ECG Monitoring in the Elderly. ECG Monitoring in the Elderly

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1 William A. Shapiro, M.D. Alternative Title for this Talk Arrhythmias in the elderly: A Broken Heart or Just Getting Old What is old? What is a normal old heart? What ECG abnormalities increase with age? What ECG rhythms increase with age? What are current recommendations for preop ECG s? What surgeries are common in the elderly population? Rhythm devices, anything new? Biomarkers, what are they, and how might they help? World Health Organization- 9/28/2007 Long life is a sign of good health. The aging of the world's population - in developing and developed countries - is an indicator of improving global health. The world's elderly population - people 60 years of age and older - is 650 million. By 2050, the greying population is forecast to reach 2 billion. United Nations- There is no United Nations standard numerical criterion, but the UN agreed cutoff is 60 years to refer to the older population US Retirement Systems- The definition of retirement ages is typically 65 years A society is considered relatively old when the fraction of the population aged 65 and over exceeds 8-10% elderly fraction in the US was 4.1% elderly fraction in the US was 12.6% projected to increase to 20% Gavrilov L.A., Heuveline P. Aging of Population

2 Medical Literature- Conventionally, elderly has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as early elderly and those over 75 years old as late elderly. However, the evidence on which this definition is based is unknown. Life expectancy at Birth US- by race, sex Geriatrics & Gerontology International, Volume 6, Issue 3, September 2006 World Bank, World Development Indicators, Apr 26, Hospitalization rates US- by age What is the normal age-related heart rate Although normal pulse rate values change a bit as you age, those differences are insignificant, according to the Topend Sports Network. A 21-year-old man in good physical condition, for example, typically has a pulse rate between 62 and 65 beats per minutes. This norm fluctuates a little over the years, but by age 65 years, his pulse rate will once again run between 62 and 65 Mean values from the physiological indices in participants of the original cohort of the Framingham Heart Study (pooled data) Curr Gerontol Geriatr Res

3 Intrinsic Heart Rate The SA node exhibits automaticity that is determined by sympathetic and parasympathetic influences. Intrinsic automaticity is the heart rate unmodified by neurohumoral factors, and is a spontaneous firing rate of beats/min. This intrinsic firing rate decreases with age. Intrinsic Heart Rate Hear_Rate_w.htm What are the most common ECG Abnormalities Abnormalities increase with age At least 50% have ECG abnormalities LVH Increases in PR, QRS, and QT intervals Decrease in QRS amplitude Left ward axis shift in the frontal plane Prior MI Bundle branch block and Atrial Fibrillation Non-specific ST-segment and T-wave changes Preop ECG Abnormalities- age > 70 75% had at least one ECG abnormality 76% in patients with a cardiac history 71% in patients without cardiac history Q-waves- 34% Left axis deviation- 19% LVH- 7% ST-T wave abnormalities- frequent Atrial fibrillation- 3.5% No ECG abnormality was predictive of a post op event Liu, et al. J Am Geriatr Soc 50: , 2002 Atrial Fibrillation 3

4 Preop ECG s- When are they indicated? Age not considered a reason to obtain a preop ECG Symptoms determine testing - ASA Preop Practice Advisory: No added predictive risk value over symptoms - Centers for Meidcare and Medicaide Services do not reimburse for preop ECG s, or age-based ECG s AHA/ACC Recommendations for a preop ECG - Determined by clinical risk factors AND - Type of surgery Preop ECG s- When are they indicated? AHA/ACC Clinical Risk Factors - coronary artery disease - heart failure - diabetes, - cerebrovascular disease - creatinine >2.0 mg/dl Preop ECG s- When are they indicated? AHA/ACC Recommendations for preop ECG - Class I: Recommended At least 1 clinical risk factor for vascular surgery - Class IIa: Reasonable No clinical risk factors and vascular surgery - Class IIb: May be reasonable At least 1 clinical risk factor and intermediate risk surgery - Class III: Not indicated Asymptomatic persons for low-risk (out-pt) surgeries Preop ECG s- Significant Arrhythmias AHA/ACC: Arrhythmias to postpone elective surgery High grade block or Mobitz II AV block - High-Grade: 2 sinus P waves block consecutively in the context of periodic AV conduction 3 rd degree AV block Symptomatic ventricular arrhythmias SVT with an uncontrolled ventricular rate Symptomatic bradycardia Newly recognized VT Classification of AV Block Degree of Block Partial (less than 1:1 conduction) First-degree AV block Second-degree AV block Types I (Wenckebach) and Type II Complete AV block (no conduction at all) Third-degree AV Block Location of Block Nodal- At the level of the AV node Second-degree Type I (Wenchebach) AV block Infranodal Second-degree Type II AV block Third-degree (complete) AV block N Engl J Med 2011;364:

5 N Engl J Med 2011;364: Trends in Hospital Volume and Operative Mortality for High-Risk Surgery all patients from 65 to 99 years of age who underwent one of the following eight cancer and cardiovascular operations from 1999 through 2008 N Engl J Med 2011;364: ECG and Heart Transplants The transplanted heart initially has no sympathetic, parasympathetic, or sensory innervation. Loss of vagal tone results in higher than normal resting heart rate ( bpm). The donor sinus node pacing mechanisms and coronary autoregulation remain intact. Two p waves may be observed if enough atrial tissue remains for the surgical anastamosis with the new donor heart. Reinnervation of the transplanted heart is unpredictable. ECG and Heart Transplants Beebe et al presented two patients, 4 and 8 yrs after cardiac transplantation, reversed with neostigmine 5mg and gycopyrrolate 1mg after outpatient non-cardiac surgery resulting in asytole. Electrophysiology and cardiac cath revealed no evidence of intrinsic conduction or SA disease. Casta et al. report cardiac arrest after NMB (neo/glyco) reversal 1 month following heart transplant in a 20 month old. Anesth Analg 1994; Anesthesiology: Oct 2007 Vol 107-4, ECG and Heart Transplants Directing acting beta agonists, as well as atropine and epinephrine should be available No muscle relaxants, if possible, otherwise, use a short acting muscle relaxant to minimize the need for reversal Consider glycopyrrolate or epinephrine first, then neostigmine Where is sugamadex? Internal or external pacing should be available Pacemakers & ICDs Millions have pacemakers, many hundred thousands ICDs Patients have Pacemaker/ICD cards Companies have 24-hr phone lines with humans Batteries won t run out during surgery Devices should be checked after surgery to ensure they are still functioning as intended; that they were not inadvertently altered during electro-cautery activation 5

