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Chapter06:Arrhythmias
RelatedQuestions
Previous:MyocardialDisease

Arrhythmias

AntiarrhythmicMedications
Antiarrhythmicmedicationsareusedtopreventrecurrentarrhythmiasandmaintainsinusrhythm.
Althoughantiarrhythmicmedicationshavehistoricallybeenorganizedaccordingtotheirpredominant
mechanismofactionusingtheVaughanWilliamsclassificationsystem(Table23),itisincreasingly
recognizedthatthisnomenclaturesystemhaslimitationsbecausemostantiarrhythmicdrugshave
severalmechanisticactions.
Themembraneactiveantiarrhythmicagents(classIandclassIII)principallyaffectionchannels.
ClassIagentsdecreaseimpulseformationandspeedofdepolarizationandareoftenusedinpatients
withatrialarrhythmiasandnostructuralheartdisease.SeveralclassIAagentsareusedless
frequently,althoughtheyarehelpfulinspecificsituations(seeTable23),includingtheuseof
procainamideinpatientswithpreexcitedatrialfibrillation.ClassICagentsareavoidedinpatients
withcoronaryarterydiseaseandstructuralheartdiseaseastheyhavebeenshowntocause
proarrhythmicactivity(ventriculararrhythmias)andincreasemortality.ClassIIagents(blockers)
andclassIVagents(nondihydropyridinecalciumchannelblockers)arefrequentlyusedtoslowheart
ratesinpatientswithsupraventricularoratrialarrhythmiashowever,theyshouldbeavoidedin
patientswhohaveatrialfibrillationwithpreexcitation.ClassIIIagentsareusedtotreatatrialand
ventriculararrhythmias.Theseagentsareclearedbythekidneysandshouldbeavoidedinpatients
withsignificantchronickidneydiseaseowingtoincreasedtoxicityandproarrhythmia.Becauseclass
IIIagentsleadtoQTcintervalprolongation,initiationofthistherapyisusuallydoneonaninpatient
basiswithregularassessmentoftheQTcinterval.PatientstakingclassIIIagentsshouldavoidother
QTprolongingmedications,andserumpotassiumandmagnesiumlevelsshouldbecheckedregularly.
Amiodarone,amultichannelblocker,isamongthemostcommonlyusedantiarrhythmicmedications.
Itisfrequentlyusedtotreatatrialfibrillationinolderpersonsandtopreventrecurrentventricular
tachycardia.Amiodaroneisthepreferredantiarrhythmicagentinpatientswithstructuralheartdisease
andheartfailure.Althoughhighlyeffective,amiodaronehasmultipletoxicities.Amiodaronetherapy
isassociatedwithrisksforthyroidtoxicity,hepatotoxicity,lungtoxicity,photosensitivity,cornealand
lenticulardeposits,opticneuropathy,andotherneurologicadverseeffects.Patientsonamiodarone
requireroutinemonitoringofthyroidandliverfunction,pulmonaryfunctiontestingatbaselineand
withsymptoms,andperiodicophthalmologicevaluation.Amiodaroneinteractswithseveral
medications.Patientsonamiodaronerequirelowerdosesofwarfarin,statins,anddigoxin.
Dronedaroneisamultichannelblockerusedtotreatatrialfibrillation.Owingtoincreasedmortalityin
patientswithheartfailureorpermanentatrialfibrillation,itsuseshouldberestrictedtopatientswith
intermittentatrialfibrillationandnoovertheartfailure.
Digoxinisanoralpositiveinotropicagentthatactsonthesodiumpotassiumexchangerandhasvagal
propertiesthatleadtodecreasedatrioventricular(AV)nodalconduction.Asaresultofitsvagal
mechanism,itprimarilycontrolstheheartrateatrestandislesseffectiveduringactivity.Adenosine

isanA1receptorblockerthatcaninhibitAVconduction.Adenosineisfrequentlyusedasa
therapeuticagenttoterminatesupraventriculartachycardia.

KeyPoint
Calciumchannelblockersandblockersareoftenusedtotreatsupraventricularandatrial
arrhythmiashowever,theseagentsshouldbeavoidedinpatientswhohaveatrialfibrillation
withpreexcitation.

ApproachtothePatientwithBradycardia
ClinicalPresentation
Symptomsofbradycardia(heartratelessthan60/min)includefatigue,exertionalintolerance,
dyspnea,lightheadedness,andsyncope.Bradycardiacanresultfrompathologyinthesinusnode,the
AVnode,ortheHisPurkinjesystem.Physiciansshouldmaintainahighsuspicionforreversible
causesofbradycardia,includingelevatedintracranialpressure,hypothyroidism,hyperkalemia,Lyme
disease,andmedicationeffects(mostcommonlyAVnodalblockers,especiallyblockersand
digoxin).
Thediagnosticevaluationofbradycardiaincludes(1)establishingacorrelationbetweentherhythm
(bradycardia)andsymptomsand(2)excludingsevereconductionabnormalitiesthatrequireurgent
intervention.Evaluationincludesacarefulhistory,afocusedlaboratoryevaluation(includingan
assessmentofthyroidfunction),resting12leadelectrocardiogram(ECG),exercisetreadmilltesting
toassesstheheartrateresponsetoexercise(chronotropiccompetence),andambulatoryECG
monitoringbasedonthenatureandfrequencyofthepatient'sepisodesorsymptoms(seeDiagnostic
TestinginCardiology).Rarely,electrophysiologictestingcanbeusedtohelpascertainifsinusnode
dysfunctionispresent.

SinusBradycardia
Sinusbradycardia(sinusrhythmwithaheartrate<60/min)maybeappropriateinseveralsituations,
includingintrainedathletesorduringsleep,whentheheartratemayfallaslowas30/min.Themost
commonintrinsiccauseofinappropriateorpathologicsinusbradycardia(sinusnodedysfunction)is
agerelatedmyocardialfibrosisinthevicinityofthesinusnode.Themostcommonextrinsiccauseof
sinusbradycardiaismedicationeffect.Sinusnodedysfunctioncanalsopresentwithchronotropic
incompetence,andthisisfrequentlyoverlooked.Other,lesscommon,causesofsinusnode
dysfunctionincluderightcoronaryischemia,intracranialhypertension,postsurgicalscarringafter
cardiothoracicsurgery,andinfiltrativeorinflammatorydisorders(suchassarcoidosis).

AtrioventricularBlock
AVblockisclassifiedasfirstdegree,seconddegree,orthirddegree.FirstdegreeAVblockis
characterizedbyprolongedAVconduction,whichmanifestsontheECGasaPRintervalgreaterthan
200msec.FirstdegreeAVblockisnotatrueblockbecauseallPwavesconducttotheventricles.It
hasbeenassociatedwithanincreasedriskofatrialfibrillation,pacemakerimplantation,andallcause
mortalityinlongtermfollowup.
InseconddegreeAVblock,somePwavesconducttotheventricleandsomedonot.Therearetwo
formsofseconddegreeAVblock.WhenprogressivePRprolongationisobservedpriortoablocked
beat,seconddegreeMobitztype1(Wenckebachblock)ispresent.SeconddegreeMobitztype1
blockischaracterizedbygroupedbeatingandprogressiveshorteningoftheRRintervals.Mobitz

type1blockisalmostalwayslocalizedtotheAVnode.Itgenerallycarriesabenignprognosisand
frequentlyimproveswithexerciseorincreasedsympathetictone.
WhenthePRintervalisconstantpriortononconductedPwaves,theseconddegreeblockistermed
Mobitztype2block.When2:1blockispresent,Mobitztype1versustype2blockcannotbe
differentiated.Mobitztype2blockusuallyrepresentsblocklowerintheconductionsystemandhasa
higherriskofprogressiontocompleteheartblock.
ThirddegreeAVblock,orcompleteheartblock,isdefinedasthefailureofanyPwavestoconductto
theventricles,anditischaracterizedbyAVdissociationontheECG.

