Transcript Arrhythmia Conference

Arrhythmia Conference
Sandeep Gautam
James McKinnie
08/24/07
• 46 WF presented to Lakeview Hospital with
several days of palpitations.
• Baseline dyspnea on exertion NYHA II-III.
• PMH: Marfan’s Syndrome, TOF s/p complete
repair ‘72, Pulmonic porcine valve replacement
‘90, CAD s/p PCI, Atrial fibrillationBulimia
nervosa, palpitations of lower frequency, OA,
FM, Scoliosis, osteoporosis.
• F&SH: No alcohol or tobacco abuse.
• Allergies: Sulfa, Celebrex, Vioxx, Vicodin,
tape.
• Meds at home: Coumadin, metoprolol 25
mg bid, Lisinopril 2.5 mg daily, Digoxin
0.125 daily, Spironolactone 25 mg daily,
Percodan prn, Trazodone 100 mg daily.
• Labs: Na 124 K 4.3 TSH 4.4 Dig 1.35
• CxR – Large right perihilar mass with
bilateral pleural effusions.
WQRS tachycardia algorithm
VT Cluster (VTC)
• A VTC is defined as ≥ 3 sustained VTs/24 h.
• Ventricular tachycardia that repeatedly recurs and persists for more
than half of a 24-h period despite repeated attempts to terminate the
arrhythmia is designated “incessant.”
• Irrespective of the number of VTs, only 30.2% of patients survived
and 15.5% survived without heart transplantation four years after the
first cluster.
• Incessant VT typically takes one of two forms. The most common
situation is for VT to be sustained, terminated by external
cardioversions, but recurrent. The time between cardioversion and
recurrence may be seconds, minutes or more. A second form,
common with the idiopathic VTs, manifests as repeated bursts, with
runs of VT that spontaneously terminate for a few intervening sinus
beats, followed by the next tachycardia burst. Cardioversion is futile,
but may be periodically required if bursts of VT occasionally
degenerate to ventricular fibrillation.
VT Cluster (VTC)
• When incessant VT is polymorphic, drug
induced torsade de pointes associated with QT
prolongation, or myocardial ischemia are the
major concerns. Runs of polymorphic VT may
even repeatedly initiate monomorphic VT in
patients with reentry circuits in regions of scar.
Suppression of torsade de pointes with
intravenous administration of magnesium sulfate
and/or overdrive pacing may restore stability.
VT Cluster (VTC)
Treatment Options:
• Antiarrythmic drugs
• Beta Blockade
• General anesthesia (to reduce sympathetic
tone)
• Intra aortic balloon counterpulsation
• Catheter ablation – percutaneous/ epicardial
• LVAD
Inside or out? Another option for incessant ventricular tachycardia
J. Am. Coll. Cardiol., June 4, 2003; 41(11): 2044 - 2045.
Dosage
• Amiodarone — Amiodarone is given as a 150 mg (or 5
mg/kg) IV bolus over 10 minutes; additional boluses of
150 mg over 10 minutes are given every 10 to 15
minutes as needed. Alternatively, an infusion of 360 mg
(1 mg/min) over six hours followed by 540 mg (0.5
mg/min) over the remaining 18 hours can be used. The
maximum total dose (including doses given during
resuscitation) is 2.2 grams in 24 hours.
• Lidocaine — Lidocaine is given by IV push in a dose of
0.5 to 0.75 mg/kg; repeated every 5 to 10 minutes as
needed. At the same time, a continuous IV infusion of 1
to 4 mg/min is begun. The maximum total dose is 3
mg/kg over one hour.
Dosage
• Procainamide: Loading dose: 15-18 mg/kg administered
as slow infusion over 25-30 minutes or 100-200 mg/dose
repeated every 5 minutes as needed to a total dose of 1
g. Reduce loading dose to 12 mg/kg in severe renal or
cardiac impairment.
Maintenance dose: 1-4 mg/minute by continuous
infusion. Maintenance infusions should be reduced by
one-third in patients with moderate renal or cardiac
impairment and by two-thirds in patients with severe
renal or cardiac impairment.
ACLS guidelines: Infuse 20 mg/minute until arrhythmia
is controlled, hypotension occurs, QRS complex widens
by 50% of its original width, or total of 17 mg/kg is given.
SHock Inhibition Evaluation with AzimiLiDe
(SHIELD) Investigators
• A randomized trial of azimilide for suppression of
ventricular tachycardia/fibrillation (VT/VF) leading to
implanted cardioverter defibrillator (ICD) therapies.
• Of 633 ICD recipients, 148 (23%) experienced at least
one ES (electrical storm) over 1-year follow-up.
• Compared with placebo, azimilide reduced the risk of
recurrent ES by 37% (p=0.11) nonsignificantly.
• CONCLUSION: ES is common and unpredictable in ICD
recipients and it is a strong predictor of hospitalization.
• Eur Heart J. 2006 Dec;27(24):2921-2.
Left stellate ganglionic blockade
•
•
Forty-nine patients (36 men, 13 women, mean age 57 years) who had ES
associated with a recent MI were separated into 2 groups. Patients in group
1 (n=27) received sympathetic blockade treatment: 6 left stellate ganglionic
blockade, 7 esmolol, and 14 propranolol. Patients in group 2 (n=22)
received antiarrhythmic medication as recommended by the ACLS
guidelines. Patient characteristics were similar in the 2 groups. The 1-week
mortality rate was higher in group 2: 18 (82%) of the 22 patients died, all of
refractory VF; 6 (22%) of the 27 group 1 patients died, 3 of refractory VF
(P<0.0001). Patients who survived the initial ES event did well over the 1ear follow-up period: Overall survival in group 1 was 67%, compared with
5% in group 2 (P<0.0001).
