Emerging Trends in Critical Card Nursing Symposium GSLC AACCN March 17, Marye J. Gleva M.D. F.A.C.C. F.H.R.S. Professor of Medicine

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1 Understanding the ECG in Arrhythmias and Pacemakers: A Case Based Approach Emerging Trends in Critical Card Nursing Symposium GSLC AACCN March 17, 2017 Marye J. Gleva M.D. F.A.C.C. F.H.R.S. Professor of Medicine 1

2 Disclosures None relevant to today s topic Clinical Trial Endpoint Committees BIOTRONIK Protego Lead Boston Scientific CAPTIVATE KESTRA-- WCD Medtronic MRI; IMPROVE SCA NIH CABANA Research Grants BIOTRONIK to ACC/NCDR 2

3 Objectives Recognize the common causes of narrow complex tachycardia Recognize the common causes of a wide complex tachycardia Understand the basics of implantable pacemakers 3

4 Approaching an ECG of a Tachycardia Rate (bpm or CL) Atrial Ventricular Same or different QRS narrow or wide? What is the QRS morphology RBBB, LBBB, LAD, RAD etc? QRS regular or irregular? 4

5 Objectives Recognize the common causes of narrow complex tachycardia Recognize the common causes of a wide complex tachycardia Understand the basics of implantable pacemakers 5

6 Common SVTs AT= atrial tachycardia AVNRT = AV node reentry tachycardia AP = Accessory pathway mediated tachycardia General concepts to remember: The AV node can conduct forward and backwards antegrade and retrograde An AP can also conduct antegrade and retrograde Antegrade = preexcitation 6

7 Regular Narrow Complex Tachycardias 1. AVNRT= AV node reentry tachycardia The circuit is in the AV node and perinodal region; can extend to the os of the coronary sinus 2. AVRT = AV reentry tachycardia (WPW) ORT: The circuit is the AVN antegrade and the accessory pathway retrograde; so the QRS is narrow ART (wide complex): The circuit is an accessory pathway antegrade and either the AVN or another accessory pathway retrograde; the QRS is wide 3. Atrial Flutter The circuit is in the atrium 4. Atrial tachycardia Usually not reeentrant; a focal mechanism ( irritable site ) 5. Sinus tachycardia Associated with fever, illness, PE, volume depletion, tamponade etc 7

8 Another Classification of SVT The RP interval Measured from the onset of the QRS to the retrograde p wave Short RP (<½ of the R-R interval) tachycardia AVNRT ORT Long RP (>½ R-R interval)tachycardia Atypical AVNRT Atrial tachycardia PJRT the permanent form of junctional reciprocating tachycadia A decremental accessory pathway 8

9 Irregular Supraventricular Tachycardia 1. Atrial fibrillation No clear p waves; variable QRS or RR intervals 2. Atrial tachycardia Multifocal atrial tachycardia Three different p waves and PR intervals Some ATs can have rate variability based on variable autonomic tone 9

10 Multifocal Atrial Tachycardia 10

11 Atrial Fibrillation 11

12 Objectives Recognize the common causes of narrow complex tachycardia Recognize the common causes of a wide complex tachycardia Understand the basics of implantable pacemakers and ICDs 12

13 Wide Complex Tachycardia SVT with aberration Preexcited SVT Mahaim PPM mediated tachycardia VT Myocardial/scar Fascicular RVOT BBRT 13

14 VENTRICULAR TACHYCARDIA 14

15 Preexcited Atrial Fibrillation 15

16 WCT: Brugada Criteria Wide Complex Tachycardia Regular VT SVT with RBBB or LBBB aberration Irregular Caveats» Preexcited tachycardia» Mahaim tachycardia» Pacemaker mediated tachycardia Atrial fibrillation with aberration Polymorphic VT (PMVT) Bidirectional VT Brugada et al (more Brugadas) Circulation

17 WCT: Brugada Criteria 1. Absence of RS across precordium 2. R to S > 100 msec in precordial lead 3. AV dissociation 4. Morphology criteria Brugada et al Circulation 1991; 83 (5) 17

