West Herts Cardiology Arrhythmia Management Dr John Bayliss FRCP Consultant Cardiologist 17 Sept 2008

West Herts Cardiology Arrhythmia Guidelines Documents/Local Clinical Specialty/Cardiovascular NICE CG36 AF 2005 NSF CHD Arrhythmias 2006 Beds&Herts Cardiac Network Arrhythmia guidelines p 64

West Herts Cardiology Palpitations: Importance Common Often benign Often troublesome ++ Occasionally fatal  Need careful assessment – some/most in 1 y Care  Need for Rapid Access Arrhythmia services  Early involvement of specialist clinician  Ablation / Device therapy increasingly effective p 55

West Herts Cardiology Assessment of “Palpitations”/Arrhythmias Full History = most important Full History = most important Clinical Examination Heart rate response (during & after exercise) 12 lead ECG (esp during symptoms) Blood tests U&E, Glucose, Thyroid FT, Liver FT, FBC p 56-7

West Herts Cardiology Palpitations: Detailed History  Age of patient  Type and Duration of symptoms?  Individual “thumps”, “misses”, etc  Runs of tachycardia: ?Regular, ?Irregular  Duration, Frequency  Onset: ? Sudden/Gradual, ? Circumstances  Cessation: ? Sudden/Gradual, ? Circumstances  Associated symptoms  ? Polyuria (due to Atrial Natriuretic Peptide release in Atrial tachyarrhythmias)  ? Collapse/Dizzy/Breathless, etc  Concurrent illness  Family History (Sudden Death, Cardiomyopathy, CHD)  Drug History (incl OTC) p 58

West Herts Cardiology Palpitations: Low risk features = Manage in Primary Care History:  Not known to have heart disease  No family history of collapse or sudden death at age < 40 years  No previous collapse/blackouts  Only infrequent attacks Symptoms:  Palpitations last < 30 minutes  “Missed” beats (= ectopics) or brief rhythm irregularity only p 57

West Herts Cardiology Palpitations: High risk features = Refer to Heart Rhythm Specialist Pre-existing heart disease:  Previous angina, MI, angioplasty,heart surgery  Clinical heart failure, or LV systolic dysfunction (ejection fraction < 40%)  Structural heart disease: valve disease, cardiomyopathy, congenital heart disease Family history of collapse or sudden death at age < 40 years Previous or recurrent collapse/blackouts. p 57

West Herts Cardiology Should GPs report 12 lead ECGs ?! 24yr old woman, occasional brief “flutters”

West Herts Cardiology Long QT and Brugada syndrome “Ion channelopathies” QTc > ms = high risk of VT/SCD

West Herts Cardiology Investigation of Arrhythmias May be useful Ambulatory ECG (24hr – 7 days) Echocardiogram Exercise ECG – if exercise related or ?CHD Tilt Test – if postural or vagal symptoms Cardiac MRI - esp in young patient Implantable ECG Loop Recorder (ILR, “Reveal”) if infrequent but serious events Electrophysiological Study (EPS)  Catheter Ablation therapy

West Herts Cardiology Implantable Loop Recorder (ILR, “Reveal” device) 15 mins daycase procedure Local anaesthetic implant in upper L chest Battery lasts 18 months High quality downloadable ECG before+during attack Most cost-effective test  Yield 43% 1  Cost 26% less than usual Ix 2 1 Krahn AD, et al. Circ. 2001;104: Krahn AD, et al. JACC. 2003;42:

West Herts Cardiology Arrhythmias: Treatment Depends on (ECG) diagnosis ! S Tachy: ? Cause (POTS ! “heartsink”) A Tachy: β blocker AVNRT / AVRT: Ablation (Flecainide/Propafenone) A Flutter: Ablation (Verapamil,Dig,Amio) Paroxysmal AF: Sotalol, Propafenone, Flecainide Permanent AF: Rate v Rhythm... VT: ICD (β blocker, Amio, Ablation) Bradycardias: Pacing p 59

West Herts Cardiology Catheter Ablation for arrhythmias with localised anatomical substrate often curative (no need to continue anti-arrhythmic Rx)

West Herts Cardiology Device Therapy Pacemakers Cardiac Resynchronisation Therapy (CRT, Biventricular pacing) Implantable Cardioverter Defibrillators (ICD)

