Basics of arrhythmology L.Křivan Dept. of Medicine and Cardiology , University Hospital Brno 60 bpm, 3600 bph, 100.000 bpd, 36.000.000 bpy, 2.520.000.000 bpl ECG – sinus rhythm ECG (Willem Einthoven 1893) ECG – limb leads ECG- precordial leads ECG Arrhythmia development • AUTOMATICITY • TRIGGERED ACTIVITY • REENTRY Basic principle of reentry Noninvasive assessment of arrhythmias • History • ECG • Holter monitoring • Long FU ECG recorders (R – test. Rhythm card) • ILR - REVEAL Noninvasive arrhythmia assessment Invasive assessment of arrhythmias ICEG Treatment • Medication • Radiofrequency ablation • Pacemaker • Implantable Cardioverter Defibrillator Tachyarrhythmias • SV - arrhythmias A Fib., A Flu., Atr. Tach, AVNRT, AVRT • Ventricular arrhythmias Ventricular tachycardia (120-230/min) Fast ventricular tachycardia ( >230/min ) Ventricular fibrillation Supraventricular arrhythmias Occurrence depends on the age and cardiac disease 64 4 8 25 WPW AFL AVNRT AT 22 18 23 25 WPW AFL AVNRT AT < 20 yrs > 60 yrs AVNRT • History - childhood • Abrupt start/stop • F 120-220/min • Vagal manouevres • Female • Frog sign AVNRT • Vagal man. • Adenosin - 12-24mg i.v. • Verapamil - 5-10mg i.v. • Metoprolol - 5mg i.v. • RFA of slow pathway • Verapamil • BB Radiofrequency ablation -RFA • Special catether creating endocardial tissue heating causing local necrosis and damage of contact place. • Conatct place - arrhythmic focus, accessory pathway, arrhythmogenic substrate Cathether placement during AVNRT RFA AVRT Delta wave in WPW syndrom Preexcitation with risk of SCD • In patients with AP fast conduction • During Afl, or AFib Atrial flutter Typical AFL RFA of AFL Epidemiologie • nárůst prevalence FISI z 3,2% (68-70) → 9,1% (87-89) Wolf PA et al. Arch Intern Med 1987;147:1561-1564 Psaty BM et al. Circulation 1997;96:2455-2461 Mechanismus vzniku a trvání FISI Anatomické struktury Levá síň Plicní žíly Koronární sinus Marshallovo ligamentum Pravá síň Spouštění - ektopická aktivita z plicních žil Udržování - reentry okruhy v levé síni Mechanismy Ektopická aktivita Rotory Makroreentry ANS AF • Population - 0,95% • Patients > 80 - 9,0% • Remodellation: electric contractile structural • 2 x higher mortality in AF x S.R. Atrial fibrillation Atrial fibrilation Indikace k RFA FISI ❑ paroxysmální formy ❑ symptomatické formy ❑ mladší pacienti (< 65 let) ❑ nepřítomnost organického onemocnění srdce ❑ selhání ≥ AA I / III třídy Kontrola frekvence při permanentní FISI • Digoxin • Betablokátory • CAA • Propafenon • Sotalol • Amiodaron • Dronedaron?! • Neselektivní ablace AV uzlu + implantace PM MRI image of LA with PW Isolation leasions RFA x Cryoablation 3D mapping Rozmístění katetrů v LAO kryobalon nástřik LHPŽ katetr v CSkatetr HIS teploměr Verifikace okluze PŽ kontrastem Dosažení optimálních teplot při aplikaci Signály v PŽ před a po aplikaci Stimulace do Laso k. 3D mapping Ventricular arrhythmias Lown PVCs classification • 0 without PVCs • I < 30 PVCs / hour • II > 30 PVCs / hour • IIIa PVCs of multiple origin • IIIb bigeminal, trigeminal PVCs • IVa couplets, triplets • IVb NSVT, Ssustained VT, ventricular fibrillation • V fenomen R / T Risk classification • Benign (PVCs up to NSVT without organic disease, or CHF) • Potentially malignant (NSVT – in presence of CHF, CAD, DCMP) • Malignant (ventricular tachycardia, ventricular fibrillation) VT LBBB-like VT Sudden cardiac death • Natural death due to cardiac causes with abrupt loss of consciousness within one hour of the onset of acute symptoms. Preexisting heart disease may be known, but time and mode of death are unexpected. Braunwald 1992 Epidemiology ❑ USA SCD / year: 200.000 – 450.000 ❑ World / year: 3.000.000 with estimated survival 1% ❑ ¾ CAD and 80% SCD is due to malignant arrhythmias ❑ Symptomatic HF: 20-25% risk of death in 2,5 years ❑ 50% deaths in CHFS is due to VT and VF Cobb LA., et. al. JAMA 2002 Cannom DS. J Cardiovasc Electrophysiol 2005 Huikuri - N Engl J Med 2001 Echt DS. N Engl J Med. 1991;324:781-788. 