Ventricular Arrhythmias

1
Ventricular Arrhythmias

• From Palpitations
• to Sudden Death

2
Variability of Ventricular Ectopy with Age

• Effect of age on probability () ofhaving more
  than agiven number ofPVCs per 24 hoursin
  subjects withnormal hearts.

60-69
40-49
50-59
10-29
30-39
Age
Data from Kostis JB. Circulation.
198163(6)1353.
3
Rhythm Strip During Episodeof Sudden Death
602 AM
605 AM
607 AM
611 AM

• Source After Josephson, ME

4
Sudden Death Syndrome

• Incidence
• 400,000 - 500,000/year in U.S.
• Only 2 - 15 reach the hospital
• Half of these die before discharge
• High recurrence rate

5
Underlying Arrhythmia of Sudden Death
Primary VF 8
Torsades de Pointes 13
VT 62
Bradycardia 17
Adapted from Bayés de Luna A. Am Heart J.
1989117151-159.
6
Proportion of Sudden Death Survivors with Acute MI
100
Acute Transmural MI (n 39)
80
Total group (N 245)
60
Percent survival
All other ECGs (n 200)
40
20
0
0
2
4
6
12
18
24
30
36
42
48
Time (months)

• lt 20 of sudden death survivors have an acute MI
• Sudden death associated with acute MI has a
  better prognosis

Cobb LA. Circulation. 197551(III)223.
7
Clinical Substrates Associated with VF Arrest

• Coronary artery disease
• Idiopathic cardiomyopathy
• Hypertrophic cardiomyopathy
• Long QT syndrome
• RV dysplasia
• Rarely WPW syndrome

8
Risk Factors for Sudden Death inPost-MI Patients

• LVEF lt 40
• Frequent ventricular ectopy

9
Multicenter Post-Infarction Study 1984

• Risk of sudden death increased as PVC frequency
  increased, plateauing at 10 PVCs/hr
• As EF decreased from 40 to 30, the risk
  increased
• EF PVC frequency were independent risk factors

Bigger JT. Circulation. 198469250-258.
10
Survival After Acute MI
1.0
A
0.8
B
C
0.6
Survivorship
D
0.4
N 536 113 80 37
EF ³ 30 ³ 30 lt 30 lt 30
VPD lt 10/hr ³ 10/hr lt 10/hr ³ 10/hr
A B C D
0.2
0
3
2
1
Year
Bigger JT. Am J Cardiol. 19865712B.
11
Risk of Sudden Death in Relation to Complexity of
Ventricular Arrhythmia
25
25
Sudden Coronary Deaths
Other Cardiac Deaths
20
20
15
15
Cumulative Probability of Death(age-adjusted )
10
10
5
5
0
0
0
1
2
3
4
5
0
1
2
3
4
5
Years After Baseline
Years After Baseline
Runs a/o early VPC (202) Other complex VPC
(260) Simple VPC only (433) No VPC (844)
Ruberman W. Circulation. 198164(2)297-305.
12
Risk of Sudden Death Data from GISSI-2 Trial
1.00
1.00
0.98
0.98
p log-rank 0.002
0.96
0.96
0.94
0.94
Survival
Survival
0.92
0.92
p log-rank 0.0001
0.90
0.90
0.88
0.88
A
B
0.86
0.86
0
30
60
90
120
150
180
0
30
60
90
120
150
180
Days
Days

• Patients withoutLV Dysfunction

Patients withLV Dysfunction
No PVBs1-10 PVBs/hgt 10 PVBs/h
Maggioni AP. Circulation. 199387312-322.
13
Improved Survival of Revascularization over
Medical Therapy from CASS Study
N 2102
1109
1101
1061
895
617
100
100
99
1131 N
2071
2038
1927
1562
995
80
A
P 0.0951
0
N 1739
2028
2013
1925
1611
1109
99
100
2094 N
1695
96
1654
1532
1237
776
Surgically Treated Medically Treated
80
Patients Without Sudden Death
B
P lt .0001
0
A One-Vessel Disease B Two-Vessel Disease C
Three-Vessel Disease
N 1467
3088
3050
2900
2469
1690
98
100
3229 N
92
1367
1281
1173
931
571
80
C
P lt .0001
0
Holmes DR. Circulation. 198673(6)1254-1263.
0
1
2
3
4
5
Year
14
Improved Survival of Revascularization over
Medical Therapyfrom CASS Study
N 242
152
148
136
116
83
98
100
168 N
205
83
174
151
80
117
80
A
P lt 0.0001
Surgically Treated Medically Treated
0
Patients Without Sudden Death
N 335
339
322
296
236
100
151
91
A Two-Vessel Disease B Three-Vessel Disease
388 N
252
80
192
69
149
110
58
B
P lt 0.0001
0
0
1
2
3
4
5
Year
Holmes DR. Circulation. 198673(6)1254-1263.
15
Improved Cardiac Survival in Modern Thrombolytic
Era
Use of Thrombolytics
In-Hospital Mortality
50
40
40
P lt 0.0001
30
P lt 0.05
30

