Tachyarrhythmia Case Based Group Discussion.pptx

Group Discussion of Tachycardia cases for medical students

1. Case based learning af Jane Nader, MD

2. A 74-year-old woman presents for her annual physical examination and notes increasing fatigue over the prior 3 months. Her history is notable for longstanding, but well-controlled , systolic hypertension. A physical examination demonstrates a blood pressure of 120/70 mm Hg and an irregular pulse of approximately 120 bpm at rest. The patient weighs 60 KG with a body mass index of 22. The rest of her examination is completely normal with no clinical evidence of right- or left-sided heart failure. The patient has no family history of coronary artery disease, cardiomyopathy or atrial fibrillation. Her review of systems is notable only for fatigue without complaint of snoring, chest pain, palpitations, weight gain or loss, orthopnea, dyspnea, peripheral edema or syncope. . . . . . . . . .

3. A 74-year-old woman presents for her annual physical examination and notes increasing fatigue over the prior 3 months. Her history is notable for longstanding, but well-controlled , systolic hypertension. A physical examination demonstrates a blood pressure of 120/70 mm Hg and an irregular pulse of approximately 120 bpm at rest. The patient weighs 60 KG with a body mass index of 22. The rest of her examination is completely normal with no clinical evidence of right- or left-sided heart failure. The patient has no family history of coronary artery disease, cardiomyopathy or atrial fibrillation. Her review of systems is notable only for fatigue without complaint of snoring, chest pain, palpitations, weight gain or loss, orthopnea, dyspnea, peripheral edema or syncope.

4. Q . What investigations should you order for this patient?

5. Tests including complete blood count, electrolytes, HbA1c and liver function to eliminate potential causes of fatigue were within normal limits. An ECG confirms the diagnosis of atrial fibrillation with a rapid ventricular response of 120 bpm and criteria for left ventricular hypertrophy.

6. An Echo done a year earlier to evaluate left ventricular hypertrophy was notable only for mild, global left ventricular dysfunction with a left ventricular ejection fraction of 40% and mild mitral regurgitation. A subsequent exercise Echo showed no evidence of myocardial ischemia . The patient’s medication includes lisinopril 20 mg, metoprolol XL 25 mg and 81 mg aspirin daily. A repeat Echo performed in the office demonstrates an ejection fraction of 20% but normal left ventricular dimensions with normal pulmonary arterial systolic pressure. BEFORE NOW

7. The primary goals of AF management include symptom relief and thromboembolic prophylaxis. The acute management of this patient should be centered first on symptom relief in the form of improved rate control to reduce the resting heart rate to less than 110 bpm. Digoxin is less effective for rate control than beta-blockers or calcium-channel blockers (e.g., verapamil or diltiazem), but it can be considered if blood pressure is low.

8. 9 Clinical Questions This is a common clinical scenario that raises a number of important management questions

9. Q . Should you restore sinus rhythm or choose a strategy of rate control? Rate vs. Rhythm Control In this patient case, the presence of worsened left ventricular function is likely the result of tachycardia and necessitates aggressive rate control in the short term. The condition is a reasonable justification to attempt restoration of sinus rhythm with the hope that left ventricular function will return to normal .

10. If the decision is made to maintain sinus rhythm after the cardioversion, what are the best medical or procedural options ?

11. Q . What are the anticoagulation requirements for this patient? Recommendations for chronic anticoagulation in patients with AF are determined by clinical risk factors such as History of congestive heart failure Hypertension Age older than 64 OR 75 Diabetes mellitus Past stroke or TIA Female sex Vascular disease

12. In this case the risk factors for stroke : including sex age hypertension

13. All together mandate chronic anticoagulation regardless of the decision for rhythm or rate control . The choices for anticoagulation include warfarin with a target INR of ? or NOACs In this case the risk factors for stroke : including sex age hypertension

14. In this case dabigatran was initiated .

15. The decision for Rate control was made with an increased dose of metoprolol but was limited by hypotension.

16. 20 As a consequence, a TEE (trans-esophageal echo) was performed to exclude an existing thrombus and allow cardioversion. The procedure demonstrated a clear left atrium and this allowed DC cardioversion to be performed safely.

17. Choice of anti-arrhythmic drugs according to cardiac condition Digoxin Digoxin

18. THANK YOU