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Dr hoppe arrythmias

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  • Burke JH, et al. evaluated 43 (20 male and 23 female) healthy volunteers. The graph represents sinus cycle length before and after autonomic blockade in men and women. Each value plotted on the graph represents an individual RR value. Both at rest and following autonomic blockade, men had a significantly slower heart rate than women. 1 J. Larsen and A. Kadish in their review of the literature on gender differences in cardiac arrhythmias conclude that differences in autonomic tone and menstrual cycle variability at rest do not appear to be responsible for the gender differences in the QT interval. 2 1 Burke JH, Goldberger JJ, Ehlert FA, et al. Gender differences in heart rate before and after autonomic blockade: Evidence against an intrinsic gender effect. Am J Med. 1996;100:537-543. 2 Larsen JA, Kadish AH, Effects of Gender on Cardiac Arrhythmias. J Cardiovasc Electrophysiol. 1998:9:655-664.
  • Palpitation is a symptom, often due to a cardiac arrhythmia, and should be considered as such. Common cardiac causes of arrhythmia include acute and chronic coronary artery disease, valvular heart disease, cardiomyopathies, acute myocardial infarction and its sequelae, and in children, congenital heart disease. 6 6 Rosano GMC, Rillo M, Leonardo F, et al. Palpitations: What is the Mechanism, and When should We Treat Them? In J Fertil. 1997;42:94-100.
  • This graph from the paper published by John Hopkins University School of Medicine represents 500 patients who participated in the Atakar Ablation System (Medtronic CardioRhythm) clinical trial and who had undergone catheter ablation of a single Accessory Pathway (AP); 373 patients who underwent ablation of AVNRT, and 121 who underwent ablation or the AVJ between 1992 and 1995. Patients who underwent ablation of AVNRT were more likely to be female (70%) than were patients who underwent ablation of an AP (42%) or the AVJ (52%, p<0.001). 4 4 Calkins H, Yong P, Miller JM, et al. Catheter Ablation of Accessory Pathways, Atrioventricular Nodal Reentrant Tachycardia, and the Atrioventricular Junction: Final Results of a Prospective, Multicenter Clinical Trial. Circ. 1999;99:262-270.
  • Studies of canine coronary arteries treated with 17  -estradiol has led to the suggestion that the hormone acts by increasing K + conduction. Recent studies on cardiac myocytes have shown that estradiol has calcium-antagonistic properties. Ovarian hormones exhibit a cyclic variation in their plasma levels during the menstrual cycle and these changes seem to be associated with changes in plasma catecholamine levels and adrenergic activity, such that catecholamines are higher during the luteal phase of the menstrual cycle. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is The Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
  • This slide represents data from a study of 26 young women complaining of palpitations and diagnosed with SVT. All patients underwent 48-hour ambulatory ECG monitoring and measurement of plasma concentrations of estradiol and progesterone on days 7, 14, 21, and 28 of their menstrual cycle. A significant increase in the number and duration of episodes of arrhythmia was recorded on day 28. Patients also complained of a higher incidence of symptomatic episodes on day 28 as opposed to day 7 (77% versus 43%, p<0.05). The higher incidence of arrhythmia during the luteal phase of the menstrual cycle may be related to the electrophysiological effects of ovarian hormones or increased sympathetic activity, which often occurs at this time in the menstrual cycle. 6 6 Rosano GMC, Leonardo F, Sarrel PM, et al. Cyclical variation in paroxysmal supraventricular tachycardia in women. Lancet. 1996;347:786-788.