Pacemakers
RelatedQuestion
Question109
Pacemakersareindicatedinpatientswithsymptomaticbradycardiaintheabsenceofareversible
cause,hencetheimportanceofestablishingsymptomswhenevaluatingpatientswithbradycardia.In
patientswithminimalsymptoms,apersistentrestingheartratebelow40/minisalsoconsideredan
indicationforpermanentpacing.PacemakersalsoareindicatedinpatientswithevidenceofAV
conductiondisturbancesthathaveahighlikelihoodofprogressingtocompleteheartblockorlife
threateningsuddenasystole.Indicationsforpermanentpacemakerimplantationareshownin
Table24.
Patientswithintraventricularconductiondelayshavealowriskofprogressiontocompleteheart
block(1%3%annually)anddonotrequirepermanentpacing.Whenapatientdevelopsnewonset
conductiondiseaseinthesettingofanacutecoronarysyndrome,temporarypacingmayberequired,
butdecisionsonpermanentpacingshouldbedelayeduntilapatienthasbeenrevascularizedand
stabilizedtodeterminewhetherthearrhythmiapersists.
Patientswithpacemakerswhorequiresurgeryshouldhaveapreoperativedeviceevaluationto
determinewhetherpreoperativereprogrammingofthedeviceisnecessary.AlthoughMRI
conditionalpacemakersarenowavailable,thepresenceofapacemakerremainsacontraindicationto
MRIscanningformostpatients.
Thereareseveraltypesofimplantedcardiacdevices,withvariouscapabilities.Implantedcardiac
electronicdevicesincludeimplantedloopmonitors,pacemakers,implantablecardioverter
defibrillators(ICDs),andcardiacresynchronizationdevices.Withtheexceptionofsubcutaneous
ICDs,whichdonotutilizeintracardiacleads,allICDsalsohavepacemakerfunctions.Table25
reviewsthevarioustypesofimplantedcardiacelectronicdevices,theirfunctions,andtheirgeneral
indications.

KeyPoint
Apacemakerisindicatedforsymptomaticbradycardiawithoutareversiblecauseaswellasfor
atrioventricularconductionabnormalitiesthatarelikelytoprogresstocompleteheartblock.

ApproachtothePatientwithTachycardia
Patientswithsymptomatictachycardiaoftenreportpalpitations,lightheadednessordizziness,chest
discomfort,dyspnea,exertionalintolerance,orsyncope.Somepatientsareasymptomaticandare
foundtohavearrhythmiasincidentallyduringmonitoringinthesettingofhospitalizationorother

medicalcare.Themostimportantpartoftheevaluationisthedocumentationoftachycardiaand
correlationwithsymptoms(seeDiagnosticTestinginCardiology).Inadditiontoahistoryand
physicalexamination,allpatientswithtachycardiashouldhavearesting12leadECG.Mostpatients
withtachycardiashouldundergoechocardiographytoexcludethepresenceofstructuralheartdisease
andthyroidfunctionevaluation.
Inbothhospitalandambulatorysettings,sinustachycardia(sinusrhythmwithheartrate>100/min)is
themostcommonlyencounteredtachycardia.Sinustachycardiaisusuallycausedbyphysiologic
distress,includingpain,fever,anemia,oranxiety.Theevaluationandtreatmentofsinustachycardia
aredirectedattheunderlyingetiology.Significantsinustachycardiainacriticallyillpatientisa
worrisomefindingasitusuallyindicatesadvancedphysiologiccompromise,includingrespiratory
failure,insufficientcardiacoutput,orsevereinfection.
Olderpatientswithpalpitationsaremorelikelytohaveatrialfibrillation,atrialflutter,orventricular
tachycardia(VT).AlthoughVTisoftenassociatedwithhemodynamiccompromise,VTisoftenwell
tolerated,whereasmanypatientshavehemodynamicallysignificantsupraventriculartachycardiaor
atrialarrhythmias.Therefore,vitalsignsarenothelpfulindeterminingthenatureofanarrhythmia.
Inyoungerpersonswithtachycardicsymptoms,supraventriculartachycardiasaremorecommon,
includingAVnodalreentranttachycardia(AVNRT)andaccessorypathwaymediatedtachycardia.
Patientswithanaccessorypathwayoftenhaveevidenceofanterogradeconductionandadeltawave
onECG.
Atrialandventricularectopyarepresentinmanyifnotmostpersons.Thefrequencyofectopyand
symptomsusuallydictateboththeworkupandsubsequentmanagement.

KeyPoint
Inadditiontoarestingelectrocardiogram,diagnostictestingformostpatientswithtachycardia
shouldincludeanechocardiogramandevaluationofthyroidfunction.

SupraventricularTachycardias
ClinicalPresentation
RelatedQuestion
Question100
Supraventriculartachycardias(SVTs)areagroupofarrhythmiasthatariseinatrialtissueortheAV
node.BecauseconductionofsupraventricularimpulsesbelowtheAVnodeisconductednormally,the
ECGinSVTusuallyrevealsanarrowcomplextachycardia,althoughtheQRScomplexescanbewide
(>120msec)inthepresenceofbundlebranchblock,aberrancy,pacing,oranterogradeaccessory
pathwayconduction(antidromictachycardia).
SVTsincludeabnormalelectricalactivityarisingintheatrium(prematureatrialcontractions,
tachycardia,atrialfibrillationandflutter,multifocalatrialtachycardia)orAVnode(junctional
tachycardia,AVNRT,atrioventricularreciprocatingtachycardia[AVRT]).Becausetheyareso
commonandforthepurposeofthisreview,atrialfibrillationandatrialflutterarediscussed
separatelytherestofthissectionwillfocusexclusivelyontheotherSVTs.
SVTcanoccurinallagegroupsbutisfrequentlyencounteredinyoungerpatients.SVTismore
commoninwomenthanmenandusuallyoccurswithoutstructuralheartdisease,althoughthisshould

beevaluatedwithanechocardiogram.PatientswithSVToftenhaverepeatedepisodesoftachycardia.
Patientsmayhavepalpitations,asensationofpoundingintheneck,fatigue,lightheadedness,chest
discomfort,dyspnea,presyncope,and,lesscommonly,syncope.
TheECGclassificationofSVTisusuallybasedontherelationshipofthePwaveandtheQRS
complex.InshortRPtachycardias(RPinterval<PRinterval),thePwavecloselyfollowstheQRS
complex.InlongRPtachycardias(RPinterval>PRinterval),thePwaveismorethanhalfthe
distancebetweentheQRScomplexes.ShortRPtachycardiasincludetypicalAVNRT,AVRT,and
junctionaltachycardia.Junctionaltachycardiasarelesscommoninadults,buttheycanoccurin
patientswithdigoxinintoxicationandotherconditions.LongRPtachycardiasincludeatypical
AVNRT,sinustachycardia,atrialtachycardia,andthepermanentformofjunctionalreciprocating
tachycardia.
EpisodesofSVTcanoftenbeterminatedwithValsalvamaneuvers(bearingdown),carotidsinus
massage,orfacialimmersionincoldwater.AdenosinecanbeusedtoterminateSVTandtohelp
diagnosetheetiology.TerminationwithadenosineoftensuggestsAVnodedependence(AVNRTand
AVRT),whereascontinuedatrialactivity(Pwaves)duringAVblockcanhelpidentifyatrialflutter
andatrialtachycardia.

