drug interactionTheophylline – Less effect
Dipyridamole – Potentiate effect
C b
Carbamazepine
i – Potentiate
P t ti t effect
ff t
Heart Transplant- Only Use 3 mg.
Caution
Severe Bronchial Asthma
Known Severe CAD
Small Peripheral IV
WPW Syndrome- Can precipitate A fib (1-5%) and rapid conduction
down the accessory pathway.
Dose
6 mg Rapid IV followed by 12mg x2 doses if needed.
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•
1.
2.
3
3.
4.
•
Sinus Tachycardia
Physiologic Sinus Tachycardia
POTS (Postural Orthostatic Tachycardia Syndrome)
Sinus Node Reentry.
Reentry
Inappropriate Sinus Tachycardia – Failure of Mechanism that controls
Sinus rate
Diagnosis
P wave Morphology on Surface EKG.
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•
Sinus Node Reentry
1.
Paroxysmal
2.
P wave Morphology and Endocardial activation identical to sinus
rhythm.
Induction and Termination of Arrhythmia occurs with PAC
PAC.
Termination occurs with adenosine and Vagal maneuvers.
3
3.
4.
•
Treatment
B-Blocker, CCC, AAD
Catheter Ablation in Refractory cases.
•
1.
2
2.
3.
4.
Inappropriate Sinus tachycardia
Exclusion of Secondary cause- Thyroid, Pheochromocytoma and
Deconditioning.
Symptoms is nonparoxysmal
nonparoxysmal.
Tachycardia at rest with excessive rate increase in response to activity
and normalization of rate at night confirmed by Holter
P wave and Endocardial activation identical to sinus rhythm
•
T t
Treatment
t
1.
2.
BB, CCB
Catheter Ablation and Sinus Node modification in refractory cases.
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• AVNRT( AV nodal Reentry Tachycardia)
•
•
Most common SVT- Slot-Fast being more common, Fast-Slow uncommon
Treatment
Acute Treatment
Chronic TreatmentPharmacotherapy
- Life Long
- 30-50% effective
- Side effect and Long
g term cost
Ablation Therapy
- Usually One procedure
- 96-98% Success
- Invasive Procedure
* High risk Job, Pt preference, Pregnancy, Frequency of Symptoms, Tolerance
ACC/AHA/ESC Guideline for Management of SVT
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Insert slide of Fluro of AVNRT
Focal Junctional Tachycardia
•
Paroxysmal usually occurs in pediatric population
•
Nonparoxysmal
Dig Toxicity,
Toxicity Myocardial Ischemia,
Ischemia COPD
COPD, Myocarditis
Myocarditis, Hypokalemia
Hypokalemia.
Usually Treating Underlying Cause is sufficient.
BB, CCB can be considered.
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ACCESSORY PATHWAY LOCATION
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ACCESSORY PATHWAY MEDIATED TACHYCARDIA
AVRT- Orhtodromic
AVRT- Antidromic
A-Tach, A fib, A-flutter with Conduction down the accessory pathway
Some Pt has A FIB with Ventricular Preexitation as presenting Rhythm
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Risk of SCD in Patient with WPW
•
•
•
•
Shortest Preexited R-R Interval of <250msec either during Spontaneous A
FIB or during Induced A FIB.
History of Tachycardia
Multiple Accessory Pathway
Ebstein Anomaly.
Management of Asymptomatic Patient with Preexitation
Di
Diagnosis
i <40
40 Y
Year- 1/3 patient
ti t will
ill h
have S
Symptoms
t
Diagnosis after 40 Year unlikely to have symptoms
Pt should be advised to seek attention if symptoms occur or any syncope
Family H/O SCD or Prior Syncope
Catheter Ablation is a choice if pt desires and in High Risk Public Job
Catheter Ablation has Success rate of 95% with Complication rate 1-2%
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• Atrial Tachycardia
Focal Atrial TachycardiaP wave Morphology can Help in judging Origin
EP Study to Locate Origin and Ablation can be curative.
Suboptimal Evidence but AAD can be used.
Macro Reentry Atrial Tachycardia- Atrial Flutter, Scar Related Flutter, Post
A FIB Ablation
12 Lead EKG can be confusing in Many Occasion.
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45 YM with Long standing H/O Palpitation
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Which of the following is true?
A.
Mechanism of
t h
tachycardia
di is
i VT
B.
Intravenous verapamil
should help
C.
Immediate DCCV is
needed
D.
Catheter ablation
could be performed
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A. VT
B. SVT with aberrancy C. Antidromic tachycardia
Atrial Fibrillation
•
•
•
•
Paroxysmal
Persistent
Long standing Persistent
Permanent
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CAUSE
Pulmonary disease
Infection, IHD
Rheumatic
h
ti H
Heartt di
disease
Alcohol intoxication (Holiday heart)
Thyrotoxicosis, Toxins
Electrolyte Imbalance
Surgery, Structural heart disease
Hypertension
Acute Management
• ACUTE MANAGEMENT
- Rate control
- BB + CCB first line
- Digoxin is preferred if Hypotension, LV failure,
cardiomyopathy
- IV amiodarone is rarely needed
- Anticoagulation
if >48hr, duration depends on underlying
cause
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CHRONIC MANAGEMENT
- is patient symptomatic ?
- is there LV dysfunction ?
- is it possible to keep in NSR with
acceptable risk and Effort ?