  • A study of 68 consecutive patients (42 women and 26 men) referred because of symptomatic paroxysmal SVT was evaluated to determine the prevalence of perimenstrual clustering of spontaneous SVT in women. The study was designed to test the hypothesis that women with a history of perimenstrual clustering would be less inducible during testing at high estrogen states (midcycle or with estrogen replacement therapy) than at low estrogen states (perimenstrual or without estrogen replacement). Those patients with a history of perimenstrual clustering who had negative electrophysiologic studies at midcycle or while receiving ERT had repeat procedures premenstrual or after stopping estrogen replacement therapy. Six patients who were non-inducible at higher estrogen states were inducible at low estrogen states. Successful ablations were then performed in five of these six patients (four AVNRT, one both AVNRT and reciprocating atrial tachycardia, and one with atrial tachycardia). Among women with a history of perimenstrual clustering and of paroxysmal SVT, scheduling elective electrophysiologic procedures at the time of low estrogen levels (premenstrual or off ERT) may facilitate the probability of a successful procedure. 7 7 Myerburg RJ, Cox MM, Interian Jr A, et al. Cycling of Inducibility of Paroxysmal Supraventricular Tachycardia in Women and Its Implications for Timing of Electrophysiologic Procedures. Am J Cardiol. 1999;83:1049-1054
  • At menopause there is marked decline in ovarian estradiol production, which has been associated with increased, and uncontrolled adrenergic activity. Palpitations are the most common cardiovascular complaint and often associated with vasomotor symptoms. Palpitations during the perimenstrual period are primarily due to sinus tachycardia and seem related to an increased sympathetic drive. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is the Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
  • Although palpitations do not require treatment, symptoms can be minimized with  -blockers if estrogen replacement therapy is not effective in controlling symptoms, or if estrogen replacement therapy is not preferred. If progesterone often given in association with estrogen, triggers arrhythmias, it is recommended to reduce the dose of progesterone or to change to a different one. Natural progesterone may prove helpful for those patients with palpitations worsened by synthetic progesterone. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is the Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
  • Percentage of LQTS probands with new-onset cardiac events before, during, and after pregnancy. New-onset cardiac events were significantly more common among probands during the postpartum interval. 14 14 Rashba EJ, Zareba W, Moss AJ, et al. Influence of Pregnancy on the Risk for Cardiac Events in Patients With Hereditary Long QT Syndrome. Circ. 1998;97:451-456.
  • The patient was subsequently brought to the electrophysiology lab and her RVOT ventricular tacycardia was successfully ablated. She has had no reoccurrence of symptoms after three years.
  • A 29 year old female complaining for two years of increased fatigue and being unable to water-ski and play tennis for long periods as she previously been able to do. Admitted to the emergency room after a minor auto accident caused by feeling “light-headed” and “dizzy”. No LOC. The ECG showed RVOT ventricular tachycardia at a rate of 187 bpm. The patient was sedated and successfully cardioverted to sinus rhythm.
  • Miyasaka Y. Barnes ME. Gersh BJ. Cha SS. Bailey KR. Abhayaratna WP. Seward JB. Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.[erratum appears in Circulation. 2006 Sep 12;114(11):e498]. [Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't] Circulation. 114(2):119-25, 2006 Jul 11. bstract Background—: Limited data exist on trends in incidence of atrial fibrillation (AF). We assessed the community-based trends in AF incidence for 1980 to 2000 and provided prevalence projections to 2050. Methods and Results—: The adult residents of Olmsted County, Minnesota, who had ECG-confirmed first AF in the period 1980 to 2000 (n=4618) were identified. Trends in age-adjusted incidence were determined and used to construct model-based prevalence estimates. The age- and sex-adjusted incidence of AF per 1000 person-years was 3.04 (95% CI, 2.78 to 3.31) in 1980 and 3.68 (95% CI, 3.42 to 3.95) in 2000. According to Poisson regression with adjustment for age and sex, incidence of AF increased significantly (P=0.014), with a relative increase of 12.6% (95% CI, 2.1 to 23.1) over 21 years. The increase in age-adjusted AF incidence did not differ between men and women (P=0.84). According to the US population projections by the US Census Bureau, the number of persons with AF is projected to be 12.1 million by 2050, assuming no further increase in age-adjusted incidence of AF, but 15.9 million if the increase in incidence continues. Conclusions—: The age-adjusted incidence of AF increased significantly in Olmsted County during 1980 to 2000. Whether or not this rate of increase continues, the projected number of persons with AF for the United States will exceed 10 million by 2050, underscoring the urgent need for primary prevention strategies against AF development.
  • There was significant AF-sex interaction demonstrated in the Framingham Heart Study reported in 1998. In these graphs both women and men with AF had significantly higher mortality than age-, sex- and calendar year-matched non-AF subjects. Results are shown for men with AF (n=137), men without AF (n=274+, women with AF (n=192), and women without AF (n=384). AF remained significantly associated with excess mortality, with about doubling of mortality in both sexes. 21 21 Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circ. 1998;98:946-952.
  • There was significant AF-sex interaction demonstrated in the Framingham Heart Study reported in 1998. In these graphs both women and men with AF had significantly higher mortality than age-, sex- and calendar year-matched non-AF subjects. Results are shown for men with AF (n=137), men without AF (n=274+, women with AF (n=192), and women without AF (n=384). AF remained significantly associated with excess mortality, with about doubling of mortality in both sexes. 21 21 Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circ. 1998;98:946-952.
