Cardiovascular Cardiovascular DysfunctionDysfunction

Arrythmias in the Critically IllArrythmias in the Critically Ill

S. MountainS. Mountain

Sept. 25, 2008Sept. 25, 2008

For each case, please answer the following 4 For each case, please answer the following 4 questions:questions:

1. What is the rhythm? Why do you think so? What 1. What is the rhythm? Why do you think so? What is your approach to the diagnosis of this rhythm?is your approach to the diagnosis of this rhythm?

2. What are some likely causes/risk factors?2. What are some likely causes/risk factors? 3. What is the potential impact of this rhythm in the 3. What is the potential impact of this rhythm in the

ICU patient? What are the risks of not treating this ICU patient? What are the risks of not treating this rhythm?rhythm?

4. How do you treat this rhythm? What are some of 4. How do you treat this rhythm? What are some of the risks of treating? How efficacious are the various the risks of treating? How efficacious are the various treatments?treatments?

Case 1. (Todd) Case 1. (Todd) *  Difficulty rating.*  Difficulty rating. See EKG See EKG 1, below. You are called to see a 78 year old 1, below. You are called to see a 78 year old man in emerg. regarding hypotension and man in emerg. regarding hypotension and tachycardia. His wife noted he had a fever and tachycardia. His wife noted he had a fever and was more difficult to rouse this morning. You was more difficult to rouse this morning. You quickly interpret the EKG, and for the benefit quickly interpret the EKG, and for the benefit of your med student, you delineate the answers of your med student, you delineate the answers to the 4 questions above.to the 4 questions above.

Sinus Tachycardia Sinus Tachycardia ……With 1st-degree bock and left atrial With 1st-degree bock and left atrial

enlargementenlargement Why? It’s a regular rhythm at about 100 Why? It’s a regular rhythm at about 100

bpm, with a narrow QRS, prolonged PRI bpm, with a narrow QRS, prolonged PRI (driven by wide P wave, but that’s the way it (driven by wide P wave, but that’s the way it goes), normal axis, and no evidence of goes), normal axis, and no evidence of intraventricular conduction delay. There are intraventricular conduction delay. There are no ST or T-wave abnormalities, nor Q waves.no ST or T-wave abnormalities, nor Q waves.

Approach is systematic, or something will be Approach is systematic, or something will be missed. The computer on the ECG cannot be missed. The computer on the ECG cannot be trusted.trusted.

Sinus Tachycardia Sinus Tachycardia Likely cause? Likely cause?

Sinus tachycardia is the heart’s response Sinus tachycardia is the heart’s response to stress. In this case, an elderly to stress. In this case, an elderly gentleman with a likely clinical gentleman with a likely clinical presentation of sepsis may have sinus presentation of sepsis may have sinus tachycardia for several reasons:tachycardia for several reasons:– FeverFever– VasodilationVasodilation– Intravascular volume depletionIntravascular volume depletion– AcidosisAcidosis– Anxiety/fear/discomfortAnxiety/fear/discomfort

Sinus TachycardiaSinus Tachycardia Why might this be bad? What’s the worst that Why might this be bad? What’s the worst that

can happen?can happen?– Increased myocardial oxygen demandIncreased myocardial oxygen demand

Degeneration into other arrhythmias, including Degeneration into other arrhythmias, including interventricular conduction delaysinterventricular conduction delays

CHF (tachycardia-mediated cardiomyopathy)CHF (tachycardia-mediated cardiomyopathy)

– Hypotension (decreased diastolic filling time, Hypotension (decreased diastolic filling time, although this is rare with sinus rhythm, as atrial although this is rare with sinus rhythm, as atrial component is preserved, and rate is usually slow component is preserved, and rate is usually slow enough)enough)

– On the plus side, it is a diagnostic clue (i.e. SIRS On the plus side, it is a diagnostic clue (i.e. SIRS criteria, Wells criteria, early sign of hemorrhage, etc)criteria, Wells criteria, early sign of hemorrhage, etc)

Treatment: Underlying cause. Treatment: Underlying cause.

