Disclosures Common Heart Rhythms in the Hospital Research Support: NIH, PCORI, Medtronic, Cardiogram Consulting: InCarda, Johnson & Johnson, Lifewatch Equity: InCarda Gregory M Marcus, MD, MAS Associate Professor of Medicine Division of Cardiology University of California, San Francisc Goals of the Talk What to do when encountering an arrhythmia Leveraging the encounter to maximize benefit to the patient long-term SVT Tachyarrhythmias- Unstable Atrial fibrillation Unconscious, altered mental status, ongoing chest pain Hypotension is a clinical judgment AF with WPW VT/ VF SHOCK THE PATIENT 1
SHOCK THE PATIENT Unstable SVT, AF, VT Is the defibrillator on synch? Anything other than VF MAKE SURE IT IS ON SYNCH SHOCK THE PATIENT SHOCK THE PATIENT STILL in unstable SVT, AF, VT Is the defibrillator on synch? Atrial fibrillation SVT AF with WPW VT Atrial Fibrillation Nondihydropyrdine Calcium channel blockers Diltiazem Verapamil Beta-blockers Metoprolol Atenolol Carvedilol Labetolol Propanolol Blood Pressure 1. Address underlying condition 2. Esmolol 3. Digoxin 4. Amiodarone 5.?Dronaderone? 2
How about cardioversion? Elective Cardioversion 46 year old man without cardiovascular risk factors and symptomatic AF on propafenone DC cardioversion is the most efficacious but requires sedation If the patient has no structural heart disease (no CAD, normal EF, not severe LVH) 200-300 mg of flecainide or 600 mg of propafenone (MUST BE GIVEN WITH AV NODAL BLOCKER DUE RISK OF 1:1 ATRIAL FLUTTER) Ibutilide IV- Torsades risk, requires 4 hours of monitoring Tikosyn (dofetilide) can work, but usually in 1-2 days and generally in setting of careful QT monitoring over 3 days 46 year old man without cardiovascular risk factors and symptomatic AF on propafenone A SLOWER FLUTTER PARADOXICALLY CAN RESULT IN A FASTER RHYTHM BECAUSE THE AV NODE CAN ACCOMMODATE A GREATER PROPORTION OF DEPOLARIZATIONS PATIENTS ON FLECAINIDE OR PROPAFENONE REALLY SHOULD BE ON AN AV NODAL BLOCKER How about cardioversion? Elective Cardioversion Most thrombi in atrial fibrillation arise from the left atrial appendage Cardioversion can reduce left atrial appendage function Even from AF to sinus The pericardioversion period is a particularly prothrombotic time Regardless of mode: DC/ electrical, pharmacologic, spontaneous 3
I decide to go with Elective Cardioversion I decide to go with Elective Cardioversion Prior to cardioversion: 1, 2 Can exclude preexisitng thrombus by TEE Can anticoagulate (therapeutic/ for at least 3 weeks) prior to cardioversion 1. JACC 2006;48:e149-246 2. Chest 2004;126:429S-456 During and after cardioversion: 1, 2 Anticoagulation for at least 4 weeks Applies even to those who would otherwise not require anticoagulation Generally does not make sense to cardiovert AF in order to avoid anticoagulation 1. JACC 2006;48:e149-246 2. Chest 2004;126:429S-456 The magic 48 hours I decide to go with Elective Cardioversion Must be documented! Reason to consider starting anticoagulation NOW in the hospital as it may stop the clock There are cases of stroke even within this time window, so only do this if you need to and start anticoagulation if you can Bigger Picture on AF THREE GOALS IN TREATING AF IN GENERAL 1. We want to prevent THROMBOEMBOLISM 2. We want to avoid fast ventricular rates over a long period of time to prevent ventricular myopathy 3. We want to improve quality of life 4
Bigger Picture on AF THREE GOALS IN TREATING AF IN GENERAL 1.We want to prevent THROMBOEMBOLISM We want to prevent THROMBOEMBOLISM 1. Atrial fibrillation increases the risk of stroke 5 times 2. 23.5% of all strokes in those age 80-89 are attributed to AF How do we know this? From clinically recognized atrial fibrillation. Wolf et al. Stroke 1991 ATRIAL FIBRILLATION IS OFTEN ASYMPTOMAIC Audience Response Question Among Cryptogenic Stroke Patients, AF can be found in: 0-3% 3-10% 10-20% 20-30% Page et al. Circulation 1994 5
AF is common if you look hard enough among cryptogenic stroke patients We want to prevent THROMBOEMBOLISM Brachman et al. Circ A&E 2016 Atrial Fibrillation Predicts a Higher Risk of MI Atrial fibrillation is association with a 30%-40% increased risk of dementia 6
