35 - Premature Ventricular Contractions and Ventricular Tachycardia/Fibrillation Flashcards
Which PVCs are we concerned about?
Premature Ventricular Contractions
NOT always a problem, can occur ANYWHERE in heart
- *COMPLEX PVCs**
- *Frequent > 5/min**
- *Multiform**
- *COUPLET / TRIPLET**
- *R on T**
Patients with complex PVCs + heart disease
are at an INCREASED risk for DEATH
- *CAST Trial**
- *Purpose / Conclusions**
Use of 1c Agents to suppress PVCs
Flecainide / Encainide / Moricizine / Imipramine
in patients that are:
Post MI** with **Complex PVCs
Conclusion:
- *INCREASE IN MORTALITY**
- even though they DID suppress PVC*
Morals of CAST Trial
Drugs to use / not use
Do NOT use AADs / 1c agents for PVC supression
in patients with
Post-MI** or **Heart Disease
only drugs with mortality NEUTRAL in Heart Failure:
Amiodarone** & **Dofetilide
BETA BLOCKERS
are the preffered treatment if necessary
Sudden Cardiac Death
death due to cardiac issues, heralded by abrupt loss of conciousness within 1 hour of onset of symptoms
Causes for <35 y/o and >35y/o
- *SCD in <35yo:**
- *HYPERtrophic CM** (Cardiac Myopathy) + Idiopathic LVH
- *SCD in > 35yo:**
- *CORONARY HEART DISEASE >>>**
Sudden Cardiac Death
death due to cardiac issues, heralded by abrupt loss of conciousness within 1 hour of onset of symptoms
Etiology / Causes
Accounts for 50% of ALL deaths
- *80-90%** are due to VT
- *Ventricular Tachyarrhythmias**
Rest:
- *VF** = V. Fibrillation = no PULSE
- *Asystole_ + _EMD**
VT = Ventricular Tachycardia
S/Sx + Types
HR** > **100bpm
Mortality Risk correlates with degree of structural heart disease
Symptoms:
Dypsnea / Syncope / Palpitations
- *NSVT** = Non-Sustained
- *< 30 seconds** + terminates spontaneously
Sustained VT
>30sec or
<30 but requires termination due to hemodynamic compromise
Ventricular Tachycardia
RISK FACTORS
Idiopathic - no cause
Sleep Apnea
CAD / NIDCM / Myocardial Scarring
Electrolyte Abnormalities
R.Ventricular Dysplasia
HYPERtrophic CM (Cardiomyopathy)
- *Monomorphic_ vs _Polymorphic**
- *VT = Ventricular Tachycardia**
Impulse is generated from increased automaticity of a single point in either the left or right ventricle, triggered or caused by a re-entry circuit within the ventricle
Monomorphic VT
every QRS complex looks IDENTICAL
SINGLE discharging focus
Polymorphic VT
every QRS complex VARIES in amplitude & duration
MULTIPLE discharging foci
Torsades De Pointes
Definition + Presentation
- *POLYMORPHIC VT_ with a _PROLONGED Qtc**
- *>470ms** in MEN // >480ms in WOMEN
- *QTC > 500msec** = ↑↑TDP Risk
TDP:
Waxing + Waning of QRS aplitude
TWISTING of points
caused primarily by
R on T phenomena
RISK FACTORS
- *Torsades De Pointes**
- *POLYMORPHIC VT_ with a _PROLONGED Qtc**
- *>470ms** in MEN // >480ms in WOMEN
- *QTC > 500msec** = ↑↑TDP Risk
K+ blockade –> Delayed V.Repolarization –> Prolonged QTc
Genetics
Congenital Long QT syndrome
Conditions:
Myocarditis / MI / HF
hypoKalemia - hypoMAGnesemia
starvation / SAH
severe bradycardia / hypoTHERMia
- *DRUGS**:
- *Class 1a** / Class 3 / Abx
DRUG INDUCED RISK FACTORS
- *Torsades De Pointes**
- *POLYMORPHIC VT_ with a _PROLONGED Qtc**
- *>470ms** in MEN // >480ms in WOMEN
- *QTC > 500msec** = ↑↑TDP Risk
- *HIGH DOSE** / concentration
