Arrhythmias on the AMU

Transcription

1 Arrhythmias on the AMU Dr Andrew R. Houghton United Lincolnshire Hospitals NHS An arrhythmia is present in 10% of admissions to the AMU Case history AMU referral to cardiology 25 yr 2-3 month history of progressive SOB and peripheral oedema 1

2 Focal atrial tachycardia Focal atrial tachycardia Multifocal atrial tachycardia Atrial flutter Cardiomyopathy secondary to incessant focal atrial tachycardia Tachycardiomyopathy Tachycardiomyopathy Can present at any age, even with foetal arrhythmias Can be caused by any tachyarrhythmia Incidence poorly defined (?25% of cases of AF/flutter/tachycardia) Treatment aimed at correction of the arrhythmia plus concurrent treatment of heart failure as appropriate After arrhythmia cessation marked improvement in LVEF within one month (near) normalisation of LVEF within one year Top tips 1 Don t miss atrial tachycardia always ask yourself why someone is tachycardic, and check P wave morphology Rate control in atrial fibrillation We commonly choose a rate control strategy for AF But what do we mean by rate control on the AMU? 2 Beware of incessant tachycardia, and include tachycardiomyopathy in your differential for unexplained heart failure 2

3 Top tips 3 In the AMU, current guidelines advocate a target heart rate <110 bpm in atrial fibrillation 4 Whilst amiodarone is an acute rate control option for some, beware of accepting amiodarone for long-term rate control Incidental, asymptomatic ECG finding on the AMU Refer or reassure? 3

4 In an asymptomatic patient with a WPWpattern ECG, what s the worst that could happen? How likely is it that this: Will turn into this: Top tips 5 Don t ignore an incidental WPW pattern on an ECG in an asymptomatic patient refer for risk 6 Pre-excited atrial fibrillation (or flutter) is potentially lifethreatening and is usually best managed by urgent DC cardioversion 4

5 Two questions: (1) Left or right ventricle? (2) Apex or base? LV ectopic = RBBB morphology RV ectopic = LBBB morphology 5

6 Top tips 7 Ectopic beats that arise from the right ventricle have an LBBB morphology (and vice versa) 8 Ectopic beats that arise from the ventricular apex have a negative QRS in the inferior leads (and vice versa) Incidental, asymptomatic and a normal echo VEs and left ventricular dysfunction Up to 1/3 of patients with frequent VEs develop cardiomyopathy What is the definition of frequent? >20,000 per day (Niwano et al.) >10,000 per day (Kanei et al.) >10% burden (Paysin et al.) Refer or reassure? 6

7 Circulation: Arrhythmia and Electrophysiology 2012; 5: Top tips J Am Coll Cardiol 2005;45: Ventricular ectopic beats are often benign, but if frequent can be associated with the development of a VEinduced cardiomyopathy 10 Patients with frequent VEs should have surveillance of their left ventricular function Incidental, asymptomatic ECG finding on the AMU Refer or reassure? 7

8 Beware artefactual problems If an ECG doesn t fit the clinical context, always think Could this be artefact? The patient who presents with palpitations: When to refer to cardiology 8

9 Hypotension Extreme bradycardia/tachycardia Syncope/pre-syncope Chest pain Heart failure : clinical History Frequency and duration Provocation and onset/offset Associated symptoms Pre-existing heart condition Family history of heart disease or sudden death Examination Pulse rate and rhythm Heart murmur Heart failure Investigations 12 lead ECG is mandatory Moderate/high risk features? Risk stratification Moderate/high risk features? Yes Cardiology referral Outpatient Inpatient Brit J Cardiol :

10 Moderate/high risk features? No Investigate further before referral Yes Cardiology referral Outpatient Inpatient Moderate/high risk features? No Investigate further before referral Yes Cardiology referral Outpatient Inpatient Bloods: FBC, U&E, TFT Ambulatory ECG for symptom-rhythm correlation Echo if murmur or suspected heart disease (e.g. heart failure, LBBB, LVH, Q waves) Moderate/high risk features? No Investigate further before referral Yes Cardiology referral Outpatient Inpatient Bloods: FBC, U&E, TFT Ambulatory ECG for symptom-rhythm correlation Echo if murmur or suspected heart disease (e.g. heart failure, LBBB, LVH, Q waves) In summary Don t miss atrial tachycardia Be aware of the risk of tachycardiomyopathy For AF, aim for a target HR of <110 bpm (initially) Refer all patients with a WPW ECG for cardiological Remember how to localise the origin of VEs Be aware of the risk of VE-induced cardiomyopathy Stay alert for ECG artefacts Remember how to risk stratify patients with palpitations for referral to 10