Synopsis of Management on Ventricular arrhythmias M. Soni MD Interventional Cardiologist
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Premature Ventricular Contraction (PVC) Ventricular Bigeminy
Ventricular Trigeminy Multifocal PVC s
Ventricular Couplet or Paired PVC s Unifocal Multifocal
Ventricular Tachycardia: Non Sustained
Ventricular Tachycardia to V Fib
(Torsades de pointes) Twists of points Comment: The QRS changes from negative to positive polarity and appears to twist around the isoelectric line.
Ventricular Fibrillation
Clinical presentation
Ventricular arrhythmias Asymptomatic ventricular arrhythmias in the absence of identifiable heart disease predicted a small increase in risk (Ann Intern Med 1992;117:990 6), while another study suggested no increased risk.(j Intern Med 1999;246:363 72) PVCs and runs of NSVT in subjects with structural heart disease contribute to an increased mortality risk. Suppression of PVCs Severe and disabling symptoms. Beta blocker Antiarrhythmic Refractory cases: Radiofrequency catheter ablation.
Ventricular arrhythmias SCD is leading cause of death in USA. estimates in the range of 300,000 to 350,000 SCDs annually. At least 50% of all SCDs due to CHD occur as a first clinical event or among subgroups of patients thought to be at relatively low risk for SCD. The rhythm most often recorded at the time of sudden cardiac arrest is ventricular tachyarrhythmia (VF>>VT).
Automated external defibrillator Approximately 80% of cardiac arrests occur out-of hospital. AED saves lives when external defibrillation can be rendered within minutes of onset of VF. Its use by both traditional and nontraditional first responders appears to be safe and effective. Federal, state and community efforts have been effective in placing AEDs in schools, sporting events, high-density residential sites and airports as well as on airplanes and in police and fire department vehicles.
EVALUATION OF PATIENTS WITH DOCUMENTED OR SUSPECTED VENTRICULAR ARRHYTHMIAS Resting Electrocardiogram Exercise Testing Ambulatory Electrocardiography Left Ventricular Function and Imaging Echocardiogram, Cardiac CT/MRI, Myocardial perfusion SPECT, Coronary angiogram Electrophysiological Testing EP testing for the evaluation of VT was introduced in 1972 by Wellens et al.
Ventricular arrhythmias Beta blocker Antiarrhythmic till 1980 (Class I III) ICD (First ICD placed in feb 1980) Ischemia Electrolytes (K and Mg) Drugs Ablation Surgery
Therapies For Ventricular Arrhythmia Beta blockers are effective in suppressing ventricular ectopic beats and arrhythmias as well as in reducing SCD in a spectrum of cardiac disorders in patients with and without HF. With the exception of beta blockers, the currently available antiarrhythmic drugs have not been shown in randomized clinical trials to be effective in the primary management of patients with life-threatening ventricular arrhythmias or in the prevention of SCD.
Special Considerations Where Antiarrhythmic Drugs May Be Indicated Patients With Ventricular Tachyarrhythmias Who Do Not Meet Criteria for an Implantable Cardioverter- Defibrillator Patients With ICD Who Have Recurrent Ventricular Tachycardia/Ventricular Fibrillation With Frequent Appropriate ICD Firing. Patients With ICD Who Have Paroxysmal or Chronic Atrial Fibrillation With Rapid Rates and Inappropriate ICD Firing.
Conclusions: Among survivors of ventricular fibrillation or sustained ventricular tachycardia causing severe symptoms, the implantable cardioverter defibrillator is superior to antiarrhythmic drugs for increasing overall survival. (N Engl J Med 1997;337:1576-83.)
Conclusions:: In patients with a prior myocardial infarction who are at high risk for ventricular tachyarrhythmia, prophylactic therapy with an implanted defibrillator leads to improved survival as compared with conventional medical therapy. (N Engl J Med 1996;335:1933-40.)
Conclusions In patients with a prior myocardial infarction and advanced left ventricular dysfunction, prophylactic implantation of a defibrillator improves survival and should be considered as a recommended therapy. (N Engl J Med 2002;346:877-83.)
Conclusions:: In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent. NEJM 352;3 January 20, 2005
Implantable Cardioverter Defibrillator ICD therapy, compared with conventional or traditional antiarrhythmic drug therapy, has been associated with mortality reductions from 23% to 55% depending on the risk group participating in the trial, with the improvement in survival due almost exclusively to a reduction in SCD. ACC/AHA/ESC 2006
Catheter Ablation Therapy Used for more than 25 years. Success rate; Normal heart > 90%, Structural heart disease 50-75% Initially used in the treatment of patients with multiple ICD shocks for VT (VT storm), it is now used more frequently and earlier in the management of VT. Excellent choice for patients when medications are not effective, tolerated, or preferred. Mapping of VT
Surgical therapy EP mapping and surgical resection of an arrhythmogenic focus. Left cervicothoracic sympathetic ganglionectomy in LQTS Large myocardial aneurysms secondary to MI are associated with hemodynamic compromise and are frequently accompanied by major ventricular arrhythmias. In selected patient aneurysm resection can improve cardiac function and may reduce or eliminate the accompanying ventricular arrhythmia.