Case 2. (Neil)Case 2. (Neil)* *  Difficulty rating. * *  Difficulty rating. While your junior While your junior medicine resident is writing up the E.R. patient, you are paged medicine resident is writing up the E.R. patient, you are paged back to the ICU to see one of your patients. She is a 79-year-back to the ICU to see one of your patients. She is a 79-year-old woman who is admitted to the unit with heart failure, and old woman who is admitted to the unit with heart failure, and was intubated yesterday. She was stable until a few minutes was intubated yesterday. She was stable until a few minutes ago when her EKG tracing changed, and her sats dropped. ago when her EKG tracing changed, and her sats dropped. Previous physical exam had revealed a systolic murmur Previous physical exam had revealed a systolic murmur loudest at the apex radiating to the axilla. An EKG was done loudest at the apex radiating to the axilla. An EKG was done while you were on the way up from the E.R. and is available while you were on the way up from the E.R. and is available for your interpretation. Your med student wonders what the for your interpretation. Your med student wonders what the diagnosis is, and what it’s significance is to your patient.diagnosis is, and what it’s significance is to your patient.

Atrial Fibrillation w/ rapid Atrial Fibrillation w/ rapid Ventricular responseVentricular response

NO P wavesNO P waves Usually Narrow complexUsually Narrow complex Irregularly irregular ventricular Irregularly irregular ventricular

responseresponse Fibrillary waves of irregular atrial Fibrillary waves of irregular atrial

activation may be seen (inferior or activation may be seen (inferior or V1)V1)

Causes/Risk FactorsCauses/Risk Factors Ischemic Heart DiseaseIschemic Heart Disease Valvular disease (esp. Mitral)Valvular disease (esp. Mitral) PericarditisPericarditis Sick SinusSick Sinus Myocardial contusionMyocardial contusion Hypertensive Heart diseaseHypertensive Heart disease CardiomyopathyCardiomyopathy Cardiac SurgeryCardiac Surgery CHFCHF Accessory pathway (WPW)Accessory pathway (WPW) PEPE Catecholamine excessCatecholamine excess Acute Ethanol ingestion (Holiday heart)Acute Ethanol ingestion (Holiday heart) IdiopathicIdiopathic HyperthyroidismHyperthyroidism SAHSAH

Potential Impact of this Potential Impact of this rhythmrhythm

Can cause hemodynamic instabilityCan cause hemodynamic instability– Worsens NYHA classWorsens NYHA class– Especially MS or HOCMEspecially MS or HOCM– Loss of atrial systole can decrease Loss of atrial systole can decrease

LVEDP by 20-35%LVEDP by 20-35% AF in the ICUAF in the ICU

– Increase in stroke, heart failure, all Increase in stroke, heart failure, all cause mortalitycause mortality

– W>MW>M

RisksRisks

CHADS2 scoreCHADS2 score

TreatmentTreatment

Stable vs. UnstableStable vs. Unstable– HemodynamicallyHemodynamically– Pulm edemaPulm edema– Chest painChest pain

DC Cardioversion vs. Chemical DC Cardioversion vs. Chemical ElectricalElectrical

– Conversion rates reported high(67-94%), but Conversion rates reported high(67-94%), but one reported 35% in surgical ICU patientsone reported 35% in surgical ICU patients

– Recommended for AF 50-100JRecommended for AF 50-100J

When is it safe to cardiovert?When is it safe to cardiovert?HD stableHD stable

AHA Class IAHA Class I– <48 hours<48 hours– Anticoagulated > 3 weeks (INR 2-3)Anticoagulated > 3 weeks (INR 2-3)– No atrial clot on TEENo atrial clot on TEE

Which drug to use?Which drug to use?

