arrhythmias and dysrhythmias€¦ · • sex category (female sex) ... • pre-existing...

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Arrhythmias and Dysrhythmias

Craig Barstow, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Craig Barstow, MD, FAAFPProgram Director, Hospitalist Fellowship at Womack Army Medical Center, Fort Bragg, North Carolina; Assistant Professor of Family Medicine at Uniformed Services University of Health Sciences, Bethesda, Maryland; Director of Ultrasound Education, Family Medicine Residency Program, Womack Army Medical Center; Physician, Scotland Memorial Hospital Emergency Department, Laurinburg, North Carolina.

Dr. Barstow is a graduate of the Uniformed Services University of the Health Sciences –F. Edward Herbert School of Medicine in Bethesda, Maryland. He completed undergraduate studies at the U.S. Military Academy. Dr. Barstow joined the Womack Army Medical Center Family Medicine Residency Program in 2012, and created the fellowship program, accepting the first fellow in July 2015. His areas of interest include inpatient family medicine, newborn care, and point-of-care ultrasound teaching.

Learning Objectives1. Identify the causes of ventricular arrhythmias and differentiate the types of

ventricular arrhythmias and identify the causes of atrial arrhythmias and differentiate the types of atrial arrhythmias.

2. Manage life-threatening ventricular arrhythmias, and assess, diagnose and stratify for risk patients who have, or are at risk for, ventricular arrhythmias.

3. Develop collaborative care plans with patients, emphasizing medication adherence and follow-up.

4. Establish quality improvement plans to maximize care coordination and minimize hospital readmission.

Associated Session(s)

• Arrhythmias and Dysrhythmias: PBL

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Audience Engagement SystemStep 1 Step 2 Step 3

Arrhythmias and Dysrhythmias

Tachyarrhythmia

• Atrial fibrillation

• Supraventricular tachycardia

• Ventricular tachycardia

Bradyarrhythmia

Tachyarrhythmias

Case 1

Evelyn is a 65-year old woman who presents for a routine office visit. On physical exam, she is noted to have an irregular heart rate.

AES POLL QUESTIONWhat is the most common arrhythmia worldwide?

A. Atrioventricular blockB. Wolf Parkinson White syndromeC. Atrial fibrillationD. Atrial flutter

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Atrial Fibrillation

• Most common cardiac arrhythmia worldwide

• Disease of aging

– 1% patients < 60

– 8-12% patients > 80

• 450,000 admission per year in the US

• Significant cause of stroke

– Increased mortality and morbidity from stroke from AFGo AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics‐2014 update: a report from the American Heart Association. Circulation.2014; 129(3):e28‐e292.

Atrial Fibrillation

• Paroxysmal AF

• Persistent AF

• Long-standing AF

• Permanent AF

• Nonvalvular AF

Treatment of Atrial FibrillationAcute Management

If hemodynamically unstable– Electrical cardioversion

If hemodynamically stable but symptomatic(with no pre-excitation)

– Metoprolol 2.5-5.0 mg IV bolus every 3 min; up to 3 doses– Verapamil 0.075-0.15 mg/kg IV bolus over 2 min; may give an

additional 10.0 mg after 30 min in no response, then 0.005 mg/kg/min infusion

– Diltiazem 0.25 mg/kg IV bolus over 2 min; then 5-15 mg/hrJanuary CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J AM Coll Cardiol 2014; 64: e1‐76.

Treatment of Atrial FibrillationRate vs. Rhythm Control

• AFFIRM and RACE trials• Rate control equivalent to rhythm control• Rhythm control

– Proarrhythmic– Requires monitoring– Reoccurs in 20-60% at one year– Increased hospitalization rate

Rate Control• Beta blockers

– esmolol– propranolol– metoprolol

• Nondihydropyridine calcium channel blockers– diltiazem– verapamil

• Digoxin• Amiodarone

Rhythm Control

• Cardioversion

• Antiarrhythmic drugs

• Catheter ablation

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Cardioversion

• Electrical• Pharmacological

– Flecainide– Dofetilide– Propafenone– Ibutilide– Amiodarone

Catheter Ablation

• Symptomatic paroxysmal AF refractory to medication when rhythm control is desired (Class 1: LOE A)

• Recurrent symptomatic paroxysmal AF in some patients (Class 2a: LOE A)

• Reasonable for persistent AF refractory to medication (Class 2a: LOE A)

January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J AM Coll Cardiol 2014; 64: e1‐76.

