Rare Arrhythmias: Do You Know What to Look For?

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Geralyn Warfield (host): I'd like to welcome our audience today where we're going to be speaking with Dr. Sorajja about arrhythmias, and I'm hoping you can introduce yourself to our audience. 

Dan Sorajja (guest): Sure. My name is Dan Sorajja. I'm an Associate Professor of Medicine at the Mayo Clinic in Arizona. I'm the Program Director for the EP Fellowship, and the Associate Program Director for the Cardiology Fellowship. I'm also the Department Education Coordinator for the Cardiovascular Diseases Department. 

Geralyn Warfield (host): So, we've got a great expert sitting across the table from us today. And we'd like to start our conversation talking a little bit about specific arrhythmias, talking a little bit about AFib and flutter. And I'm wondering if you could talk just a little bit about that for us.  

Dan Sorajja (guest): Yeah, sure. So atrial [00:01:00] fibrillation is probably the most common arrhythmia that we see in America, particularly as people get older. Once people get to about 65, the incidence strikingly increases over time. You know, with atrial fibrillation and atrial flutter, they're basically closely related cousins. They typically hang out together. So, if you see one, you’ve got to be suspicious the other is around. 

Geralyn Warfield (host): And we were talking right before we came on air about the elephant in the room…  

Dan Sorajja (guest): Yeah.  

Geralyn Warfield (host): …when it comes to these diseases. Could you talk about that please?  

Dan Sorajja (guest): Yeah. So, you know, atrial fibrillation doesn't keep just company with the atrial flutter. It keeps company with a lot of really bad things. 

Like there's an increased chance of death. There's an increased risk of stroke. There’s a higher risk of hospitalization. For heart failure, there's less quality of life once you get diagnosed with atrial fibrillation. 

And a lot of those are tied to its risk of stroke.  

The predominant [00:02:00] method used to assess a person's risk of stroke is the CHA2DS2-VASc scoring system. That's comprised of a lot of components, mainly heart failure—really, systolic heart failure, like ejection fraction under 40%, or being hospitalized for heart failure, even if it was diastolic heart failure, in the past six months.  

Hypertension, which is like blood pressure over 160 mmHg, or being on an anti-hypertensive. 

Age: you get a point for that if it's 65 years old, you get two points if it's 75; diabetes, prior stroke.  

They also include pulmonary embolism. Some of us don't include pulmonary embolism as much, because we feel that's a right-sided process rather than an arterial sort of side of embolization risk.  

And then there's also the VASc, which is a new part of the scoring system, which is, are you a woman? Then you would get a point for that.  

And then if you have any issues [00:03:00] with prior heart attack, carotid artery blockage or peripheral vascular disease, we get a point for that. 

And we total it all up. And usually if your score is over three, three or more for women, I should say, we recommend anticoagulation. 

And if it's two or more for men, we recommend anticoagulation.  

Geralyn Warfield (host): So, there's a lot of components that go into the actual diagnosis of this, and I'm hoping you might enlighten our audiences as to how you work with patients to understand that risk and that need for anticoagulation?  

Dan Sorajja (guest): Yeah, sure. You know, we do see a lot of patients that have already been diagnosed, but sometimes it is up in the air, and part of the issue is trying to catch atrial fibrillation. 

Only 20% of people are actually symptomatic for all of their episodes of atrial fibrillation. So, it can be pretty tricky to kind of really assess what the burden is. The first place to start is just trying to figure out how often people are symptomatic when they [00:04:00] do have symptoms.  

The most common symptoms, 90% of people have one of three symptoms or a combination of them, and that includes shortness of breath, palpitations, and fatigue. 

So, when you get people's frequency of symptoms, what the next step is to do is to do a monitor that is going to catch at least two to four episodes of that. So, if they're having episodes about once a week, you don't want to do a monitor for one day and say, “Okay, it wasn't there. He doesn't have it,” or “She doesn't have it.” 

You want to basically try to cast a net that is two to four times that. So, that'd be like a two-week monitor or a four-week monitor. The idea is kind of like fishing. If you went to a lake and you dropped your fishing pole into the lake and you pulled it right back up and you didn't catch a fish, you can't say, “Oh, there's no fish in the lake.” 

You may have just not fished for long enough. And that's kind of the rule of thumb we employ when we're trying to catch something.  

Now, if people don't have symptoms, that's a little trickier. There are a lot of [00:05:00] issues with insurance coverage of longer duration monitoring in this country. So, you couldn't just go straight to an implantable loop recorder, because insurance frequently doesn't want to pay for that. And that's, that's pretty reasonable.  

So usually, you have to start out with a shorter duration monitor, like a Holter monitor for 24 to 48 hours. And if you don't catch it, then you have to think about doing longer duration monitors, which could be a 30-day monitor or an implantable loop recorder.  

They do have this old study, where they compared basically this stepwise capture of atrial fibrillation that was asymptomatic, and by and far and large, the implantable loop recorder was way better than going through a Holter monitor, than an event recorder, and all of the steps in between. 

