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Similar to Atrial tachy 26 Oct 22.pptx
Atrial tachy 26 Oct 22.pptx
- 1. Col Bharat Malhotra SeniorAdvisor (Medicine) REFERENCE Harrison’s Principles of internal medicine Harrisons 21th Ed Davidson’s Principles and practice of Medicine (2018) European and American Cardiology guidelines
- 2. LEFT ATRIA Normal Electrical Activity •60 – 100 /min • Sinus origin • Within Conduction system • At defined Velocity SVT VT / VF
- 3. LEFT ATRIA Sinus Tachycardia Inappropriatesinus tachycardia Paroxysmal Supraventricular tachycardia Atrial Flutter, Atrial Fibrillation Ventricular Tachycardia & Fibrillation 100 /min 60 /min Sinus Bradycardia SA Disease or Sick Sinus syndrome AV Block First degree block Second degree block – type 1 & Type 2 Third degree block Can have Atrial/ Ventricular Ectopic LBBB, RBBB NORMAL TACHYARRHYTHMIA S BRADYARRHYTHMIA S Atrial Tachycardia AVNRT AVRT & Accessory pathways
- 4. • Automaticity (usuallydue to catecolamines) • Triggered Automaticity (Ectopic focus) • Reentry – Macro re-entry / Micro re-entry
- 5. DEFINITION • A clinicalsyndrome characterized by the presence of a regular and rapid tachycardia of abrupt onset and termination. • These features are characteristic of • AVNRT • AVRT & Accessory pathways • less frequently ATRIAL TACHYCARDIA • PSVT represents a subset of SVT.
- 6. TYPICAL AVNRT (Slow- FastPathway) ATYPICAL AVNRT (Fast- Slow Pathway) FAST PATHWAY LONG RP SLOW PATHWAY SHORT RP FAST PATHWAY SLOW PATHWAY Slow Pathway SLOW PATHWAY FAST PATHWAY
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- 9. Hemodynamically stable Hemodynamically unstable CLINICAL PRSENTATIONS Hemodynamically Stable Palpitations,Syncope Dyspnea, Fatigue Post tachycardia diuresis (maneuvers or medications that cause AV block terminates the PSVT) Hemodynamically unstable Palpitations, Syncope Tachycardia, Hypotension WPW Syndrome: Preexcited QRS during sinus rhythm & episodes of PSVT
- 10. Rate: 150-250 Regular QRS Narrow Pwave absent or inverted Abrupt Onset Abrupt termination – by AV block drugs
- 11. ECG T3 T4 TSH ECHO HOLTERSTUDY ELECTRO PHYSIOLOGICAL STUDY
- 12. STABLE HAEMODYNAMICALLY UNSTABLE Hemodynamically Unstable SyncDC Cardioversion Hemodynamically Stable ECG Vagal manoeuvre IV Adenosine 6-12mg fast bolus IV Diltiazem or verapamil IV Betablocker If Ineffective Sync DC Cardioversion
- 13. STABLE Only if Nopreexcitation HAEMODYNAMICALLY UNSTABLE Hemodynamically Unstable Sync DC Cardioversion Hemodynamically Stable ECG Vagal manoeuvre IV Adenosine – if no preexcitation IV Procainamide or IV Amiodarone Not recommended – CCB & BB
- 14. • ORAL BBLOCKER • OR DILTIAZEM • OR VERAPAMIL • EP STUDY & CATHETER ABLATION (Recurrent PSVT)
- 15. Macro reentrant circuitaround the tricuspid valve Atypical flutters -> cardiac surgery or ablation NON ISTHMUS DEPENDENT FLUTTER General Mechanism Macro reentry CAVO-TRICUSPID ISTHMUS DEPENDENT FLUTTER
- 16. Narrow QRS complex Regular,sometimes irregular Characteristic Saw-tooth p wave (“F – Waves”) Atrial Rate approx. 300/min Has 2:1 AV block ( rate 150/min) 0r 3:1 AV block ( rate 100/min) Or 4:1 AV Block (rate 75/min)
- 17. Hemodynamically unstable • SynchronizedDC cardioversion Hemodynamically stable • Synchronized DC cardioversion If trained person present • Rate Control oral B Blocker/ CCB (avoid amiodarone in acute setting)
- 18. Catheter ablation -cornerstone management If catheter ablation C/I then antiarrhythmics or rate control therapy (considered after a first episode OR recurrent episodes) Anticoagulant management- Due to the frequent coexistence
- 19. DEFINITION • Tachyarrhythmia arisewithin the atria • The atria beat rapidly in an uncoordinated manner • Consequent leads to ineffective atrial contraction • The ventricles are activated irregularly at a rate determined by conduction through the AV node
- 20. American Heart AssociationCardiology Guidelines 2019 • Terminates < 7 DAYS • Spontaneous or by Intervention. AF may recur PAROXYSMAL AF • Sustained > 7 DAYS PERSISTENT AF • Sustained > 12 MONTHS LONGLASTING PERSISTENT AF • Joint decision by patient and clinician to cease further attempts to restore sinus rhythm. PERMANENT AF
