the ecg and its clinical context: syncope · 2019. 10. 8. · modes of death in chronic heart...

The ECG and its clinical context: Devices in heart failure

Presented by:

Dr Isabel Tan, Cardiologist/Electrophysiologist – Western Australia

Pre-disposing Question

Which patient has an indication for implantable device-based therapy for heart failure?

1) Shortness of breath on exertion, ejection fraction 45%, narrow QRS?

2) No symptoms, ejection 25%, LBBB

3) Shortness of breath on exertion, ejection fraction 30%, narrow QRS, no medication

4) No symptoms, ejection fraction 60%, LBBB

5) Shortness of breath at rest, ejection fraction 35%, narrow QRS

Case Study 1 : Mr C.R.

61 years old

Initial consultation 2010

Ischaemic heart disease

Anterior MI 2008, associated with borderline cardiogenic shock

Totally occluded LAD – successful stenting to distal and mid LAD

No cardiac symptoms (NYHA II)

Medications : Aspirin, Lipitor, Carvedilol, Ramipril (previously on Spironolactone, withdrawn due to gynaecomastia)


Echocardiogram shows mildly dilated and hypertrophied LV, with thinning/akinesis of anteroseptal, inferoseptal and apex. Overall systolic function moderately impaired (EF 30%)

Key features:

Ischaemic cardiomyopathy

Successful revascularisation, but persistent LV impairment 2 years on

Asymptomatic

Optimal medications

Narrow complex QRS

Case Study 2 : Mrs B.H.

71 years old

Presented 2013 with exertional breathlessness (NYHA III), orthopnoea and peripheral oedema.

Background:

Breast cancer 2006 ; lumpectomy followed by chemotherapy (Epirubicin) and radiotherapy. Stable, no evidence of recurrence. On Letrozole

Family history : father had “enlarged heart”, transplant discussed. No history of ischaemic heart disease

Investigations

Echo: Severely dilated LV with severely reduced systolic function (EF 25%). Mitral regurgitation secondary to annular dilatation.

Angiogram : Normal arteries.

Case Study : Mrs B.H.

Case Study : Mrs B.H.

Medications:

Perindopril 2.5mg

Frusemide 40mg

Bisoprolol 2.5mg

Letrozole

6 month review

Well, resolution of symptoms

Echo : Minimal improvement in systolic function (EF 35%). Mild MR.

Key features

Non-ischaemic cardiomyopathy ?chemotherapy induced ?familial

Asymptomatic on medications

Improvement in systolic function, although remains moderately impaired.

Modes of Death in Chronic Heart Failure

12%

24%

64%

CHF

Other

SuddenDeathn = 103

NYHA II(103 pts)

26%

15%

59%

CHF

Other

SuddenDeath

n = 103

NYHA III(232 pts)

CHF

Other56%

11%

33%

SuddenDeath

NYHA IV(27 pts)

SCD is the #1 Cause of

Death in NYHA Class II/III

Heart Failure Patients

ACC/AHA HF Guidelines

ICD Class I and II Recommendations:

•Secondary prevention for patients with a history of SCA, VF, or haemodynamically destabilising VT

•Primary prevention in ischaemic CHF patients:

-40 days post MI, LVEF ≤35%, NYHA Class II or III

•Primary prevention of non-ischaemic CHF patients:

-NYHA Class II-III, LVEF ≤ 35%

Case Studies

Mr C.R.

Prophylactic ICD inserted

Review May 2016 : Device interrogation showed one episode of VT, terminated with pacing therapy from ICD. Pt asymptomatic

Mrs B.H.

Prophylactic ICD inserted

Review March 2016 : asymptomatic, no therapy

Case Study 3 : Mrs S.F.

50 years old

Presented May 2013

4 week history of intermittent palpitations

Denies chest pain, breathlessness

Background

Hypertension

Diabetes

Previous smoker

Scanty family history

Medications: Amlodipine, Irbesartan HCT, Metformin


Echo : Dilated left ventricle with septal dyssynchrony and severe global impairment of systolic function (EF 25%). Possible LV non-compaction. Severe MR due to annular dilation.

Medications

Amlodipine ceased. Bisoprolol, Spironolactone, Frusemide started.

Admitted to ICU with pneumonia and exacerbation of CCF

Normal coronary angiogram

Cardiac MRI – mild trabeculation considered to be within normal limits. No evidence of ischaemic, infiltrative or granulomatous disease


Echo Nov 2013

Mild improvement in LV function. EF 32%

Mildly symptomatic on medications

NYHA II-III: Fatigue, mild dyspnoea, but “managing ok”

Discussion regarding device : Fearful of procedure, declined

July 2014

Early appointment due to increasing symptoms, unable to sing or dance. “Cannot live like this anymore”

Echo unchanged.

Case 3 : Mrs S.F.

Biventricular ICD inserted October 2014

November 2014

Doing well, increased stamina

April 2015

LV size and systolic function normal. EF 58%

Diuretics ceased

Case Study 4 : Mr C.S.

93 years old – active, independant

March 2013 : Incidental rapid AF during Plastics review. Echo showed mild LV dysfunction and moderate AS. Commenced on Diltiazem and Warfarin

June 2013 : Increasing breathlessness associated with palpitations, Echo now showed moderate to severe global impairment of systolic function. Commenced on Bisoprolol and Amiodarone.

July 2013 – Aug 2013

Unwell : dizzy, tired, lacking in energy, intermittent palpitations


Sept 2013

Biventricular pacemaker inserted.

Improved energy and exercise tolerance

Mar 2014

Echo : Mildly impaired systolic function

ESC 2013 Guidelines

CRT is recommended in chronic HF patients

LVEF< 35%

symptomatic in NYHA functional II, III and ambulatory IV despite adequate medical treatment

LBBB with QRS duration >120ms on ECG

CRT should be considered in HF patients

non-LBBB and QRS duration >150ms

Benefits less clear if QRS 120-150ms

ESC 2013 Guidelines

Patients with AF

CRT should be considered in chronic HF patients

• intrinsic QRS >120ms

• LVEF < 35%

• NYHHA functional class III and ambulatory class IV despite adequate medical treatment

• biventricular pacing as close to 100% as possible can be achieved

Patients with uncontrolled heart rates who are candidates for AV junction ablation if EF is reduced.

Thank you

7-Oct-1923

the ecg and its clinical context: syncope · 2019. 10. 8. · modes of death in chronic heart...

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