2MKSAP Item #119A 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.
3MKSAP Item #119ECG 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.
4Item 119 (con’t)Which of the following is the most appropriate management?Electrophysiology study24-hour continuous ambulatory electrocardiographic monitoringImplantable cardioverter-defibrillator placementLooping event recorder implantationSotalol administration
5MKSAP Item #54A 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.
6MKSAP 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%.
7Item 54 (con’t)Which of the following is the most appropriate treatment?Biventricular pacemaker with implantable cardioverter defibrillator (ICD)Dual chamber (right atrial and right ventricular leads) ICDDual chamber (right atrial and right ventricular leads) pacemakerSingle chamber (right ventricular lead) ICD
8Classification of Ventricular Arrhythmias ACC/AHA/ESC 2006 Guidelines Classification by Clinical PresentationClassification by ECGClassification by Disease EntityJACC 2006;48:e
22Premature Ventricular Complexes Paired PVCs or CoupletsTrigeminy
23Non-sustained monomorphic VT Non-sustained Ventricular Tachycardia3 or more PVC’s, rate >100 bpmLess than 30 seconds durationNo hemodynamic symptoms
24Therapy: PVC’s and Non-Sustained VT In patients with structurally normal hearts, PVC’s including runs of non-sustained VT are not prognostically significant.PVC’s including frequent PVCs and non-sustained VT are not targets for anti-arrhythmic therapy.
25PVC’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:
26Ventricular Arrhythmias AtriaBifurcation of the bundle of HisVentriclesVentricular Arrhythmias
27Supraventricular Arrhythmias AtriaBifurcation of the bundle of HisVentriclesSupraventricular Arrhythmias
28Not all beats with a wide QRS complex are ventricular Wide complex beats may also be supraventricular in origin.
29Wide Complex Beats Supraventricular Ventricular Pre-existent bundle branch blockAccessory pathwayAberrancy also called functional or rate related bundle branch blockVentricular
30Wide Complex Tachycardia Preexistent BBBBypass TractRate related BBBVentricularSupraventricular Beats With Wide QRS Complexes