  • Figure 3. TEE in a Patient with Atrial Fibrillation and a Thrombus in the Left Atrial Appendage. The region of the left atrial appendage is shown in horizontal (left-hand panel) and vertical (right-hand panel) planes, with two types of application of color. Inside the appendage, a large thrombus is seen (arrow) that originates at the tip of the appendage. AO denotes aortic valve, LA left atrium, and LV left ventricle.
  • A 5-mm Thrombus (Arrow) in the Left Atrial Appendage in a Patient with Atrial Fibrillation. Emboli of this size can occlude the middle cerebral artery, resulting in a disabling stroke. Thrombi located in the appendage can be reliably detected by transesophageal echocardiography but not by precordial echocardiography. Reproduced from the Case Records of the Massachusetts General Hospital (N Engl J Med 1969;281:555).
  • Transcript

    • 1. A Different Beat: Arrhythmias and Heart Palpitations Bobbi L. Hoppe, M.D. North Memorial Heart & Vascular Institute
    • 2. Cardiac Electrical Differences in Women
      • Basal and intrinsic heart rate higher in women
      • Longer QTc interval compared to men
        • May be important especially in terms of response to medciations (especially ones that prolong the QTc interval)
    • 3. Autonomic Blockade in Men and Women * P < 0.05 * * 1400 1300 1200 1100 1000 900 800 700 600 500 400 Women Men Women Men Baseline Post Blockade Cycle Length Burke JH, et al. Am J Med. 1996;100:537-543.
    • 4. Prevalence of Palpitations
      • One of the most common problems of outpatients who present to internists or cardiologists
      • Accounts for 30-40% of new visits at NMWHC
      • Very high association with panic disorder (20%), often delaying definitive diagnosis (median 3.3 years).
      • Occur frequently during the certain times during the menstrual cycle, pregnancy, and perimenopause.
    • 5. Cardiac and Noncardiac Causes of Palpitations
      • Cardiac
        • Sick sinus syndrome
        • Valvular heart disease
        • Coronary artery disease
        • Cardiomyopathy
        • Congenital heart disease
        • SVT
        • VT
      • Noncardiac
        • Anxiety
        • Emotions
        • Caffeine
        • Nicotine
        • Hyperthyroidism
        • Increased release of catecholamines (menopausal)
        • Electrolyte disturbances
        • Contraceptive pills
        • Various drugs (e.g., antiarrhythmics)
      Adapted from Rosano GMC, et al. Int J Fertil. 1997;42:94-100.
    • 6. Palpitations in Women Associated With:
      • Young women and rapid HR
        • Frequently re-entrant tachycardias
        • Associated with heart valve abnormalities
      • Pregnancy
        • SVT may be due to mechanical stimuli or possible effects of pregnancy
      • Perimenopause
        • Usually benign
        • May be due changes in nervous system activity
      Rosano GMC, et al. Int J Fertil. 1997;42:94-100.
    • 7. Etiology of Palpitations
      • Extra beat from the upper chamber- Premature atrial complex (PAC)
      • Extra beat from the lower chamber- Premature ventricular complex (PVC)
      • Patients with palpitations may experience isolated extra beats or….
      • These premature beats often result in sustained arrhythmias
    • 8. Case #1
      • 35 y.o. female with long standing history of palpitations occurring with exercise
      • Describes palpitations as strong fast heart rate associated with shortness of breath
      • Seen by primary physician and told symptoms are likely due to normal heart rate response with exercise
    • 9.  
    • 10. Case #1 - Continued
      • She was referred for electrophysiology study (EPS)
      • At EPS, Typical Slow-Fast AVNRT was identified and the slow pathway (extra pathway) was eliminated by ablation (heating the tissue)
      • The patient had no further palpitations and returned to exercise
    • 11. Catheter Ablation of Accessory Pathways, AVNRT, and AV Junction: Accessory Pathways AVNRT AV Junction Women Men Calkins H, et al. Circ. 1999;99:262-270. Gender Distribution % 42% 58% 70% 30% 52% 48%
    • 12. Effect of Ovarian Hormones in Palpitations
      • Ovarian hormone levels vary during the menstrual cycle
      • Estradiol has properties with slows electrical conduction in the heart
        • Protective mid-cycle
        • Reduces incidence of SVTs
        • Effect lost premenstrual
      Rosano GMC, et al. Int J Fertil. 1997;42:94-100.
