Dos and Don t in Cardiac Arrhythmia. Case 1 -ECG. Case 1. Management. Emergency Admissions. Reduction of TE risk -CHADS 2 score. Hospital Admissions

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1 Emergency Admissions Dos and Don t in Cardiac Arrhythmia Tom Wong, MD, FESC Consultant Cardiologist, Honorary Senior Lecturer Royal Brompton & Harefield Hospitals National Heart and Lung Institute, Imperial College London Top 10 Reasons for Hospital Admissions Baily et al, J Am Coll Cardiol. 1992;19(3):41A Case 1 Case 1 -ECG 75-years old man Chest infection 2 weeks ago 10 days history of Rapid palpitation Increased Breathlessness Hypertension Bendrofluazide Tachypnoeic HR bpm Irregular pulse BP 130mmHg systolic Signs of heart failure Management Reduction of TE risk -CHADS 2 score Underlying causes AF Infection Heart failure Others Electrolyte imbalance Thyroid dysfunction

2 Rate control NICE beta-blockers or rate limiting calcium antagonists should be administered as the preferred initial monotherapyin all patients digoxinshould only be considered as monotherapy in sedentary patients. DC Cardioversion Duration of AF predict likelihood of remaining in normal sinus rhythm after cardioversion Patients in sinus rhythm (%) *P = <0.02 Initial * One month post-cv Length of time in AF prior to cardioversion Six months post-cv < 3 Months 3-12 Months > 12 Months Dittrich HC. Am J Cardiol. 1989;63: AF Begets AF Amiodarone CTAF Trial AFFIRM : Antiarrhythmic Drug Substudy Trigger PV Non-PV SVT Substrate Electrically remodeling Neurohormonal changes Atrial fibroses Atrial size AF Ablation in Heart Failure Catheter Ablation for AF 58 patients NYHA II-III EF increased by 21% Improved exercise capacity and QoL Left upper PV Right upper PV Hsu LF et al. N EnglJ Med Dec 2;351(23): Left lower PV Right lower PV Coronary sinus

3 Key Messages Case 2 -History Immediate management of AF Treat underlying course of AF Within 48 hours safe for DC Otherwise consider Anticoagulation Rate control Digoxin Beta-blockers Avoid class I drugs in structural heart disease AV node ablation and pacemaker Rhythm control Amiodarone DC cardioversion Catheter Ablation 48-year-old Banker presented with prolong palpitation and dizziness, no chest discomfort Intermittent palpitation for 5 years One episode of syncope during a biking trip to Romania 2 years ago Stressful job No other risk factors for CAD No previous MI Case 2 - ECG Case 2- Differential diagnoses VT Aberrancy What difference does it make! Case 2 -VT Case 2 -Cardiac MRI H. Unstable Terminate the arrhythmia immediately DC shock On-going MI? Drug to prevent recurrence H. Stable Terminate the arrhythmia without the aid of anaesthesia Beta-blocker Lignocaine Amiodarone Prevent/Treat recurrence Drugs Temporary pacing Arrhythmia suppression Arrhythmia termination

4 Key messages Broad Complex tachycardia, to treat as VT unless proven otherwise DC cardioversion if haemodynamicly unstable? Coronary Disease, Acute coronary syndrome 18-year old Man Hypertrophic cardiomyopathy ICD inserted 2-year-ago Seven shocks when he was watching TV He was well and conscious at the time of the therapy Case 3 History Ventricular Arrhythmia Resuscitation Success vs. Time 6:02 AM :05 AM % Success Success rates decrease 7-10% each minute 6:07 AM :11 AM 10 Source: Josephson, ME Time (minutes) Adapted from text: Cummins RO, Annals EmergMed. 1989, 18: Inappropriate ICD shock Time-Dependent Occurrence of Inappropriate Shock by Type Daubert, J. P. et al. J Am Coll Cardiol 2008;51: Daubert, J. P. et al. J Am Coll Cardiol 2008;51:

5 Key messages Be-aware that not all shock are appropriate Patients at risk of inappropriate shocks AF SVT Young To have a magnet available in A&E Wear gloves when examine patients who had frequent shock! Case 4 46-year-old female Case 4 - ECG Pre-excited AF Intermittent rapid palpitation for 1 year Dizziness and one episode of syncope A&E with a prolong attack (12 hours), dizziness. BP 80mmHg, pulmonary congestion No previous medical history Well No risk factors of IHD Case 4 ECG Irregular broad complex tachycardia? Pre-excited AF Avoid the use of verapamil Digoxin ß-blocker adenosine

6 AV nodal re-entry tachycardia Orthodromic Case 4 - ECG Antidromic Sudden Cardiac Death in WPW Key messages Irregular broad complex tachycardia Incidence 0.15 to 0.6% per year. Unusual for SCD to be the first symptomatic Thinks of pre-excited AF Low threshold for DC cardioversion manifestation of WPW. Amongst cardiac arrest survivors, it was the first Risk of sudden cardiac death in young Refer to an electrophysiologist symptomatic manifestation in 50%. Emergency Treatment of Cardiac Arrhythmia Tachycardias Haemodynamic instability DC cardioversion Broad complex tachycardia Treat as VT unless proven otherwise Irregular broad complex tachy. Avoid digoxin, beta-blocker, verapamil and adenosine Not all ICD shocks are appropriate Magnet should be available in all A&E department Pre-excitation and palpitation AF