Ventricular Arrhythmias

From Palpitations
to
Sudden Death
Internal Medicine Dept.
Abdul Moeloek General Hospital

Variability of Ventricular Ectopy

with Age
Effect of age on
probability (%) of
having more than a
given number of
PVCs per 24 hours
in subjects with
normal hearts.

10-29 30-39 40-49 50-59 60-69

Data from Kostis JB. Circulation. 1981;63(6):1353.

Age

Rhythm Strip During Episode

of Sudden Death
6:02 AM

6:05 AM

6:07 AM

6:11 AM

Source: After Josephson, ME

Sudden Death Syndrome

Incidence
400,000 - 500,000/year in U.S.
Only 2% - 15% reach the
hospital
Half of these die before
discharge
High recurrence rate

Underlying Arrhythmia of Sudden

Death
Primary
VF
8% Torsades
de Pointes
13%
VT
62%

Bradycardia
17%

Adapted from Bays de Luna A. Am Heart J. 1989;117:151-159.

Proportion of Sudden Death Survivors with Acute MI

100

Acute Transmural MI (n = 39)

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)

< 20% of sudden death survivors have an acute MI

Sudden death associated with acute MI has a better prognosis
Cobb LA. Circulation. 1975;51(III):223.

Clinical Substrates Associated with VF Arrest

Coronary artery disease

Idiopathic cardiomyopathy
Hypertrophic cardiomyopathy
Long QT syndrome
RV dysplasia
Rarely: WPW syndrome

Risk Factors for Sudden Death

in
Post-MI Patients
LVEF < 40%
Frequent ventricular ectopy

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.

High-Risk Subgroups Who

Need Further Evaluation

Survivors of sudden death

Post-MI, reduced EF, and ventricular ectopy
Recurrent unexplained syncope
Idiopathic cardiomyopathy with syncope or VT
Hypertrophic cardiomyopathy with syncope or
VT
Right ventricular dysplasia
Long QT syndrome

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

Cardiac Electrophysiology Study

Invasive study to characterize electrical properties of
heart including:
Sinus node dysfunction
AV nodal function
Conduction abnormalities infra-Hisian block
Accessory pathways of conduction
WPW
Mahaim
AV nodal reentry
Bundle branch reentry

Cardiac Electrophysiology Study

Inducibility of VT
Reentrant (ischemic VT)
Triggered (idiopathic VT)
Assessment of antiarrhythmic therapy via
serial drug testing
May lead to therapy with radiofrequency
catheter ablation

Intracardiac Electrograms During SVT

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

Calcium Channel Blockade

*Other class properties present

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

Chest X-Ray of Patient with Amiodarone Toxicity

Chest X-Ray of Same Patient with Previous Amiodarone

Toxicity Now with ICD (1994)

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)

Amiodarone: Tests for Followup

CXR
CBC
Liver function tests
Renal panel
Thyroid function tests
Opthalmologic exam
Pulmonary function tests

14

BHAT

12

Beta Blocker
Heart
Attack
Trial

Cumulative Mortality (%)

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

Adapted from Chadda K. Circulation. 1986;73(3):503-510.

CHF

No CHF

Sudden Death
47

13

Thank you