PrematureAtrialContractionsandAtrialTachycardia
Atrialectopycanbeisolated(prematureatrialcontractions[PACs]),occurinsalvos,orbesustained
(atrialtachycardia).PACsareextremelycommon,andthefrequencyincreaseswithage.Only1%of
personsinthegeneralpopulationhavenoPACsduringambulatoryECGmonitoring.However,PAC
burdenisassociatedwithincreasedriskofatrialfibrillation.SymptomaticPACsaretypicallytreated
withblockersorcalciumchannelblockers.
Atrialtachycardiacanoccurinpatientswithorwithoutstructuralheartdiseasewhensymptomatic,
firstlinetreatmentisablockerornondihydropyridinecalciumchannelblocker(diltiazemor
verapamil).Secondlinetreatmentincludescatheterablationorantiarrhythmicdrugtherapy.In
general,successratesforablationofatrialtachycardiaarelowerthanthoseforotherSVTs.
Multifocalatrialtachycardia,characterizedbymultiple(3)Pwavemorphologiesandaheartrate
greaterthan100/min,isfrequentlyseeninpatientswithendstageCOPD.Treatmentisusually
directedattheunderlyingetiologyandelectrolytedisturbances,althoughblockersandcalcium
nondihydropyridinecalciumchannelblockerscanbeusedcautiously.

AtrioventricularNodalReentrantTachycardia
AVNRTisthemostcommontypeofSVT,accountingfortwothirdsofallpatientswithSVT
(excludingatrialfibrillationandatrialflutter).AVNRTiscausedbyreentrantconductionwithinthe
AVnode,utilizingboththefastandslowpathways(Figure17).IntypicalAVNRT,theelectrical
conductiongoesdowntheslowpathwayandconductsbackuptowardtheatriumoverthefast
pathway(slowfast).ThisleadstoashortRPintervalwitharetrogradePwaveinscribedverycloseto
theQRScomplex.ThecloselycoupledretrogradePwavesmaybeburiedintheQRScomplexesand
maynotbevisible,ortheymayappearasapseudoRwaveinleadV1andapseudoSwaveinthe
inferiorleads.InatypicalAVNRT,conductiongoesdownthefastpathwayandreturnstotheatrium
viatheslowpathway(fastslow)thisleadstoalongRPinterval.Rarely,AVNRTcaninvolve
conductionovermorethanoneslowpathway(slowslowAVNRT).
Beyondacuteterminationwithphysicalmaneuversoradenosine,treatmenttopreventrecurrent
AVNRTincludesAVnodalblockingtherapywithblockersornondihydropyridinecalciumchannel
blockers.PatientswhohaverecurrentAVNRTordonottolerateorprefertoavoidlongtermmedical
therapyareusuallyreferredforcatheterablation,whichhasahighsuccessrate.Themajorriskof

ablationisa1%riskofinjurytotheAVnoderequiringpacemakerimplantation.

AtrioventricularReciprocatingTachycardia
RelatedQuestion
Question115
AVRTisanaccessorypathway(bypasstract)mediatedtachycardia.Accessorypathwayconduction
isoftenobservedaspreexcitationonECG.Becauseofearlyventricularactivationovertheaccessory
pathway,thePRintervalisshortenedandtheinitialpartoftheQRScomplexisslurred(deltawave)
becauseofventriculardepolarizationadjacenttothepathway.InAVRT,conductionisanterograde
overtheAVnode(orthodromicAVRT)oranterogradeovertheaccessorypathway(antidromic
AVRT).OrthodromicAVNRT,themostcommontypeofAVRT(morethan90%to95%ofcases)is
characterizedbyanarrowQRScomplexresultingfromconductionovertheAVnodeandtheHis
Purkinjesystem.AntidromicAVRTischaracterizedbyawide,slurredQRScomplexresultingfrom
conductionoverthebypasstractandactivationoftheventriclewithoutuseofthespecialized
conductionsystem.AdenosinecanbegiventoterminateorthodromicAVRThowever,adenosineor
otherAVnodalblockersarecontraindicatedinpreexcitedatrialfibrillationandantidromicAVRT.
AVnodalblockadeinpatientswiththeserhythmscanpromoterapidconductiondownthebypass
tractandinductionofventricularfibrillation(VF).
PatientswithevidenceofpreexcitationontheirrestingECG(deltawave)andsymptomaticSVThave
WolffParkinsonWhite(WPW)syndrome.UptoonethirdofpatientswithWPWsyndromehaveor
willdevelopatrialfibrillation.Rapidconductionoveranaccessorypathwayinatrialfibrillationcan
leadtoVFandsuddencardiacdeath(SCD),althoughthisisarelativelyrareevent.Riskfactorsfor
VFinWPWsyndromeincludedocumentedAVRT,multiplebypasstracts,Ebsteinanomaly(right
heartenlargementandseveretricuspidvalveregurgitation),andarapidlyconductingaccessory
pathway.WPWsyndromeisoftenseeninpatientswithEbsteinanomaly.
Ingeneral,evaluationofapatientwithpreexcitationincludesa12leadECG,echocardiogram,
ambulatoryECGmonitoring,andanexercisestresstest.Stresstestingisaneffectivemeansof
noninvasiveriskstratificationforpatientswithpreexcitation.Lossofpreexcitationduringexercise
generallyindicateslowrisk.Electrophysiology(EP)testingcanhelpdeterminerapidityofconduction
andriskforsuddendeathitalsocanhelplocalizethepathwayandfacilitatecatheterablation,which
hasahighsuccessrate(althoughsuccessdependsonthelocationofthebypasstract).Ingeneral,
catheterablationisfirstlinetherapyforpatientswithpreexcitationandsymptoms.Antiarrhythmic
agentsarereservedforsecondlinetherapy,particularlyinpatientswithaccessorypathwaysinclose
vicinitytotheAVnode.
ManagementofasymptomaticpreexcitationonECGiscontroversial.Intheabsenceofsymptoms,
however,invasivetestingisgenerallynotrequired,unlessthepatienthasahighriskoccupation,such
asanairlinepilotorbusdriver.

KeyPoints
Therapeuticoptionsforpreventionofrecurrenceofatrioventricularnodalreentranttachycardia
includeatrioventricularnodalblockingdrugsandcatheterablation.
FirstlinetherapyforWolffParkinsonWhitesyndrome(preexcitationwithsymptoms)is
catheterablation.

AtrialFibrillation

Atrialfibrillationisthemostcommonsustainedcardiacarrhythmia.Thediagnosisofatrialfibrillation
isbaseduponthedemonstrationofdisorganizedatrialactivity,seenasanirregularlyirregular
ventricularresponseonECG.Fibrillationoftheatrialmyocardiumcanleadtostasisandintracardiac
thrombusformation.Inpatientsolderthan40years,thelifetimeriskofatrialfibrillationis1in4.The
incidenceofatrialfibrillationisagerelated,andmorethan10%ofpersonsaged80yearsandolder
haveatrialfibrillation.Atrialfibrillationisassociatedwithafivefoldincreasedriskofstrokeaswell
asanincreasedriskofheartfailureanddementia.Atrialfibrillationcanoccursecondarytoreversible
oracutephysiologicinsults,includinghyperthyroidism,cardiacsurgery,andpulmonaryembolism.
Morecommonly,atrialfibrillationistheresultoflongstandingdiseaseaffectingtheheart,
particularlyhypertension,structuralheartdisease,andobstructivesleepapnea.

