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1 2016 Annual Spring Scientific Conference of the KSC Nursing Management of Patients with Arrhythmia Kang young ae, CNS Cardiovascular surgery intensive care unit ASAN medical center

2 Arrhythmia Abnormality in the heart rhythm or heart beat pattern ; too fast, too slowly, extra beat, skip a beat, or beat irregularly d/t change of ion current Cause the heart to pump improperly Completely harmless or life-threatening

Heart cell Electrical cells * Specialized

3 Heart cell Electrical cells * Specialized cell which conducted electrical impulses * Start and transmit electrical activity in the heart Mechanical cells * Cells which make up bulk musculature in the heart * Contract in response to stimuli from the electrical cell

4 Action potential curve

5 Mechanism of arrhythmia(1) Automaticity 비정상적인세포의자발적인탈분극이증가되어자동능이증가 * Ectopic beat or premature beat: SA node 이외의부위에서비정상적으로자동능이증가하여젂기자극형성 * Escaped beat : SA node 의기능부젂으로인해 SA node 이하부위에서자극형성

6 Mechanism of arrhythmia(2) Trigger activity 심근의활동젂위에서재분극시작후발생하는후탈분극에의해세포가다시 탈분극

7 Mechanism of arrhythmia(3) Reentry 젂기적특성이다른 dual pathway가하나의회로를형성한조직에조기박동이도달할때발생대부분빈맥성부정맥의원인

8 Diagnostic test Non-invasive arrhythmia assessment is the critical first step to arrive at a definitive diagnosis Electrocardiography : Basic diagnostic test of arrhythmia or baseline EKG abnormalities Easily accessible BUT artifact Obscuration of electrical data from body surface Holter monitor : 24 or 48 h evaluation with timestamps and event markers

9 Diagnostic test In-hospital telemetry : Multi-channel, real-time monitoring Technology allows patients to be ambulatory Correlation of symptoms with arrhythmia Exercise test : Reproduce activity so that arrhythmia may be provoked in patients with symptoms upon exercise Cardiac imaging, electrophysiologic test

10 Approach to patients with arrhythmia History and ECG are pivotal in directing the diagnostic workup and therapy From asymptomatic to life-threatening ECG abnormality Review of system : Palpitation, syncope Physical examination : Cardiopulmonary disease, thyroid disease Presence of structure heart disease and prior myocardial infarction

11 Treatment of arrhythmia Antiarrhythmic drug therapy : Structural similarity of target ion channel Regional difference in the level of expression of channels and transporters Catheter ablation : Critical anatomic region of abnormal impulse generation or propagation Destruction of critical region using radio-frequency or cryoablation Device therapy : Permanent pacemaker, internal cardioverter defibrillator (ICD) implantation

12 CASE 1 63Y/M 2~3 개월젂부터시작된심계항짂으로내원고혈압, 당뇨는없고, 최근검짂시촬영한관상동맥 CT에서심각한관상동맥질환은없음

13 ECG

14 Atrial fibrillation Multifocal ectopic pacemaker P wave(f 파 ) : bpm Rhythm : 방실젂도차단으로심실로매우불규칙하게젂도 (irregularly irregular) QRS complex : 정상 Paroxysmal AF : 7일이하로지속되다가저젃로없어짐 Persistent AF : 7일이상지속 Long-standing persistent AF : 비가역적상태로치료가불가능한상태

15 Management of atrial fibrillation 뇌졸중예방, 삶의질개선을포함한증상완화, 입원및심혈관이환율과사망률감소 Rate control : Beta blocker, non-dihydrophyridine Ca channel antagonist Cardioversion in case of hemodynamically unstable state Anticoagulation Sinus rhythm conversion : Electrical cardioversion in case of hemodynamically unstable state Pharmacological cardioversion amiodarone, dronedarone, flecainide, January et al., JACC. 2014; 64(21),

16 Anticoagulation therapy 심방세동환자에서뇌졸증발생은 5배증가 Non-valvular A-fib을가짂환자에서뇌졸중과젂신혈젂색적증을예방하기위해항응고요법시행 Vt K antagonist anticoagulant (warfarin) - INR 2~3 유지 Novel Oral Anticoagulants Stroke 위험성사정 : CHA 2 DS 2 -VASc score 1에서항응고요법을권장 출혈위험성사정 Jung, BC et al., Korean Circ J. 2015; 45(1): 9-19

17 CHA 2 DS 2 -VASc score Jung, BC et al., Korean Circ J. 2015; 45(1): 9-19

18 Action of novel oral anticoagulants Saraf K, et al., Postgrad Med J. 2014; 90:

19 NOAC (novel oral anticoagulants) In place of warfarin in patients requiring anticoagulation therapy who have hypersensitivity or contraindication against warfarin, cannot maintain optimal INR range, or have cerebral hemorrhage despite adequate INR level therapy Not recommended in patients with stable anticoagulation control without bleeding Not recommended in patients with severe renal dysfunction

20 CASE 2 F/75Y Aortic stenosis로 aortic valve replacement 시행후 ICU care POD # 0

21 Management of bradyarrhthmia Cardiac arrest : atropine, Epinephrine Pacing if needed YES Severe bradycardia unstable NO NO Temporary pacing bridge Permanent pacing Reversible causes YES/unsure Temporary pacing YES Observe with rhythm follow-up Treat causes & observe Recovery NO Reversible causes YES NO Symptomatic YES Permanent pacing YES NO NO Coexsistent CV disease/av block

22 Transcutaneous pacing (External pacing)

23 Paddle position

24 External pacing ON Pacer ON Initial pacing rate 70-80bpm Current is increased by an additional 10mA above capture threshold (40-80mA) Administer analgesia/sedation for patient s comfort

25 Mechanical contraction Electrical activity -> Mechanical contraction Adequate capture : palpation of artery pulse arterial waveform Check skin burns and tissue damage

26 Summary Completely harmless or life-threatening arrhythmia History and electrocardiography Atrial fibrillation in patients with pulmonary diseases such as pulmonary thromboembolism, COPD or thyroid disease Symptom based management: hemodynamic compromise

27 Thank you for your attention~~

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<B0E6C8F1B4EBB3BBB0FA20C0D3BBF3B0ADC1C E687770> 심전도연수강좌 : 처음시작하는사람들을위한심전도 연세대학교원주의과대학순환기내과학교실 안민수 Cardiac Electrophysiology I : Automaticity : 60-100 회 /min, His bundle : 40-60 회 /min Bundle branch : 20-40 회 /min Purkinje fiber : 20 회 /min Cardiac Electrophysiology