So, it was about 70% yield using an implantable loop recorder. And those implantable loop recorders, they're, they're quite a bit smaller than in the old days. In the old days, they used to be the size of a Bic lighter, if you [00:06:00] remember what those used to look like. But now they're about the size of a AAA battery cut vertically into a third. 

So, we inject a third of that under the skin. It's able to monitor for two to four years of this rhythm. We follow it on a monthly basis in our device clinic at Mayo Clinic, and once it finds the rhythm, we can take it out. That procedure takes about eight minutes to put in, takes about 10 minutes to pull out, and it's a nice non-invasive way for people to go about their business without having to be ho hooked up to a bunch of wires or a patch system. 

Geralyn Warfield (host): So, one of the key factors that we talked about was age, getting a point on the CHA2DS2-VASc score of one, if you were over 65, 2 if you were over 75.  

Dan Sorajja (guest): Right. 

Geralyn Warfield (host): And, you also talked about symptomology, including shortness of breath and fatigue. So, I suspect that many patients who actually may be experiencing AFib, are attributing that to simply getting older. 

Dan Sorajja (guest): Yeah. That is very common and that can make it [00:07:00] pretty tricky because, like you said, the Venn diagram of being old and getting atrial fibrillation, they overlap to a large degree.  

And, you know, you also run into people who just don't want additional treatment. There is this inertia where, you know, you'll meet patients and they'll say, “Well, I'm already on a lot of stuff. Do I really want to take more medications to address this thing that you're talking about?” 

And, like I said, there's a risk of mortality, there's a risk of stroke, there's a risk of hospitalization, lower quality of life. So, when you present the data that way, people are more likely to be like, “Okay, yeah, let's, let's go out and find this, and treat this so I can live this...be with my wife, my spouse, my grandkids,” and whatnot. People always have something to live for to a large, large extent. And working it up is definitely in everyone's best interest.  

Geralyn Warfield (host): We're going to take a quick break and we will be right back.  

 

Geralyn Warfield (host): We're back talking [00:08:00] about arrhythmias and we're going to shift just a little bit from atrial fibrillation to some of the more rare arrhythmias that we might suspect or see in practice. Could you tell us a little bit more about those?  

Dan Sorajja (guest): Yeah, there's a ton of rare arrhythmias and certainly there are certain ones that we don't want people to miss. And probably the most common one we don't want people to miss is Long QT. And that's where the QT prolongation is over 500 milliseconds. And that's something that's easy to pick up on an ECG. 

For the most part, the computer does a pretty good job of measuring the QT interval, but we always recommend manually rechecking it, if the computer seems a little bit off.  

But there are a number of patients who have congenital Long QT syndrome and they may have a normal ECG, and it's only under certain conditions that their QT interval prolongs. 

For instance, the Long [00:09:00] QT type 1, which is probably the most common congenital arrhythmia. When people have extra adrenaline, usually due to exercise or some arousal of some sort, it can really push out that QT interval and that's when they're at risk to get PVCs and such during the repolarization of the heart. 

And then that's what puts them into that dangerous polymorphic VT, or Torsade de pointes. That is something that we want people to be able to recognize.  

But you know, the ECG abnormality isn't always there. So, if you see it on an ECG and it's pretty definitive ,and you look back with your 20/20 hindsight and you see one that may be kindly prolonged, don't beat yourself off over that, that's just something that happens. And, sometimes you just have to be looking at the right time to see what you need to see. 

Geralyn Warfield (host): And when we find these rare arrhythmias in clinical practice, what should our next steps be? Or if we suspect [00:10:00] them and haven't seen them yet?  

Dan Sorajja (guest): Yeah. I think it's very reasonable to refer people on to an expert in that field. 

For Long QT type 1, you can put people on a beta blocker. And non-selective beta blockers are better than Metoprolol. So, we would recommend nadolol or propranolol and then send them on their way to see an electrophysiologist or a congenital arrhythmia specialist. 

You know, I think most people, like, if you likened a person's body to a house, people are pretty comfortable dealing with plumbing issues. 

But when there's an electrical problem, I think it's totally fine to say, “Well, let's go get the expert electrician and get this addressed.” But there's some steps you can take before that.  

You know, when you see a patient and you suspect that they may have a congenital Long QT issue, it would be great to, number one, go ahead and think about referring them to a genetics counselor so they can understand what [00:11:00] they may be in store for, the ramifications for their kids or other family members. And then consider waiting to have the genetic counseling done after they meet with that genetics counselor or a congenital arrhythmia specialist.  

But I think it's certainly pretty reasonable to go ahead and put people on a non-selective beta blocker before you send those people on to meet with those people. 

Geralyn Warfield (host): Great. Is there anything else that you'd like to share that I've neglected to ask?  

Dan Sorajja (guest): No, thank you for having me.  

Geralyn Warfield (host): It's been a delight to speak with you today. I'm your host, Geralyn Warfield, and we will see you next time. 

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