ClinicalPresentation
Aswithmostarrhythmias,patientswithatrialfibrillationcanexperienceawiderangeofsymptoms,
includingpalpitations,lightheadednessordizziness,dyspnea,exerciseintolerance,chestpain,and
syncope.Somepatientsareasymptomaticandarefoundtohaveatrialfibrillationasanincidental
findingonECG.Initsmostsevereforms,particularlyinpatientswithadvanceddiastolicdysfunction
orrestrictivecardiomyopathy,atrialfibrillationcanresultinhemodynamiccompromise.Some
patientsinitiallypresentwithheartfailurecausedbytachycardiainducedcardiomyopathy.
Atrialfibrillationisclassifiedasfirstdetected,paroxysmal,persistent,orlongstandingpersistent
atrialfibrillation.Paroxysmalatrialfibrillationstartsandstopsspontaneously.Persistentatrial
fibrillationlastsfor7daysormoreandrequireselectricalorpharmacologiccardioversion.Long
standingpersistentatrialfibrillationispersistentatrialfibrillationthatismorethan1yearinduration.

AcuteManagement
Bothacuteandchronicmanagementofatrialfibrillationarebasedonthreetherapeuticgoals:(1)
preventingstroke,(2)controllingtheheartrate(preventingtachycardia/rapidventricularrates),and
(3)symptomrelief.Onceadiagnosisofatrialfibrillationismade,asearchforreversiblecauses
shouldbecompleted,includinganevaluationofthyroidfunction.Patientswithatrialfibrillation
shouldundergoscreeningforsleepapneawithmoreextensivetestingiftheclinicalhistoryis
suggestive.Anechocardiogramshouldbeobtainedtoinvestigatepotentialvalvularorotherstructural
heartdisease.
AcuteAnticoagulation
Inpatientswithnewlydiscoveredatrialfibrillationinwhomcardioversionwillnotbeperformed,
institutionofintravenousanticoagulationisusuallynotnecessary.Inthesepatients,oral
anticoagulationcanbestartedbasedonriskfactors(seeLongTermManagement).Ifcardioversionis
planned,anticoagulationtherapyisbasedonthedurationofatrialfibrillation.Forpatientswhoare
knowntohavebeeninatrialfibrillationforlessthan48hours,preproceduralanticoagulationisnot
necessaryastheriskofthrombusformationislow.Patientswithatrialfibrillationofunclearduration
orthosewithatrialfibrillationformorethan48hoursrequirepreproceduralanticoagulation.These
patientsshouldreceive3weeksoftherapeuticanticoagulationpriortocardioversion.Alternatively,
transesophagealechocardiography(TEE)canbeperformedtolookforanintracardiacthrombus.If
TEEisnegativeforthrombus,acutecardioversioncanbeperformedimmediately.Allpatients
(regardlessofthedurationofatrialfibrillation)mustbeanticoagulatedatthetimeofcardioversion
andaftercardioversionforaminimumof4weeksowingtoanincreasedriskofthromboembolic
eventsafterrestorationofsinusrhythm.
CardioversionandAcuteRateControl

RelatedQuestion
Question51
Manypatientswhopresentwithaninitialepisodeofatrialfibrillationconvertspontaneously,often
withinhours.However,thepresenceofhypotension,myocardialischemia,orheartfailureisan
indicationforimmediatecardioversionregardlessofthedurationofatrialfibrillation.Acute
cardioversionofatrialfibrillationshouldbesynchronizedtotheRwavesoastoavoidanRonT
eventandprovocationofVF.
Patientswithrapidventricularconductionrequireheartratecontrolinordertoimprovecardiac
functionandsymptoms.Targetheartratesshouldbebetween60/minand110/minintheacutesetting.
Acuteratecontrolismostoftenachievedwithblockersornondihydropyridinecalciumchannel
blockers.Intravenousmedications,includingmetoprolol,esmolol,diltiazem,andverapamil,canbe
used,withsubsequenttransitiontooralformulations.Inpatientswithmildsymptoms,oralagentscan
beconsideredwithoutinitialintravenoustherapy.Calciumchannelblockersshouldbeavoidedin
patientswithleftventriculardysfunction.Digoxincanbeaddedtoimproveratecontrol,especiallyin
patientswithheartfailure.Patientswithevidenceofpreexcitationshouldnotbetreatedwith
blockersorcalciumchannelblockers.Inpatientswithpreexcitedatrialfibrillation,procainamideis
thetreatmentofchoice.
Ifcardioversionisfavoredbecauseofsignificantsymptomsdespiteratecontrol,pharmacologicor
electricalcardioversioncanbepursued.ClassICagents(flecainide,propafenone)oributilide(an
intravenousclassIIImedication)canbeconsideredforpharmacologiccardioversioninpatients
withoutstructuralheartdisease.

LongTermManagement
Anticoagulation
RelatedQuestions
Question4
Question27
Question70
Strokeisthemostconcerningconsequenceofatrialfibrillation.Theabsoluteriskofstrokeis4%per
yearamongpatientswithnonvalvularatrialfibrillation,butcomorbiditiescanincreasetherisk15to
20times.Hypertensionisanimportantriskfactorforbothatrialfibrillationandstroketherefore,
aggressivebloodpressurecontrolisparamountinthemanagementofatrialfibrillation.
Strokepreventionwithantithrombotictherapiesispredicatedonapatient'saggregateriskprofile.
Severalriskstratificationscoresareavailabletoclinicians.Inpatientswithnonvalvularatrial
fibrillation,theCHADS2scorewas,untilrecently,thebasisformostguidelineandconsensus
documents.OwingtothelimitedabilityoftheCHADS2scoretodiscernbetweenlowand
intermediaterisk,theCHA2DS2VAScriskscorewasdevelopedandnowistherecommendedscore
toassessriskofstrokeinpatientswithnonvalvularatrialfibrillation(Table26).TheCHA2DS2
VAScscoreisparticularlyhelpfulinpatientswith0or1CHADS2riskfactors.Inadditiontothe
CHADS2points,thisscoregivesanadditionalpointforage65to74years,femalesex,andthe
presenceofatheroscleroticdisease,andgives2pointsforage75orolder.PatientswithaCHADS2
scoreof0or1whohaveaCHA2DS2VAScscoreof2ormoremaybenefitfromoral
anticoagulation.Certainhighriskfeatures,suchasmitralstenosisorrheumaticheartdisease,prior