- *CONCURRANT USE** of qt-prolongating drugs
Prolonged QT Interval @ BASELINE
>440 for dofetilitde // >450 sotolol
ANY increase in QTc > 500 after drug initiation
- *ELECTROLYTE DISTURBANCES**
- *K < 4** // Mg < 2
- *Structural Heart Disease** / Bradycardia / adv age
- *FEMALE > male**
QT Interval Prolonging DRUGS
concurrant use increases RISK for:
- *Torsades De Pointes**
- *POLYMORPHIC VT_ with a _PROLONGED Qtc**
- *>470ms** in MEN // >480ms in WOMEN
- *QTC > 500msec** = ↑↑TDP Risk
METHADONE + AMANTADINE** + **RANOLAZINE
AntiEMETICS:
- *Dopamine Antagonist + Serotonin Antagonist**
- *ARSENIC**
TCAs** + **AntiPsychotics** + **SSRI/SNRIs
-AZOLES
Antibiotics:
FQs** + **Macrolides** + **Trimethoprim
-floxacins + -mycins
AntiArrhythmics:
- *Class 1a** = Quinidine + Procainamide + Disopyramide
- *Class 3** = Amio/Dronedarone + Sotolol + Dofetilide
Which ANTIARRHYTHMICS can cause
QT INTERVAL PROLONGATION?
↑TDP Risk
- *Class 1a**
- *Quinidine + Procainamide + Disopyramide**
- *Class 3**
- *Amio/Dronedarone + Sotolol + Dofetilide**
Which ANTIBIOTICS can cause
QT INTERVAL PROLONGATION?
↑TDP risk
-AZOLES
antifungals
- *Fluoroquinolones**
- floxacin
- *Macrolides**
- mycins
Trimethoprim
Electrical Storm VT/VF
vs
Incessant VT
- *Electrical Storm VT/VF**
- *>3 seperate episodes of VT** within 24 hours
Incessant VT
Multiple recurrences over a short period of time
AFTER conversion to SR
Electrical Storm VT/VF & Incessant VT
Risk / Triggers / Treatment
Risk:
Structural Heart Disease > Class 1c / Electrolyte Abn / HF-Ischemia
Symptoms:
palpitations / syncope / repeated ICD shocks / cardiac arrest
Treatment:
IV AMIODARONE** / **IV B-Blocker** / **ABLATIOn
Prevention:
ICD for decondary prevention / reprogramed ICD
Ventricular Fibrillation = VF
Etiology / Definition
Etiology:
Secondary to MI, usually PRE-ceeded by VT
NO coordinated beating** = **QUIVERING Ventricles
Vetricular Rate > 300 BMP
RHYTHM HAS
NO PULSE
- *VENTRICULAR TACHYCARDIA**
- *Treatment Strategies**
Sustained VT
+NO PULSE+
>30 seconds or:
<30 seconds but requires termination due to:
hemodynamic compromise
unconcious / dizzy / SOB
Sustained VT + NO PULSE
VVV
ACLS ALGORHYTHM
S-C-R-E-A-M
Start CPR –> SHOCKING –> EPINEPHRINE
VV
AMIODARONE** OR **LIDOCAINE
repeated / complicated
Mag for TDP
- *VENTRICULAR TACHYCARDIA**
- *Treatment Strategies**
Sustained VT
+PULSE PRESENT+
and
HEMODYNAMICALLY STABLE
concious / not dizzy or SOB
PULSE + Hemodynamically STABLE
- *VAGAL MANEUVERS**
- *Bear Down** + Cold Water + Carotid Massage
Antiarrhythmic Drugs:
AMIODARONE IV/IO
alternatives if NO structural HD:
Procainamide or Flecainade
- *VENTRICULAR TACHYCARDIA**
- *Treatment Strategies**
Sustained VT
+PULSE PRESENT+
&
HEMODYNAMICALLY UNSTABLE
Pulse + Hemodynamically UNSTABLE
SYNCHRONIZED DC CARDIOVERSION
VV
Shock DURING the QRS
avoid the T-interval
- *Epinephrine in ACLS**
- *Function**
ACLS for Sustained VT (>30 sec) + NO PULSE
S-C-R-E-A-M
a-Peripheral Vascular Tone + +B-Inotrope + +B-Chronotropy
VV
↑Myocardial, coronary, cerebral and arterial blood flow during CPR
VV
↑likelyhood of achievingROSCduringCPR
Return of Spontaneous Circulation
Torsades MANAGEMENT
VV
DC QTc Prolonging Drugs & Correct hypoK or hypoMg
VV
if Hemodynamically UNSTABLE?