18 WCT Brugada Criteria/Morphology 18

19 WCT: Wellens Criteria Original paper Am J Med 1978: 64: $40 to get from journal website Not available through Becker Updated version published in 2001 Same guy who described pre infarction anterior TW inversions 19

20 WCT: Wellens Criteria Do not panic when confronted with a wide QRS tachycardia QRS width >160 msec Concordance All Qs or all Rs in precordial leads Axis AV Dissociation Use of Lewis lead 20

21 avr Criteria for WCT 21

22 avr Criteria Presence of an initial R wave in avr? yes no VT Presence of initial q wave or r wave > 40 msec no Presence of a notch on descending limb of a predominately negative onset and predominately negative QRS no yes yes VT VT v i /v t 1 yes no VT SVT Vereckei A et al HR 2008; 5:

23 avr Criteria for VT 23

24 Objectives Recognize the common causes of narrow complex tachycardia Recognize the common causes of a wide complex tachycardia Understand the basics of implantable pacemakers 24

25 Why do Patients Have Pacemakers? Symptoms from a slow heart beat Sinus node dysfunction AV node dysfunction Complete heart block Heart Failure indications NYHA Class II-IV LBBB LVEF <35% 25

26 Indications for permanent pacing Class I Symptomatic sinus bradycardia, chronotropic incompetence, or bradycardia due to required drug therapy Symptomatic second-degree AVB (Mobitz I or II) and thirddegree AVB Asymptomatic Mobitz II Asymptomatic third-degree AVB with escape > 40 bpm with cardiomegaly Alternating bundle branch block Transient AVB with associated bundle branch block after STEMI Recurrent syncope with carotid pressure and asystole of > 3 seconds Heart Rhythm 2008;5:934 26

27 Indications for permanent pacing Class II Class IIa Sinus brady < 40, symptoms, but no clear correlation between the two HV 100 ms during EPS Syncope with bifascicular block when other causes are excluded Syncope of unclear cause, and asystole > 3sec with carotid pressure Class IIb Minimal symptoms with sinus brady at < 40 bpm while awake Syncope with significant bradycardia documented on tilt table testing 27

28 Indications for permanent pacing Class III A PPM is NOT indicated in these situations: Asymptomatic sinus node dysfunction Asymptomatic first-degree AVB Bifascicular block ± first-degree AVB without symptoms or AVB Situational vasovagal syncope when behavior modification is preferred 28

29 The Basics of PPMs To have a device interrogated, you need to know Manufacturer Medtronic Boston Scientific (Guidant) St. Jude Biotronik ELA Don t know? Ask the patient! Should have ID card Look at CXR 29

30 Pacemaker MODE 30

31 Important concepts in pacing: it s all about TIMING Lower rate limit (LRL) Upper rate limit (URL) Atrioventricular delay (AVD) ~ PR interval HR (bpm) CL (ms) Bpm=60,000/CL 31

32 Commonly seen PPM Modes VVI Paces Ventricle only Senses Ventricle only Response to an event sensed in the ventricle = Inhibit pacing output 32

33 DDD Paces - atrium and ventricle (Dual) Senses atrium and ventricle (Dual) Response: of atrial lead to a sensed event in the atrium = inhibit pacing output in the atrium of ventricular lead to a sensed event in the ventricle = inhibit pacing output in the ventricle of ventricular lead to a sensed event in the atrium = track Therefore, response is both inhibit and track (Dual) 33

34 Lower rate limit (LRL) VVI 60 bpm 1000 ms Sensed event: Timer resets 1000 ms 34

35 DDD bpm, AVD=200 ms URL 500 ms AVD URL is inviolable If URL is 120 bpm, then ventricular paced beats cannot be more than 120 bpm 35

36 PPM Response to Atrial Arrhythmias: Mode switch Avoids tracking of atrial fibrillation Only possible in dual chamber pacemakers Programmable On/ Off/ Detection rate For example, if mode switch rate is at 150 bpm, the device will automatically switch from DDD to VVI mode when > the atrial rate is > 150 bpm Mode switch episodes in general can correlate to episodes of atrial fibrillation 36

