Study Points

Clinical Management of Ventricular Arrhythmias

Course #90373 - $75 • 15 Hours/Credits

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Study Points

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  1. Define basic concepts of normal cardiac conduction, including cellular events, and normal electrocardiogram (ECG) waveform.
  2. Identify premature ventricular complexes (PVCs), including electrophysiologic characteristics, patterns of occurrence, related symptoms and common precipitating causes.
  3. Describe monomorphic ventricular tachycardia (VT), including electrophysiologic characteristics, impact on physiologic functioning, and underlying pathophysiology.
  4. Identify polymorphic VT, including electrophysiologic characteristics, impact on physiologic functioning, and underlying pathophysiology.
  5. Describe ventricular fibrillation, including electro­physiologic characteristics, impact on physiologic functioning, and underlying pathophysiology.
  6. List key points in the American Heart Association's Chain of Survival, including the use of automated external defibrillators (AEDs).
  7. Summarize key points in the emergency management of life-threatening ventricular arrhythmias for patients, as recommended by Advanced Cardiovascular Life Support (ACLS) guidelines.
  8. Outline the assessment, diagnosis, and risk stratification process for patients who have, or are deemed to be at risk for, ventricular arrhythmias.
  9. Describe the management of PVCs and nonsustained VT in persons with and without heart disease.
  10. State major indications for implantable cardioverter-defibrillators (ICDs) and outline the basic components, functions, therapy options, and implantation procedure for current generation ICDs.
  11. Discuss basic discharge education, home safety measures, psychosocial considerations, and medical follow-up for a person post-ICD implantation.
  12. Evaluate problems that may occur with ICD functioning, including ICD storm, delivery of inappropriate shocks, and failure to deliver therapy.
  13. Describe the use of antiarrhythmic medications in the long-term management of ventricular arrhythmias.
  14. Describe additional therapies that may be used in the management of ventricular arrhythmias, including the optimization of medical therapy for underlying heart disease and the use of ventricular reconstruction surgery.
  15. Analyze current trends and issues in the management of persons who have, or are at risk for, ventricular arrhythmias.
  16. Using simulated clinical data, discuss the clinical management of a person with ischemic cardiomyopathy and nonsustained VT, and the clinical management of a person who experiences multiple ICD shocks.
  1. The absolute refractory period is defined as the

    BASIC CONCEPTS: A REVIEW

    After the myocardial cell has depolarized, there is a period of time that the cell cannot generate an action potential in response to another electrical impulse; this is referred to as the "absolute refractory period." As the cell continues to repolarize, an "effective refractory period" occurs in which the cell can transiently depolarize in response to an electrical impulse but generally will not develop enough of an action potential to propagate the impulse to surrounding cells. As repolarization nears completion, the cell is said to be in a "relative refractory period;" in this period, a strong electrical stimulus can trigger the cell to depolarize and create another action potential [13,14].

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  2. In the normal ECG waveform, atrial depolarization is represented by the

    BASIC CONCEPTS: A REVIEW

    The electrical events that occur in the heart are reflected in the ECG waveform. Components of a normal beat are illustrated in Figure 1[15].

    • The P wave represents atrial depolarization.

    • The PR interval represents the amount of time the electrical impulse takes to travel from the SA node through the AV node. The normal PR interval is 0.12 to 0.20 seconds.

    • The QRS represents the amount of time it takes the ventricles to depolarize. In normal conduction, ventricular depolarization occurs rapidly; this rapid conduction is reflected in a narrow QRS interval. The normal duration of a QRS interval is <0.10 seconds.

    • The T wave represents ventricular repolarization.

    • The QT interval represents the amount of time that it takes the ventricles to depolarize and repolarize; it is measured from the beginning of ventricular depolarization (i.e., the start of the QRS complex) to the end of repolarization (i.e., the end of the T wave). During the early part of the QT interval, the ventricles are completely refractory and unable to respond to another electrical impulse. During the latter part of the interval, the ventricles are only partially refractory and may respond to some impulses but not to others. The normal QT interval is <0.44 seconds.