Anticoagulation• In patients with AF, antithrombotic therapy should be

individualized based on absolute and relative risks of stroke and bleeding (Class I; LOE: C)

• Selection of antithrombotic therapy should be based on the risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent, or permanent (Class 1; LOE C)

• In patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of stroke risk. (Class 1: LOE B)


CHA2DS2-VASc• Congestive heart failure• Hypertension• Age > 75 (2 points)• Diabetes mellitus• Prior stroke or TIA or thromboembolism (2 points)• Vascular disease• Age 65-74 years• Sex category (female sex)


HAS-BLED Score• Hypertension (Uncontrolled > 160 mm Hg)• Abnormal liver/renal function• Stroke• Bleeding history• Labile INR (<60% time in therapeutic range)• Elderly (Age >65)• Drug/alcohol use

Pister R, et al. A novel user‐friendly score (HAS‐BLED) to assess 1‐year risk of major bleeding in patients with atrial fibrillation. Chest. 2010; 138: 1093‐1100.

Anticoagulation

WarfarinNovel oral anticoagulants• dabigatran• rivaroxaban• apixaban• edoxaban

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AES POLL QUESTION

For patients with atrial fibrillation, aspirin provides an absolute risk reduction of…A. 8%B. 80%C. 4%D. 0.8%

Case 2

A 76-year old male presents to your office complaining of palpitations. He has a history of atrial fibrillation. An ECG reveals the following:

Atrial Flutter

• Reentrant atrial arrhythmia• Regular atrial rate• Constant p-wave morphology• Similar risk factors for atrial fibrillation• Atrial flutter and atrial fibrillation can

coexist in same patient

Atrial Flutter• Acute Management• Hemodynamically unstable

– Rhythm control• Synchronized cardioversion (Class 1)

– Rate control• IV amiodarone (Class 2a)

• Hemodynamically stable– Rhythm control

• Synchronized cardioversion (Calls 1)– Rate control

• IV beta blockers, diltiazem, verapamil (Class 1)• IV amiodarone (Class 2a)

Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016; 67: e27‐115.

Atrial Flutter

Chronic Management1. Rate control

• Beta blockers, diltiazem, verapamil (Class 1)2. Rhythm control

• Catheter ablation (Class 1)• Amiodarone, dofetiliide or sotalol (Class 2a)• Flecainide or propafenone (Class 2b)

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Case 3

A five-week old infant presents for her well baby exam. A fast heart rate is noted on physical examination. An ECG shows the following:

ECG courtesy of Ryan Flannigan, MD FAAP FACC

Supraventricular Tachycardia• Atrial or ventricular rates above 100 bpm• Involves tissue from the bundle of His or above• Includes

– Inappropriate sinus tachycardia– Junctional sinus tachycardia– Atrial tachycardia– Macroreentrant atrial tachycardia– AVNRT– AVRT

SA Node

AV Node

Bundle of His

Left and right bundle branches

Supraventricular Tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT)

• Involved two distinct pathways– Fast and slow

• Most common SVT

SA Node

AV Node

Bundle of His


Fast pathwaySlow pathway

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Atrioventricular Reentrant Tachycardia (AVRT)

• Reentrant tachycardia

• Electrical pathway– Atrium

– Atrioventricular node

– Accessory pathway

• Most common in young children

AVRTAccessory pathway• Extranodal AV pathway that connects the atrium to the

ventricle• Manifest pathway

– Conducts anterograde, causing pre-excitation• Concealed pathway

– Conducts only retrograde• Pre-excitation

– Manifest pathway leading to short PR interval and slurring of QRS

Atrium

AV Node

Bundle of His


Accessory pathway

16-year old female with palpitations


Treatment of SVTAcute Management

1. Vagal maneuver or adenosine (Class 1)2. Hemodynamically stable or unstable?

– Hemodynamically unstable• Synchronized cardioversion

– Hemodynamically stable• IV beta blocker, diltiazem, verapamil• Synchronized cardioversion

Treatment of SVTOngoing Management

• EP study and ablation• Medical therapy

– Beta blockers, diltiazem or verapamil (if no pre-excitation) (Class 1)

– Flecainide or propafenone (Class 2a)– Amiodarone, dofetilide or sotalol (Class 2b)– Digoxin (if no pre-excitation) (Class 2b)

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Tachycardia-Induced Cardiomyopathy

• Cardiomyopathy secondary to sustained tachycardia

• Dilated cardiomyopathy

• Sustained tachycardia for months to years

• Reversible with control of underlying rhythm

AES POLL QUESTION

Which of the following are relatively contraindicated in AVRT with preexcitation?

