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Ventricular Arrhythmias: From Palpitations To Sudden Death
Ventricular Arrhythmias: From Palpitations To Sudden Death
From Palpitations
to
Sudden Death
Internal Medicine Dept.
Abdul Moeloek General Hospital
Age
6:05 AM
6:07 AM
6:11 AM
Bradycardia
17%
Percent survival
80
Total group (N = 245)
60
All other ECGs (n = 200)
40
20
0
0 2
4 6
12
18
24
30
36
42
48
Time (months)
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. 1984;69:250-258.
Methods of Evaluating
Patients for Risk of Ventricular
History and Arrhythmias
physical
12-Lead ECG
Holter monitor
Event recorder
Echocardiogram
Cardiac catheterization
Signal-averaged ECG
Cardiac electrophysiology study
Pharmacologic Management of
VT/VF
Empiric
Holter-guided
EPS-guided
Combination
Non-Pharmacologic Management
of VT/VF
Catheter ablation
ICD
Transplant
Pharmacologic Management of
VT/VF
Vaughn-Williams Classification of Antiarrhythmic Drug Actions
Class
I
Action
Sodium Channel Blockade
II
III
Beta Blockade
Potassium Channel Blockade
IV
Drug
IA: Disopyramide
Quinidine
Procainamide
IB: Lidocaine
Mexiletine
Tocainide
IC: Flecainide
Propafenone
Beta Blockers
Amiodarone*
Sotalol*
Calcium Channel Blockers
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
Pharmacologic Management of
VT/VF
Disadvantages:
Often empiric, even if EP-guided, since not
all 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 remain
non-suppressible and have a poor prognosis
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)
14
BHAT
12
Beta Blocker
Heart
Attack
Trial
10
Placebo
Propranolol
4
0
BHAT Research Group. JAMA.
1982;247(12):1707-1714.
N = 3,837
3,706
12
18
24
Months of Follow-Up
3,647
2,959
2,163
30
36
1,310
406
Management of VT/VF
Effect of Propranolol on Mortality After Myocardial Infarction (BHAT)
18.4
Mortality (%)
13.3
10.4
7.8
5.9
5.5
3.3 2.9
CHF
%
Difference
No CHF
Total Mortality
27
25
CHF
No CHF
Sudden Death
47
13
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