1. Arrhythmias: The Good, the Bad and the Ugly
Soori Sivakumaran MD, FRCPC
Clinical Associate Professor of Medicine
University of Alberta
October 4, 2014

2. What is this rhythm?

5. Ventricular Tachycardia
History of previous MI or cardiomyopathy
Abnormal cardiac exam
Family history of sudden/premature cardiac death
A slow rate doesn’t mean its not VT

10. Supraventricular Tachycardias
Atrial fibrillation
Atrial flutter
Atrial tachycardia
Multifocal atrial tach
Junctional tachycardia
AV nodal re-entry
AV re-entry tachycardia
Murgatroyd, Krahn Yee Skanes and Klein

11. History Previous heart disease Onset Associated symptoms Termination
Regular or irregular
Chest discomfort, SOB, lightheaded, syncope
Termination
Spontaneous or by patient maneuvers

12. ECG Criteria What is the heart rate? Are there P waves?
Is the rhythm regular or irregular?
What is the relationship of P waves to QRS complexes?
Are the QRS complexes wide or narrow?

13. Sinus Tachycardia Most common fast rhythm
Response to another condition
Treat primary problem (sepsis, pain etc.)
Do not treat tachycardia!
Murgatroyd, Krahn Yee Skanes and Klein

16. AVRT vs AVNRT
Murgatroyd, Krahn Yee Skanes and Klein

21. Atrial fibrillation can keep bad company
Hypertension
Pulmonary embolus
Cardiomyopathy
Valvular heart disease
Ischemia
Thyrotoxicosis
Pericarditis
Murgatroyd, Krahn Yee Skanes and Klein

22. Anticoagulation prevents strokes
Valvular AF
Stroke Risk Factors (Non Valvular AF)
Age over 65
Hypertension
Diabetes
Previous Stroke or TIA
Structural Heart Disease

23. Anticoagulation prevents strokes
Warfarin reduces the risk of stroke by 2/3
ASA reduces the risk of stroke 30%
Recommended in non valvular AF with no stroke risk factors but arterial vascular disease
INR target 2.0 to 3.0
Newer oral anticoagulants an alternative

24. Electrical and chemical cardioversion have the same risk of stroke
CV safe within 48 hours of the onset of atrial fibrillation
Do not start anti-arrhythmic drugs that may cardiovert the patient beyond this window
After 3 weeks of anticoagulation with the INR between 2.0 and 3.0
CV safe following a TEE to rule out LA thrombus

25. Rate Control Usually safest strategy in ER
Digoxin is a poor rate control agent unless patient is at rest
Beta blocker and calcium channel blockers much more effective for rate control
Digoxin can be used in combination with above and in patients in acute CHF

26. Rate control = Rhythm control
Misconceptions
People live longer if sinus rhythm is maintained
The risk of stroke is less if sinus rhythm is maintained

27. Atrial Fibrillation: Follow-up Investigation of Rhythm Management (AFFIRM)
Primary Endpoint - Total Mortality 5 10 15 20 25 30 1 2 3 4
Mortality (%)
Rate
Rhythm
p =
Time (Years)
Rhythm:
2033
1932
1807
1316
780
255
Rate:
2027
1925
1825
1328
774
236
AFFIRM Investigators N Engl J Med 347: , 2002

28. Symptoms determine whether to pursue a rhythm control strategy
Patients with atrial fibrillation have a wide range of symptoms
Patients are more likely to have symptoms:
Younger
Female
Paroxysmal AF
LVH
CHF

29. Symptoms determine whether to pursue a rhythm control strategy
Common Symptoms
Palpitations
Dyspnea
Fatigue
Decreased exercise tolerance
The degree of symptoms may not be clear until the patient is back in sinus rhythm

30. Antiarrhythmic drugs can be pro-arrhythmic
Class I and III antiarrhythmic drugs are potentially proarrhythmic
VF is worse than AF
Contraindicated in patients with structural heart disease
Need to rule out structural heart disease and ischemia and other factors before using

31. Asymptomatic PAF is common
Many patients have who have symptomatic episodes of atrial fibrillation also have asymptomatic episodes of atrial fibrillation
Cannot use symptoms to determine that AF is not recurring
Probably safest to continue anticoagulation indefinitley in most cases
For stroke risk, PAF = CAF

32. Anti-arrhythmic Rx should be stopped in chronic atrial fibrillation
Risks with no benefit
Rate control agents
Continue anticoagulation with monitoring (maybe affected by discontinuation)

35. AF with Pre-Excitation
Murgatroyd, Krahn Yee Skanes and Klein

37. Conclusions Record the rhythm on 12 lead ECG
Consider running 12 lead rhythm strip with CSM or adenosine
The presence of structural heart disease greatly increases the risk of ventricular arrhythmias
Don’t use amiodarone IV for everything