    • 13. Cyclical Variation in Tachycardia (SVT) in Women 28 Rosano GMC, et al. The Lancet. 1996;347:786-788. 12 25 11 36 27 49* 38* * = p < 0.02 Number of Episodes Day (Menstrual Cycle)
    • 14. Tachycardia (SVT): Inducibility During Menstruation
      • Prospective study of 42 women with SVT
      • 17 (40%) perimenstrual clustering
      • 6 (35%) non-inducible during EPS (mid-cycle or receiving ERT)
      • All 6 women were inducible during repeat EPS when premenstrual or ERT withdrawn
      Myerburg RJ, et al. Am J Cardiol. 1999;83:1049-1054.
    • 15. SVT: Inducibility During Menstruation
      • Premenstrual clustering of spontaneous arrhythmia has been observed in women with SVT
      • Scheduling elective EP procedures at times of low estrogen levels may facilitate successful procedures
      Myerburg RJ, et al. Am J Cardiol. 1999;83:1049-1054.
    • 16. Palpitations During Menopause or Perimenopause
      • Menopause:
        • estradiol production
        • Associated with nervous system activity
        • Palpitations frequent CV complaint
      • Perimenopause:
        • Palpitations sometimes due to sinus tachycardia
        • Related to increased nervous system activity
      Rosano GMC, et al. Int J Fertil. 1997;42:94-100.  
    • 17. Palpitations During Menopause or Perimenopause
      • Treatment:
        • If documented arrhythmia consider EPS/RFCA
      • Improvement of symptoms:
        • Medications if palpitations persist after initiation of hormone replacement therapy
        • Progesterone may trigger cardiac arrhythmia in certain patients
      Rosano GMC, et al. Int J Fertil. 1997;42:94-100.
    • 18. Evaluation for Patients with Palpitations
      • 12 lead ECG
      • Event/Holter/Cardionet monitor
      • Thyroid test (TSH)
      • Exercise treadmill if symptoms occur with exercise
      • Consider a transthoracic echocardiogram to rule out structural heart disease
    • 19. Case #2
      • 19 y.o. female with previous history of syncope 2 months postpartum is admitted for recurrent syncope.
      • Heart ultrasound reveals poor heart function
      • Heart monitor shows abnormal heart rhythm
    • 20. Case #2 ECG
    • 21. Case #2 ECG
    • 22. Pregnancy and the Long QT Syndrome Rashba EJ, et al. Circ. 1998;97:451-456. 0.0% 1.8% 9.0%* % New 0nset Cardiac Events * p<0.02 vs the pregnancy or prepregnancy interval
    • 23. Case # 3
      • 50 year old nurse manager
      • Presents with palpitations while riding her bicycle
      • Following exercise, symptoms subside within 30 seconds
      • Exercise echocardiogram ordered and terminated prematurely
    • 24. Case # 3
    • 25. RVOT VT Courtesy of Dr. Brian Olshansky.
    • 26. Right Ventricular Outflow Tract (RVOT) Tachycardia in Women
      • Exacerbated by gender specific hormonal fluctuation that can occur with menopause, gestation, and menstrual cycle
      • Not always precipitated by exercise
      Deely M, et al. JACC. 1998;31:Suppl A:91A.
    • 27. RVOT VT
    • 28. Case # 3: Carto Maps
    • 29. Case # 4
      • 51 y.o. peri-menopausal female with a history of HTN presents with 1 year history of palpitations.
      • Her episodes have gradually increased in both frequency and duration
      • She describes her heart beat as fast, irregular
      • Following the episodes she reports generalized fatigue
    • 30. Case # 4 ECG- Premature Atrial Contraction Triggering AF
    • 31. Case # 4 Evaluation/Treatment
      • Heart ultrasound was normal
      • Thyroid function (TSH) normal
      • She was started on Coumadin, beta-blockers and a Class Ic drug (flecainide) with no recurrences
    • 32. Why Do We Care About Atrial Fibrillation?
      • Most common sustained arrhythmia in humans
      • Extremely prevalent and increases with each decade of life
      • Associated with high hospitalization rate and morbidity
      • Expected to increase 2.5 fold over the next 50 years
    • 33. Trends in Incidence of AF Olmsted County, MN Miyasaka Y. Circulation 114:119-25, 2006 Fixed incidence Projected increased incidence
    • 34. Prevalence of Atrial Fibrillation
    • 35. Atrial Fibrillation
      • Women who have atrial fibrillation are more likely to have a life-threatening stroke
      • Atrial fibrillation diminishes the female advantage in survival compared to men
      Benjamin EJ, et al. Circ. 1998;98:946-952.
