Arrhythmia Management: the view from Secondary/Tertiary Care · 2008. 7. 14. · Arrhythmia...
Transcript of Arrhythmia Management: the view from Secondary/Tertiary Care · 2008. 7. 14. · Arrhythmia...
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Arrhythmia Management: the view
from Secondary/Tertiary Care
Tim Cripps
Consultant Cardiologist/Electrophysiologist
Bristol Royal Infirmary
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Secondary/Tertiary Arrhythmia Care:
What do we do?
• Referrals
– Guidelines
– Advice by letter
– Cardiac Physiologist
led arrhythmia clinic
– Syncope clinic
– General clinic
• Investigations
– Open access ECG, 24
hour tape
• Procedures
– Cardioversion
– Implantable loop
recorders
– Pacemakers
– Implantable
defibrillators
– Ablations
– Device Follow-up
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The PCI Specialist’s approach to Palpitation
Patient complaining of palpitation
Order 24 hour tape
Refer to electrophysiologist
Press on with next PCI case
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Arrhythmia management
• Stage I:
– Treat according to guidelines
• NICE AF guidelines
• Locally agreed guidelines
– AGW guidelines for palpitation, AF, syncope
– Advice by letter or e mail
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Palpitation: arrhythmia
diagnosis
• Consider possible arrhythmias:
1. Sinus tachycardia
2. Ectopic beats
3. Paroxysmal atrial fibrillation
4. Paroxysmal supraventricular tachycardia
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Ectopic beats
ventricular
atrial
Missed beats and thumps…more at rest, in bed, lying on L side, go away with exercise…may last
hours, all day…(examination) had one just then!
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Sinus tachycardia
Rate = 300/ No. of large squares
Not clearly defined episodes…there all the
time…have it now…rate 80-120…thumping, not fast…background of anxiety
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Paroxysmal AF
Clearly defined episodes, up to days
at a time…fluttery, like a bird, all over the place, weak and strong beats,
exhausted, SOB, chest pain with it
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Supraventricular tachycardia (probable atrioventricular
node tachycardia (AVNRT)
Clearly defined episodes…7minutes…45 minutes…rapid, 140/min or more…can see it in chest or neck, partner can feel it…has been terminated with adenosine
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The EP Specialist’s approach to palpitation
History
History
History
Ectopic beats
Sinus tachycardia
AF (permanent,
persistent or
paroxysmal) SVT
Aspirin or Warfarin
Beta blocker, flecainide or
amiodarone
Ablation for PAF
Reassure, occasionally drugs
Reassure, pill in
pocket, low threshold for
ablation
Uncertain
Appropriate
ambulatory
monitoring
ECG
Echo
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Arrhythmia Management
• Stage 2:
– Referral
• Choose and Book system
– Cardiac Physiologist led arrhythmia Clinic
– Syncope Clinic
– General Cardiology Clinic
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Cardiac Physiologist led arrhythmia clinic at BRI
• Selection from GP referrals:
– Redirect generic Cardiology referral
– Redirect Choose and Book referral
– Direct referral (?)
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Conduct of CP led arrhythmia clinic
• CPs tutored in arrhythmia symptoms and
proforma
• Patients sent information booklet to explain clinic
• ECG and CXR on arrival
• Proforma completed together with provisional
diagnosis
• Appropriate ambulatory monitoring arranged
• Overview by EP; GP letter copied to patient
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Tertiary Care issues
• Where have all the devices gone?
? Under-reporting
? Under-referral from
Primary Care
? Under-referral from
A&E/General
Physicians
? Cardiologists
interpretation of indications: VVS/CSS
37
1
56
3
56
4
32
60
57
33
10
7
72
0
100
200
300
400
500
600
pe
r m
illi
on
po
pu
lati
on
New PPM New ICD New CRT
AGW Dorset & Somerset Penninsula
National (pmp):
New PPM: 469
New ICD: 48
New CRT: 56
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AGW New PPM implants by PCT(per million population; National average 469)
347
355
449
275
395
550
438
235
381
344
312
0 100 200 300 400 500 600
S Glos
W Wilts
BANES
N Brist
S&W Brist
Swindon
Ken& Wilts
Chelt & Tewks
W Glos
Cotsw & Vale
N Somerset
DGH cardiologist
with major pacing
interest; well
developed syncope
clinic
Local access
to major
Centre
Big DGH
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Ablation
WPW syndrome and SVT can be
treated with a 90%+ cure rate and no
risk of heart block using cryoablation.
Atrial flutter can be treated with a 75%
cure rate with ablation
All WPW, SVT should be referred for
consideration of ablation
Paroxysmal AF can be treated with
a 75% success rate in a procedure
taking <2.5 hours using cryoablation
balloon
All paroxysmal AF should be
referred for consideration of ablation
Chronic AF… watch this space!