Disclosures None
Ventricular Arrhythmias When do I need to worry? Fred Kusumoto MD Professor of Medicine Mayo Clinic College of Medicine Kusumoto.Fred@mayo.edu 18th Annual Primary Care and Cardiovascular Symposium Jacksonville Fl – May 19, 2017
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? Funny Genetic Disorder? Symptoms?
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? Funny Genetic Disorder? Symptoms?
Number of consecutive beats: “Sustained >>> Nonsustained > PVCs” Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009
Rate: “Slow = Less scary” Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009
Coupling Interval: “Shorter = scarier” (“R on T”)
Coupling interval “Longer = less scarier”
Ventricular Arrhythmias: When do I need to worry? How scary? How many in a row? Rate Coupling Structural Heart Disease? Funny Genetic Disorder? Symptoms?
Ventricular Arrhythmias: When do I need to worry? How scary? How many in a row? Rate Coupling Structural Heart Disease? Funny Genetic Disorder? Symptoms?
Abnormal LV: Hypertrophic cardiomyopathy Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
Bernath and Kusumoto. ECG Interpretation for Everyone 2011
Normal ventricular activation Precordial morphology
Normal ventricular activation Precordial morphology
Abnormal LV: Hypertrophic cardiomyopathy Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
Abnormal LV: Myocardial Infarction Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
Abnormal RV: Congenital heart disease? Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? LV: LVEF, HCM RV: Congenital heart disease Funny Genetic Disorder? Symptoms?
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? LV: LVEF, HCM RV: Congenital heart disease Funny Genetic Disorder? Symptoms?
Commonest funny genetic “channelopathies” Brugada Syndrome Na+
Commonest funny genetic “channelopathies” Brugada Syndrome Na+
ECG: Brugada Syndrome Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009
Ventricular action potential
Ventricular action potential
Ventricular action potential
Commonest funny genetic “channelopathies” Brugada Syndrome Long QT Syndrome Na+ K+
Commonest funny genetic “channelopathies” Brugada Syndrome Long QT Syndrome Na+ K+
Ventricular action potential
Ventricular action potential EAD Action potential lengthening can lead to early reactivation of the cells (EADs)
Ventricular action potential EAD Action potential lengthening can lead to early reactivation of the cells (EADs)
Anna Nicole Smith Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009
Long QT Syndrome: Assessing risk Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009 Schwartz Circ 2010
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? Funny Genetic Disorder? Long QT Brugada Syndrome Symptoms?
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? Funny Genetic Disorder? Long QT Brugada Syndrome Symptoms?
Probability of Survival Prognosis of Syncope: Framingham 5 10 15 20 25 0.0 0.2 0.4 0.6 0.8 1.0 Follow-up (yr) Probability of Survival No syncope Vasovagal and other causes Unknown cause Neurologic cause Cardiac cause Figure 2. Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope. P<0.001 for the comparison between participants with and those without syncope. The category “Vasovagal and other causes” includes vasovagal, orthostatic, medication-induced, and other, infrequent causes of syncope. The only difference between syncope and sudden cardiac death is that in syncope, you wake up. Anonymous Recently, the Framingham Heart Study provided an update regarding the incidence, specific causes, and prognosis of transient loss of consciousness episodes. Of 7814 study participants followed for an average of 17 years, 822 reported ‘syncope’. The incidence of a first report of syncope was 6.2 per 1000 person-years. The most frequently identified causes were vasovagal (21%), cardiac (9.5%), and orthostatic (9.4%); for 37% the cause was unknown. The participants with syncope from any cause, as compared with those who did not have syncope, had 1.31 increased risk for death from any cause, 1.27 for myocardial infarction or death from coronary heart disease, and 1.06 for fatal or nonfatal stroke. Persons with cardiac syncope were at increased risk for death from any cause (hazard ratio of 2.1) and cardiovascular events (hazard ratio of 2.66), and persons with syncope of unknown cause and neurologic syncope were at increased risk for death of 1.32 and 1.54 respectively. There was no increased risk of cardiovascular morbidity or mortality associated with vasovagal (including orthostatic and medication-related) syncope. Patients with cardiac causes for syncope have a significantly increased mortality risk. Over 30% of adults will have an episode of syncope during their lifetime. Framingham Soteriades ES, Evans JC, Larson MG, et al. NEJM. 2002;347:878-85.
Etiology of Syncope and Age Parry et al, BMJ 2010
Identifying cardiac syncope based on clinical history Berecki Gisolf et al PLOS 2013
Ventricular Arrhythmia Algorithm What did the ventricular arrhythmia look like? Rhythm strip, ECG History ECG Echocardiography (MRI) Does the patient have structural heart disease? Does the patient have something funny? Family History ECG Symptoms? History
Ventricular Arrhythmias: When do I need to worry? How scary? Structural Heart Disease? Funny Genetic Disorder? Symptoms? History Exam ECG Echo