20

P lt 0.05
20
10
10
P lt 0.001
NS
0
0
1987
1988-89
1989-90
1987
1988-89
1989-90
Patients lt 70 yr
Patients ³ 70 yr
Both groups combined
Montague TJ. Can J Cardiol. 19928(6)596-600.
16
High-Risk Subgroups Who Need Further Evaluation

• Survivors of sudden death
• Post-MI, reduced EF, and ventricular ectopy
• Recurrent unexplained syncope
• Idiopathic cardiomyopathy with syncope or VT
• Hypertrophic cardiomyopathy with syncope or VT
• Right ventricular dysplasia
• Long QT syndrome

17
Methods of Evaluating Patients for Risk of
Ventricular Arrhythmias

• History and physical
• 12-Lead ECG
• Holter monitor
• Event recorder
• Echocardiogram
• Cardiac catheterization
• Signal-averaged ECG
• Cardiac electrophysiology study

18
Cardiac Electrophysiology Study

• Invasive study to characterize electrical
  properties ofheart including
• Sinus node dysfunction
• AV nodal function
• Conduction abnormalities infra-Hisian block
• Accessory pathways of conduction
• WPW
• Mahaim
• AV nodal reentry
• Bundle branch reentry

19
Cardiac Electrophysiology Study

• Inducibility of VT
• Reentrant (ischemic VT)
• Triggered (idiopathic VT)
• Assessment of antiarrhythmic therapy via serial
  drug testing
• May lead to therapy with radiofrequency catheter
  ablation

20
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21
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22
HRA
HIS
HIS
HRA
CS
RVA
CS
RVA
RAO
LAO
23
Intracardiac Electrograms During SVT
24
Pharmacologic Management of VT/VF

• Empiric
• Holter-guided
• EPS-guided
• Combination

25
Non-Pharmacologic Management of VT/VF

• Catheter ablation
• ICD
• Transplant

26
Pharmacologic Management of VT/VF
Vaughn-Williams Classification of Antiarrhythmic
Drug Actions

• Class Action Drug
• I Sodium Channel Blockade IA Disopyramide Quini
  dine Procainamide
• IB Lidocaine
• Mexiletine
• Tocainide
• IC Flecainide
• Propafenone
• II Beta Blockade Beta Blockers
• III Potassium Channel Blockade Amiodarone
• Sotalol
• IV Calcium Channel Blockade Calcium Channel
  Blockers

Other class properties present
27
A New Approachto DrugClassificationThe
Sicilian Gambit
Adapted from the Task Force of the Working
Groupon Arrhythmias, European Society of
Cardiology.Circulation. 1991841831-1851.
28
Pharmacologic Management of VT/VF

• Advantages
• Non-invasive
• Almost no surgical morbidity or mortality
• Inexpensive in short run
• May be appropriate for certain subgroups
• Refused surgery
• Multisystem disease
• Poor overall prognosis

29
Pharmacologic Management of VT/VF

• Disadvantages
• Often empiric, even if EP-guided, since notall
  drugs can be serially tested due to expense
• Often associated with intolerable side effects,
  organ toxicity, and non-compliance
• Even if EP-guided, many patients
  remainnon-suppressible and have a poor prognosis

30
Chest X-Ray of Patient with Amiodarone Toxicity
31
Chest X-Ray of Same Patient with Previous
Amiodarone Toxicity Now with ICD (1994)
32
Amiodarone

• Toxicity
• Pulmonary fibrosis
• Hypo- or hyper-thyroidism
• Liver failure
• Bone marrow suppression
• Renal failure
• Photosensitivity
• Corneal deposits
• Side effects
• Myalgias
• Gait disturbance
• Insomnia
• Prolongation of coagulation time (PT)(need to
  reduce coumadin dosage)
• Digoxin toxicity (need to reduce digoxin dosage)

33
Amiodarone Tests for Follow-up

• CXR
• CBC
• Liver function tests
• Renal panel
• Thyroid function tests
• Opthalmologic exam
• Pulmonary function tests

34
Outcome of EP-Guided Antiarrhythmic Drug Therapy
in Sudden Death Survivors
100
Noninducible (N 57, SD/CA 2)
90
Inducible/Suppressed(N 20, SD/CA 1)
80
70
60
Survival ()
Inducible/Not Suppressed(N 20, SD/CA 7) P
lt 0.001
50
40
30
20
10
4
8
12
16
20
24
Follow-up (months)
Wilber DJ. Circulation. 199082350-358.
35
BHAT

• Beta Blocker
• Heart
• Attack
• Trial

Cumulative Mortality ()
BHAT Research Group. JAMA. 1982247(12)1707-17
14.
Months of Follow-Up
N 3,837
3,706
3,647
2,959
2,163
1,310
406
36
Management of VT/VF
Effect of Propranolol on Mortality After
Myocardial Infarction (BHAT)
18.4
13.3
10.4
Mortality ()
7.8
5.9
5.5
3.3
2.9
CHF
No CHF
CHF
No CHF
Total Mortality
Sudden Death
Difference
27
25
47
13
Adapted from Chadda K. Circulation.
198673(3)503-510.