ETIOLOGY, TREATMENT AND SHORT TERM OUTCOME OF VENTRICULAR ARRHYTHMIAS IN PATIENTS ADMITTED TO A TERTIARY CARE HOSPITAL.
Objective: To determine the frequency of various types of ventricular arrhythmias, its causes, treatment, in-hospital course and short term outcome of ventricular arrhythmias in patients admitted to a tertiary care hospital.
Methodology: This observational study was conducted in Cardiology Unit of Lady Reading Hospital, Peshawar from Ist September 2014 to 31st March 2015. All patients with ventricular arrhythmias admitted during study duration were included after fulfilling the inclusion and exclusion criteria. Their baseline, clinical, echocardiographic characteristics, treatment and hospital outcome were recorded in a specially designed proforma. SPSS version 19 was used for statistical analysis.
Results: A total of 127 patients were included in the study. Males were 93 (73.22%). Mean age was 43.42 +-10.7 years. Causes of ventricular arrhythmias were acute coronary syndrome 51 (40.15%), ischemic cardiomyopathy 27 (21.25%) and idiopathic dilated cardiomyopathy 13 (10.23%). Successful pharmacological cardio version was achieved in 29 (22.83%) patients with amiodarone and 3(2.36%) patients with lignocaine. The rest of patients were cardioverted with electrical cardio version. A total of 8 (6.3%) patients expired.
Conclusion: Most common cause of ventricular arrhythmias was coronary artery disease followed by ischemic and dilated cardiomyopathies. Commonly used technique of cardio version was pharmacological for hemodynamically stable patients and electrical for hemodynamically unstable patients.
Key words: Ventricular arrhythmias, Ischemic cardiomyopathy, Electrical cardioversion, Pharmacological cardio version.
Ventricular tachycardias (VT) arise from ventricular foci and are classified as broad complex tachycardias morphologically. It is the commonest form among all types of ventricular tachyarrythmias. It is either sustained i.e. lasting for more than 30 seconds or non-sustained, which lasts for 5 mg/dl###13###10.23
Long QT Interval###5###3.93
Wheat Pills Poisoning###6###4.72%
Arrythmogenic Right Ventricular
Severe Bradycardia Induced Ven-
Severe Mitral Regurgitation###6###4.72%
Severe Aortic Regurgitation###4###3.15%
Tetrology of Fallot###3###2.36%
Severe Pulmonary Hypertension###7###5.5%
No Pathology Identified###38###29.92%
Table 3: Treatment given to patients with ventricular arrhythmias
Amiodarone and DC Cardioversion/Defibrillation###16###12.6%
DC Cardioversion/Defibrillation Only###64###50.4%
Pacemaker Implantation for Bradycardia Induce Arrhythmia###6###4.7%
Monomorphic VT occur in 83 (65.35%), polymorphic VT occurred in 19 (14.96%), torsade depointes in 9 (7.08%) and ventricular fibrillation in 16 (12.6%) patients. Hemodynamically stable patients with monomorphic VT were 48 (37.8%), while hemodynamically unstable with low blood pressure were 18 (14.17%) and hemodynamically unstable with acute heart failur were 17(13.38%) patients.
Specific etiology for ventricular arrhythmia was acute coronary syndrome in 51 (40.15%) patients, ischemic cardiomyopathy in 27 (21.25%) patients and idiopathic dilated cardiomyopathy in 13 (10.23%) patients. Some patients with VT have multiple abnormalities. Relative frequencies of other causes are shown in table 2.
Amiodarone was the sole agent used for reverion to sinus rhythm in 29 (22.83%) patients, while 16 (12. 6%) patients were given amiodarone followed by DC cardio-version because of either failure to cardiovertion with drugs or because of hemodynamic instability. Lignocaine was given to 3(2.36%) patients. Other treatment modalities for VT are shown in table 3. In-hospital mortality was 8 (6.3%).
