Management of common arrhythmias Dr. Fawzia Al-Kandari - PowerPoint PPT Presentation

Management of common arrhythmias Dr. Fawzia Al-Kandari Cardiologist, cardiac Electrophysiologist Chest Diseases Hospital Head of cardiology unit- Jaber Al Ahmed Hospital

Common Arrhythmias • SVT ( supra-ventricular Tachycardia) • AF ( Atrial Fibrillation ) • PAC’s ( Premature Atrial Contractions) • PVC’s ( Premature Ventricular contractions ) • VT ( Ventricular Tachycardia )

Basic Principles Basic principles for the management of all types of arrhythmias: • Instability = DC • Documentation is paramount = 12 lead ECG or Rhythm strip • Future Risks

1- Supra-Ventricular Tachycardia ( SVT )

1- Supra-Ventricular Tachycardia ( SVT )

SVT Prevalence is 2.29 per 1000 persons Usually young with no structural heart disease. Women twice the Men ≥ 65 of age has higher risk of developing PSVT

Approach to Dx of SVT 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

Approach to Dx of SVT 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

Common Regular SVT causes • Narrow QRS tachycardia • Can be wide if BBB ( Aberrancy) AVNRT 60% AVRT 30% AT 10% Short RP ( P fused in QRS) Short RP ( VA>80) Long RP ( P wave different from sinus)

ACC/HRS 2015 SVT Guidelines (Acute) 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

ACC/HRS 2015 SVT Guidelines (Acute) 1 2 Options in Pregnancy 3 4 5 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

In the Emergency Room • Stability. • Document with 12 leads ECG. • Cardiovert ( medical or electrical). • Observe for few hours in ER . • Discharge with referral to Cardiology clinic. • Verapamil/diltiazem or BB is optional until Cardiology clinic. • NO antiarrhythmics

ACC/HRS 2015 SVT Guidelines (Ongoing) 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

ACC/HRS 2015 SVT Guidelines (Ongoing) 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

In The Cardiology Clinic First episode = Either wait and see or Ablation if the patient prefers. Multiple episodes = Strongly advise for ablation. Failed Ablation or Patient’s Preference = Medical Therapy : • CCB or BB as first option • Flecainide or Propofol • Sotalol or Dofetilide • amiodarone

If wide QRS tachycardia • If in doubt, always Treat as VT = synchronized cardioversion. • If patient is stable , one could try Adenosine for diagnostic purposes. • NO Verapamil 2015 ACC/AHA/HRS SVT Guideline . JACC VOL. 67, NO. 13, 2016.

WPW Symptomatic WPW ( narrow or wide SVT) • Catheter Ablation is recommended ( class I ) Asymptomatic WPW • Observation or Ablation are reasonable ( Both options can be offered for the patient ( class IIa) )

2- Atrial Fibrillation ( AF )

2- Atrial Fibrillation ( AF )

2- Atrial Fibrillation ( AF ) Irregular heart beats due to chaotic and disorganized atrial conduction. With loss of organized atrial contractions ( loss of P wave ).

Atrial Fibrillation Prevalence (1% < 60 yrs of age), (12% in > 75 yrs of age ) Life time risk of developing AF in Europe is ( 23% to 26 %) after the age of 40 yrs. Risks : • 5 Folds risk of Stroke • 3 Folds risk of HF • 2 Folds risk of Dementia and Mortality

AF Definitions 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC VOL. 64, NO. 21, 2014. • Valvular AF = Moderate to Severe MS or Mechanical Valve prosthesis 2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019. • ‘Lone AF’ and ‘Chronic AF’ terms are Obsolete.

AF management Management of AF includes : • Determining the Aetiology. • Decide about stroke risk and need for Anticoagulation. • Rate control for all patients. • Decide whether Rhythm control strategy is required

AF Anticoagulation : ( Includes Men = 2 and Women =3 ) CHA2DS2VASc = 2 For patients with AF and CHA 2 DS 2 -VASc score of 2 or greater in men or 3 or greater in women, oral anticoagulants are recommended. 2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019. 2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719 – 2747

AF Anticoagulation : ( Includes Men = 0 and Women = 1) CHA2DS2VASc = 0 Both the 2014 ACC/HRS guidelines and 2012 European (ESC) guidelines agree that patients with (Score 0) Receive NO therapy. 2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019. 2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719 – 2747

AF Anticoagulation CHA2DS2VASc = 1 ( Men = 1 and Women = 2) 2019 focused update of 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC 2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719 – 2747