80 85 90 95 100 0 91 182 273 364 455 Days After Randomization PatientsWithoutEvent(%) Placebo (n = 743) Encainide or Flecainide (n = 755) P = 0.001 CAST I – Prognosis of Post-MI Patients Waldo AL. Lancet. 1996;348:7-12. 1.00 0.98 0.94 0.92 0.90 0.88 60 240 300 Time from randomization (days) Proportionevent-free Placebo d-sotalol P = 0.006 1801200 0.96 SWORD – Survival with d-sotalol vs. Placebo Cairns JA. Lancet. 1997;349:675-682. Time since randomization (months) 24 12 10 8 6 4 2 6 12 18 0 Cumulativerisk(%) Non-arrhythmic deaths P = 0.72 Placebo Amiodarone 0 6 12 18 24 All-cause mortality P = 0.130 0 CAMIAT Results Julian DG. Lancet. 1997;349:667-674. By group and ejection fraction 1.00 0.95 0.90 0.85 0.80 0.75 EF < 30% EF 31-40% 0 6 12 18 24 Months since randomization P = 0.96 By group 1.00 0.95 0.90 0.85 0.80 0.75 Amiodarone Placebo 0 6 12 18 24 Months since randomization EMIAT Results – All Cause Mortality BB and SCD Huikuri HV. JACC 2003 Metaanalyses with BB after MI showed RR reduction 30-50% • 1899 – Prevost + Battelli terminated VF in dogs by the DC discharge • 1930 – Electric current influence on heart may induce / terminate VF • 1931 – White P.D. „…a condition of little importance so far as we know now“ • 1947 – Claude Beck 1. succ. Defibrillation in human during the thorax operation • 1970 - Mirowski automatic standby defibrillator in animals • 1980 – Mirowski ICD first 3 patients ICD history ICD therapy Arrhythmic episode from ICD memory 31% 28% 20% 0% 5% 10% 15% 20% 25% 30% 35% AVID CASH CIDS Secondary prevention studies Malignant ventricular arrh. • Sustained VT, FVT • Ventricular fibrillation • Risk SCD after CPR - in 1 year 40 - 55% • Therapy - NECESSARY!!, Antiarrhythmics, revascularization, ICD 0 100 200 300 400 1 2 3 4 5 6 0 10 20 30 40 1 2 3 4 5 6 celá populace multirizko koronární př. EF LK < 35 % KT/FK komb. počet příhod x 1000incidence % / rok INCIDENCE / number of SCDs Myerburg et al., Circulation, 1998 Primary prevention studies MADIT MUSTT MADITII 196pacientů 704pacientů 1232pacientů sledování27m sledování39m sledování20m 54%redukceCM 55%redukceCM 31%redukceCM 54% 55% 31% 0% 10% 20% 30% 40% 50% 60% MADIT MUSTT MADIT II Moss. N Engl J Med 1996 Buxton. N Engl J Med 1999 Moss. N Engl J Med 2002 CAD patients – inclusion criteria Vstupní kriteria MADIT MUSTT MADIT II ICHS po IM x x x EF LK <35% <40% <30% NSKT x x Induc. KT při EPS x x Nesupresibilní KT x SCD HeFT 2.521 patients 70% NYHA II, 30% NYHA III LVEF ≤ 35% 52% CAD, 48% DCMP Placebo x Amiodaron x ICD therapy Follow – up: 40,8 months ICD terapie comparatively reduced total mortality by 23% irrespective of cardiac failure etiology. Bardy GH., et. al.N Engl J Med 2005;352:225-237 COMPANION 1520 patients NYHA III, IV, CAD, DCMP, SR, QRS > 120 ms, LVEF < 35% randomized 1:2:2 - OPT, OPT+CRT, OPT+CRT – D Total mortality CRT -24%, CRT/ICD - 36% 36% reduction of mortality in CRT – D group !! N Engl J Med 2004 Baldasseroni, AHJ 2002 Number needed to treat to save 1 life during 5 years ICD longevity study RRR ARR – 5 yrs NNT-5 yrs MADIT I 54 46 2,2 MUSTT 51 36 2,8 MADIT II 31 16 6,3 COMPANION 36 34 2,9 DEFINITE 35 12 8,3 SCD-HeFT 23 8 12,5 Dorian P., et al. Can J Cardiol 2005;21:31A-36A Risk factors increasing nonarrhythmic mortality Patients with low profit from PP ICD Patients with high profit from PP ICD female male age > 70 years age < 70 years renal failure QRS > 120ms NYHA I, IV NYHA II,III MTWA negative LVEF> 35% Cumulation of risk factors in the left column increase the likelihood of noncardiac or nonarrhythmic death. Goldenberg I., et al. JACC 2008 Křivan L. Vnitř Lék 2010 Křivan L. Cor Vasa 2010 Congenital VD (TCPC) SQ ICD Arrhythmia treatment • AA, RFA, no Tx - for SV arrhytmias • ICD - for ventricular tachycardias