systemicembolism,aprostheticheartvalve,leftatrialappendagethrombus,andhypertrophic
cardiomyopathyrequireoralanticoagulationregardlessofriskscore.
Forpatientswhoaretreatedwithaspirin,therecommendeddoseis81to325mgdaily.Forpatients
whorequireoralanticoagulation,severalagentsarenowavailable.Doseadjustedwarfarin(avitamin
Kantagonist)remainsaneffectivelowcostalternativeforstrokepreventioninpatientswithahigher
riskofstroke.Theefficacyandsafetyofwarfarintherapyarecloselyassociatedwiththeamountof
timeinthetherapeuticrange(INR23).ThechieflimitationsofwarfarinareitsneedforfrequentINR
monitoringandadjustmentanditsnumerousfoodanddruginteractions.Recently,severalneworal
anticoagulantshavebeenapprovedbytheFDAforthepreventionofstrokeinpatientswith
nonvalvularatrialfibrillation,includingdabigatran,rivaroxaban,andapixaban(Table27).Warfarin
remainstheagentofchoiceinpatientswithvalvularatrialfibrillation,generallydefinedasatrial
fibrillationwithmitralstenosisormitralvalvereplacement.
Dabigatranissuperiortowarfarinforthepreventionofstrokeandisassociatedwithlessintracranial
bleeding,butcarriesahigherriskofgastrointestinalbleeding.Rivaroxabanisnoninferiortowarfarin
forthepreventionofstrokeorsystemicembolismandisassociatedwithlessintracranialandfatal
bleeding.Similartopatientsreceivingdabigatran,patientsonrivaroxabanhaveahigherriskof
gastrointestinalbleedingcomparedwithwarfarin.Apixabanalsoissuperiortowarfarinforthe
preventionofstrokeandisassociatedwithlessbleedingoverall,includingintracranialbleeding,but
similarratesofgastrointestinalbleeding.Allofthenoveloralanticoagulantsareclearedbythe
kidneys.Thus,doseadjustmentisrequiredbasedonestimatedglomerularfiltrationrate(eGFR),and
theseagentsarecontraindicatedinpatientswithendstagekidneydisease.Forthisreason,annual
measurementofserumcreatininelevelisrecommendedforpatientstreatedwiththesedrugs.Allof
thenoveloralanticoagulantshaveshorterhalflivesrelativetowarfarinhowever,therearenoquick,
readilyavailableserumassaystoaccuratelydetermineanticoagulantactivity.Furthermore,currently
thereisnoantidotefortheseagentsinpatientswithseverehemorrhage.
Inpatientswithconcomitantcoronaryarterydiseaseandatrialfibrillation,antithrombotictherapy
presentssignificantchallenges.Formostpatientswithstablecoronaryarterydisease,singleagent
therapywithanoralanticoagulantissufficientforpreventionofbothacutecoronarysyndromesand
strokeevents.Combinationantiplateletandoralanticoagulanttherapyincreasestheriskofbleeding,
includingintracranialhemorrhage.However,patientswithanacutecoronarysyndromeor
revascularizationintheprevious12monthsarethoughttobenefitfromcombinationtherapywith
lowdoseaspirin(<100mg/d)andoralanticoagulation.Inpatientswhoreceiveacoronarystent,triple
therapywithlowdoseaspirin(<100mg/d),athienopyridine(suchasclopidogrel),andwarfarinis
indicatedforasshortaperiodaspossible.Inpatientswithadrugelutingstent,thisperiodmayextend
to6monthsorayear.Ongoingclinicaltrialsareevaluatingthecombinationofanticoagulanttherapy
foratrialfibrillationandantiplateletagentsforcoronaryarterydisease.
RateVersusRhythmControl
Thereisnoevidenceofasurvivaladvantageorreductioninstrokewithrestorationandmaintenance
ofsinusrhythminpatientswithatrialfibrillation,includingthosewithheartfailure.Therefore,the
decisiontoinstitutearateorrhythmcontrolstrategylargelydependsonsymptomsandpatient
preference.Patientswhoareasymptomaticcanbemanagedwithratecontrolonly,witharestingheart
rategoaloflessthan110/min.Patientswithtachycardiainducedcardiomyopathy,heartfailure,orleft
ventricularejectionfractionoflessthan40%mayrequiremorestringentratecontrol(heartrate60
80/minatrest).AVnodalblockers,includingblockersandnondihydropyridinecalciumchannel
blockers,canbeusedtocontroltheheartrate.Combinationtherapyisoftenrequiredtoadequately
controltheheartrate.Inadditiontoassessingtherestingheartrate,assessmentoftheheartratewith
activityshouldbeconsidered,eitherwithambulatoryECGmonitoring,astresstest,ora6minute
walktest.

Inpatientswhocontinuetohavesymptomsdespiteadequateratecontrol,arhythmcontrolstrategy
shouldbeconsideredtoimprovequalityoflife.Rhythmcontrolmayrequirecardioversionfollowed
byantiarrhythmictherapy.Antiarrhythmicdrugselectionisbasedonpatientcomorbiditiesandthe
safetyprofileoftheantiarrhythmicdrugs.Somepatientswithinfrequentsymptomaticatrial
fibrillationmaynotrequiredailytherapy.Patientswithinfrequentatrialfibrillationandneither
structuralheartdiseasenorconductiondiseasemaybenefitfromapillinthepocketapproach,
wherebypatientstakeaclassICdrug(flecainideorpropafenone)onlywhentheydevelopanepisode
ofatrialfibrillation.PatientswhofollowthisapproachshouldbetakinganAVnodalblockeror
shouldtakeonebeforetakingtheirpillinthepocket.Thefirsttimethisapproachisused,itshould
takeplaceinamonitoredsettingtoensurethatthepatientcansafelytoleratethetherapywithout
developmentofproarrhythmiaorconductiondisturbance(forexample,postterminationpause).
Regardlessoftherateorrhythmcontrolstrategyused,strokepreventionshouldbeguidedbypatient
risk(CHA2DS2VAScscore).
NonpharmacologicStrategies
RelatedQuestion
Question78
Inpatientswhohaverefractorysymptomaticatrialfibrillationdespiteantiarrhythmicdrugtherapy,
catheterablationwithpulmonaryveinisolationisaneffectiverhythmcontroltherapy.Atrial
fibrillationablationisbestreservedforpatientswithearlyatrialfibrillationwithoutevidenceof
significantleftatrialenlargementandthosewithoutmultiplecomorbidities.Thesuccessratesfor
atrialfibrillationablationarevariable,butinpatientswithparoxysmalatrialfibrillation,between70%
and90%aresymptomfreeat1year.Complicationscanincludeintraproceduralorlatetamponade,
vascularcomplications,anda0.5%to1%riskofstroke.Patientswhodevelopdyspneamonthsto
yearsafteranatrialfibrillationablationmayhavepulmonaryveinstenosis.Anticoagulationis
mandatoryforthefirst2to3monthsafterablation,andthereafterisguidedbyriskfactors.Inpatients
withsymptomaticatrialfibrillationwhoareundergoingcardiacsurgeryforotherreasons,themaze
procedurecanbeperformedasameansofmaintainingsinusrhythm.
Patientswithrefractorysymptomatictachycardiadespiteattemptsatrateandrhythmcontrolmaybe
candidatesforAVnodeablation.Inthisapproach,patientsreceiveapacemakerandundergo
therapeuticablationoftheAVnode,renderingthempacemakerdependentbutnolongertachycardic.
Thesepatientsremaininatrialfibrillationandstillrequirestrokepreventiontherapy.

KeyPoints
Allpatientswithatrialfibrillationwhoundergocardioversionrequireanticoagulationtherapy
foraminimumfor4weeksfollowingtheprocedure.
TheCHA2DS2VAScscoreforestimatingstrokeriskinatrialfibrillationissimilartothe
CHADS2scorebutbetterdifferentiateslowandintermediateriskpatientsinadditiontoheart
failure,hypertension,age,diabetesmellitus,andpreviousstroke,theCHA2DS2VAScscore
incorporateslowerage(6574years),sex,andthepresenceofatheroscleroticdisease.
Optionsforlongtermanticoagulationinpatientswithatrialfibrillationincludewarfarin,
dabigatran,rivaroxaban,andapixabanthelatterthreeagentsdonotrequirebloodmonitoring
andlackthefoodanddruginteractionsofwarfarin,buttheyaresubstantiallymoreexpensive.