West Herts Cardiology Pacemakers : 1958 – 2008 : 50 years 1st "Permanent" Implantable Pacemaker & Bipolar Hunter-Roth Lead (1958)

West Herts Cardiology ICD function VF terminated by single 34J shock VF = Dead SR = Alive

West Herts Cardiology

AF: Types 22% of PAF progress to permanent AF within 2 years 50-60% of patients are back in AF 1 year after cardioversion Aetiology vs Timing Circulation 2001;104:2118–2150 OR First Episode (New onset) First Episode (New onset) Paroxysmal (PAF) Paroxysmal (PAF) Persistent Permanent “Lone” AF Alcohol Acute infection Hypertension Ischaemia / CHD Sick Sinus Syndrome Heart Failure Cardiomyopathy Valve disease Hyperthyroid, etc Alcohol Acute infection Hypertension Ischaemia / CHD Sick Sinus Syndrome Heart Failure Cardiomyopathy Valve disease Hyperthyroid, etc p 58

West Herts Cardiology AF: Management ? Rate or Rhythm Control  Rate control Control of Ventricular Rate at rest + on exercise  Rhythm control Restoration of SR + Maintenance of SR ? Anticoagulation  Risk of thromboembolism  Risk of Warfarin=1-2% yearly risk of serious bleed p 60 p 64

West Herts Cardiology AF: Rate v Rhythm control Choose Rhythm Control:  Symptomatic, Younger  Uncontrolled Heart Failure  First episode (?), or now corrected precipitant DC Cardioversion  ≥3 weeks anticoagulation before + 4 weeks after Try to Maintain SR (50% revert to AF in 1 yr)  ? Need for Amiodarone / Sotalol Propafenone / Flecainide p 60 p 64

West Herts Cardiology AF: Rate v Rhythm control - AFFIRM AFFIRM NEJM 2002;347: The Atrial Fibrillation Follow-up Investigation of Rhythm Management n=4060, age >65, AF Mean age = 69.7 Hypertension in 71% Rate control = <80 at rest <110 on walk + Warfarin (INR 2-3) Rhythm control = Drugs ± Cardioversion(s) + Warfarin (INR 2-3) unless SR for 4 (-12) weeks p 62

West Herts Cardiology AF: Rate v Rhythm control Choose Rate Control: if patient stable and if  Age >65  Underlying CHD, Hypertension, Valve Disease  Anti-arrhyhtmic Rx not tolerated / contraindicated  Cardioversion inappropriate Use β Blocker first : Atenolol, Bisoprolol, Metoprolol or rate controlling Ca ++ blocker: Verapamil, Diltiazem  Add Digoxin if necessary, or if CHF p 60 p 64

West Herts Cardiology IMPORTANT Digoxin : a drug of 2 nd -3 rd choice !

West Herts Cardiology AF: Digoxin = Increased Mortality SPORTIF III+V (Warfarin v Ximelagatran) n=7329 in AF Mod-high stroke risk 53% on Digoxin Mortality = 6.5% 47% not on Digoxin Mortality = 4.1% Hazard ratio (adjusted for risks) 1.53 ? ↑ Platelet activation Gjesdal, K et al. Heart 2008;94:

West Herts Cardiology AF: Thromboprophylaxis NICE CG36 June WarfarinAspirin ? ≥5% / year <3% / year p 61 p 64

West Herts Cardiology AF: Warfarin or Aspirin In AF, compared to placebo Aspirin ↓ relative risk of stroke by 20% Warfarin ↓ relative risk of stroke by 60% Warfarin increases absolute annual risk of serious haemorrhage by 2 + % Benefit Risk Echo is usually unnecessary for decision

West Herts Cardiology CHADS 2 risk score in AF Points CHF 1 Hypertension 1 Age 75 or older 1 Diabetes 1 Stroke or TIA 2 RISK SCORE Gage BF et al JAMA 2001;285: Risk Score Stroke rate* % (95%CI ) 01.9 ( ) 12.8 ( ) 24.0 ( ) 35.9 ( ) 48.5 ( ) ( ) ( ) Predicts annual risk of stroke in non-rheumatic AF * Assuming no Aspirin taken p 60-1 Warfarin indicated if CHADS 2 Score = 2 or more

West Herts Cardiology