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Arrhythmias in the Intensive Care Patient Hans-Joachim Trappe, Bodo Brandts and Peter Weismueller

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Arrhythmias in the Intensive Care Patient Hans-Joachim Trappe, Bodo Brandts and Peter Weismueller Arrhythmias in the intensive care patient Hans-Joachim Trappe, Bodo Brandts and Peter Weismueller Purpose of review ventricular fibrillation. The use of automatic external Atrial fibrillation, atrial flutter, AV–nodal reentry tachycardia defibrillators by basic life support ambulance providers or first with rapid ventricular response, atrial ectopic tachycardia, and responder in early defibrillation programs has been associated preexcitation syndromes combined with atrial fibrillation or with a significant increase in survival rates. Drugs such as ventricular tachyarrhythmias are typical arrhythmias in intensive lidocaine, procainamide, sotalol, amiodarone, or magnesium care patients. Most frequently, the diagnosis of the underlying were recommended for treatment of ventricular arrhythmia is possible from the physical examination, the tachyarrhythmias in intensive care patients. Amiodarone is a response to maneuvers or drugs, and the 12-lead surface highly efficacious antiarrhythmic agent for many cardiac electrocardiogram. In all patients with unstable hemodynamics, arrhythmias, ranging from atrial fibrillation to malignant immediate DC-cardioversion is indicated. Conversion of atrial ventricular tachyarrhythmias, and seems to be superior to other fibrillation to sinus rhythm is possible using antiarrhythmic antiarrhythmic agents. drugs. Amiodarone has a conversion rate in atrial fibrillation of up to 80%. However, caution in the use of short-term Keywords administration of intravenous amiodarone in critically ill patients atrial fibrillation, arrhythmias, amiodarone, ibutilide, automatic with recent-onset atrial fibrillation is absolutely necessary, and external defibrillators the duration of therapy should not exceed 24 to 48 hours. Ibutilide represents a relatively new class III antiarrhythmic Curr Opin Crit Care 9:345–355. © 2003 Lippincott Williams & Wilkins. agent that has been reported to have conversion rates of 50% to 70%; it seems that ibutilide is even successful when Department of Cardiology and Angiology, Ruhr-University Bochum, Germany intravenous amiodarone failed to convert atrial fibrillation. Recent findings Correspondence to Hans-Joachim Trappe, MD, Department of Cardiology and Angiology, Ruhr-University Bochum Hoelkeskampring 40, 44625 Herne, Germany Newer studies compared the outcome of patients with atrial E-mail: [email protected] fibrillation and rhythm- or rate-control. Data from these studies Current Opinion in Critical Care 2003, 9:345–355 (AFFIRM, RACE) clearly showed that rhythm control is not superior to rate control for the prevention of death and © 2003 Lippincott Williams & Wilkins 1070-5295 morbidity from cardiovascular causes. Therefore, rate-control may be an appropriate therapy in patients with recurrent atrial fibrillation after DC-cardioversion. Acute therapy of atrial flutter in intensive care patients depends on the clinical presentation. Introduction Atrial flutter can most often be successfully cardioverted to Emergency medicine and critical care are fields that sinus rhythm with energies less than 50 joules. Ibutilide trials often require rapid diagnosis and intervention for spe- showed efficacy rates of 38–76% for conversion of atrial cific situations [1]. These critical interventions can be flutter to sinus rhythm compared with conversion rates of life-saving or severely debilitating, depending on their 5–13% when intravenous flecainide, propafenone, or appropriateness and timeliness. In cardiac emergencies, verapamil was administered. In addition, a high dose (2 mg) of accurate differentiation of ventricular and supraventricu- ibutilide was more effective than sotalol (1.5 mg/kg) in lar tachyarrhythmias is essential for appropriate manage- conversion of atrial flutter to sinus rhythm (70% versus 19%). ment [2]. Most frequently, the diagnosis of the underly- Summary ing arrhythmia is readily apparent, but occasionally it is There is general agreement that bystander first aid, necessary to use clues from the physical examination, defibrillation, and advanced life support is essential for the response to maneuvers or drugs, in addition to the neurologic outcome in patients after cardiac arrest due to 12-lead surface electrocardiogram [3,4]. Treatment of ventricular tachyarrhythmias. The best survival rate from cardiac arrhythmias in intensive care and emergency cardiac arrest can be achieved only when (1) recognition of medicine is sometimes difficult. Correct therapy based early warning signs, (2) activation of the emergency medical on an understanding of the mechanism that caused the services system, (3) basic cardiopulmonary resuscitation, arrhythmia may not only be lifesaving in the immediate (4) defibrillation, (5) management of the airway and ventilation, situation, but may also improve the quality of life. The and (6) intravenous administration of medications occurs as purpose of the present chapter is to summarize new rapidly as possible. Public access defibrillation, which places strategies for patients with supraventricular or ventricu- automatic external defibrillators in the hands of trained lar tachyarrhythmias in intensive care or cardiac emer- laypersons, seems to be an ideal approach in the treatment of gencies. 