In this article, we have documented the etiologies and management of ventricular arrhythmias in patients presenting to our hospital. Ali et al4 showed mean age of 57.1 years supporting our study. Male to female ratio was 1.38:1. Major cardiovascular risk factors were encountered in 58% of the patients. Tachyarrhythmia's occurred in 42% patients without any associated risk factor supporting our data. Only 28% of patients with VT were managed with drugs alone. In their study defibrillation was required in all the patients with VF again supporting our data. All the patients with pulseless VT (33%) were defibrillated but the stable VT with pulse were treated with anti-arrhythmic drugs (28%) and unstable VT with pulse (72%) received synchronized cardioversion. Amiodarone and combination of drugs was used in the same frequency as in our study4,5.
The frequency of various types of ventricular arrhythmiasin our study is supported by international data5-7.These international studies demonstrated that monomorphicVT was more common than polymorphic VTand most of the patients were hemodynamically stable.Frequency of ischemic etiology for most cases ofventricular arrythmia is supported by Terranova et al8,Wright et al9 and other international studies10-12. Veryfew patients in our study were hemodynamically unstableand needed CPR. The CPR in our study populationwas as effective as the international Data13-15. Volpi etal16 observed in their study that ischemia was the maintrigger for ventricular fibrillation.
In our study, 3.15% patients were having severe hypomagnesaemia and all of these patients have torsade de pointes as the presenting arrhythmia suggesting that severe hypomagnesaemia is an important cause of torsade de pointes. This observation is supported by Banai et al17, which showed that magnesium replacement is the best strategy to treat torsade de piontes. Intravenous magnesium is an effective and safe therapy for torsade de pointes and is now regarded as the treatment of choice for this arrhythmia.
About 10% of patients had deranged renal function tests with mean creatinine more than 5mg/dl and hyperkalemia was documented in 2.36% of them. Chronic kidney disease (CKD) patients are more susceptible to the occurrence of various ventricular arrhythmias; a leading cause of death in these subset of patients.
There are various pathophysiological mechanism involve for arrhythmias in these patients which is complex and seems to be related to structural and functional cardiac abnormalities caused by CKD, associated with several triggers, such as water and electrolyte disorders, disturbances in acid base balance, hormonal disturbances, arrhythmogenic drugs and the dialysis procedure itself. Data is limited about the clinical outcomes in CKD patients with asymptomatic ventricular arrhythmias18. The frequency of these metabolic derangement as the cause for ventricular arrhythmias were also similar as with other national and international data.
Wheat pills poisoning was the cause of VT in 06 (4.72%) patients, of which 04 (3.15%) were expired and 02(1.57%) were reverted to sinus rhythm. Wheat pills contain aluminum phosphide which is cardiotoxic. These patients usually have severe metabolic abnormalities which leads to polymorphic VTs. The treatment offered to these patients was conservative and correction of metabolic abnormalities. Also the data regarding the VT associated with wheat pills poisoning is lacking in international guidelines. About 14% patients were referred for EP studies/VT ablation/ICD insersion to electro-physiologist.
Ebstein anomaly (1.57%) and tetrology of Fallot (2.36%) were found in our study. Both of these are associated with ventricular arrhythmias in variousstudies19,20. Severe pulmonary hypertension was presentin 5.5% patients. All of them were having ventricularfibrillation. Hoeper etal 21 reported the outcome of CPRin patients with pulmonary artery hypertension. He reported that about 16% of his study population experienced cardiac and respiratory arrest over 3 years follow-up. The initial rhythm in ECG at time of arrest was VF in8% and VT in 4% of cases. It also support our findings.
A total of 6.3% patients expired. Mortality in ourstudy was lower than a similar study performed in Pakistan4,which may be because of more monomorphicVTs and hemodynamically stable patients and also asignificant number of our study population had reversiblecauses.
Most common cause of ventricular arrhythmias was coronary artery disease followed by ischemic and dilated cardiomyopathies. Commonly used technique of cardio version was pharmacological for hemodynamically stable patients and electrical for hemodynamically unstable patients.
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|Publication:||Journal of Postgraduate Medical Institute|
|Date:||Dec 31, 2017|
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