AFFIRM (2002)AFFIRM (2002)– Rate control = rhythm control in Rate control = rhythm control in

mortalitymortality– Less ADR’s in rate control Less ADR’s in rate control – Not our population (ie. Not stressed or Not our population (ie. Not stressed or

hypotensive)hypotensive)

Which drug to use?Which drug to use?Rate controlRate control

AHA Class IAHA Class I– B-blockersB-blockers– Calcium channel blockersCalcium channel blockers

AHA Class I in Heart FailureAHA Class I in Heart Failure– DigoxinDigoxin– AmioderoneAmioderone

Which drug to use?Which drug to use?Rhythm controlRhythm control

AHA Class IAHA Class I– FlecanideFlecanide– PropafenonePropafenone– DofetilideDofetilide– ibutilideibutilide

AHA Class IIbAHA Class IIb– amioderoneamioderone

Which drug to use?Which drug to use?Rhythm controlRhythm control

Case 3. Case 3. (Todd)(Todd) * *  Difficulty rating* *  Difficulty rating . See EKG 3. . See EKG 3. Just as you have finished making your Just as you have finished making your diagnosis and educating your student about diagnosis and educating your student about the last patient, the alarm goes off on the the last patient, the alarm goes off on the patient’s monitor across the hall. He is an 80 patient’s monitor across the hall. He is an 80 year old man with a remote history of an MI. year old man with a remote history of an MI. He is in the ICU post abdominal surgery, and He is in the ICU post abdominal surgery, and has been recovering from intra-abdominal has been recovering from intra-abdominal sepsis, but is nearly ready for the ward. His BP sepsis, but is nearly ready for the ward. His BP has dropped with this new rhythm. You call for has dropped with this new rhythm. You call for an EKG, interpret it, and make a diagnosis and an EKG, interpret it, and make a diagnosis and management plan. What are they? management plan. What are they?

Supraventricular Supraventricular tachycardia; AVRTtachycardia; AVRT

How do we know what it is? It’s a rapid, regular How do we know what it is? It’s a rapid, regular rhythm with a narrow QRS. There are small P rhythm with a narrow QRS. There are small P waves before every QRS (best seen in lead II waves before every QRS (best seen in lead II here, but look also in II, aVF and V1), with a here, but look also in II, aVF and V1), with a short PR interval.short PR interval.

The R wave has a slight slur to it (delta wave), The R wave has a slight slur to it (delta wave), indicating a bypass tract (classically associated indicating a bypass tract (classically associated with Wolff Parkinson White Syndrome, but not with Wolff Parkinson White Syndrome, but not pathognomonic)and ventricular preexcitationpathognomonic)and ventricular preexcitation– WPW: short PR, wide QRS, secondary repolarization WPW: short PR, wide QRS, secondary repolarization

abnormalities, and PSVTabnormalities, and PSVT

Accessory PathwayAccessory Pathway

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Differential diagnosis Differential diagnosis includes:includes:

Atrial flutter. The ventricular rate is often a Atrial flutter. The ventricular rate is often a factor of 300 (“classic” is 150 bpm), factor of 300 (“classic” is 150 bpm), indicating 2:1 conduction of…indicating 2:1 conduction of…– Flutter waves. These are the “sawtooth” waves Flutter waves. These are the “sawtooth” waves

between the QRS complexes, which often look between the QRS complexes, which often look like T-waves. 250-350 bpm.like T-waves. 250-350 bpm.

– A reentry circuit in the right atrium, which A reentry circuit in the right atrium, which usually runs counterclockwise, with a well-usually runs counterclockwise, with a well-known path between the IVC and TV annulusknown path between the IVC and TV annulus

– Classic flutter: negative F waves in II, III, aVF, Classic flutter: negative F waves in II, III, aVF, positive in V1. Clockwise flutter is the opposite.positive in V1. Clockwise flutter is the opposite.

Atrial FlutterAtrial FlutterLikely cause?Likely cause?

Usually associated with organic heart Usually associated with organic heart disease, and is most commonly seen disease, and is most commonly seen in post-bypass patients. Like atrial in post-bypass patients. Like atrial fibrillation, may be associated with fibrillation, may be associated with physiologic stress, including sepsis, physiologic stress, including sepsis, myocardial ischemia, fever, etc.myocardial ischemia, fever, etc.