AtrialFlutter

Unlikeatrialfibrillation,atrialflutterisanorganizedmacroreentrantrhythmwithdiscreteand
organizedatrialactivityontheECG,usuallywithanatrialrateof250/minto300/min.Althoughthey
aredistinctrhythms,atrialfibrillationandatrialflutterareoftenfoundinthesamepatientsbecauseof
similarriskfactorsandpathophysiology.Episodesofatrialfluttercaninduceatrialfibrillationand
viceversa.
TypicalatrialflutterhasasawtoothappearanceonECG,withnegativeflutterwavesintheinferior
leadsandpositiveflutterwavesinleadV1(Figure18).Typicalatrialflutteriscausedby
counterclockwisereentryaroundthetricuspidannulus.Atypicalfluttercanbeclockwiseorcanoccur
inotherlocationsintheatria,includingtheleftatriumafteratrialfibrillationablation.
Inmanyrespects,atrialflutterismanagedsimilartoatrialfibrillation,includingstrokeprevention.
However,owingtotheatrialrateandtheratioofconductionthroughtheAVnode(forexample,2:1
or4:1),ratecontrolofatrialfluttercanbedifficultandoftenrequireslargedosesofAVnodal
blockers.Therefore,atrialflutterisusuallymanagedwitharhythmcontrolstrategy.Catheterablation
oftypicalatrialflutterisoftenpreferredowingtoahighsuccessrateandlowercomplicationrate
relativetootherablationprocedures.Inasymptomaticpatientsinwhomratecontrolcanbeachieved,
amedicalratecontrolstrategyisacceptable.

WideComplexTachycardias
Awidecomplextachycardiaisanytachycardia(heartrate100/min)withaQRScomplexof120
msecorgreater.Thedifferentialdiagnosisincludessupraventricularrhythmswithaberrantconduction
(suchasunderlyingbundlebranchblock),preexcitation,pacedrhythms,andventriculartachycardia.
Often,patientspresentwithawidecomplextachycardiaofunknownetiology.Inadultswith
structuralheartdisease,95%ofwidecomplextachycardiasareVT.Widecomplextachycardiasthat
arepositiveinleadaVR,haveaQRSmorphologythatisconcordantintheprecordialleads
(monophasicwiththesamepolarity),haveaQRSmorphologyotherthantypicalrightorleftbundle
branchblock,andexhibitextremeaxisdeviation(90to180,sometimescalledanorthwestaxis),
areusuallyVT.ThepresenceofAVdissociation,fusionbeats(QRScomplexcreatedbyfusion
betweenasinuscapturebeatandaVTbeat),andcapturebeats(sinusbeatthatcapturesthe
myocardiuminbetweenVTbeats)areallhighlysuggestiveofVT.
Whentheoriginofawidecomplextachycardiacannotbedetermined,VTshouldbeassumeduntil
expertconsultationcanbeobtained.

VentricularArrhythmias
PrematureVentricularContractions
RelatedQuestion
Question33
Prematureventricularcontractions(PVCs)arecommonandcanoccurinupto75%ofhealthy
persons.PatientswithPVCsgenerallyreportpalpitationsandasensationofskippedbeats.Forceful
palpitationswithPVCsareusuallycausedbyexaggeratedcardiacfillingduringthepauseafterthe
PVC.PVCsaremorecommoninpatientswithhypertension,leftventricularhypertrophy,prior
myocardialinfarction,andotherformsofstructuralheartdisease.Forpatientswithbothersome
palpitations,thefirstdiagnostictestisanECG.Ifthediagnosisisnotestablished,24to48hour
ambulatorymonitoringisusedtodiagnoseandquantifythefrequencyofPVCsanddetermineifthey

aremonomorphicorpolymorphic.FrequentPVCs(>10%ofallbeatsor10,000PVCsina24hour
period)canleadtotachycardiainducedmyopathy.PatientswithfrequentPVCsorpolymorphicPVCs
shouldundergoechocardiographyorothercardiovascularimaging(suchascardiacmagnetic
resonance[CMR]imaging)toevaluateforthepresenceofstructuralheartdisease.
Inpatientswithouthighriskfeatures(suchassyncope,afamilyhistoryofprematureSCD,coronary
arterydisease,orstructuralheartdisease),PVCs(includingventricularbigeminyandtrigeminy)are
generallybenignanddonotrequireadditionaltestingortreatment.Treatmentshouldbelimitedto
thosewithsymptomsorahighburdenofPVCs(10,000ina24hourperiod).TreatmentforPVCs
usuallybeginswithblockerornondihydropyridinecalciumchannelblockertherapy.
AntiarrhythmicdrugtherapycanalsobeusedwhenPVCspersistdespiteblockadeorcalcium
channelblockade.EPstudyandcatheterablationcanbeconsideredinpatientswhocannottolerate
medicaltherapyorifmedicaltherapyfailstosuppressthePVCs.

VentricularTachycardiawithStructuralHeartDisease
Instructuralheartdisease,includingbothischemicandnonischemiccardiomyopathy,thepresenceof
myocardialscartissuefacilitatesreentryandthedevelopmentofVT.VTcanpresentasnonsustained
orsustainedVT(>30seconds).Inpatientswithventricularscarring,VTisusuallyregularand
monomorphic.Figure19showsECGfindingsofmonomorphicVTinapatientwithcardiac
sarcoidosis.Inpatientswithstructuralheartdisease,VTmayleadtohypotension,syncope,
degenerationintoVF,andcardiacarrest.Alternatively,shortrunsofVTorslowsustainedVTmaybe
welltoleratedorasymptomatic.
AllpatientswithVTshouldundergorestingECG,exercisetreadmilltestingtoprovokethe
arrhythmia,andcardiacimagingtoevaluateforstructuralheartdisease.Patientswithischemic
cardiomyopathywhopresentwithVTshouldundergoanischemiaevaluationandrevascularizationif
indicated.Patientswithcardiomyopathyandheartfailureshouldreceiveoptimalmedicaltherapyin
ordertoreducetheirriskofventriculararrhythmia.Patientswithstructuralheartdiseaseor
cardiomyopathyandsustainedVT/VFshouldundergoICDimplantationforsecondaryprevention.In
patientswithanICD,ifVTrecursdespiteblockertherapy,antiarrhythmicdrugtherapyshouldbe
considered.Inmostpatientswithstructuralheartdisease,amiodaroneisfirstlineantiarrhythmicdrug
therapy.PatientswithrecurrentVTdespitemedicaltherapyshouldbeconsideredforEPstudyand
catheterablation,whichhasbeenshowntoreduceICDshocksandthusimprovequalityoflife.

