ventricular arrhythmias august 14, 2013 part i. mksap item #119 a 31-year old man is evaluated in...

Ventricular Arrhythmias

August 14, 2013

Part I

MKSAP Item #119• A 31-year old man is evaluated in the ED after

experiencing a syncopal episode while playing basketball. A friend playing with him reported that he was unconscious for about 15 seconds with no evidence of seizure-like activity. Medical history is significant for arrhythmogenic RV cardiomyopathy/dysplasia. His only medication is atenolol.

• On PE, the patient is afebrile, BP is 128/76 mm Hg and pulse rate is 64/min.

MKSAP Item #119• ECG shows normal sinus rhythm with T

wave inversions in leads V1-V3 with an epsilon wave.

• Echo demonstrates moderate RV dysfunction and enlargement. Cardiovascular magnetic resonance (CMR) imaging of the heart shows dilatation and akinesia of the RV outflow tract.

Item 119 (con’t)

• Which of the following is the most appropriate management?

(A) Electrophysiology study

(B) 24-hour continuous ambulatory electrocardiographic monitoring

(C) Implantable cardioverter-defibrillator placement

(D)Looping event recorder implantation

(E) Sotalol administration

MKSAP Item #54

• A 52-year old woman is evaluated for a 1-year history of nonischemic cardiomyopathy. She reports feeling shortness of breath with exertion when walking up one flight of stairs or walking one city block. Medical and family histories are unremarkable. Medications are carvedilol, lisinopril, digoxin, spironolactone and furosemide.

• On PE, she is afebrile, BP is 112/74 mm Hg and pulse rate is 82/min. Cardiac evaluation reveals a regular rate and rhythm, positive S3, and a grade 2/6 holosystolic murmur heard best at the apex and radiating to the axilla.

MKSAP Item #54 (con’t)

• An ECG demonstrates sinus rhythm and left bundle branch block with QRS interval of 155 msec.

• Echocardiogram shows a moderately dilated LV and severely depressed left ventricular systolic function, with an ejection fraction of 25%.

Item 54 (con’t)• Which of the following is the most

appropriate treatment?

(A) Biventricular pacemaker with implantable cardioverter defibrillator (ICD)

(B) Dual chamber (right atrial and right ventricular leads) ICD

(C)Dual chamber (right atrial and right ventricular leads) pacemaker

(D)Single chamber (right ventricular lead) ICD

Classification of Ventricular Arrhythmias

ACC/AHA/ESC 2006 Guidelines

• Classification by Clinical Presentation

JACC 2006;48:e-247-346

• Classification by ECG

• Classification by Disease Entity

Ventricular Arrhythmias

• Classification by Clinical Presentation– Hemodynamically stable

• Asymptomatic (no symptoms)• Minimal symptoms (palpitations, skipped beats)

– Hemodynamically unstable• Presyncope (dizziness, lightheadedness, faint)• Syncope• Sudden cardiac death • Sudden cardiac arrest

JACC 2006:e247-346

Classification of Ventricular Arrhythmias

ACC/AHA/ESC 2006 Guidelines

• Classification by Clinical Presentation

JACC 2006;48:e-247-346

• Classification by ECG

• Classification by Disease Entity

Ventricular Arrhythmias

• Classification by Electrocardiography– Nonsustained VT– Sustained VT– Bundle branch block reentrant tachycardia– Bidirectional tachycardia

– Torsades de pointes– Ventricular flutter– Ventricular fibrillation

JACC 2006:e247-346

Classification of Ventricular Arrhythmias

ACC/AHA/ESC 2006 Guidelines

• Classification by Clinical Presentation

JACC 2006;48:e-247-346

• Classification by ECG

• Classification by Disease Entity

Ventricular Arrhythmias

• Classification by Disease Entity– Chronic coronary heart disease– Heart failure– Congenital heart disease– Neurological disorder

– Structurally normal hearts– Sudden infant death syndrome– Cardiomyopathies (Dilated, hypertrophic,

arrhythmogenic RV cardiomyopathy)

JACC 2006:e247-346

Ventricular Arrhythmias

• Classification by Electrocardiography– Single PVCs and nonsustained VT– Sustained VT– Bundle branch block reentrant tachycardia– Bidirectional tachycardia

– Torsades de pointes– Ventricular flutter– Ventricular fibrillation

JACC 2006:e247-346

Premature Ventricular Complex

Full Compensatory Pause

Premature Ventricular Complexes

Multifocal PVCs

PVCs in bigeminy

Premature Ventricular Complexes

Compensatory pause is not full

Retrograde P waves due to V-A conduction

Ventriculo-Atrial Conduction

Ventriculo-Atrial Conduction

Interpolated PVC

PVCs in Bigeminy

Premature Ventricular Complexes

Paired PVCs or Couplets

Trigeminy

Non-sustained monomorphic VT

• Non-sustained Ventricular Tachycardia– 3 or more PVC’s, rate >100 bpm– Less than 30 seconds duration– No hemodynamic symptoms

Therapy: PVC’s and Non-Sustained VT

• PVC’s including frequent PVCs and non-sustained VT are not targets for anti-arrhythmic therapy.

• In patients with structurally normal hearts, PVC’s including runs of non-sustained VT are not prognostically significant.

PVC’s and Non-Sustained VT

• If the PVCs are frequent (>10,000 PVCs over a 24 hour period or >20% of total heart beats counted), LV function should be reassessed annually because it can result in tachycardia mediated CMP.

JACC 2012;59:1733-1744

Atria

Ventricles

Bifurcation of the bundle of His

Ventricular Arrhythmias

Atria

Ventricles

Bifurcation of the bundle of His

Supraventricular Arrhythmias

Not all beats with a wide QRS complex are ventricular

Wide complex beats may also be supraventricular in origin.

• Supraventricular– Pre-existent bundle branch block

– Accessory pathway

– Aberrancy also called functional or rate related bundle branch block

• Ventricular

Wide Complex Beats

Wide Complex Tachycardia

Ventricular

Supraventricular Beats With Wide QRS Complexes

Preexistent BBB

Bypass Tract

Rate related BBB

Aberrantly Conducted PAC

Aberrantly Conducted PACs

Wide Complex Tachycardia

Ventricular

Supraventricular Arrhythmias With Wide QRS Complexes

Preexistent BBB

Bypass Tract

Rate related BBB

Pre-Excitation

V1 Rhythm Strip is Continuous

Wide Complex Tachycardia

Ventricular

Supraventricular Arrhythmias With Wide QRS Complexes

Preexistent BBB

Bypass Tract

Rate related BBB

Pre-Existent Right Bundle Branch Block

Diagnosis?