- 21. REFERENCE Table 16.21 DAVIDSONTextbook of medicine (2018) & European guidelines on A F (2020)
- 22. Yu-ki Iwasaki. Circulation.Atrial Fibrillation Pathophysiology, Volume: 124, Issue: 20, Pages: 2264-2274 • Automaticity • Triggered Automaticity (Ectopic focus) • Reentry Single circuit reentry Multiple wave reentry Due to genetic variants and signaling changes Gradually lead to electrical and structural remodeling General Mechanism Micro reentry
- 23. SVC IVC P Artery PVein Aorta Lungs Lt A Rt A Rt V Lt V
- 24. Asymptomatic Hemodynamically stable Hemodynamically unstable CLINICAL PRSENTATIONS Asymptomatic Hemodynamically Stable Palpitations,Syncope Dyspnea Fatigue, Poor effort tolerance Hemodynamically unstable Palpitations, Syncope Tachycardia, Hypotension Symptoms due to etiology Acute HF, LVF, ACS, Cardiogenic Shock, Valvular Disease Lung pathology, Hyperthyroidism, Others
- 25. EXAMINATION Irregularly Irregular Pulse IrregularS1, Apex Pulse Deficit Findings due to possible etiology OUTCOMES • Stroke • Cognitive decline/ Vascular dementia • LV dysfunction/ HF • Sudden Cardiac Death
- 26. The diagnosis ofAF requires rhythm documentation with an (ECG) tracing showing AF • Irregularly Irregular QRS interval • No P Wave • Fibrillatory wave (“f waves”) • Rate can vary over time
- 27. ALL AF PATIENTS 12Lead ECG CXR- PA view ECHO T3 T4 TSH CBC Kidney functions, Liver functions Electrolytes, PT INR Cognitive function assessment TREATMENT – AF Rhythm control Rate Control Treat comorbidities Intervention in selected cases by Catheter ablation SELECTED AF PATIENTS Ambulatory ECG Monitoring Transesophageal ECHO CRP, Troponin T, Pro BNP Biomarkers for angina, HF Coronary Angiography Suspected CAD/ACS Brain CT/MRI Suspected stroke CMRI, EP Mapping for LA assessment - Evaluation for catheter ablation CHA2DS2-VASc Score AF related symptoms AF burden Comorbidity & risk factors
- 28. • CHA2DS2-VASC SCORE,HAS-BLED SCORE • ANTICOAGULANTS Optimized stroke prevention • DC CARDIOVERSION • IV AMIODARONE / other antiarrhythmic agents • CATHETER ABLATION Rhythm control • B BLOCKER • CALCIUM CHANNEL BLOCKER • DIGOXIN • EXCEPTIONAL CASES – IV AMIODARONE Rate Control • TREAT UNDERLYING CAUSE AND RISK FACTORS Rx Comorbidities & Risk • Life style modification • Psychosocial support • Structured follow-up Supportive care
- 29. Valvular disease –MS HCM Prior stroke Score > 2 Loss of atrial contraction & Left atrial dilatation Cause stasis of blood in the LA & thrombus formation in the left atrial appendage. This predisposes patients to stroke Antiplatelet therapy should not be used in AF Vitamin K Antagonist WARFARIN New Oral Anticoagulants RIVOROXABAN APIXABAN ENDOXABAN DABIGATRAN No INR monitoring Fixed Dose Less drug interactions For: NON VHD INR: 2 to 3 Monitor INR Drug Interactions For: VHD
- 30. Attempt to restorerhythm + achieve rate control • If troublesome symptoms to improve QoL- correctable cause • Recurrent symptomatic paroxysmal or persistent AF Hemodynamically unstable: (Emergency) Emergency - synchronized DC cardioversion Hemodynamically stable (ECHO with OAC prior & after procedure) Pharmacological especially in Sick, HF, IHD – IV Amiodarone Resistant Cases – Catheter ablation, Surgical therapy – MAZE
- 31. Sedate Press Sync button Applyjelly over pads and place over chest as demonstrated Select Charge 100-200 J Do synchronized DC cardioversion Monitor patient
- 32. IV AMIODARONE 150 mgover 10 mins infusion then 360 mg (1mg/min) over 6 hours infusion Then 540 mg (0.5 mg/min) over 18 hours infusion Class III Anti arrhythmic Drug Increase refractoriness of myocardium
- 33. Prepare – TEE,ECG, CT Angio of Heart Ablation Cath Lab Electrical mapping Ablate around pulmonary veins
- 35. Attempt to restorerhythm + achieve rate control Accept presence of AF but achieve rate control B Blocker (IV Metoprolol, IV Esmolol) (Oral Metoprolol, Bisoprolol, Carvedilol) Calcium Channel Blocker – (Diltiazem, Verapamil) Digoxin Exceptional Cases- Implant a permanent pacemaker Plus Complete AV node block with catheter ablation Last Resort - IV Amiodarone <110/min < 80/Min
- 36. Treat the coexistingillness & Risk Factors