Atypical (clockwise) atrial flutter may Atypical (clockwise) atrial flutter may be a transition between sinus rhytm be a transition between sinus rhytm and atrial fibrillation, according to and atrial fibrillation, according to animal models.animal models.

Supraventricular Supraventricular TachycardiaTachycardia

Why might this be bad? What’s the worst Why might this be bad? What’s the worst that can happen?that can happen?– Ventricular rate of 150 leaves little time for Ventricular rate of 150 leaves little time for

diastolic filling for patients who need it…diastolic filling for patients who need it…– HypotensionHypotension– Stroke risk thought to be similar to that of Stroke risk thought to be similar to that of

atrial fibrillationatrial fibrillation– In case of atrial flutter, 1:1 conduction is rare, In case of atrial flutter, 1:1 conduction is rare,

but the resulting HR would be 250-300 bpm.but the resulting HR would be 250-300 bpm. May degenerate to a-fib, as evidenced by common May degenerate to a-fib, as evidenced by common

presentation of atrial fib/flutter on rhythm strips.presentation of atrial fib/flutter on rhythm strips.

Supraventricular Supraventricular arrhythmias in the ICUarrhythmias in the ICU

Very common between 03:00 and 07:30…Very common between 03:00 and 07:30… Goodman, Shirov, et al Goodman, Shirov, et al Critical Care and TraumaCritical Care and Trauma

104 (4) 2007:104 (4) 2007:– Patients with new-onset supraventricular arrhythmia Patients with new-onset supraventricular arrhythmia

(SVA) had higher APACHE II scores, sepsis/SIRS, ARF, (SVA) had higher APACHE II scores, sepsis/SIRS, ARF, catecholamine infusions, and longer LOS (ICU and catecholamine infusions, and longer LOS (ICU and hosp) compared to those without SVA.hosp) compared to those without SVA.

– Risk factors for new-onset supraventricular Risk factors for new-onset supraventricular arrhythmia:arrhythmia: Sepsis/SIRS (OR 50), (LD) dopamine or other catecholamines, Sepsis/SIRS (OR 50), (LD) dopamine or other catecholamines,

hypothyroidism, pulmonary diseasehypothyroidism, pulmonary disease In ICU, ischemia, ARF and hemorrhagic shock in the setting of In ICU, ischemia, ARF and hemorrhagic shock in the setting of

new-onset SVA were associated with in-hospital mortalitynew-onset SVA were associated with in-hospital mortality

SVA: bottom lineSVA: bottom line

According to this paper, mortality in According to this paper, mortality in hospital, ICU and after discharge was hospital, ICU and after discharge was statistically significantly higher (38%, statistically significantly higher (38%, 36%, 16%) in the new onset SVA 36%, 16%) in the new onset SVA group compared to those who had no group compared to those who had no SVASVA– SVA included atrial fibrillation, atrial SVA included atrial fibrillation, atrial

flutter, “other”/paroxysmal flutter, “other”/paroxysmal supraventricular tachycardiassupraventricular tachycardias

SVA: TreatmentSVA: Treatment If hemodynamically unstable: synchronized If hemodynamically unstable: synchronized

cardioversion (often responds to lower energy cardioversion (often responds to lower energy than VT, i.e. 120 J biphasic ); 95% effectivethan VT, i.e. 120 J biphasic ); 95% effective– Save the patient now, chin-scratch over the ECG laterSave the patient now, chin-scratch over the ECG later

If diagnosis is in doubt, may try to slow A-V If diagnosis is in doubt, may try to slow A-V conduction to either diagnose the origin or conduction to either diagnose the origin or terminate the rhythm, whichever occurs firstterminate the rhythm, whichever occurs first– Vagal maneuverVagal maneuver– AdenosineAdenosine

Rapid atrial pacing, usually done with Rapid atrial pacing, usually done with endocardial electrodes (such as those left in endocardial electrodes (such as those left in post CABG)post CABG)

SVA: Pharmacologic SVA: Pharmacologic TreatmentTreatment

Adenosine (6 mg, proceed to 12 mg if Adenosine (6 mg, proceed to 12 mg if unsuccessful, rapid IV push with saline chaser)unsuccessful, rapid IV push with saline chaser)

