1. Disclosures
None

2. Ventricular Arrhythmias When do I need to worry?
Fred Kusumoto MD
Professor of Medicine Mayo Clinic College of Medicine
18th Annual Primary Care and Cardiovascular Symposium Jacksonville Fl – May 19, 2017

4. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
Funny Genetic Disorder?
Symptoms?

5. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
Funny Genetic Disorder?
Symptoms?

6. Number of consecutive beats: “Sustained >>> Nonsustained > PVCs”
Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009

7. Rate: “Slow = Less scary”
Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009

8. Coupling Interval: “Shorter = scarier” (“R on T”)

9. Coupling interval “Longer = less scarier”

10. Ventricular Arrhythmias: When do I need to worry?
How scary?
How many in a row?
Rate
Coupling
Structural Heart Disease?
Funny Genetic Disorder?
Symptoms?

11. Ventricular Arrhythmias: When do I need to worry?
How scary?
How many in a row?
Rate
Coupling
Structural Heart Disease?
Funny Genetic Disorder?
Symptoms?

12. Abnormal LV: Hypertrophic cardiomyopathy
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009

14. Bernath and Kusumoto. ECG Interpretation for Everyone 2011

15. Normal ventricular activation Precordial morphology

16. Normal ventricular activation Precordial morphology

17. Abnormal LV: Hypertrophic cardiomyopathy
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009

18. Abnormal LV: Myocardial Infarction
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009

19. Abnormal RV: Congenital heart disease?
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical Application 2009

20. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
LV: LVEF, HCM
RV: Congenital heart disease
Funny Genetic Disorder?
Symptoms?

21. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
LV: LVEF, HCM
RV: Congenital heart disease
Funny Genetic Disorder?
Symptoms?

22. Commonest funny genetic “channelopathies”
Brugada Syndrome
Na+

23. Commonest funny genetic “channelopathies”
Brugada Syndrome
Na+

24. ECG: Brugada Syndrome
Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009

25. Ventricular action potential

26. Ventricular action potential

27. Ventricular action potential

28. Commonest funny genetic “channelopathies”
Brugada Syndrome
Long QT Syndrome
Na+ K+

29. Commonest funny genetic “channelopathies”
Brugada Syndrome
Long QT Syndrome
Na+ K+

30. Ventricular action potential

31. Ventricular action potential
EAD
Action potential lengthening can lead to early reactivation of the cells (EADs)

32. Ventricular action potential
EAD
Action potential lengthening can lead to early reactivation of the cells (EADs)

33. Anna Nicole Smith
Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009

34. Long QT Syndrome: Assessing risk
Kusumoto FM, ECG Interpretation: From Physiology to Practical Application 2009
Schwartz Circ 2010

35. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
Funny Genetic Disorder?
Long QT
Brugada Syndrome
Symptoms?

36. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
Funny Genetic Disorder?
Long QT
Brugada Syndrome
Symptoms?

37. 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:

38. Etiology of Syncope and Age
Parry et al, BMJ 2010

39. Identifying cardiac syncope based on clinical history
Berecki Gisolf et al PLOS 2013

40. 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

41. Ventricular Arrhythmias: When do I need to worry?
How scary?
Structural Heart Disease?
Funny Genetic Disorder?
Symptoms?
History
Exam
ECG
Echo