37 How to Look at a PPM ECG Scan the tracing for the following: What is the rhythm? How many types of pacing spikes seen? Is there capture in each chamber? Is there sensing in each chamber? Is the paced morphology appropriate? Are there appropriate periods of non paced timing? Pauses Other algorithms functioning (ie EP fellowship) Consider a peek at the CXR,,,, 37

38 Now for the Case Based Approach Narrow complex tachycardias Wide complex tachycardias PPM cases An overview of arrhythmia management 38

39 Narrow Complex Tachycardia Case #1: SS 70 y/o female with LE edema for 3 days Presented to ED and developed elevated HR PMHx: HTN Remote CVA 39

40 Narrow Complex Tachycardia Case 1 Rate 180 bpm Narrow QRS, no clear p waves Short RP tachycardia; likely AVNRT Treated with adenosine; added oral BB Outpt follow-up for ablation 40

41 SVT Case 1: After Adenosine 41

42 Narrow Complex Tachycardia Case #2: KB 27 y/o male with palpitations Presented to ED with elevated heart rate for 3 days Admitted to inpatient service PMHx: Repaired congenital heart disease dtga; s/p Mustard 42

43 SVT Case #2 HR 150s, almost RBB and RAD. Given CHD, likely SVT Adenosine 6 mg IV then 12 mg IV 43

44 SVT Case #2: After Adenosine Now can see the flutter waves Heparin drip started, BB for rate control TEE to r/o LAA clot and then CV Taken to EP lab and underwent ablation of the atrial isthmus between the TV and the IVC 44

45 SVT Case #3: VZ Young female with racing heart beats Persistent after walking across campus To ED, seen in consult in ED after adenosine given PMHx: None 45

46 46 SVT Case #3: VZ

47 47 SVT Case #3: NSR

48 SVT Case #3: NSR Again. 48

49 Wide Complex Tachycardia: Case 1 83 y/o male Ischemic CM with EF 20% ICD present S/P VT RFA Presents with palpitations 49

50 WCT Case #1 WG AVR criteria = VT Brugada Step 2 = VT RBBB LAD WCT Rate 100 bpm ECG consistent with VT by two algorithms Acute Management Amiodarone 150 mg IV, then drip Attempted ATP 50

51 WCT Case #2: JI 49 y/o male Presents with worsening CHF Hypercoagulable state with mutiple prior embolic events R ICD Allergy to amiodarone 51

52 WCT Case #2: JI LBBB LAD WCT tachycardia Rate 140 bpm VT by AVR criteria and Brugada; probable AV diss Lidocaine IV 100 mg then 1 mg/min 52

53 WCT Case #3 SC 70 y/o male S/P Aortic root repair for aneurysm Remote hx of AVR for bicuspid aortic valve Known LV dysfunction with EF 35% BIV ICD Arrhythmia noted on telemetry one night at BJH.. 53

54 WCT Case #3 SC RBBB RAD WCT Rate 170 msec Possible P wave in lead V2 preceeding each QRS. AVR with q wave suggests Hmmmm SVT or VT???? 54

55 WCT Case #3 SC ATP from ICD terminates VT 55

56 WCT Case #4 DC 43 y/o male with NICM EF 30% Prior history of VSD repair VHD with AI Admitted with frequent palpitations and associated SOB 56

57 WCT Case #4 DC RBBB RAD irregular WCT Average rate 150 bpm VT suggested by AVR criteria Slowed with beta blockers Recurred so taken to EP lab AT near CS os ablated 57

58 WCT Case #4: NSR 58

59 WCT Case #5 53 y/o male with recurrent angina and palpitations ECG recorded upon arrival in ED Tachycardia spontaneously terminated Not on digoxin 59

