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Acute Arrhythmias in the Hospitalized Patient
Gregory M Marcus, MD, MAS Associate Professor of Medicine
Division of Cardiology University of California, San Francisc
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Disclosures
• Medtronic: Research Support • SentreHeart: Reserch Support
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Don’t Forget the Basics
• 79 yo man with a history of CHF s/p remote ICD presents with progressive, severe dyspnea at rest
• Compliant with his medicines; described some diarrhea after a recent trip to Mexico
• Sitting up, diaphoretic, tachypneic, oxygen saturation ~87%, blood pressure ~88/40
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Don’t Forget the Basics
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Don’t Forget the Basics
When you have a questionable ECG: IF you can, always… 1. Compare it to a previous ECG
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Current:
2 months prior:
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Don’t Forget the Basics
When you have a questionable ECG: IF you can, always… 1. Compare it to a previous ECG
2. Think about electrolytes (K+, Mg2+, Ca2+)
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Tachyarrhythmias- Unstable
SVT Atrial fibrillation AF with WPW VT/ VF
• Unconscious, altered mental status, ongoing chest pain
• “Hypotension” is a clinical judgment
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Tachyarrhythmias-quasi-stable
SVT Atrial fibrillation AF with WPW VT/ VF
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Tachyarrhythmias-quasi-stable
SVT
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Tachyarrhythmias-quasi-stable
SVT
Vagal Manuevers
WAIT!
GET A 12 LEAD ECG!
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Tachyarrhythmias-quasi-stable
SVT
Vagal Manuevers
• Carotid sinus massage
• Valsava
• Will terminate ~20%1
1. Lim SH et al. Ann Emerg Med 1998;31:30-35
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Tachyarrhythmias-quasi-stable
SVT
Adenosine
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The primary method of adenosine clearance is
1. Liver metabolism 2. Renal excretion 3. Red blood cell metabolism
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Tachyarrhythmias-quasi-stable
SVT
Adenosine
• Metabolized by red blood cells and endothelium
• Give 6 mg IV with 20 cc flush
• Repeat with 12 mg IV X 2
• How do I know if I’ve given enough?
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SVT can be cured with ablation
1. >95 % of the time 2. 85-95% of the time 3. 75-85% of the time 4. 65-75% of the time 5. 55-65% of the time 6. 45-55% of the time
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SVT can be cured with ablation
Hazard Ratio for Emergency Department Visits (95% CI) Multivariable adjusted Cox proportional hazard ratios for predictors of recurrent Emergency Department visits for SVT taking clustering of individuals into account. The vertical line represents a hazard ratio of 1 (no difference), and the error bars denote 95% confidence intervals. Filled circles denote baseline (static) variables, and open circles represent variables that were time-updated throughout the study period.
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Tachyarrhythmias-quasi-stable
Atrial Fibrillation
Nondihydropyrdine Calcium channel blockers Diltiazem Verapamil Beta-blockers Metoprolol Atenolol Carvedilol Labetolol Propanolol
Blood Pressure 1. Address underlying condition
2. Esmolol
3. Digoxin
4. Amiodarone
5. ?Dronaderone?
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Tachyarrhythmias-quasi-stable
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The most likely diagnosis is: 1. Ventricular Tachycardia 2. Atrial fibrillation with WPW 3. SVT with aberrancy
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Tachyarrhythmias-quasi-stable
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Tachyarrhythmias-quasi-stable Atrial Fibrillation with preexcitation
AV nodal blockers
Give:
Procainamide
Ibutilide
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A Patient with WPW Syndrome Should Be Referred to an EP
Because 1. Genetic testing will be helpful for family
counseling 2. An implantable defibrillator may be
indicated to prevent sudden death 3. An ablation may be indicated to prevent
sudden death
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Tachyarrhythmias-quasi-stable Ventricular Tachycardia
• Scarcity of data
• Amiodarone probably the most effective1,2
-- Can cause bradycardia
-- Can hinder EP studies/ ablation Extrapolate from cardiac pulseless VT/ VF
versus placebo:
1. Kudenchuck PJ et al. N Engl J Med 1999;341:871-878
versus lidocaine:
2. Dorian P et al. N Engl J Med 2002;346:884-890
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Tachyarrhythmias-quasi-stable Ventricular Tachycardia
• Scarcity of data
• Consider
-- Lidocaine gtt
-- Procainamide
- watch for hypotension and
prolonged QT