AF Anticoagulation- European 2012 Focused update of the ESC Guidelines on the management of a trial fibrillation European Heart Journal (2012) 33, 2719 – 2747

Warfarin or NOAC NOACs are Recommended over warfarin in NOAC-eligible patients with AF (i.e. all except with moderate-to-severe mitral stenosis or a mechanical heart valve) 2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019. Guidelines approved NOACs include : • Dabigatran (PRADAXA) - Approved Reversal Agent ( Idarucizumab ) • Rivaroxaban ( XARELTO) - Approved Reversal Agent ( Adexanet alfa) • Apixaban (ELIQUIS) - Approved Reversal Agent ( Adexanet alfa) • Edoxaban ( SAVAYSA) Betrixaban = Waiting FDA approval

Anticoagulation But Bleeding ? AF patients on anticoagulant who develop bleeding require multidisciplinary team decision. Risk of stroke versus Risks of the bleeding ? Options of Management : • Hold anticoagulant • Stop bleeding source • Reversal agents • Supportive measures ( FFP, PPC, VIIa, RBC Transfusion … ..etc) * An important question always rises after the bleeding episode ? when to resume anticoagulant and is there alternative? ( Future Risks )

Anticoagulation But Bleeding ? Evidence suggests that LAA is the main site of thrombus formation (90%) and subsequent cardioembolic stroke in AF patients. Ann Thorac Surg . 1996;61:755 – 759. Acta Med Scand . 1969;185:373 – 379. J Am Coll Cardiol . 1995;25:452 – 459. Circulation 2002;105:1887 – 1889. J Am Coll Cardiol . 2007;49:1490 – 1495. Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation (class IIb recommendation) 2019 AHA/ACC/HRS focused update of 2014 Guideline for the Management of Patients With Atrial Fibrillation. JACC 2019.

AF cardioversion AF for Cardioversion Onset < 48 hr YES No Conventional OAC or TEE 3 Weeks Anticoagulant TEE Strategy Heparin Heparin No LAA Thrombus LAA Thrombus Cardioversion Cardioversion Opt for rate control if LAA Therapeutic OAC thrombus still present for 3 weeks SR AF SR AF CHA2DS2Vasc 4 Weeks Anticoagulant score 1 Consider if Long Term OAC indicated Score 0 No Long Term Anticoagulant NO CHA2DS2Vasc YES Long Term Anticoagulant

AF cardioversion AF for Cardioversion Onset < 48 hr < 48 hours YES No Conventional OAC or TEE 3 Weeks Anticoagulant TEE Strategy Heparin Heparin No LAA Thrombus LAA Thrombus Cardioversion Cardioversion Opt for rate control if LAA Therapeutic OAC thrombus still present for 3 weeks SR AF SR AF CHA2DS2Vasc 4 Weeks Anticoagulant score 1 Consider if Long Term OAC indicated Score 0 ( IIb Recommendation) (IIb Recommendation) No Long Term Anticoagulant NO CHA2DS2Vasc YES Long Term Anticoagulant

AF cardioversion AF for Cardioversion Onset < 48 hr > 48 hours- conventional YES No Conventional OAC or TEE 3 Weeks Anticoagulant TEE Strategy Heparin Heparin No LAA Thrombus LAA Thrombus Cardioversion Cardioversion Opt for rate control if LAA Therapeutic OAC thrombus still present for 3 weeks SR AF SR AF CHA2DS2Vasc 4 Weeks Anticoagulant score 1 Consider if Long Term OAC indicated Score 0 No Long Term Anticoagulant NO CHA2DS2Vasc YES Long Term Anticoagulant

AF cardioversion AF for Cardioversion Onset < 48 hr > 48 hrs - TEE YES No Conventional OAC or TEE 3 Weeks Anticoagulant TEE Strategy Heparin Heparin No LAA Thrombus LAA Thrombus Cardioversion Cardioversion Opt for rate control if LAA Therapeutic OAC For patients with AF or atrial flutter of 48 hours’ duration or longer or of unknown duration who have not thrombus still present for 3 weeks SR AF SR AF been anticoagulated for the preceding 3 weeks, it is reasonable to perform transesophageal echocardiography before cardioversion and proceed with cardioversion if no left atrial thrombus is CHA2DS2Vasc 4 Weeks Anticoagulant score 1 identified, including in the LAA, provided that anticoagulation is achieved before transesophageal echocardiography and maintained after cardioversion for at least 4 weeks ( IIa Recommendation) Consider if Long Term OAC indicated Score 0 No Long Term Anticoagulant NO CHA2DS2Vasc YES Long Term Anticoagulant