Atrial Fibrillation is associated with a higher risk of kidney disease How is This Relevant to Hospital Medicine? That patient who develops atrial fibrillation in the setting of cellulitis or pneumonia ASSUME YOU WERE LUCKY TO CATCH IT BECAUSE THE PATIENT WAS BEING MONITORED ANTICOAGULTE UNLESS THERE IS A COMPELLING REASON NOT TO Examples:»CHADSVASC of 0 or perhaps 1»History of hemorrhagic stroke Gialdini et al. JAMA 2014 7
A patient never calls you in the middle of the night to thank you for not having a stroke. What if I have a suspicion for AF but we don t catch it? Can order a Zio patch (monitors for 1-2 weeks) Injectable Loop Recorder -Michael Ezekowitz, M.B., Ch.B., D.Phil 8
Atrial fibrillation ablation Elective, generally takes time to schedule For SYMPTOMATIC AF- not stroke prevention Empiric (target PV isolation) Efficacy ~70% in PAF and ~50% in persistent AF at 1 year, attrition in many over time Can have early recurrence with long-term success Audience Response Question The success of a typical atrial flutter ablation is: 40-50% 50-70% 70-95% 95-100% Atrial FLUTTER ablation SVT Quicker procedure, easier to schedule We have a very clear target Flutter tends to be more difficult to rate control Antiarrhythmic drugs do not work so well for flutter Ablation of atrial flutter is FIRST LINE Success rate is ~97% 9
SVT Vagal Manuevers WAIT! SVT Vagal Manuevers Carotid sinus massage Valsava GET A 12 LEAD ECG! Will terminate ~20% 1 1. Lim SH et al. Ann Emerg Med 1998;31:30-35 SVT Adenosine Metabolized by red blood cells and endothelium Give 6 mg IV with 20 cc flush Repeat with 12 mg IV X 2 How do I know if I ve given enough? 75% reduction in ED visits among those undergoing catheter ablation (p=0.003). 10
The most likely diagnosis is: 1. Ventricular Tachycardia 2. Atrial fibrillation with WPW 3. SVT with aberrancy Atrial Fibrillation with preexcitation AV nodal blockers Give: Procainamide Ibutilide Then refer to EP for ablation 11
Ventricular Tachycardia Scarcity of data Amiodarone probably the most effective 1,2 -- Can cause bradycardia -- Can hinder EP studies/ ablation Extrapolate from cardiac pulseless VT/ VF versus placebo: 1. Kudenchuck PJ et al. N Engl J Med 1999;341:871-878 versus lidocaine: 2. Dorian P et al. N Engl J Med 2002;346:884-890 Ventricular Tachycardia Scarcity of data Consider -- Lidocaine gtt -- Procainamide - watch for hypotension and prolonged QT Ventricular Tachycardia Get EP involved May respond to beta-blockers or calcium channel blockers May be amenable to ablation Tachyarrhythmias- a long QT 1.Electrolytes Hypokalemia Hypo-Mg2+ Hypo-Ca2+ 2. DRUGS 3. Congenital 12
Tachyarrhythmias Bradyarrhythmias 1. IV magnesium 2. Isoproterenol 3. Transvenous pacing 4. Unstable DC shock THINK ABOUT TORSADES IF AMIODARONE ISN T WORKING FOR VF OR PERHAPS MAKING THINGS WORSE Important questions: Is this dynamic/ reversible/ vagal? IE, more likely benign IE, less likely respond to pacing IE, more likely transient Or is this structural IE, more likely dangerous IE, more likely needs pacing In the absence of SYMPTOMS, type II second degree AV block or third degree AV block pacemaker 1. Atropine 1 2. Transcutaneous 1 pacing OR Dopamine OR Epinephrine (then mention isoproterenol) Bradyarrhythmias + + Short term: 3. Consider consultation ± transvenous pacing 1. AHA Guidelines. Circulation 2010;18:S749 13
Pacemakers Should be interrogated/ checked every 6 months Eg, doesn t necessarily need to be checked while in the hospital Generally CAN now do MRIs with certain restrictions regarding machine and personnel available We want to avoid RV pacing It s an EP sin to RV pace frequently in anyone with a depressed EF Biventricular Pacemaker His Bundle Pacing Implantable Cardioverter- Defibrillators Generally interrogated/ checked every 3 months All ICDs can also pace Anti-tachycardia pacing (ATP) is one way to break a VT circuit without pain But can always accelerate VT or lead to VF Generally ALSO CAN now do MRIs with certain restrictions regarding machine and personnel available Trend towards longer delays in detection, allowing faster rates with reduction in inappropriate shocks and DECREASE mortality 14
Pt. comes in with multiple, recurrent shocks from his ICD 1. Place external pads 2. Place magnet on chest 1. PUTS DEVICE IN MAGNET MODE 2. FOR AN ICD: INHIBITS THERAPY DETECTION 3. FOR A PACEMAKER: INHIBITS SENSING Thank You 15