60 WCT Case #5 RBBB alternating axis WCT Rate 140 bpm Very bizarre axis leads II, III AVR criteria suggests VT 60

61 AVR Criteria Bidirectional VT CC with RCA and LAD disease; s/p PCI Abnormal MRI ICD implant with BB 61

62 PPM Case #1: What is shown on this ECG? 62

63 PPM Case #2: What is Happening Here? 63

64 PPM Case #3: Appropriate PPM Function? 64

65 PPM Case #4: Is this Appropriate Pacemaker Function? 65

66 PPM Case #4: Does this CXR Confirm Your Dx? 66

67 PPM Case #5 A new patient is admitted with syncope. She s getting dizzy again. The problem is: A. Failure to capture B. Failure to sense 67

68 PPM Case #6 The problem is: A. Failure to capture B. Failure to sense C. Oversensing Solutions: Increase sensitivity (make less sensitive) Asynchronous pacing 68

69 Management of Arrhythmias Diagnosis Crucial as it guides therapy Management Rate control Adenosine Beta blockers Calcium channel blockers IV and/or PO diltiazem» Rare to use verapamil as it is a potent negative inotrope. Is used in HCM IV and/or PO amiodarone AVN ablation with PPM or ICD implant Rhythm control Adenosine/ Beta blockers/ Calcium channel blockers if triggered activity such as atrial tachycardia Digoxin (rarely) AA drugs Ablation 69

70 ACLS

71 Acute Management of Atrial Fibrillation Hemodynamically stable or unstable? If unstable, urgent synchronized cardioversion Anticoagulation: yes or no If anticoagulation contraindicated, rate control strategy Rate control vs. rhythm control Symptoms Concomitant cardiac conditions HCM CHD Factors affecting choices for pharmacologic rhythm control Liver renal or lung problems LVEF 71

72 From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society J Am Coll Cardiol. 2014;64(21): doi: /j.jacc Figure Legend: Strategies for rhythm control in patients with paroxysmal and persistent AF. *Catheter ablation is only recommended as first-line therapy for patients with paroxysmal AF (Class IIa recommendation). Drugs are listed alphabetically. Depending on patient preference when performed in experienced centers. Not recommended with severe LVH (wall thickness >1.5 cm). Should be used with caution in patients at risk for torsades de pointes ventricular tachycardia. Should be combined with AV nodal blocking agents. AF indicates atrial fibrillation; AV, atrioventricular; CAD, Date coronary of download: artery disease; HF, heart failure; Copyright and LVH, The left ventricular American hypertrophy. College of Cardiology. 4/28/2015 All rights reserved. 72

73 Common Drugs for Intravenous Rate Control Drug IV Dose Metoprolol 1.25 to 5 mg q6-12 hours Propranolol Diltiazem 1mg IV; repeat q5 min up to 5 mg 0.25mg/kg bolus over 2 minutes (15-20 mg) then mg/hr Amiodarone 150 mg IV; then mg/min Digoxin 0.25 mg IV 73

74 Common Drugs for Intravenous Rhythm Control Drug IV Dose Amiodarone 150 mg IV bolus; 1 mg/min for 6 hours then 0.5 mg/min Lidocaine 1 Procainamide 1,2 1 mg/kg bolus, then 1-3 mg/min mg/kg bolus then 1-4 mg/min ECG and continuous telemetry for all anti-arrhythmic drugs 1 Monitor levels 2 Caution if renal dysfunction 74

75 Other Rate Control Strategies AVN ablation with pacemaker implant The ultimate in rate control 75

76 Ventricular Arrhythmias: Treatment ICDs are the mainstay of treatment for patients with mmvt, PMVT or VF [secondary prevention] Beta blockers Maximize doses AA drugs (Class III) and ablation are adjuvant treatments Amiodarone, sotalol, mexilitene ICDs provide a mortality benefits Ablation to reduce shocks or events 76

77 Conclusions A straightforward approach can be used for diagnosis of tachycardias based on the ECG Regular vs irregular If regular, one of 5 diagnoses likely If irregular, one of 2 diagnoses likely Do not panic with any WCT; remember AVR Management is ACLS Consider expert consultation 77

78 Selected References American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation. 2015;132:S315-S367, originally published October 14, AHA/ACC/HRS AF 2014 Guidelines J Am Coll Cardiol. 2014;64(21): doi: /j.jacc avr Criteria Vereckei A et al HR 2008; 5: