West Herts Cardiology Arrhythmia Management Dr John Bayliss FRCP Consultant Cardiologist 17 Sept...

West Herts Cardiology

Arrhythmia ManagementArrhythmia Management

Dr John Bayliss FRCP

Consultant Cardiologist

17 Sept 2008


Arrhythmia GuidelinesArrhythmia Guidelines

www.bhcardiacnetwork.nhs.uk/std_glnsClinical.htm

www.westhertscardiology.com Documents/Local

www.starpace.co.uk Clinical Specialty/Cardiovascular

www.nice.org

2006NICE CG36 AF

2005NSF CHD Arrhythmias

2006Beds&HertsCardiac Network Arrhythmia guidelines

p 64


Palpitations: ImportancePalpitations: Importance

CommonOften benignOften troublesome ++Occasionally fatal

Need careful assessment – some/most in 1y Care Need for Rapid Access Arrhythmia services Early involvement of specialist clinician Ablation / Device therapy increasingly effective

p 55


Assessment of “Palpitations”/ArrhythmiasAssessment of “Palpitations”/Arrhythmias

Full History = most importantFull History = most important

Clinical ExaminationHeart rate response (during & after exercise)12 lead ECG (esp during symptoms)

Blood testsU&E, Glucose, Thyroid FT, Liver FT, FBC

p 56-7


Palpitations: Detailed HistoryPalpitations: Detailed History Age of patient Type and Duration of symptoms?

Individual “thumps”, “misses”, etc Runs of tachycardia: ?Regular, ?Irregular Duration, Frequency

Onset: ? Sudden/Gradual, ? Circumstances

Cessation: ? Sudden/Gradual, ? Circumstances

Associated symptoms ? Polyuria (due to Atrial Natriuretic Peptide release in Atrial tachyarrhythmias)

? Collapse/Dizzy/Breathless, etc

Concurrent illness Family History (Sudden Death, Cardiomyopathy, CHD)

Drug History (incl OTC)

p 58


Palpitations: Low risk featuresPalpitations: Low risk features

= Manage in Primary CareHistory:

Not known to have heart disease No family history of collapse or sudden death

at age < 40 years No previous collapse/blackouts Only infrequent attacks

Symptoms: Palpitations last < 30 minutes “Missed” beats (= ectopics) or brief rhythm

irregularity only

p 57


Palpitations: High risk featuresPalpitations: High risk features

= Refer to Heart Rhythm SpecialistPre-existing heart disease:

Previous angina, MI, angioplasty,heart surgery Clinical heart failure, or LV systolic dysfunction

(ejection fraction < 40%) Structural heart disease: valve disease,

cardiomyopathy, congenital heart disease

Family history of collapse or sudden death at age < 40 years

Previous or recurrent collapse/blackouts.

p 57


Should GPs report 12 lead ECGs ?!Should GPs report 12 lead ECGs ?!24yr old woman, occasional brief “flutters”


Long QT and Brugada syndromeLong QT and Brugada syndrome“Ion channelopathies”

QTc >450-500ms = high risk of VT/SCD


Investigation of ArrhythmiasInvestigation of Arrhythmias

May be usefulMay be useful Ambulatory ECG (24hr – 7 days) Echocardiogram Exercise ECG – if exercise related or ?CHD

Tilt Test – if postural or vagal symptoms Cardiac MRI - esp in young patient Implantable ECG Loop Recorder (ILR, “Reveal”)

if infrequent but serious events Electrophysiological Study (EPS)

Catheter Ablation therapy


Implantable Loop Recorder Implantable Loop Recorder (ILR, “Reveal” device)(ILR, “Reveal” device)

15 mins daycase procedure Local anaesthetic implant in upper L chest Battery lasts 18 months High quality downloadable

ECG before+during attack

Most cost-effective test Yield 43% 1

Cost 26% less than usual Ix 2

1Krahn AD, et al. Circ. 2001;104:46-51. 2Krahn AD, et al. JACC. 2003;42:495-501.