CHRONIC MANAGEMENT
RATE CONTROL
RHYTHM CONTROL
Asymptomatic
Symptomatic patient
Long Persistent a fib
LV dysfunction/CHF
Reversible cause
Recent onset or paroxysmal
Young patient
Beta blocker
Nondihydropyridine CCB
Digoxin
Class III A
Cl
Amiodarone,
i d
sotalol, dofetalide
Class Ic Flecainide,
propafanone
Anticoagulation is needed in either treatment strategy based on RF for Stroke
always use AV nodal blocker with class Ic drugs
Atrial flutter and Fibrillation should be treated same for Anticoagulation
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Maintenance of Sinus Rhythm
Minimal or no
heart disease
Sotalol
Flecainide
Propafanone
Amiodarone
RFA
HTN WITH LVH
NO
Sotalol
Flecainide
Propafanone
Amiodarone
dofetalide
RFA
Weak risk factor
Female gender
Age 65-74
CAD
Thyrotoxicosis
CHF
CAD
YES
Amiodarone
RFA
Sotalol
Dofetalide
Amiodarone
RFA
Moderate Risk factor
Age >75 year
HTN
DM
Heart failure
LVEF <35%
3 %
Amiodarone
Dofetalide
RFA
High risk factor
Prior Stroke, TIA, embolism
Mitral Stenosis
Prosthetic Heart valve
Risk category
Recommended Therapy
No Risk factor
ASA 81-325mg
One moderate Risk factor
ASA or Coumadin (INR 2-3)
Any high risk factor or >1
moderate Risk factor
Coumadin (INR 2-3)
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CHADS 2 Risk criteria
Prior stroke or TIA - 2
Age >75 year
- 1
Htn
- 1
Dm
- 1
Heart failure
- 1
Patient
Stroke risk % /ye
120
463
523
337
220
65
5
1.9
2.8
4
5.9
8.5
12.5
18.2
CHADS 2 score
0
1
2
3
4
5
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Syncope
•
T-LOC due to global cerebral
hypoperfusion characterized by rapid
onset short duration and spontaneous
onset,
recovery.
•
•
Is LOC complete?
Was LOC rapid, transient, and short
duration?
Recovery complete?
Did the pt lost postural tone?
•
•
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Classification of Syncope
Prognosis
•
Risk of SCD - Usually channalopathies, Cardiomyopathy.
•
Risk of recurrance and Injury
2 episode of syncope – 15 and 20% recurrance after 1 and 2 yr.
3 or more episode of syncope- 36 and 42% recurrance after 1 and 2 yr.
Major injury and MVA accident- 6%
Minor injury- 29%
Elderly patient in general tends to have more injury related events.
Physical Impairment of recurrent syncope is comparable to Arthritis, ESRD
and Depression
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Economic Issue
•
1% ER visit and 45% being admitted
•
Medicare estimated cost for syncope was US$2.4billion/year.
•
Comparative study showed 29% reduced cost if guidelines are followed.
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• Initial Evaluation- 23-50% diagnosis
Careful H&P
Orthostatic Vital check
12 lead EKG.
Carotid Sinus Massage if age >40 yr and No carotid Bruit or CVA within 3 month
Positive CSM
Reproduction of syncope with Asystole>3 sec and SBP drop>50mmhg.
If diagnosis can not be made than risk stratification
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Tilt Table Testing
In pt with structural heart disease arrhythmic cause should be evaluated before HUT
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In Hospital Monitoring
For High Risk pt.
Yield is only up to 16% in selected pt.
Holter Moniter
Symptoms and Rhythm correlation
Only Useful if Frequent Syncope
may help to exclude arrhythmia cause.
Event Moniter
Long Monitoring
Limited value in evaluation of syncope.
Implantable Loop recorder
Symptom-rhythm correlation in upto 88% of cases.
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Electrophysiologic Study
•
•
•
•
•
Role is Limited Now days as ICD is implanted prophylactically in high risk
pt.
Baseline sinus bradycardia<50bpm
Baseline BBB and progression to CHB at FU of 4 Year.
HV iinterval
t
l <55msec
55
- 4%
HV interval >70msec – 12%
HV interval >100msec -24%
IF EPS negative for VT in pt with MI- Low risk for tachyarrhythmia.
Sensitivity is limited and Loop recorder is usually advised if arrhythmic
diagnosis is still likely.
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Exercise testing.
Only For pt with Syncope during exercise or soon after exercise.
Psuedosyncope
Last Longer
No recorded Hemodyanamic or EEG abnormality during episode
Several Episode a day with Eye closed
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Differentiating Seizure vs Syncope
• Jerk lasts longer in seizure than syncope
• Jerk is synchronus and rhyhtmic in epilepsy
post ictal state longer
g in epilepsy
p p y
• p
• muscle pain, elevated CK and prolactin level more in epilepsy
• In syncope Jerk happens after Loss of consiouseness and after fall.
• Aura of unpleasant taste and rising epigestric pain more likely in epilepsy.
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• Treatment
General Rule for Nonarrhyhtmic Syncope
Reassure Patient
Identify Trigger and Advice to Avoid
Proper Hydration 2-3L/day of water
Up to 10gm of Salt
Teach PCM maneuver
Supine Position upon warning
Avoid Diuretics, Vasodilator.
Discuss Medication option for frequent recurrent syncope.
General Rule for Arrhythmic Syncope
Evaluate Risk of SCD
SVT- Refer for Ablation
For VT ICD- Does not prevent syncope but reduce Risk of SCD
For Bradyarrhythmia consider PPM.
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25 YM with First Time syncope
56 YF with Recurrent Syncope and Hospitalization
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61 YM with recurrent syncope
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