345 346 Cardiovascular system Types of tachyarrhythmias rhythmia episodes were assessed during the study period Supraventricular tachyarrhythmias include atrial fibrilla- in 133 patients, with a mean of 2.91 episodes per patient tion, atrial flutter, AV-nodal reentrant tachycardia with (range 1–14). Admission diagnoses were cardiac (n = 48), rapid ventricular response, atrial ectopic tachycardia, and cardiac surgery (n = 45), resuscitation (n = 12), pulmonary preexcitation syndromes combined with atrial fibrilla- (n = 15), sepsis (n = 5), neurologic (n = 2), and others tion. Ventricular tachyarrhythmias still remain the main (n = 6). Among the 310 arrhythmia episodes, there were cause of death; these arrhythmias include monomorphic 278 tachycardia (179 episodes regular, 97 episodes irreg- and polymorphic ventricular tachycardia, torsade de pointes ular) and 32 bradycardia events (heart rate <40 beats/min). tachycardia, ventricular flutter, and ventricular fibrilla- There were 108 narrow-QRS complex tachycardia and tion. In the assessment of patients with life-threatening 168 wide-QRS complex tachycardia with two episodes of supraventricular or ventricular arrhythmias, attention primary ventricular fibrillation. Among the 278 tachycar- should be given to identify whether the tachycardia is dias, 135 episodes (48.6%) were ventricular, 13 episodes associated with worsening angina or low cardiac output. (4.7%) were torsade de pointes tachycardia, and 83 epi- There is general agreement that many cardiac or extra- sodes (29.8%) were atrial fibrillation, 10 episodes were cardiac causes can lead to supraventricular or ventricular atrial flutter (3.6%), 21 were supraventricular tachycardia tachyarrhythmias and to cardiac arrest; left ventricular (7.6%), and 2 were ectopic atrial tachycardia (0.7%). It function (or dysfunction) plays an important role in prog- seems that in critically ill patients, two types of arrhyth- nosis and outcome (Fig. 1). mias are dominantly visible: sustained ventricular tachy- cardia and atrial fibrillation. Lampert and Ezekowitz re- Incidence and type of cardiac arrhythmias ported recently that the aging heart is susceptible to in critically ill or elderly patients diverse cardiac arrhythmias, and in many of these ar- It has been well known for many years that cardiac ar- rhythmias intensive care medicine is mandatory [6]. rhythmias can occur in healthy people or in patients with Baine et al. studied the incidence of arrhythmia types, cardiac or extracardiac diseases. Arrhythmias are well de- hospital and intensive care stay in 144,512 elderly pa- fined in patients after myocardial infarction, in patients tients (age 65 years or older) with cardiac arrhythmias with underlying cardiac or pulmonary disease, and in (time interval 1991–1998) [7]. In 1998, atrial fibrillation patients after cardiac surgery or heart transplantation [5]. was the most frequent arrhythmia and accounted for However, only few data are available regarding incidence 44.8% of the relevant discharges. Atrial flutter was ob- and type of arrhythmias in critically ill patients. Reinel et served in 5.2%, sinoatrial node dysfunction in 13.2%, and al. studied all consecutive arrhythmia episodes in criti- complete AV block in 5.8%. Supraventricular tachycardia cally ill patients in a medical–cardiologic intensive care was observed in only 3.8%. Cardiac arrest was present in unit between 1996 and 1999 [5]. All episodes of patients 1.3%, ventricular tachycardia in 6.9%, and ventricular fi- with new-onset, sustained arrhythmias (duration Ն30 brillation in 1.3%. It is interesting to note that lengths of seconds) were included that were either self-term- stay in hospital and intensive care are determined by the inated or that required intervention. A total of 310 ar- underlying arrhythmia: mean hospital stay was 7.8 days Figure 1. Diagnostic methods in intensive care patients after cardiac arrest caused by ventricular fibrillation Mechanisms and diagnostic methods in intensive care patients after cardiac arrest caused by ventricular fibrillation. Angio, angiography; BRS, baroreflex sensitivity; ECG, electrocardiogram; EPS, programed electrical stimulation; HRV, heart rate variability; LVEF, left ventricular ejection fraction. Arrhythmias in intensive care
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