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Tachyarrhythmias-quasi-stable Ventricular Tachycardia
• Get EP involved
• May respond to beta-blockers or calcium channel blockers
• May be amenable to ablation
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Tachyarrhythmias
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Tachyarrhythmias
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Tachyarrhythmias
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Tachyarrhythmias 1.Electrolytes
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Tachyarrhythmias 1.Electrolytes
Hypokalemia
Hypo-Mg
T U
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Tachyarrhythmias 1.Electrolytes
Hypokalemia
Hypo-Mg2+
Hypo-Ca2+
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Tachyarrhythmias 1.Electrolytes
Hypokalemia
Hypo-Mg2+
Hypo-Ca2+
2. DRUGS
3. Congenital
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Tachyarrhythmias
1. IV magnesium
2. Isoproterenol
3. Transvenous pacing
4. Unstable DC shock
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Bradyarrhythmias
+
+
Blood Flow
+ SYMPATHETIC
NERVOUS SYSTEM
PARA- SYMPATHETIC
NERVOUS SYSTEM
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Bradyarrhythmias
+
+
Blood Flow
+ SYMPATHETIC
NERVOUS SYSTEM
PARA- SYMPATHETIC
NERVOUS SYSTEM
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Bradyarrhythmias
+
+
Blood Flow
+ SYMPATHETIC
NERVOUS SYSTEM
PARA- SYMPATHETIC
NERVOUS SYSTEM
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Bradyarrhythmias
+
+
Blood Flow
+ SYMPATHETIC
NERVOUS SYSTEM
PARA- SYMPATHETIC
NERVOUS SYSTEM
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Bradyarrhythmias
+
+
Blood Flow
+ SYMPATHETIC
NERVOUS SYSTEM
PARA- SYMPATHETIC
NERVOUS SYSTEM
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Bradyarrhythmias
Blood Flow
• Important questions: – Is this dynamic/ reversible/ vagal?
• IE, more likely benign • IE, less likely respond to pacing • IE, more likely transiet
– Or is this structural • IE, more likely dangerous • IE, more likely needs pacing
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Bradyarrhythmias
+
+ Vagal tone Lengthening P-P interval before pause
Lengthening PR before a pause
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Bradyarrhythmias
+
+ 1. Atropine
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Bradyarrhythmias +
+ 1. Atropine
2. Dopamine
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Bradyarrhythmias +
+ 1. Atropine
2. Dopamine
3. Epinephrine
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Bradyarrhythmias +
+ 1. Atropine1
2. Dopamine1
3. Epinephrine1
4. Isoproterenol (vasodilating) 1. AHA Guidelines. Circulation 2005;112:67-77
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Bradyarrhythmias
+
+ Beta-blocker
Calcium channel blocker
Glucagon
Calcium
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Bradyarrhythmias
+
+ Conduction disease Lev’s disease/ fibrosis or an MI
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Bradyarrhythmias +
+ 1. Atropine
2. Dopamine
3. Epinephrine
4. Isoproterenol
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Bradyarrhythmias +
+ 1. Atropine
2. Place external pacing pads
3. Pace if atropine fails
4. Dopamine
5. Epinephrine
6. Isoproterenol
7. Transvenous pacer
AHA Guidelines. Circulation 2005;112:67-77
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Bradyarrhythmias +
+ 1. Atropine1
2. Transcutaneous1 pacing OR Dopamine OR Epinephrine
(then mention isoproterenol)
3. Consider
consultation ± transvenous pacing
1. AHA Guidelines. Circulation 2010;18:S749
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Bradyarrhythmias
Transcutaneous Pacing
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Pt. comes in with multiple, recurrent shocks from his ICD
1.PUTS DEVICE IN “MAGNET MODE”
2.FOR AN ICD: INHIBITS THERAPY DETECTION
3.FOR A PACEMAKER: INHIBITS SENSING
1. Place external pads
2. Place magnet on chest
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Pt. comes in with catastrophic bleeding on warfarin…but needs warfarin for atrial fibrillation and a high CHADS2 score (>2)
Or
Patient comes in with apparent embolic stroke in atrial fibrillation with an INR of 2.5
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Devices for stroke prevention
• All anticoagulants by nature will be associated with an increased risk of bleeding
• In AF patients with thrombus/ thromboembolism, the left atrial appendage is thought to be the site of thrombus formation in more than 90%
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Devices for stroke prevention • Consider referral for a percutaneous left
atrial appendage occlusion: – Watchman (occlusion device) – Lariat (epicardial suture)
• No guidelines for now • Reimbursement may be an issue • Likely indicated for:
– If CHADS2 score warrants warfarin or a novel
anticoagulant and there are contraindications (mainly bleeding)
– If patient has a stroke on therapuetic anticoagulation
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Thank You