    • 36. Atrial Fibrillation and Risk of Death Adapted from Benjamin EJ, et al. Circ. 1998;98:946-952. 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 Percent of Subjects Dead in Follow-up Years of Follow-up Age 55 - 74 yrs Men AF Women AF Men no AF Women no AF
    • 37. Atrial Fibrillation and Risk of Death Benjamin EJ, et al. Circ. 1998;98:946-952. 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 0.5 1 1.5 42 2.5 3 3.5 4 4.5 5 Percent of Subjects Dead in Follow-up Years of Follow-up Age 75 - 94 yrs Men AF Women AF Men no AF Women no AF
    • 38. Age Distribution of Atrial Fibrillation
    • 39. Atrial Fibrillation accounts for 1/3 of all patient discharges with arrhythmia as principal diagnosis.
        • 2% VF
      Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.
        • 34% Atrial Fibrillation
        • 18% Unspecified
        • 6% PSVT
        • 6% PVCs
        • 4% Atrial Flutter
        • 9% SSS
        • 8% Conduction Disease
        • 3% SCD
        • 10% VT
    • 40. Types of Atrial Fibrillation
      • Paroxysmal
        • Spontaneously converts back and forth from sinus (normal) rhythm
      • Persistent
        • AF remains until terminated medical (drugs) or electrically
      • Permanent
        • AF is irreversible and fails medical interventions
    • 41. Dr. Mauritz Allessie: “AF begets AF” Paroxysmal Persistent Permanent
    • 42. Clinical Characteristics Associated with AF
      • Cardiac Causes
      • Hypertension
      • Coronary Artery Disease
      • Congestive Heart Failure
      • Pericarditis/Myocarditis
      • Valvular Heart Disease
      • Cardiac Surgery
      • Noncardiac Causes
      • Electrolyte disturbances
      • Thyroid dysfunction
      • ETOH/drugs
      • Vagal imbalance
      • Pulmonary disease/OSA
      • Systemic disease
    • 43. Morbidities Associated with AF
      • Stroke/embolic events
      • Decompensated congestive heart failure
      • Tachycardia induced cardiomyopathy
      • Worse for women than men
        • Longer corrected QTc interval
        • Higher base heart rate
    • 44. Stroke Associated with AF
      • Extremely prevalent based on Framingham Data
      • Average risk of 4 - 5% per year
      • Risk is cumulative
        • Example: AF duration 10 yrs x 5 % = 50% overall risk
    • 45. TEE in a Patient with Atrial Fibrillation and a Thrombus in the Left Atrial Appendage Daniel, W. G. et al. N Engl J Med 1995;332:1268-1280
    • 46. A 5-mm Thrombus (Arrow) in the Left Atrial Appendage in a Patient with Atrial Fibrillation Hart, R. G. N Engl J Med 2003;349:1015-1016
    • 47. Risk Factors For Thromboembolic Stroke
    • 48. Odds Ratio for Ischemic Stroke/Intracranial Bleeding
    • 49. Anti-arrhythmic Drugs and Side Effects
    • 50. Mechanism of Atrial Fibrillation
    • 51. Anatomy Left Atrium (Posterior View)
    • 52. PV Potential Leading To Ectopic Activity Haissaguerre, NEJM, 1998
    • 53. Radiofrequency Ablation for AF
      • Relatively new approach for treatment AF
      • Evolving process in terms of ablation approach
      • Equipment (3D mapping systems) improving
      • Training/experience is incorporated in most electrophysiology training programs
      • Success rates of AF RFCA vary in the literature
    • 54. Example of AF RFCA
      • Image of a patient’s
      • left atrium obtained
      • from a surface CT
      • scan uploaded into
      • 3D Carto mapping
      • system
    • 55.  
    • 56. Women and Atrial Fibrillation Ablation
      • Men are 5x more likely to be referred for ablation
      • Women more likely to have complications related to ablation
      • Success rates for ablation in women are lower compared to men
    • 57. Final Thoughts
      • Women with palpitations often have real arrhythmias that can be effectively treated with procedures or medications
      • Women differ from men not only in terms of heart disease but also electrical properties and disturbances
      • Hormones likely influence arrhythmias in women, but less clear
    • 58.