IdiopathicVentricularTachycardia
VTinpatientswithoutstructuralheartdiseaseisconsideredidiopathic.Patientsoftenpresentwith
palpitationsinearlyadulthood(2040yearsofage).Episodesareoftenprovokedbystress,emotion,
orexercise.Syncopeisuncommon.IdiopathicVTusuallyarisesfromtheoutflowtracts,thefascicles,
orthepapillarymuscles.Outflowtracttachycardias,themostcommontype,aretriggeredarrhythmias
thatcanarisefromtherightorleftventricularoutflowtracts.Theyareadenosinesensitiveandoften
exhibitrepetitivesalvos.Rightventricularoutflowtracttachycardiahasaleftbundlebranchblock
appearancewithtallRwavesintheinferiorleads.PharmacologictherapyforidiopathicVTincludes
calciumchannelblockers(especiallyverapamil)orblockers.Whensymptomscontinuedespite
thesemeasures,catheterablationcanbeconsidered.ICDsarerarelyindicatedinpatientswith
idiopathicVTowingtothebenignprognosisandefficacyofothertherapies.

KeyPoint
Inpatientswithprematureventricularcontractionswithouthighriskfeatures,reassuranceis
usuallysufficienttreatmentshouldbelimitedtothosewithsymptomsorfrequentepisodes.

InheritedArrhythmiaSyndromes
RelatedQuestions
Question14
Question68
Thediagnosisandmanagementofinheritedarrhythmiasyndromesarecomplicatedbythevariable
penetranceandvariableexpressivityoftenobserved.Characteristicsandtreatmentofthemost
importantinheritedsyndromesarereviewedinTable28.Thepresenceofunexplainedpremature
(youngerthan35years)deathorsuddendeathinafirstdegreefamilymembershouldraisesuspicion
forthepossiblepresenceofaninheritedarrhythmiasyndromeandreferraltoacardiovascular
specialist.Genetictestinghasfacilitatedthediagnosticevaluationofthesedisorders,particularly
whenanaffectedfamilymemberhasaknownpathogenicmutation.Patientswithafamilyhistoryof
SCDandunexplainedsyncopeareparticularlyathighriskandmeritaggressiveevaluation.
LongQTsyndromeisoneofthemostcommoninheritedarrhythmiasandisdefinedbythepresence
ofaprolongedQTcinterval(>440msecinmenand>460msecinwomen)accompaniedby
unexplainedsyncopeorventriculararrhythmia.ThepresenceofaprolongedQTcintervalaloneisnot
sufficientforadiagnosisoflongQTsyndrome.ThediagnosticcriteriaincludeECGfindings,
symptoms,andinsomecases,resultsofgenetictesting.TherearemanycausesofaprolongedQTc
interval,mostofthemareacquired,includingmedicationssuchasantiarrhythmicagents,antibiotics
(macrolidesandfluoroquinolones),antipsychoticdrugs,andantidepressants(alistcanbeaccessedat
http://crediblemeds.org/)structuralheartdiseaseandelectrolyteabnormalities.PatientswithaQTc
intervalgreaterthan500msecareatgreatestriskforSCD.FirstlinetherapyforlongQTsyndromeis
blockertherapy.Patientswithcardiacarrestorthosewhohaverecurrentevents(syncopeorVT)
despiteblockertherapyshouldundergoICDimplantation.PatientswithdocumentedlongQT
syndromeshouldavoidparticipationincompetitiveathletics.
ShortQTsyndromeisarareandgeneticallyheterogeneousdisordercharacterizedbyashortQT
interval,usuallylessthan340msec(orQTc<350msec).Itisinheritedinanautosomaldominant
pattern.Patientscanpresentwithatrialandventriculararrhythmiasandsyncope.ShortQTsyndrome
carriesahighriskforSCD,andICDplacementisrecommendedforallpatients.
Brugadasyndrome,anautosomaldominantdisorderassociatedwithmutationsinthesodiumchannel
gene,ischaracterizedbyrightprecordialECGabnormalities,includingSTsegmentcoving(ST
segmentelevationthatdescendsintoaninvertedTwave)inleadsV1throughV3withorwithoutright
bundlebranchblock(Figure20),VF,andcardiacarrest.Brugadasyndromeismorecommoninmen
andinpersonsofAsiandescent.Arrhythmiceventsoftenoccuratnightduringsleep.TheECG
abnormalitiescanbevariableandmaybeunmaskedbyfeverorpharmacologicchallengewithsodium
channelblockade(forexample,procainamideinfusion).RiskstratificationinpatientswithBrugada
syndromeisprincipallybaseduponthepresenceorabsenceofsyncopethosewithsyncopeor
ventriculararrhythmiashouldundergoICDplacement.Patientswithrecurrentventriculararrhythmias
and/orICDshocksoftenbenefitfromquinidineantiarrhythmicdrugtherapy.
CatecholaminergicpolymorphicVTisararedisordercharacterizedbypolymorphicventricular
arrhythmiasandcardiacarrestusuallyprovokedbyhighadrenergicstates,includingstrongemotion
andexercise.Patientswiththisdisorderusuallyhaveprovocablearrhythmiaswithexerciseor
epinephrineinfusion.TreatmentincludesblockertherapyandoftenICDplacement.Patientswith
thedisordershouldabstainfromexercise.
InpatientswithunexplainedVFarrest,particularlywhenprovokedduringexercise,early
repolarizationsyndromeshouldbeconsidered.Whereasearlyrepolarization(Jpointelevation)isa
commonandbenignfindingonECG,thepresenceofinferiorandlateralearlyrepolarizationmore

than1mminapatientwithVForcardiacarrestshouldbeconsideredearlyrepolarizationsyndrome.
InpatientswithVForcardiacarrest,ICDimplantationisindicated.
Hereditarystructuralheartdisease,suchashypertrophiccardiomyopathy(seeMyocardialDisease)or
arrhythmogenicrightventricularcardiomyopathy/dysplasia(ARVC/D),oftenmanifestsassudden
cardiacarrestinayoungperson.ARVC/Discharacterizedbyfibrousandfibrofattychangesofthe
rightventricleandsubsequentventriculararrhythmias.Penetranceisvariableandagerelated,with
manypatientspresentingbetweenpubertyandyoungadulthood.PatientswithARVC/Dusuallyhave
ventricularectopyormonomorphicVT,althoughpatientswithseverediseasemayhaveheartfailure.
ThediagnosisofARVC/DisguidedbydiagnosticcriteriathatincludeECGabnormalities,family
history,thepresenceofarrhythmias,andstructuralabnormalitiesoftherightventricleasseenon
cardiacimaging.ARVC/Disusuallyprogressive,andthosewithARVC/Dshouldabstainfrom
exercise,asitmayacceleratediseaseprogressionandarrhythmogenesis.PatientswithARVC/Dand
cardiacarrestorriskfactors(nonsustainedVT,inducibleVT)areofferedICDplacement.Blockers
arefirstlinetherapyforventriculararrhythmiahowever,antiarrhythmictherapywithsotalolor
amiodaroneorcatheterablationisoftenrequiredforrecurrentVT.

SuddenCardiacArrest
EpidemiologyandRiskFactors
SCDisdefinedasinstantaneousdeathorsuddencollapsewithin1hourofsymptoms.Unwitnessed
deathisconsideredSCDifthepatientwasknowntobewellwithin24hoursoftheevent.Most
episodesofSCDarecausedbyventriculararrhythmias(VT/VFarrest).Inthegeneralpopulation,the
riskofSCDis1/1000peryear.Theincidenceisgreatestinpatientswithpreexistingstructuralheart
diseasehowever,mostepisodesofSCDoccurinpatientswithnormalleftventricularfunction.Risk
factorsforSCDinclude(butarenotlimitedto)heartfailure,diminishedleftventricularfunction,
priormyocardialinfarction,unexplainedsyncope,leftventricularhypertrophy,nonsustained
ventriculararrhythmia,chronickidneydisease,andobstructivesleepapnea.

