Lesson topic №25. Нарушения ритма (Cardiac arrhythmia in the outpatient setting)
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Ventricular arrhythmias: non-invasive and evaluation
Continuous or intermittent ambulatory recording techniques can aid in relating symptoms to the presence of the arrhythmia. Silent myocardial ischaemic episodes may also be detected.
A 24to 48-h continuous Holter recording is appropriate whenever the arrhythmia is known or suspected to occur at least once a day.
Echocardiography is indicated in patients with VA suspected of having structural heart disease and in the subset of patients at high risk for the development of serious VA or SCD
Ventricular arrhythmias: general management
The selection of appropriate therapy for the management of VA and for prevention of SCD is focused on arrhythmia, the associated medical conditions that may contribute to and/or exacerbate arrhythmia, the risk posed by arrhythmia and the risk–benefit aspects of potential therapy.
Management of a manifest arrhythmia may involve discontinuation of offending pro-arrhythmic drugs and appropriate anti-arrhythmic therapy with drugs, implantable devices, ablation or surgery.
Ventricular arrhythmias: anti-arrhythmic drugs
Beta-blockers are effective in suppressing ventricular ectopic beats and arrhythmia as well as in reducing SCD in a spectrum of cardiac disorders in patients with and without HF.
Beta-blockers are effective and generally safe anti-arrhythmic agents that can be considered the mainstay of anti-arrhythmic drug therapy.
Until now, no anti-arrhythmic drug except for beta-blockers has demonstrated reduction in all-cause mortality. Each drug has a significant potential for causing adverse events, including pro-arrhythmia.
Ventricular arrhythmias: anti-arrhythmic drugs
Amiodarone has a broad spectrum of action and may inhibit or terminate VAs by influencing automaticity and re-entry.
The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) trial showed a lack of survival benefit for treatment with amiodarone vs. placebo in patients with LVEF ≤35%. Unlike sodium channel blockers, however, amiodarone can be used without increasing mortality in patients with HF.
Chronic administration of amiodarone is associated with complex drug interactions and a host of extracardiac side effects.
Ventricular arrhythmias: anti-arrhythmic drugs
Sotalol is effective in suppressing VA. Sotalol can be used safely in patients with CAD unless they have HF.
The use of anti-arrhythmic doses of sotalol requires careful monitoring using ECG, especially in patients with a low body mass index or impaired renal function.
Ventricular arrhythmias: device therapy
Implantable cardioverter defibrillator is an integral part of treating patients surviving a cardiac arrest due to a VA or those deemed to be at high risk thereof.
ICD implantation is recommended in patients with documented VF or haemodynamically not-tolerated VT in the absence of reversible causes.
Ventricular arrhythmias: interventional therapy
Catheter ablation has evolved into an important treatment option for patients with scar-related heart disease presenting with VT or VF.
Catheter ablation is curative in most idiopathic VT patients.
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