Unstable:
DEFIBRILLATION
Torsades MANAGEMENT
VV
DC QTc Prolonging Drugs & Correct hypoK or hypoMg
VV
if Hemodynamically STABLE?
STABLE:
Mag Sulfate
1-2g IV admin over 15 min
VVV
TdP + BRADYCARDIA** => **DEFIBRILATION
if NO bradycardia:
ISOPROTERENOL** or **Rapid Pacing via Tem. Pacemaker
2-10mcg/min IV infusion
CHRONIC MANAGEMENT
of
NSVT = Non-Sustained VT
<30 sec
Depends if:
heart disease or NO HEART DISEASE
NSVT + NO HEART DISEASE
ASYMPTOMATIC = no treatment
SYMPTOMATIC:
BETA BLOCKER >>
CCB or Class 1C (+BB) or Ablation
1C = Propafenone + Flecanide
CHRONIC MANAGEMENT
of
NSVT = Non-Sustained VT
<30 sec
Depends if:
HEART DISEASE or no heat disease
NSVT + HEART DISEASE
Post-MI or LVEF < 40%
VV
if POSITIVE - EP STUDY
VVV
ICD for PRIMARY prevention
Implantable Cardioverter Defibrillator
CHRONIC MANAGEMENT of VT
When would we recommend a
ICD = Implantable Cardioverter Defibrillator?
for
SECONDARY PREVENTION
SECONDARY PREVENTION of SCD
ICD for all patients with:
H/o Sustained VF
or
Hemodynamically did NOT tolerate VT
or
RECURRENT
or
Optimal Therapy + LVEF > 50%
CHRONIC MANAGEMENT of VT
When would we NOT RECOMMEND a
ICD = Implantable Cardioverter Defibrillator?
for
SECONDARY PREVENTION
do NOT recommend ICD
REVERSIBLE cause of VT
Or
conditions LIMITING
Life Expectancy 1-2 years
PRIMARY PREVENTION
of SCD & VT
ISCHEMIC HEART DISEASE** + **NSVT
Non Sustained VT <30 sec
- *LVEF > 40%**
- -> BETA BLOCKERS
LVEF < 40%
Electrophysiology Study with inducible VT** –> **ICD**” **without inducible VT** –> **GDMT
PRIMARY PREVENTION
of SCD & VT
ISCHEMIC HEART DISEASE** + **NICM
Non-Ischemic CardioMyopathy
Ischemic Disease + NICM
w/ NO ARRHYTHMIA
- *LVEF > 35%**
- *Optimize post-MI** + HF DRUG therapies
- *LVEF <35%_ + _Class2-3 HF**
- *GDMT > 3 months FIRST** –> ICD
Treatment of
Sustained VT
if
VT RECURRS AFTER placement** or if **ICD is NOT an option
AMIODARONE
added to Beta Blocker
Sotalol
Correct underlying cause : Electrolytes / CAD
Ablation