A. Adenosine

B. Beta blockers

C. Nondihydropyridine CCB

D. B and CPage RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016; 67: e27‐115.

Wide Complex Tachycardia

Case 4

A 60-year old woman presents to your clinic with palpitations and shortness of breath. She has a history of atrial fibrillation. ECG reveals a wide-complex regular tachycardia.

Wide Complex Tachycardia

• Ventricular tachycardia

• Supraventricular rhythm with abnormal conduction

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Wide Complex TachycardiaSVT with abnormal conduction

• Pre-existing bundle-branch block or intraventricular conduction defect

• Aberrant conduction due to tachycardia (normal QRS in sinus rhythm)

• Electrolyte or metabolic disorder

• Conduction over an accessory pathway

Paced rhythm


Ventricular Arrhythmias

• PVCs

• Monomorphic SVT– Sustained (more than 30 second)

– Nonsustained

• Polymorphic SVT– Torsades de Points

Ventricular Arrhythmias• Monomorphic ventricular tachycardia

– May be SVT in origin– Result of structural heart disease– Idiopathic ventricular tachycardia

• Polymorphic ventricular tachycardia– Clinically significant structural heart disease

• Acute myocardial infarction• Cardiomyopathies• Genetic arrhythmia syndromes

– ICD may be indicated• PVCs and non-sustained ventricular tachycardia

– Low risk in absence of structural heart disease or arrhythmia syndrome

Causes of Sudden Cardiac Death

Ventricular fibrillation (62.4%)

Bradyarrhythmias (16.5%)

Torsades de pointes (12.7%)

Ventricular tachycardia (8.3%)

Holter monitor

ECG courtesy of Ryan Flannigan, MD FAAP FACC ECG courtesy of Ryan Flannigan, MD FAAP FACC

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11-year old with syncope and a family history of seizures


11-year old with syncope and a family history of seizures 11-year old with syncope and a family history of seizures

Management of Wide Complex Tachycardia

If patient is unstable• Synchronized cardioversionIf regular and monomorphic• Consider adenosine• Antiarrhythmic therapy

– Procainamide– Amiodarone– Sotalol

• CardioversionIf irregular• Treat as atrial fibrillation or flutterIf polymorphic• Defibrillation

American Heart Association. Part 7: Advanced Cardiovascular Life Support. Web‐based integrate 2010 and 2015 Guidelines. https://eccguidelines.heart.org/wp‐content/themes/eccstaging/dompdf‐master/pdffiles/part‐7‐adult‐advanced‐cardiovascular‐life‐support.pdf. Accessed July 2016.

Management of Ventricular Tachycardia

• Treat underlying disease

• No antiarrhythmic proven to prevent sudden cardiac death– metoprolol

• ICD placement in appropriate patients

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Sudden Cardiac Death (SCD)In patients with heart disease

• Older patients– Coronary artery disease– Valvular heart disease– Heart failure

• Predictors– Severity of underlying disease

• Coronary heart disease• Heart failure

– Ejection fraction strongest predictor (< 30-40%)

Sudden Cardiac Death (SCD)In patients without heart disease

• 50% have undiagnosed ischemic heart disease

• Younger patients– Chanelopathies– Cardiomyopathy– Myocarditis– Substance abuse

CardiomyopathiesPrimary Cardiomyopathies Secondary Cardiomyopathies

Genetic Mixed Acquired Infiltrative/Storage

Endocrine Other

Hypertrophic cardiomyopathy

Dilated cardiomyopathy Myocarditis Amyloidosis Diabetes mellitus Sarcoidosis

Arrhythmogenic right ventricular dysplasia

Restrictive Takotsubo Gaucher disease Hyperthyroidism Neuromuscular

LV Noncompaction Peripartum Hurler’s disease Hypothyroidism Neurological

Glycogen storage diseases Tachycardia induced Hunter’s disease Hyperparathyroidism Nutritional deficiencies

Conduction defects Hemochromatosis Pheochromocytoma Dermatomyositis

Mitochondrial myopathies

Fabry’s disease Acromegaly Scleroderma

Ion channel disorders Glycogen storage disease Electrolyte imbalance

Niemann‐Pick disease Cancer therapy

Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: An American Heart Association scientific statement from the council on clinical cardiology, heart failure and transplantation committee; quality of care and outcomes research and functional genomics and translational biology interdisciplinary working groups; and council on epidemiology and prevention. Circulation. 2006;113:1807‐1816.

