arrhythmias noted in cardiac rehab - mnacvpr · arrhythmias in cardiac rehab niloufar tabatabaei,...
TRANSCRIPT
![Page 1: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/1.jpg)
Arrhythmias in Cardiac Rehab
Niloufar Tabatabaei, MD., MS., FACC
Director of Cardiac Rehabilitation
Division of Cardiology
Olmsted Medical Center
![Page 2: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/2.jpg)
Disclosures: None
![Page 3: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/3.jpg)
![Page 4: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/4.jpg)
Arrhythmias can be promoted by exercise
• Sympathetic nervous system
• Circulating catecholamines
• Automaticity enhanced triggered activity
• Electrolyte shifts
• Baroreceptor activation
• Myocardial stretch and ischemia
![Page 5: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/5.jpg)
Objectives
• Review common abnormal rhythms noted in cardiac rehab – in a case based presentation
• Identify common abnormal rhythms
• Discuss management of common abnormal rhythms
• Discuss significance of rhythm abnormalities
![Page 6: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/6.jpg)
Case 1: Atrial Fibrillation
![Page 7: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/7.jpg)
Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?
A. Patient has excellent heart rate variability finish exercise and discharge home routine follow-up
B. Patient has excellent heart rate variability finish exercise but call MD for treatment of Heart failure
C. Don’t exercise patient
![Page 8: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/8.jpg)
Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?
A. Patient has excellent heart rate variability finish exercise and discharge home routine follow-up
B. Patient has excellent heart rate variability finish exercise but call MD for treatment of Heart failure
C. Don’t exercise patient
![Page 9: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/9.jpg)
73 year-old male with known paroxysmal atrial fibrillation • Cardiac rehab session
normal heart rate variability
• SYMPTOMATIC • Heart failure symptoms
• Discuss with MD and plan for treatment of CHF.
![Page 10: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/10.jpg)
Atrial fibrillation • New atrial fibrillation: notify MD as discussion for anticoagulation and
rhythm/rate control may be necessary
• Known atrial fibrillation: evaluate for symptoms and heart rate variability • No symptoms and good heart rate variability: routine follow-up
• Symptoms notify MD
• Heart rate suppression and or tachy/brady syndrome -> further clinical evaluation
![Page 11: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/11.jpg)
![Page 12: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/12.jpg)
![Page 13: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/13.jpg)
![Page 14: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/14.jpg)
Stroke Prevention in AF -wading in the deep
![Page 15: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/15.jpg)
Case 2: 48 year old female s/p AV canal repair and mitral valve replacement, Tricuspid repair with a pacemaker
![Page 16: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/16.jpg)
Case 2
What do you do? A. This is VT stop patient and start
CPR
B. The rate of 245 is incorrect recalculate rate. Importantly patient is asymptomatic and you see pacing marks
C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician
![Page 17: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/17.jpg)
Case 2
What do you do? A. This is VT stop patient and start
CPR
B. The rate of 245 is incorrect recalculate rate importantly patient is asymptomatic you see pacing marks
C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician
![Page 18: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/18.jpg)
Case 2
What do you do? A. This is VT stop patient and start
CPR
B. The rate of 245 is incorrect recalculate rate importantly patient is asymptomatic you see pacing marks
C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician
Device settings are DDDR 60-140 bpm
![Page 19: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/19.jpg)
Pacemaker patient • Please determine settings on pacemaker and if they are pacemaker
dependent. (DDDR 60-130)
• Determine if intrinsic rate or pacemaker rate
• Symptoms important
• Questions - call MD or pacemaker nurse
![Page 20: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/20.jpg)
What about Patients with a Defibrillator
• Settings are different as usually they don’t need pacing and usually single chamber unless pacing is needed (VVIR 40)
• With defibrillators it is important to see what the VT/VF Zones programmed for shock. (you don’t want the patient’s heart rate at that zone). • Common VT zones (monitor zone above 180 bpm, VF
rate 200bpm)
![Page 21: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/21.jpg)
Case 3: 63 year-old with defibrillator
![Page 22: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/22.jpg)
Case 3: panel to the right 63 year-old with defibrillator What is happening in panel 4? DDDR 85-130
A. Patient is in VT
B. Patient is paced
C. Patient will be shocked shortly and should be cooled down
1
2
3
4
5
![Page 23: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/23.jpg)
63 year-old patient with Defibrillator for out of hospital arrest is in the middle of session 88 what do you do?
