Tachycardias II. Štěpán Havránek
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1 Tachycardias II Štěpán Havránek
2 Summary 1) Supraventricular (supraventricular rhythms) Atrial fibrillation and flutter Atrial ectopic tachycardia / extrabeats AV nodal reentrant a AV reentrant tachycardia 2) Ventricular (ventricular rhythms) Ventricular ectopia / extrabeats Accelerated idioventricular rythm Ventricular tachycardia mono a polymorfic sustained and unsustained Ventricular fibrillation
3 Management of arrhythmias 1) Diagnosis ECG, ECG monitoring Personal and family history 2) Underline condition Personal and family history / Physical examination ECG Cardiac imaging (ECHO, MRI, CT) Stress testing, coronary angiography 3) Suffering of symptoms Palpitations, dizziness, syncopy, shorting of breath, chest pain, heart failure symptoms 4) Risk stratification Personal and family history / ECG / Cardiac imaging Stress testing / coronary angiography EP study
4 Ventricular rhythms wide QRS complex tachycardia
5 Classification 1) Ventricular premature beats 2) Accelerated idioventricular rhythm 3) Ventricular tachycardia 4) Ventricular fibrillation
6 Ventricular premature beats
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9 Ventricular premature beats Frequent finding in cardiological practice Symptoms: Asymptomatic, symptomatic Palpitations (irregular and slow) VPB exclude structural heart disease Therapy: Underline disease Symptoms β-blockers Antiarhythmics propafenone, amiodaron Catheter ablation NO SYMPTOMS = NO TREATMENT
10 Accelerated idioventricular rhythm
11 Accelerated idioventricular rhythm Reperfusion HR < 100 bpm Benign
12 Ventricular tachycardia Organised ventricular activity > 3 beats > 100 bpm. ECG: wide compex (QRS > 120 ms). Classification: ECG: Monomorphic, polymorphic Hemodynamic impact: Sustained: > 30 s or cardiac arrest Nonsustained: < 30 s
13 Clinical and prognostic view 1. Idiopatic VT no structural heart disease, no pathological ECG, no SCD in family history, no syncopy BENIGN treated when symptoms are present 2. VT with structural heart disease, abnormal ECG, SCD in family history, syncopy MALIGNANT / RISK of SUDDEN CARDIAC DEATH must be treated
14 VT with structural heart disease / malignant potential Coronary artery disease acute or chronic forms Dilatative cardiomyopathy Hypertrofic cardiomyopathy Arhythmogenic right / left ventricle dysplasia Postmyocarditic scarring Long QT syndrome Short QT syndrome Brugada syndrome
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21 Monomorphic VT PS LS LK PS LS LK * PK PK
22 Focal activity
23 Reentry 150 ms 100 ms 200 ms 300 ms 130 ms 140 ms 400 ms 500 ms 570 ms 0 ms
24 Polymorphic VT long QT
25 Polymorphic VT R on T
26 Polymprphic VT
27 Polymorphic VT - CAD
28 Clinical manifestation of VT Dependent on: Systolic function Heart rate Situation (standing or lying) Manifestation: Sudden cardiac death pulsless VT, progression to VF Syncope non-sustained, self-terminating Dyspnea, chest pain Asymptomatic
29 Asymptomatic VT
30 VT progression to VF
31 Ventricular fibrillation Everytime malignant Manifestation: Sudden cardiac death, cardiac arrest
32 VF
33 Therapy VT or VF Acute and initial therapy according to clinical status: 1. Cardiac arrest VF or pulsless VT - CPR + urgent defibrillation 2. Tolerated VT Antiarythmics iv. prokainamid, amiodaron, sotalol DC cardioversion Next step: Exclusion of all conditions leading to VT or VF
34 Management of VT / VF - I If patient has manifested VT looking for: Family history of sudden cardiac death - chanelopathies long / short QT - ARVC / D - Brugada syndrome Personal history - CAD, AMI, cardiomyopathies Warning symptoms - syncope
35 Management of VT / VF - II 12 lead ECG - evidence of acute / old MI - LBBB (DCMP) - left ventricular hypertrophy - repolarization changes - long QT Evidence of structural heart disease: - ECHO - MRI - Coronary angiography
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38 Occurence: 10% of all VT Idiopathic VT Prognosis: Benign!!Absence of structural heart disease and warnig symptoms!! Therapy: According to symptoms Drugs - β-blockers Antiarhythmics propafenone, amiodaron Catheter ablation in case of intolerance or resistence
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40 Therapy malignant VT or VF Definitive treatement: 1. Implantation of ICD 2. A. Drugs amiodarone B. Catheter ablation
41 Catheter ablation
42 ICD Primary prevention: Patient without manifestaion of VT/VR yet BUT who are in severe risk of VT/VF Risk: Structural heart disease Secondary prevention: Patient who survived episode of VT/VF
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