6 Pacemakers & ICDs Pacemakers & ICDs What does the magnet do? ICD devices should be deactivated for surgery involving unipolar electrical interference Converts regular pacemakers to the asynchronous When an ICD is deactivated, backup defibrillation must be immediately available CVP placement is not contraindicated, but deserves THE ANESTHESIOLOGIST IS atrial and ventricular tachycardias (VT, VF, SVT) special consideration in a patient with a pacemaker or an ICD, as there is potential lead wire dislocation or infection (fixed-rate) mode Deactivates ICD sensing, and subsequent therapy, for IN Can cause R-on-T induced arrhythmias Cautery activation Cautery activation Electrocautery Induced Pacemaker Reprogramming Cautery Induced Pacemaker Inhibition Cautery Pacemaker Inhibition Magnet Converts Pacemaker to Asynchronous Mode Magnet Converts Pacemaker to Asynchronous Mode Magnet applied Cautery activation Cautery activation 6

7 Paced rhythm with R on T Arrhythmia What the magnet does NOT do? Magnets have NO effect on devices that are patientactivated for termination of atrial fibrillation Magnets will NOT turn off the pacing function Cautery may permanently reprogram the pacemaker/icd whether or not a magnet is kept over the generator Magnets might produce an effect if the device is NOT a pacemaker or an ICD Cardiac Safety Biomarkers To assess if levels of inflammatory biomarkers serve as independent predictors for drug or procedure outcome The Role of Cardiac Biomarkers in Prediction of Outcome in Atrial Fibrillation Patients Undergoing Catheter Ablation QT as a Safety Biomarker in Drug Development Cardiac Safety Biomarkers heart rate blood pressure lipids Individualized risk assessment Critical path collaborations troponin C-reactive protein (CRP) Improved biomarkers of cardiac safety Cardiac Safety Research Consortium Clinical Pharmacology & Therapeutics (2009); 86, 1, References- preop ECGs 1. Preoperative Electrocardiogram Abnormalities Do Not Predict Postoperative Cardiac Complications in Geriatric Surgical Patients. Liu, et al. J Am Geriatr Soc 50: , Preoperative Electrocardiograms- Patient Factors Predictive of Abnormalities. Correll, et al. Anesthesiology 2009; 110: The role of testing in the preoperative evaluation. Hepner DL. Cleveland Clinic Journal of Medicine volume 76 supplement 4 November Preoperative Electrocardiograms- Obsolete or Still Useful? De Hert SG. Anesthesiology 2009; 110: (Editorial) 5. The Preoperative Electrocardiogram- What Is the Role in 2007? Annals of Surgery. Fleisher, LA. Volume 246, Number 2, August 2007 (Editorial) 6. The additional value of routine electrocardiograms in cardiovascular risk management of older people- The Leiden 85-plus study. De Ruijter, et al. Scand J Prim Health Care. 2008;26(3): References- ECG findings in the elderly 7. Prevalence, prognosis, and implications of isolated minor nonspecific ST-segment and T- wave abnormalities in older adults: Cardiovascular Health Study. Kumar, et al. Circulation, 2008 Dec 16;118(25): Preoperative electrocardiogram abnormalities do not predict postoperatvie cardiac complications in geriatric surgical patients. Liu, et al. J Am Geriatr Soc 50: , Prevalences of ECG findings in large population based samples of men and women. Bacquer, et al. Heart 2000;84: Major electrocardiographic abnormalities in persons aged 65 years and older (the Cardiovascular Health Study). Cardiovascular Health Study Collaborative Research Group. Furberg, et al. Am J Cardiol May 15;69(16):

8 References- specific surgery 11. The value of routine preoperative medical testing before cataract surgery. Schein, et al. N Engl J Med 2000;342: Routine preoperative medical testing for cataract surgery (Review). Keay, et al. Cochrane Database Syst Rev Apr 15;(2) [ hour ambulatory electrocardiographic monitoring is unhelpful in the investigation of older persons with recurrent falls. Davison, et al. Age Ageing Jul;34(4): Trends in Hospital Volume and Operative Mortality for High-Risk Surgery. Finks, et al. N Engl J Med 2011;364: Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Fleisher, et al. Arch Surg 2004; 139: References- guidelines & advisories 16. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). European Heart Journal (2009) 30, Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices. Anesthesiology, V 114 No 2, 247 February ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg Mar;106(3): References- guidelines & advisories 19. STATEMENT ON ROUTINE PREOPERATIVE LABORATORY AND DIAGNOSTIC SCREENING. Standards and Practice Parameters (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October 22, 2008) [ asahq.org/for-healthcare-professionals/standards-guidelines-and-statements.aspx] References- biomarkers 20. Biomarkers in Atrial Fibrillation, Ventricular Arrhythmias, and Sudden Cardiac Death. Mountantonakis et al. Cardiovasc Ther 2010 Nov QT as a Safety Biomarker in Drug Development. Whellan et al. Clinical Pharmacology & Therapeutics (2009); 86, 1,