A. Call 911 and transfer to ED
B. If patient is asymptomatic let him go home
![Page 24: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/24.jpg)
A. Call 911 and transfer to ED
B. If patient is asymptomatic let him go home
63 year-old patient with Defibrillator for out of hospital arrest is in the middle of session 88 what do you do?
![Page 25: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/25.jpg)
Case 4: 72 year-old mal s/p bypass surgery
A. Start CPR
B. Asymptomatic you have time to determine rhythm as SVT with Aberrancy vs. VT
C. VT in light of history of coronary artery disease until proven otherwise
D. Don’t exercise – check electrolytes, meds, notify MD
E. No symptoms go ahead and exercise
F. More than one answer is correct
![Page 26: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/26.jpg)
Case 4: 72 year-old mal s/p bypass surgery
A. Start CPR
B. Asymptomatic you have time to determine rhythm as SVT with Aberrancy vs. VT
C. VT in light of history of coronary artery disease until proven otherwise
D. Don’t exercise – check electrolytes, meds, notify MD
E. No symptoms go ahead and exercise
F. More than one answer is correct
![Page 27: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/27.jpg)
How to distinguish SVT from VT
• Rate
• Regularity: warm up phenomenon in VT
• AV dissociation
• Morphology
• QRS duration >140 in RBBB is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)
• Concordance
![Page 28: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/28.jpg)
How to distinguish SVT from VT
• Rate
• Regularity: warm up phenomenon in VT
• AV dissociation
• Morphology
• QRS duration >140 in RBBB is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)
• Concordance
![Page 29: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/29.jpg)
![Page 30: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/30.jpg)
Rare PVCs
• Rare single PVCs
• Asymptomatic
• Usually clinically insignificant unless increase with frequency during exercise
![Page 31: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/31.jpg)
Case 5: 63 year-old male with history of AA repair and coronary re-implantation • Patient has frequent PVCs
during rest and exercise
• Holter shows a 30% burden
• Patient has no symptoms of chest pain
• Cardiac rehab obtains a 12 lead ECG
• PVCs localized to Right coronary cusp
• CT shows impingement of re-implanted right coronary artery
• Patient gets Right coronary artery stent
![Page 32: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/32.jpg)
![Page 33: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/33.jpg)
![Page 34: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/34.jpg)
Case 6: 33 year-old s/p mitral valve repair
A. Conduction system disease recommend he sees physician and gets a pacemaker
B. Wenckebach may not be significant wait and see how he does with exercise
![Page 35: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/35.jpg)
Case 6: 33 year-old s/p mitral valve repair A. Conduction system disease
recommend he sees physician and gets a pacemaker
B. Wenckebach may not be significant wait and see how he does with exercise
![Page 36: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/36.jpg)
Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?
A. Normal sinus rhythm
B. Junctional escape
C. Complete heart block
D. Atrial flutter
![Page 37: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/37.jpg)
Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?
A. Normal sinus rhythm
B. Junctional escape
C. Complete heart block
D. Atrial flutter
![Page 38: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/38.jpg)
82 year-old female with CAD and RV failure – what is the rhythm?
A. Normal sinus rhythm
B. Junctional escape
C. Complete heart block
D. Atrial flutter
![Page 39: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/39.jpg)
![Page 40: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/40.jpg)
![Page 41: Arrhythmias noted in Cardiac Rehab - Mnacvpr · Arrhythmias in Cardiac Rehab Niloufar Tabatabaei, MD., MS., FACC Director of Cardiac Rehabilitation Division of Cardiology Olmsted](https://reader035.vdocument.in/reader035/viewer/2022062414/5ec8ec8d47a4c641285d9fde/html5/thumbnails/41.jpg)
Any Questions?