Arrhythmias in Cardiac Rehab

Niloufar Tabatabaei, MD., MS., FACC

Director of Cardiac Rehabilitation

Division of Cardiology

Olmsted Medical Center

Disclosures: None

Arrhythmias can be promoted by exercise

• Sympathetic nervous system

• Circulating catecholamines

• Automaticity enhanced triggered activity

• Electrolyte shifts

• Baroreceptor activation

• Myocardial stretch and ischemia

Objectives

• Review common abnormal rhythms noted in cardiac rehab – in a case based presentation

• Identify common abnormal rhythms

• Discuss management of common abnormal rhythms

• Discuss significance of rhythm abnormalities

Case 1: Atrial Fibrillation

Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?

A. Patient has excellent heart rate variability finish exercise and discharge home routine follow-up

B. Patient has excellent heart rate variability finish exercise but call MD for treatment of Heart failure

C. Don’t exercise patient

Case 1: 73 year-old male with paroxysmal AF and symptoms. What would you do?

A. Patient has excellent heart rate variability finish exercise and discharge home routine follow-up

B. Patient has excellent heart rate variability finish exercise but call MD for treatment of Heart failure

C. Don’t exercise patient

73 year-old male with known paroxysmal atrial fibrillation • Cardiac rehab session

normal heart rate variability

• SYMPTOMATIC • Heart failure symptoms

• Discuss with MD and plan for treatment of CHF.

Atrial fibrillation • New atrial fibrillation: notify MD as discussion for anticoagulation and

rhythm/rate control may be necessary

• Known atrial fibrillation: evaluate for symptoms and heart rate variability • No symptoms and good heart rate variability: routine follow-up

• Symptoms notify MD

• Heart rate suppression and or tachy/brady syndrome -> further clinical evaluation

Stroke Prevention in AF -wading in the deep

Case 2: 48 year old female s/p AV canal repair and mitral valve replacement, Tricuspid repair with a pacemaker

Case 2

What do you do? A. This is VT stop patient and start

CPR

B. The rate of 245 is incorrect recalculate rate. Importantly patient is asymptomatic and you see pacing marks

C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician

Case 2

What do you do? A. This is VT stop patient and start

CPR

B. The rate of 245 is incorrect recalculate rate importantly patient is asymptomatic you see pacing marks

C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician

Case 2

What do you do? A. This is VT stop patient and start

CPR

B. The rate of 245 is incorrect recalculate rate importantly patient is asymptomatic you see pacing marks

C. Pacemaker is not functioning well and should not track at this rate. Certainly an arrhythmia call the physician

Device settings are DDDR 60-140 bpm

Pacemaker patient • Please determine settings on pacemaker and if they are pacemaker

dependent. (DDDR 60-130)

• Determine if intrinsic rate or pacemaker rate

• Symptoms important

• Questions - call MD or pacemaker nurse

What about Patients with a Defibrillator

• Settings are different as usually they don’t need pacing and usually single chamber unless pacing is needed (VVIR 40)

• With defibrillators it is important to see what the VT/VF Zones programmed for shock. (you don’t want the patient’s heart rate at that zone). • Common VT zones (monitor zone above 180 bpm, VF

rate 200bpm)

Case 3: 63 year-old with defibrillator

Case 3: panel to the right 63 year-old with defibrillator What is happening in panel 4? DDDR 85-130

A. Patient is in VT

B. Patient is paced

C. Patient will be shocked shortly and should be cooled down

1

2

3

4

5

63 year-old patient with Defibrillator for out of hospital arrest is in the middle of session 88 what do you do?

A. Call 911 and transfer to ED

B. If patient is asymptomatic let him go home

A. Call 911 and transfer to ED

B. If patient is asymptomatic let him go home

63 year-old patient with Defibrillator for out of hospital arrest is in the middle of session 88 what do you do?

Case 4: 72 year-old mal s/p bypass surgery

A. Start CPR

B. Asymptomatic you have time to determine rhythm as SVT with Aberrancy vs. VT

C. VT in light of history of coronary artery disease until proven otherwise

D. Don’t exercise – check electrolytes, meds, notify MD

E. No symptoms go ahead and exercise

F. More than one answer is correct

Case 4: 72 year-old mal s/p bypass surgery

A. Start CPR

B. Asymptomatic you have time to determine rhythm as SVT with Aberrancy vs. VT

C. VT in light of history of coronary artery disease until proven otherwise

D. Don’t exercise – check electrolytes, meds, notify MD

E. No symptoms go ahead and exercise

F. More than one answer is correct

How to distinguish SVT from VT

• Rate

• Regularity: warm up phenomenon in VT

• AV dissociation

• Morphology

• QRS duration >140 in RBBB is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)

• Concordance

How to distinguish SVT from VT

• Rate

• Regularity: warm up phenomenon in VT

• AV dissociation

• Morphology

• QRS duration >140 in RBBB is likely VT and >160 likely VT in LBBB (likely hood ratio of 20:1)

• Concordance

Rare PVCs

• Rare single PVCs

• Asymptomatic

• Usually clinically insignificant unless increase with frequency during exercise

Case 5: 63 year-old male with history of AA repair and coronary re-implantation • Patient has frequent PVCs

during rest and exercise

• Holter shows a 30% burden

• Patient has no symptoms of chest pain

• Cardiac rehab obtains a 12 lead ECG

• PVCs localized to Right coronary cusp

• CT shows impingement of re-implanted right coronary artery

• Patient gets Right coronary artery stent

Case 6: 33 year-old s/p mitral valve repair

A. Conduction system disease recommend he sees physician and gets a pacemaker

B. Wenckebach may not be significant wait and see how he does with exercise

Case 6: 33 year-old s/p mitral valve repair A. Conduction system disease

recommend he sees physician and gets a pacemaker

B. Wenckebach may not be significant wait and see how he does with exercise

Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?

A. Normal sinus rhythm

B. Junctional escape

C. Complete heart block

D. Atrial flutter

Case 7: 82 year-old female with CAD and RV Heart failure – what is the rhythm?

A. Normal sinus rhythm

B. Junctional escape

C. Complete heart block

D. Atrial flutter

82 year-old female with CAD and RV failure – what is the rhythm?

A. Normal sinus rhythm

B. Junctional escape

C. Complete heart block

D. Atrial flutter

Any Questions?