ECG Changes in CardiomyopathyT wave inversion >1 mm 2 or more leads; V2‐V6, II and aVF or I and AVL

ST segment depression > 0.5 mm in two or more leads

Pathological Q waves > 3 mm depth or > 40ms duration two or more leads

Complete left bundle branch block QRS > 120 ms, negative QRS complex in V1 and upright monophasic R 1 and V6

Intraventricular conduction delay QRS > 140 ms

Left axis deviation ‐30o ‐ ‐90o

Left atrial enlargement

Right ventricular hypertrophy pattern

Premature ventricular contractions > 2 PVCs per 10 sec tracing

Ventricular arrhythmias Couplets, triplets and non‐sustained VT

Drezner JA, Ashley E, Baggish AL. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy. Br J Sports Med. 2013;47:137‐152.


16- year old male with a history of syncope

Bradyarrhythmias

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Bradyarrhythmias

• Bradycardia heart rate < 60 beats per minute

• Symptomatic vs. asymptomatic

• Normal variants– Sleep

– Among athletes

CO = HR X SV

MAP = (CO x SVR) + CVP

Presentation

• Syncope

• End organ hypoperfusion

• Chronotropic incompetency

Barstow CH, McDivitt JD. Cardiovascular Update. FP Essentials. 454: March 2017

Causes of bradycardia• Sinus node dysfunction (sick sinus syndrome)• Atrioventricular block• Reflex syncope• Toxins• Systemic disease• Electrolytes• Conduction disturbance• Medications

Sinus Node Dysfunction

• Problem with the sinus node and surrounding tissue• Disease of the elderly• Sinus bradycardia or tachy-brady• Indications for pacemaker placement

– Symptomatic bradycardia– Chronotropic incompetence– Symptomatic bradycardia from required drug therapy

Atrioventricular Blocks

• Delayed conduction through AV conduction system

• First degree• Second degree type 1 (Wenkebach)• Second degree type 2• Third degree

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SA Node

AV Node

Bundle of His





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Treatment• Atropine• Reversible causes• Transcutaneous pacing• Dopamine• Epinephrine• Isoproterenol• Transvenous pacing

CausesAcute bradycardia (sinus bradycardia and AV blocks)

1. Ischemia or infarction2. Conduction disease3. Medication effects

– Beta blockers– Calcium channel blockers– Tricyclic antidepressants

Practice Recommendations

• In patients with AF, antithrombotic therapy should be individualized based on absolute and relative risks of stroke and bleeding (Class I; LOE: C)

• Oral beta blockers, diltiazem, or verapamil is useful for ongoing management in patients with symptomatic SVT who do not have pre-excitation during sinus rhythm. (Class 1; LOE B-R)



Practice Recommendations• Permanent pacemaker implantation is

indicated for Sinus Node Dysfunction with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. (Class 1, LOE C)

• Atropine remains the first-line drug for acute symptomatic bradycardia (Class IIa, LOE B)

American Heart Association. Part 7: Advanced Cardiovascular Life Support. Web‐based integrate 2010 and 2015 Guidelines. https://eccguidelines.heart.org/wp‐content/themes/eccstaging/dompdf‐master/pdffiles/part‐7‐adult‐advanced‐cardiovascular‐life‐support.pdf. Accessed July 2016.

Eptsein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 Guidelines for device based therapy of cardiac rhythm abnormalities. A report of the American College of Cardiology Foundation/American Heart Society Task Force on Practice Guidelines and the Heart Rhythm Society. J AM Coll Cardiol. 2013; 61: e6‐75.

ICD-10 Codes

I48.- Atrial fibrillation and flutterI48.0 Paroxysmal atrial fibrillationI48.1 Persistent atrial fibrillationI48.2 Chronic atrial fibrillation

I49.- Other cardiac arrhythmiasI49.01 Ventricular fibrillationI49.9 Other specified cardiac arrhythmias

Questions

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Contact Information

Craig Barstow, MD FAAFP

Email: [email protected]

arrhythmias and dysrhythmias€¦ · • sex category (female sex) ... • pre-existing...

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