Diltiazem or verapamil may also be used Diltiazem or verapamil may also be used UNLESS a bypass tract (AVRT) is suspectedUNLESS a bypass tract (AVRT) is suspected– They may accelerate conduction over the bypass They may accelerate conduction over the bypass

tract!tract! Beta blockers, amiodarone Beta blockers, amiodarone Procainamide (long infusion time), Procainamide (long infusion time),

propafenone, flecanide propafenone, flecanide Ibutilide (Class III antiarrhythmic. Takes about Ibutilide (Class III antiarrhythmic. Takes about

30 minutes, may cause Torsades de Pointes)30 minutes, may cause Torsades de Pointes)

Case 4. (Yoan)Case 4. (Yoan)* *  Difficulty rating.* *  Difficulty rating. See See EKG 4. Just as you finish with the man in EKG 4. Just as you finish with the man in case 3, you are paged back to emerg. You are case 3, you are paged back to emerg. You are asked to see a 23 year old woman, who has asked to see a 23 year old woman, who has presented with a rapid heart rate, and is presented with a rapid heart rate, and is complaining of shortness of breath. Please complaining of shortness of breath. Please diagnose the arrhythmia, and answer the 4 diagnose the arrhythmia, and answer the 4 questions.questions.

Case 5Case 5

Naisan “not a cardiologist” Naisan “not a cardiologist” GarrawayGarraway

The caseThe case

As you are finishing in the E.R. you As you are finishing in the E.R. you are called back to see the man from are called back to see the man from case 3 (above). He has gone into a case 3 (above). He has gone into a new rhythm, and his blood pressure new rhythm, and his blood pressure has dropped significantly. He is has dropped significantly. He is complaining of chest pain. What do complaining of chest pain. What do you make of his EKG now?you make of his EKG now?

VT or not?VT or not?

In 1991 the In 1991 the Brugada CriteriaBrugada Criteria were were publishedpublished

4 criteria established by the authors, which 4 criteria established by the authors, which were prospectively analyzed in a total of 554 were prospectively analyzed in a total of 554 tachycardias with a widened QRS complex tachycardias with a widened QRS complex (384 ventricular and 170 supraventricular). (384 ventricular and 170 supraventricular). The sensitivity of the four consecutive steps The sensitivity of the four consecutive steps as 0.987, and the specificity was 0.965.as 0.987, and the specificity was 0.965.

– Pedro Brugada,et al. Pedro Brugada,et al. CirculationCirculation 1991;83:1649- 1991;83:1649-16591659

Step 1: Lack of RS Step 1: Lack of RS ComplexComplex

An RS complex was present in at An RS complex was present in at least one precordial lead in least one precordial lead in allall SVTs SVTs with aberrant conductionwith aberrant conduction

But only 26% of VTs did not have an But only 26% of VTs did not have an RS complex in any precordial lead.RS complex in any precordial lead.

100% specific for the diagnosis of 100% specific for the diagnosis of ventricular tachycardia.ventricular tachycardia.

Step 2: Whether the R to S Step 2: Whether the R to S interval in any precordial lead is interval in any precordial lead is

greater than 100 msgreater than 100 ms RS interval greater than 100 msec was RS interval greater than 100 msec was

not observed in any SVT with aberrant not observed in any SVT with aberrant conduction.conduction.

Half of the VTs which did have an RS Half of the VTs which did have an RS complex in at least one precordial lead complex in at least one precordial lead had an RS interval less than 100 msechad an RS interval less than 100 msec

RS interval of more than 100 msec in any RS interval of more than 100 msec in any precordial lead when an RS complex was precordial lead when an RS complex was present were each 100% specific for the present were each 100% specific for the diagnosis of VTdiagnosis of VT

Step 3: AV DissociationStep 3: AV Dissociation

When looking at an EKG of a wide When looking at an EKG of a wide complex tachycardia it is always nice complex tachycardia it is always nice to see AV dissociation because it is to see AV dissociation because it is 100% specific for the diagnosis of VT100% specific for the diagnosis of VT