Arrhythmias: TreatmentArrhythmias: Treatment

Depends on (ECG) diagnosis !S Tachy : ? Cause (POTS ! “heartsink”)

A Tachy : β blockerAVNRT / AVRT : Ablation (Flecainide/Propafenone)

A Flutter : Ablation (Verapamil,Dig,Amio)

Paroxysmal AF : Sotalol, Propafenone, Flecainide

Permanent AF : Rate v Rhythm... VT : ICD (β blocker, Amio, Ablation)

Bradycardias : Pacing

p 59


Catheter AblationCatheter Ablation for arrhythmias with localised anatomical substrate often curative (no need to continue anti-arrhythmic Rx)


Device TherapyDevice Therapy Pacemakers Cardiac Resynchronisation Therapy

(CRT, Biventricular pacing) Implantable Cardioverter Defibrillators (ICD)


Pacemakers : 1958 – 2008 : 50 yearsPacemakers : 1958 – 2008 : 50 years

1st "Permanent" Implantable Pacemaker & Bipolar Hunter-Roth Lead (1958)


ICD functionICD function

VF terminated by single 34J shock

VF = Dead SR = Alive


AF: TypesAF: Types

22% of PAF progress to permanent AF within 2 years 50-60% of patients are back in AF 1 year after cardioversion

Aetiology

vs

Timing

Circulation 2001;104:2118–2150

OR

First Episode(New onset)

Paroxysmal(PAF)

Persistent

Permanent

“Lone” AF

p 58


AF: ManagementAF: Management

? Rate or Rhythm Control Rate control

Control of Ventricular Rate at rest + on exercise Rhythm control

Restoration of SR + Maintenance of SR

? Anticoagulation Risk of thromboembolism Risk of Warfarin=1-2% yearly risk of serious bleed

p 60p 64


AF: AF: Rate v Rate v Rhythm controlRhythm control

Choose Rhythm Control: Symptomatic, Younger Uncontrolled Heart Failure First episode (?), or now corrected precipitant

DC Cardioversion ≥3 weeks anticoagulation before + 4 weeks after

Try to Maintain SR (50% revert to AF in 1 yr) ? Need for Amiodarone / Sotalol

Propafenone / Flecainidep 60p 64


AF: Rate v Rhythm control - AFFIRMAF: Rate v Rhythm control - AFFIRM

AFFIRM NEJM 2002;347:1825-33

The Atrial Fibrillation Follow-up Investigation of Rhythm Management

n=4060, age >65, AF

Mean age = 69.7Hypertension in 71%

Rate control = <80 at rest <110 on walk+ Warfarin (INR 2-3)

Rhythm control = Drugs ± Cardioversion(s)+ Warfarin (INR 2-3) unless SR for 4(-12) weeks

p 62


AF: Rate AF: Rate v Rhythm v Rhythm controlcontrol

Choose Rate Control: if patient stable and if Age >65 Underlying CHD, Hypertension, Valve Disease Anti-arrhyhtmic Rx not tolerated / contraindicated Cardioversion inappropriate

Use β Blocker first:Atenolol, Bisoprolol, Metoprololor rate controlling Ca++ blocker: Verapamil, Diltiazem Add Digoxin if necessary, or if CHF

p 60p 64


IMPORTANTIMPORTANT

Digoxin : a drug of 2nd-3rd choice !


AF: Digoxin = Increased MortalityAF: Digoxin = Increased MortalitySPORTIF III+V (Warfarin v Ximelagatran) n=7329 in AF Mod-high stroke risk

53% on DigoxinMortality = 6.5%

47% not on DigoxinMortality = 4.1%

Hazard ratio(adjusted for risks)1.53

? ↑ Platelet activation

Gjesdal, K et al. Heart 2008;94:191-196


AF: Thromboprophylaxis

NICE CG36 June 2006 www.nice.org.uk

Warfarin Aspirin?

≥5% / year <3% / year

p 61p 64


AF: Warfarin or AspirinAF: Warfarin or Aspirin

In AF, compared to placebo Aspirin ↓ relative risk of stroke by 20% Warfarin ↓ relative risk of stroke by 60%

Warfarin increases absolute annual risk of serious haemorrhage by 2+ %

Benefit Risk

Echo is usually unnecessary for decision


CHADSCHADS22 risk score in AF risk score in AF

Points

CHF 1

Hypertension 1

Age 75 or older 1

Diabetes 1

Stroke or TIA 2

RISK SCORE 0 - 6

Gage BF et al JAMA 2001;285:2864-2870

Risk ScoreStroke rate* %

(95%CI)

0 1.9 (1.2-3.0)

1 2.8 (2.0-3.8)

2 4.0 (3.1-5.1)

3 5.9 (4.6-7.3)

4 8.5 (6.3-11.1)

5 12.5 (8.2-17.5)

6 18.2 (10.5-27.4)

Predicts annual risk of stroke in non-rheumatic AF

* Assuming no Aspirin taken

p 60-1

Warfarin indicated if CHADS2 Score = 2 or more

West Herts Cardiology Arrhythmia Management Dr John Bayliss FRCP Consultant Cardiologist 17 Sept...

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