AcuteManagement
Patientswithcardiacarrestrequireimmediatecardiopulmonaryresuscitation(CPR)andadvanced
cardiaclifesupport.Thetwomostimportantinterventionsforpatientsincardiacarrestarehigh
qualityCPRchestcompressionsandrapiddefibrillationinpatientswithVT/VFarrest.Basiclife
supportguidelinesnowemphasizetheacronymCAB(Chestcompressions,Airway,Breathing)to
highlighttheimportanceofimmediate,rapid,andsustainedchestcompressionsanddeemphasizing
assistedbreathing.Onceacodehasbeencalledortheemergencymedicalsystemhasbeenactivated
andanautomatedexternaldefibrillatorhasbeenrequested,thepatient'spulseshouldbechecked
immediately.Ifnodefinitepulseisdetectedwithin10seconds,chestcompressionsshouldbegin
withoutdelay.InpatientswithVT/VF,timetodefibrillationisanimportantdeterminantofthe
likelihoodofsurvivaltohospitaldischarge.Therefore,whenashockablerhythmispresent,
defibrillationshouldbeperformedasrapidlyaspossible.
OnceCPRhasbeenstarted,the2010AmericanHeartAssociationguidelinesonCPRandemergency
cardiovascularcaredictatemanagementbaseduponthepresenceorabsenceofashockablerhythm.In
patientswithasystoleorpulselesselectricalactivity(PEA),CPRiscontinuedwithreassessmentof
rhythmstatusforashockablerhythmevery2minutes.Epinephrine(1mgintravenously)shouldbe
givenevery3to5minutes,althoughvasopressin(40unitsintravenously)canreplacethefirstor
seconddoseofepinephrine.AtropineisnotrecommendedforthetreatmentofasystoleorPEAarrest.
FurthermanagementofPEAarrestshouldincludeascertainmentandtreatmentofanycorrectable
etiology(forexample,tamponade).InpatientswithVT/VF,ashockisadvisedwithimmediate
resumptionofCPRandreassessmentoftherhythmin2minutes.Epinephrineshouldbegivenafter

thesecondshockandevery3to5minutesthereafter.IfVT/VFcontinuesdespitethreeshocksand
epinephrine,amiodaroneshouldbegivenasabolus.
Patientswithsymptomaticbradycardiaandhemodynamicdistressshouldfirstbetreatedwith
atropine.Ifatropineisineffective,dopamineorepinephrineinfusionscanbeattempteduntil
transcutaneouspacingoratemporarypacingwire(preferred)canbeimplemented.
Postresuscitationcareincludestherapeutichypothermiainpatientswhoremaincomatose.
Complicationsoftherapeutichypothermiaincludeventriculararrhythmiasduringrewarmingand
infectiouscomplications,includingsepsis.Hemodynamicsandoxygenationshouldbeoptimizedin
thepostarrestsetting.Moderateglycemiccontrolisalsorecommended.Patientswithevidenceof
acutecoronarysyndromeshouldundergoimmediatecatheterizationandrevascularizationprovided
therearenocontraindications.

DeviceTherapyforPreventionofSuddenCardiacDeath
RelatedQuestion
Question103
Patientswithsustainedventriculararrhythmiasorcardiacarrestwithoutareversibleetiologyhavea
classIrecommendationforsecondarypreventionICDplacement.Inpatientswithstructuralheart
diseasewhomeetspecificcriteria,ICDsareindicatedforprimaryprevention(seeHeartFailure).ICD
batterylifeisapproximately7to10yearsbutisvariable.AlthoughICDmalfunctionisrare,whenit
occurs,itisoftenduetoaproblemwiththeintracardiacleads.
PatientswithmodernICDshavefewlimitations.Ingeneral,lighttomoderateexercise,including
sexualintercourse,ispermissibleandisassociatedwithimprovementincardiovascularhealthand
qualityoflife.However,somedisorderscarryspecificrestrictions(seeTable28).PatientswithICDs
shouldavoidstrenuousupperextremityexercises,includingweightlifting,becausetheseactivities
candamagetheleadscoursingthroughthechest.Electromagneticinterferencecanleadto
inappropriatedetectionofVT/VFandshockstherefore,patientsshouldavoidlargesourcesof
electromagneticinterference,includingarcweldingandhighvoltagemachinery.Duringsurgery,
ICDsmayneedtobereprogrammedorhaveamagnetappliedtoavoidfalsedetectionofVT/VFdue
toelectrocautery.Forthisreason,patientswithICDsshouldhaveanevaluationordevice
programmingrecommendationfromtheirelectrophysiologistbeforeundergoinginvasiveprocedures
orsurgery.
PatientswhoexperienceshocksneedtocontacttheirICDphysician.Patientswhoexperiencemore
thanoneshockin24hoursoranyshockaccompaniedbydyspnea,chestpain,syncope,orheart
failuresymptomsrequireemergencymedicalcare.

KeyPoint
Implantablecardioverterdefibrillatorplacementisindicatedforsecondarypreventionin
patientswithsustainedventriculararrhythmias(>30sec)orcardiacarrestwithoutareversible
etiology.

DeviceInfection
RelatedQuestion

Question58
Between1993and2008,theuseofcardiacimplantedelectronicdevicesincreasedby96%.Asa
result,thenumberofpatientssusceptibletodeviceinfectionseeninclinicalpracticehasincreased
dramatically.Deviceinfectionsrangefrominfectionsinvolvingthesiteofdeviceplacement(pocket
infection)toinfectiveendocarditis.Mostdeviceinfectionsareduetostaphylococcalinfections,
particularlyStaphylococcusepidermidisandS.aureus.Whencaringforpatientswithcardiac
implantedelectronicdeviceswhopresentwithsymptomsofinfection,cliniciansmusthaveahigh
suspicionfordeviceinfection.
Patientswithcardiacdeviceinfectioncanpresentwithfever,chills,andmalaise.Thephysical
examinationmayrevealerythema,pocketswelling,anddrainagefromthepocket.Laboratory
findingsfrequentlyincludeanemia,leukocytosis,andanelevatederythrocytesedimentationrate.In
patientswithsuspecteddeviceinfection,multiplebloodculturesshouldbedrawn.Echocardiography
(mostoftenwithtransesophagealechocardiography)shouldbeperformedtoidentifyintracardiacor
leadvegetations.Thedevicepocketshouldneverbeaspiratedfordiagnosticpurposesbecause
puncturingthepocketcandamagetheleadsorintroduceinfection.
Onceacardiacdeviceinfectionisdiagnosed,treatmentincludescompleteremovalofallhardware,
debridementofthepocket,sustainedantibiotictherapy,andreimplantationatanewsite(ifandwhen
appropriate).Suppressiveantibiotictherapywithoutcompleteremovalofthedeviceisnotcurative
andisassociatedwithahighfatalityrate.

KeyPoints
Inapatientwithsuspectedimplantedcardiacdeviceinfection,thedevicepocketshouldnever
beaspiratedfordiagnosticpurposesbecausepuncturingthepocketcandamagetheleadsor
introduceinfection.
Treatmentofimplantedcardiacdeviceinfectioncomprisescompletehardwareremovaland
pocketdebridement,sustainedantibiotictherapy,andreimplantationatanewsiteif
appropriate.

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Next:PericardialDisease
Notes
Chapter06
0Notes
Arrhythmias
Questions
ReferenceRanges