Step 4: Morphology Step 4: Morphology CriteriaCriteria

the morphology criteria are analyzed the morphology criteria are analyzed in leads V1 and V6in leads V1 and V6

If both leads have a morphology If both leads have a morphology compatible with the diagnosis of VT, compatible with the diagnosis of VT, the diagnosis of VT is madethe diagnosis of VT is made

Tachycardia with a right Tachycardia with a right bundle branch block-like bundle branch block-like

QRSQRS Lead V1Lead V1 Monophasic R or QR or RS favors VT Monophasic R or QR or RS favors VT

Triphasic RSR' favors SVT Triphasic RSR' favors SVT

Lead V6Lead V6 R to S ratio <1 (R wave smaller than S wave) R to S ratio <1 (R wave smaller than S wave)

favors VT favors VT QS or QR favors VT QS or QR favors VT Monophasic R favors VT Monophasic R favors VT Triphasic favors SVT Triphasic favors SVT R to S ratio >1 (R wave larger than S R to S ratio >1 (R wave larger than S wave)favors SVT wave)favors SVT

Tachycardia with a left Tachycardia with a left bundle branch block-like bundle branch block-like

QRSQRS Lead V1 or V2Lead V1 or V2 Any of following R >30 msec, >60 Any of following R >30 msec, >60

msec to nadir S, notched S favors VT msec to nadir S, notched S favors VT

Lead V6Lead V6 Presence of any Q wave, QR or QS Presence of any Q wave, QR or QS

favors VT favors VT The absence of a Q wave in lead V6 The absence of a Q wave in lead V6 favors SVT favors SVT

So lets see…..Step 1So lets see…..Step 1

Step 2Step 2

110 MS V1

For Fun Step 3For Fun Step 3

Not sinus, looks like afib

Afib

Step 4 MorphologyStep 4 Morphology

Tachycardia with a left bundle Tachycardia with a left bundle branch block-like QRSbranch block-like QRS

Lead V1 or V2Lead V1 or V2– Any of following R >30 msec, >60 msec to Any of following R >30 msec, >60 msec to

nadir S, notched S favors VTnadir S, notched S favors VT– R is 40 msec, 70 msec to nadir SR is 40 msec, 70 msec to nadir S

Lead V6Lead V6 Presence of any Q wave, QR or QS favors Presence of any Q wave, QR or QS favors

VT VT The absence of a Q wave in lead V6 The absence of a Q wave in lead V6 favors SVTfavors SVT

Another AlgorythmAnother Algorythm

Fusion BeatsFusion Beats

Initiation and TerminationInitiation and Termination

The numbers gameThe numbers game

Other causes Wide ComplexOther causes Wide Complex

Causes of VTCauses of VT

Risk FactorsRisk Factors

Risk factors included age, past Risk factors included age, past medical history of cardiovascular or medical history of cardiovascular or endocrine diseases, and severity of endocrine diseases, and severity of illness as assessed by SAPS II and illness as assessed by SAPS II and the need for mechanical ventilation the need for mechanical ventilation or vasopressor therapyor vasopressor therapy– Annane et al, Am J Respir Crit Care Med Vol 178. pp 20–25, 2008Annane et al, Am J Respir Crit Care Med Vol 178. pp 20–25, 2008

Impact of VT in ICUImpact of VT in ICU

A large, prospective, multicenter A large, prospective, multicenter inception cohort study showed inception cohort study showed Ventricular arrhythmias increased Ventricular arrhythmias increased the risk of in-hospital mortality and the risk of in-hospital mortality and the risk of neurological sequelaethe risk of neurological sequelae

Annane et al, Am J Respir Crit Care Med Vol 178. pp 20–25, 2008

SurvivalSurvival

In adult ICU patients, ventricular In adult ICU patients, ventricular tachycardia/fibrillation was more tachycardia/fibrillation was more common than pulseless electrical common than pulseless electrical activity. Survival was highest (39%) activity. Survival was highest (39%) with pulseless electrical activity and with pulseless electrical activity and lower with ventricular arrhythmias lower with ventricular arrhythmias (33%) and asystole (24%)(33%) and asystole (24%)

Enohumah et al. Outcome of cardiopulmonary Enohumah et al. Outcome of cardiopulmonary resuscitation in intensive care units in a university resuscitation in intensive care units in a university hospital. Resuscitation 2006; 71:161–170.hospital. Resuscitation 2006; 71:161–170.

