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Atrial arrhythmia in the critically ill patients

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BY PROF DR SHERIF ZAKY

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Atrial arrhythmia in the critically ill patients

  1. 1. Sherif H Zaky, MD Professor of critical care medicine, Cairo University
  2. 2. Emergency medicine and critical care are fields that often require rapid diagnosis and intervention for specific situations. cardiac arrhythmias in intensive care are not only common ,but can be life threatening or a clue to more serious prognosis. AF in The ICU
  3. 3. The purpose of this presentation is to summarize Atrial tachyarrhythmias in the ICU and strategies for their management. AF in The ICU
  4. 4. We mean by atrial tachyarrhythmias ;  Frequent premature atrial ectopies  Atrial tachycardia.  Atrial flutter, and  Atrial fibrillation. AF in The ICU
  5. 5. Why critically ill ?  Structural heart disease  Pulmonary diseases ( hypoxia, acidosis, 2ry pulmonary HTN)  Electrolyte imbalance (K+, Mg+2)  Incidence with sepsis as high as 45% ( Cytokines ?). AF in The ICU
  6. 6. Atrial Fibrillation: Cardiac Causes  Hypertensive heart disease  Ischemic heart disease  Valvular heart disease  Rheumatic: mitral stenosis  Non-rheumatic: aortic stenosis, mitral regurgitation  Pericarditis  Cardiac tumors: atrial myxoma  Sick sinus syndrome  Cardiomyopathy  Hypertrophic  Idiopathic dilated (? cause vs. effect)  Post-open heart surgery AF in The ICU
  7. 7. Atrial Fibrillation: Non-Cardiac Causes  Pulmonary  COPD  Pneumonia  Pulmonary embolism  Metabolic  Thyroid disease: hyperthyroidism  Electrolyte disorder  Septicemia. AF in The ICU
  8. 8. “Lone” Atrial Fibrillation  Absence of identifiable cardiovascular, pulmonary, or associated systemic disease  Approximately 0.8 - 2.0% of patients with atrial fibrillation (Framingham Study).  In one series of patients undergoing electrical cardioversion, 10% had lone AF. 1 Brand FN. JAMA. 1985;254(24):3449-3453. 2 Van Gelder IC. Am J Cardiol. 1991;68:41-46. AF in The ICU
  9. 9. AF in The ICU Most common arrhythmia requiring hospitalization. Structural changes • Left atrium and left atrial appendage enlargement. • Reduced atrial contractility. • Decrease in cardiac output (loss of AV synchrony and rapid ventricular rate.) • Histologic: cardiomyocyte degeneration. • Increased propensity for clot formation.
  10. 10. Electrophysiologic background  Shortening of atrial refractory periods  Loss of normal adaptation of atrial refractoriness to heart rate.  Longer duration of AF results in shorter AF intervals  “AF begets AF” (electric remodeling) AF in The ICU
  11. 11. Management : I) Rhythm control Intravenous amiodarone (150 mg IV) in the treatment of critically ill patients with recent- onset atrial fibrillation, there are an increasing number of reports highlighting occasional serious acute pulmonary toxicity. AF in The ICU
  12. 12. Ibutilide (1 mg IV; in the case of persisting arrhythmia and body weight > 70 kg, has a 71% conversion rate with adjustment of magnesium level and high normal K+ level. AF in The ICU
  13. 13. II) Rate control : According to the AFFIRM and the RACE studies , Lower mortality and hospitalizations are documented with rate control rather than rhythm control. AF in The ICU
  14. 14.  Digoxin may be helpful for rate control, with an initial dose of 0.5 mg. After 30 minutes, 0.25 mg should be administered again.  verapamil (5 to 10 mg IV)  diltiazem (20 mg IV) AF in The ICU
  15. 15. Beta-blockade Propranolol (1 to 5 mg IV, additional infusion of 10 to 120 mgper day) and Esmolol (500 µg/kg over 1 minute, followed by a 4-minute maintenance infusion of 50 µg/kg/min with further dose adjustment as necessary) AF in The ICU
  16. 16. In one study done on critically ill ,60 patients with atrial tachy-arrhythmias (atrial fibrillation 57 patients, atrial flutter 2 patients, atrial tachycardia 1 patient) The primary end-point was a >30% heart rate reduction within 4 hours. The secondary endpoint was a heart rate <120 beats/min AF in The ICU
  17. 17.  Patients were randomized to :  diltiazem (25 mg bolus followed by a continuous infusion of 20 mg/h for 24 hours) (group I),  amiodarone (300 mg bolus) (group II) or amiodarone (300 mg bolus followed by 45 mg/h for 24 hours) (group III). AF in The ICU
  18. 18.  The primary endpoint was achieved in  70% of group I patients, 55% of patients in group II, and in 75% of patients in group III (P = 0.38).  In patients achieving heart rate control, diltiazem showed a significantly better rate reduction when compared with group II and III (P < 0.01 AF in The ICU
  19. 19. AF in The ICU
  20. 20. Atrial tachycardia Defined as a supraventricular tachycardia (SVT) that does not require the atrioventricular (AV) junction, accessory pathways, or ventricular tissue for initiation and maintenance of the tachycardia. Its rate varies between 150-250 BPM.
  21. 21. The ectopic P waves, easily seen in this example, occur in groups, separated by short pauses. This is because not all of the P waves make it to the ventricles so, 2nd degree AV block.
  22. 22. Diagnosis  The primary abnormality noted upon physical examination is a rapid pulse rate. In most atrial tachycardias this is regular. However, in rapid atrial tachycardias with variable AV conduction and in multifocal atrial tachycardia (MAT), the pulse may be irregular.
  23. 23. Very Subtle Atrial Tachycardia With 2:1 Block-KH
  24. 24. Multifocal Atrial Tachycardia (MAT) MAT often occurs in patients experiencing an exacerbation of chronic obstructive pulmonary disease, a pulmonary thromboembolism, an exacerbation of congestive heart failure, or severe illness especially under critical care with Inotropic infusion or Digitalis toxicity. Abnormal thyroid function should also be in the differential diagnosis
  25. 25. Management Carotid sinus massage and adenosine do not terminate the tachycardia even if they produce a transient AV nodal block. Electrical cardioversion is ineffective (being equivalent to attempting electrical cardioversion in a sinus tachycardia
  26. 26. Again Rate control with agents mentioned in AF management. However treating the primary pathology is the main stay. Unlike AF anticoagulation is not necessary.
  27. 27. Thanks

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