Arrhythmia in CAD
Naeem Al-Shoaibi
MD, FRCP(c), FACC
Assistant Professor
Consultant of Cardiac Electrophysiology
Disclosures
• NO
Overview
• Types
• Mechanisms
• Therapy : ICD
Ablation
• Cases
Arrhythmia in CAD
• Sudden cardiac death: ventricular tachyarrhythmia
• In-hospital mortality: 20 % VT or VF
TYPES
• Ventricular premature beats (PVC)
• Non-sustained ventricular tachycardia
• Accelerated idioventricular rhythm
• Sustained monomorphic ventricular tachycardia
• Polymorphic ventricular tachycardia
• Ventricular fibrillation
PVC/NSVT
•
Asymptomatic•
Incidence : 93 % A) Benign:Early (< 48 hours)
Does not predict short- or long-term mortality Transient abnormalities of automaticity
Triggered activity B) Malignant:
Late PVCs (>48 HOURS) Multiform
Re-entry (Scar)
Prog Cardiovasc Dis. 1977;19(4):255.
Relationship between non-sustained ventricular tachycardia after acute coronary syndrome and sudden cardiac death
•
6560 patients•
Continuous ECG recording for the first 7 days•
121 SCD at 1 year•
independent of baseline characteristics and EF•
CONCLUSIONS:Late NSVT > 4 beats is independent risk factor for SCD
PVCs NO SCD/SCD TOTAL
<3 4742 1.2%
4-7 1172 18.5%
>7 431 6.8%
Accelerated Idioventricular Rhythm
• slow VT
• 50 % of patients with acute MI.
• Association with reperfusion following fibrinolytic therapy.
• Not sensitive nor specific marker for successful reperfusion
Sustained monomorphic ventricular tachycardia
• Early (<48 hour) : STEMI 3 %
Non-STEMI 1%
Transient arrhythmogenic phenomena
• Late (> 48 hours):
Scar mediated
Permanent arrhythmic substrate
PMVT/VF
• Most frequent cause of sudden cardiac death
• First 48 to 72 hours
• Risk of VF include:
STEMI
Hypokalemia
SBP ≤120 mmHg on admission Larger infarct size
Male sex
History of smoking Tachycardia
Arrhythmia Prevention
• Reperfusion
• K: > 4meq/L GISSI-2 trial
• MG: > 2mg/dL
• BB:
COMMIT/CCS2 trial
Anti-arrhythmic Drugs
• Class 1, Lidocain
Suppression of PVC
Increase mortality (CHB, suppression of an escape ventricular rhythm, Pro-arrhythmic)
• Amiodarone:
CAMIAT/EAMIAT
Reducing arrhythmias No increase in mortality
Not improve in overall mortality
• NYHA class II, III
• EF < 35%
ICD
• Secondary prevention:
Prior episode of resuscitated VT/VF
Secondaryustained hemodynamically unstable VT (No reversible cause )
Sustained VT in the presence of structural heart disease or channelopathies NO for VT/VF limited to the first 48 hours after an acute MI
• Primary prevention :
Ischemic cardiomyopathy : EF ≤30% (40 days post MI)
EF assessment 3 months after revascularization (CABG or stent placement)
Non-ischemic cardiomyopathy: ≤35 percent, NYHA II to III ( medical therapy for 3 months)