TreatmentTreatment

ABCABC If unstable Shock/Cardiovert! …….ACLSIf unstable Shock/Cardiovert! …….ACLS If stable determine if VT or notIf stable determine if VT or not Multiple medication optionsMultiple medication options

– Amiodarone most common nowAmiodarone most common now– Procainamide 80-90% effective in VT related Procainamide 80-90% effective in VT related

to MIto MI 20 min infusion and hypotension common20 min infusion and hypotension common

– Lidocaine generally inefective (Lidocaine generally inefective (Gorgels et al, Gorgels et al, Am J Am J

Cardiol, 1996Cardiol, 1996))

Case 6. Case 6. (Yoan)(Yoan) * *  Difficulty rating* *  Difficulty rating. . See See EKG 6.EKG 6. You have finally sorted You have finally sorted everybody out, and are leaving the unit everybody out, and are leaving the unit for lunch. However, as you pass by bed for lunch. However, as you pass by bed 2, the nurse says the monitor has been 2, the nurse says the monitor has been spewing out strips for a while, and she spewing out strips for a while, and she has gotten an EKG. She asks you to has gotten an EKG. She asks you to take a quick look. What do you think of take a quick look. What do you think of the EKG from this 81 year old woman?the EKG from this 81 year old woman?

You have finally made it to lunch. As You have finally made it to lunch. As you eat your chicken stir fry, your you eat your chicken stir fry, your med student notes that every patient med student notes that every patient you saw this morning had some kind you saw this morning had some kind of arrhythmia. She wonders if this is of arrhythmia. She wonders if this is typical of all critically ill patients. typical of all critically ill patients. You fill her in with answers to the You fill her in with answers to the following questions (Scot)following questions (Scot)

1.1. What is the frequency of sustained arrhythmia (i.e. What is the frequency of sustained arrhythmia (i.e. >30s) in the ICU?>30s) in the ICU?

2. Which patients, in general, are most likely to suffer 2. Which patients, in general, are most likely to suffer an arrhythmia?an arrhythmia?

3. What is the most common arrhythmia in the ICU?3. What is the most common arrhythmia in the ICU? 4. What impact does a sustained arrhythmia have on 4. What impact does a sustained arrhythmia have on

a patient’s outcome? I.e. is there an impact on a patient’s outcome? I.e. is there an impact on mortality? How about other outcomes?mortality? How about other outcomes?

Incidence of Clinically Incidence of Clinically Significant ArrhythmiasSignificant Arrhythmias

Annane, 2008; 26 general ICUs over 1 Annane, 2008; 26 general ICUs over 1 month.month.

Recorded new, sustained arrhythmias Recorded new, sustained arrhythmias in 1,341 patients, and broke them in 1,341 patients, and broke them down as to type, and risk factors.down as to type, and risk factors.

Overall, 12% had new onset Overall, 12% had new onset arrhythmia during their ICU stay.arrhythmia during their ICU stay.

Median time to arryhthmia is day 1-2 Median time to arryhthmia is day 1-2 (as in post-op patients).(as in post-op patients).

Risk FactorsRisk Factors

Patients with arrhythmias were:– older– more likely to have past medical history

of cardiovascular, pulmonary, or endocrine diseases

– were more likely to present with sepsis/septic shock or other acute cardiovascular disorder

– had higher SAPS II score– were more likely to be on ventilator or on

vasopressors.

5.3% SVT in non-cardiac diagnoses or chronic arrhythmia (mainly AF)

When adjusting for age and SAPS, SVT not associated with poorer 90 day survival.