Conclusions—Sympathetic blockade is superior to the antiarrhythmic
therapy recommended by the ACLS guidelines in treating ES patients. Our
study emphasizes the role of increased sympathetic activity in the genesis
of ES. Sympathetic blockade2not class 1 antiarrhythmic drugs2should be
the treatment of choice for ES.
(Circulation. 2000;102:742-747.)
Therapies for VT
ABLATION
I IIa IIb III
Ablation is indicated in patients who are otherwise at low risk
for SCD and have sustained predominantly monomorphic VT
that is drug resistant, who are drug intolerant, or who do not
wish long-term drug therapy.
I IIa IIb III
Ablation is indicated in patients with bundle-branch reentrant
VT.
I IIa IIb III
I IIa IIb III
Ablation is indicated as adjunctive therapy in patients with an
ICD who are receiving multiple shocks as a result of sustained
VT that is not manageable by reprogramming or changing drug
therapy or who do not wish long-term drug therapy.
Ablation is indicated in patients with WPW syndrome
resuscitated from sudden cardiac arrest due to AF
and rapid conduction over the accessory pathway
causing VF.
Therapies for VT
Ablation
I IIa IIb III
Ablation can be useful therapy in patients who are
otherwise at low risk for SCD and have symptomatic
nonsustained monomorphic VT that is drug resistant, who
are drug intolerant or who do not wish long-term drug
therapy.
I IIa IIb III
Ablation can be useful therapy in patients who are
otherwise at low risk for SCD and have frequent
symptomatic predominantly monomorphic PVCs that are
drug resistant or who are drug intolerant or who do not wish
long-term drug therapy.
I IIa IIb III
Ablation can be useful in symptomatic patients
with WPW syndrome who have accessory
pathways with refractory periods less than
240 ms in duration.
Acute Management of Specific Arrhythmias
Incessant VT
I IIa IIb III
I IIa IIb III
Revascularization and beta blockade followed by
intravenous antiarrythmic drugs such as procainamide or
amiodarone are recommended for patients with recurrent
or incessant polymorphic VT due to acute MI.
Intravenous amiodarone or procainamide followed by VT
ablation can be effective in the management of patients
with frequently recurring or incessant monomorphic VT.
Acute Management of Specific Arrhythmias
Incessant VT
I IIa IIb III
Intravenous amiodarone and intravenous beta blockers
separately or together may be reasonable in patients
with VT storm.
I IIa IIb III
Overdrive pacing or general anesthesia may be considered
for patients with frequently recurring or incessant VT.
I IIa IIb III
Spinal cord modulation may be considered for some
patients with frequently recurring or incessant VT.
VA & SCD Related to Specific Populations
Digitalis Toxicity
I IIa IIb III
An antidigitalis antibody is recommended for patients who
present with sustained ventricular arrhythmias, advanced AV
block, and/or asystole that are considered due to digitalis
toxicity.
I IIa IIb III
Patients taking digitalis who present with mild cardiac
toxicity (e.g., isolated ectopic beats only) can be managed
effectively with recognition, continuous monitoring of cardiac
rhythm, withdrawal of digitalis, restoration of normal
electrolyte levels (including serum potassium greater than
4 mM/L), and oxygenation.
I IIa IIb III
Magnesium or pacing is reasonable for patients
who take digitalis and present with severe
toxicity (sustained ventricular arrhythmias,
advanced AV block, and/or asystole).
VA & SCD Related to Specific Populations
Digitalis Toxicity
I IIa IIb III
Dialysis for the management of hyperkalemia may be
considered for patients who take digitalis and present with
severe toxicity (sustained ventricular arrhythmias; advanced
AV block, and/or asystole).
I IIa IIb III
Management by lidocaine or phenytoin is not recommended
for patients taking digitalis and who present with severe
toxicity (sustained ventricular arrhythmias, advanced AV
block, and/or asystole).
Drug Interactions Causing Arrhythmias
Drug
Interacting Drug
Effect
QT-prolonging
antiarrhythmics
Diuretics
Increased T de P risk due to
diuretic-induced hypokalemia
Beta blockers
Amiodarone, clonidine, digoxin, dilitiazem,
verapamil
Bradycardia when used in
combination
Digoxin
Amiodarone, beta blockers, clonidine,
dilitiazem, verapamil
Verapamil
Amiodarone, beta blockers, clonidine, digoxin,
dilitiazem
Diltiazem
Amiodarone, beta blockers, clonidine, digoxin,
verapamil
Sildenafil
Nitrates
Clonidine
Amiodarone, beta blockers, digoxin, dilitiazem,
verapamil
Amiodarone
Beta blockers, clonidine, digoxin, dilitiazem,
verapamil
Increased and persistent
vasodilation; risk of
myocardial ischemia
Hospital course
• Was loaded with IV amiodarone and lidocaine
prior to transfer.
• Initially transferred to Tulane for possible VT
ablation.
• Ablation procedure cancelled due to respiratory
distress.
• She had multiple episodes of monomorphic and
polymorphic VT and was emergently intubated
after seizures during one of the codes.
• Antiarrythmic therapy included reloading
with amiodarone and lidocaine followed by
prcainamide loading and infusion.
• She continued to suffer from VT clusters
and intermittent asystole.
• IABP and LVAD were considered.
• Family decided to stop all aggressive
treatement.
• She died following a terminal VT.