Lesson topic №25. Нарушения ритма (Cardiac arrhythmia in the outpatient setting)
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Atrial fibrillation: better symptom management
AF catheter ablation is a well-established treatment for the prevention of AF recurrences.
When performed by appropriately trained operators, AF catheter ablation is a safe and superior alternative to antiarrhythmic drugs for maintenance of sinus rhythm and symptom improvement.
Atrial fibrillation: cardiovascular and comorbidity optimization
The ‘C’ component of the ABC pathway includes identification and management of concomitant diseases, cardiometabolic risk factors, and unhealthy lifestyle factors.
Management of risk factors and cardiovascular disease complements stroke prevention and reduces AF burden and symptom severity.
Atrial fibrillation: cardiovascular and comorbidity optimization
Obesity increases the risk for AF progressively according to body mass index.
Intense weight reduction with comprehensive management of concomitant cardiovascular risk factors resulted in fewer AF recurrences and symptoms than general advice in obese patients with AF.
Alcohol excess is a risk factor for incident AF and bleeding in anticoagulated patients, and high alcohol intake may be associated with thrombo-embolism or death.
It is unlikely that caffeine consumption causes or contributes to AF.
Patients should be encouraged to undertake moderate-intensity exercise and remain physically active to prevent AF incidence or recurrence, but maybe avoid chronic excessive endurance exercise (such as marathons and longdistance triathlons, etc.), especially if aged >50 years.
Ventricular arrhythmias
Ventricular arrhythmias
Premature ventricular complex (PVC): Premature occurrence of an abnormal QRS complex (duration typically ≥120 ms, corresponding T-wave typically broad and in the opposite direction of the major QRS deflection, no preceding P-wave).
Unifocal or monomorphic PVCs: PVCs with a single QRS morphology.
Multifocal, multiform, or polymorphic PVCs: PVCs with different QRS morphologies.
Short-coupled PVC: A PVC that interrupts the T-wave of the preceding conducted beat.
Ventricular arrhythmias
Ventricular tachycardia (VT): ≥3 consecutive beats with a rate >100 b.p.m. originating from the ventricles, independent from atrial and atrioventricular (AV) nodal conduction.
Non-sustained ventricular tachycardia (NSVT): Run of consecutive ventricular beats persisting for 3 beats to 30 s.
Monomorphic ventricular tachycardia (MVT): Same QRS morphology from beat to beat.
Polymorphic ventricular tachycardia (PVT): Continually changing QRS morphology.
Sustained monomorphic/polymorphic ventricular tachycardia (SMVT/SPVT): Continuous VT for at least 30 s, or which requires an intervention for termination.
Ventricular arrhythmias
Bidirectional ventricular tachycardia: Beat to beat alternation of the frontal QRS axis (e.g. in catecholaminergic polymorphic ventricular tachycardia [CPVT], Andersen–Tawil, digoxin toxicity, acute myocarditis).
Torsades de pointes ventricular tachycardia (TdP): Subtype of a polymorphic VT in the context of QT prolongation with continually changing QRS complexes that appear to spiral around the baseline of the electrocardiogram (ECG) lead in a sinusoidal pattern.
Ventricular arrhythmias
Ventricular fibrillation (VF): A chaotic rhythm with undulations that are irregular in timing and morphology, without discrete QRS complexes on the surface ECG.
Electrical storm: VA that occurs 3 or more times within 24 h (separated by at least 5 min), each requiring termination by an intervention.
Incessant VT: Continuous sustained VT that recurs promptly despite repeated intervention for termination over several hours.
Ventricular arrhythmias: clinical history
Palpitations (or sensation of sudden rapid heartbeats), presyncope and syncope are the three most important symptoms that require a thorough clinical history taking and possibly further investigations.
Palpitations related to ventricular tachycardia (VT) are usually of a sudden onset/offset pattern and may be associated with presyncope and/or syncope.
Episodes of sudden collapse with loss of consciousness without any premonition must raise the suspicion of bradyarrhythmias or VA.
Syncope occurring during strenuous exercise, while sitting or in the supine position should always raise the suspicion of a cardiac cause, while other situational events may indicate vasovagal syncope or postural hypotension.
A positive family history of sudden cardiac death (SCD) is a strong independent predictor of susceptibility to VA and SCD.
Ventricular arrhythmias: non-invasive and evaluation
A standard resting 12-lead ECG may reveal signs of inherited disorders associated with VAs and SCD such as channelopathies (LQTS, SQTS, Brugada syndrome, CPVT) and cardiomyopathies (ARVC and HCM).
Other ECG parameters suggesting underlying structural disease include bundle branch block, atrio-ventricular (AV) block, ventricular hypertrophy and Q waves consistent with ischaemic heart disease or infiltrative cardiomyopathy.
Electrolyte disturbances and the effects of various drugs may result in repolarization abnormalities and/or prolongation of the QRS duration.