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  3. Of the following, which is a defining characteristic of a premature ventricular contraction (PVC)?

    PREMATURE VENTRICULAR CONTRACTIONS

    A PVC is an abnormal beat that is initiated at some point in the ventricles of the heart. With PVC, the electrical impulse is not conducted through the ventricles normally. As a result, ventricular depolarization is abnormal and ventricular contraction is impaired. On a surface ECG, the abnormal ventricular depolarization is represented by a QRS complex that is wider and more bizarre in shape than the normal QRS complex. Frequently, PVC occurs earlier in the cardiac cycle than the next normal beat would occur and interrupts the person's underlying heart rhythm. Other names for PVCs include ventricular ectopic beats, ventricular premature depolarizations (VPDs), or ventricular extra systoles. ECG characteristics of PVC include [1,11,12,18]:

    • Absence of a normal P wave or normal PR interval. As PVC starts in the ventricle and is not initiated by the sinus node, coordinated depolarization and contraction of the atria do not occur to complete ventricular filling. On surface ECG, this is reflected by the absence of a normal P wave and the absence of a normal PR interval.

    • A widened, bizarre-appearing QRS complex. Normal conduction through the ventricles takes no more than 0.10 seconds; with PVC, conduction takes longer than 0.10 seconds and often lasts 0.14 sec.

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  4. A repeating pattern of a normal beat followed by a PVC is referred to as

    PREMATURE VENTRICULAR CONTRACTIONS

    PVCs may occur infrequently and in isolation, or they may occur in an identifiable pattern. Terms commonly used to describe PVC patterns of occurrence include [19]:

    • Isolated: PVCs occur very infrequently with no repeating or identifiable pattern

    • Bigeminy: A repeating pattern of a normal beat followed by a PVC

    • Trigeminy: Repeating pattern of two normal beats followed by a PVC

    • Couplet: Two PVCs in a row

    • R-on-T: PVC that occurs so early in the cardiac cycle that it falls on the T wave of the preceding beat. Especially in persons experiencing an acute MI or hypokalemia, an R-on-T PVC carries the risk of causing the heart to go into ventricular fibrillation.

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  5. By definition, the ventricular rate in monomorphic ventricular tachycardia (VT) may range from

    VENTRICULAR TACHYCARDIAS

    The defining ECG characteristics of monomorphic VT include:

    • Absence of normal P waves

    • Absence of a normal PR interval

    • A ventricular rate that ranges from 120 bpm to 250 bpm

    • Regular ventricular rhythm

    • QRS complexes that are wider than normal and bizarre in appearance

    • QRS complexes that remain constant in shape and configuration (in the same ECG lead)

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  6. Persons in sustained monomorphic VT may experience

    VENTRICULAR TACHYCARDIAS

    Some persons with monomorphic VT will be completely asymptomatic. Others will experience mild-to-moderate symptoms of decreased cardiac output including a drop in blood pressure, a reduction in activity tolerance, dyspnea, and dizziness or light-headedness. Still others will experience severe symptoms of syncope or near syncope, and some will develop cardiac and respiratory arrest. VT may degenerate into ventricular fibrillation. In persons with already compromised left ventricular function, persistent VT may result in signs of increased heart failure, angina, and acute MI. The impact of the VT on the patient is mediated by a number of factors, including [1]:

    • The rate of the VT

    • How long the VT lasts

    • How frequently the VT recurs

    • The presence and extent of any heart disease present

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  7. Of the following, which combination of factors greatly increases the risk of developing long runs of VT?

    VENTRICULAR TACHYCARDIAS

    Sustained monomorphic VT commonly occurs in individuals with ischemic heart disease. According to data from clinical trials, the combination of a healed MI, nonsustained VT, and a reduced left ventricular ejection fraction (LVEF) greatly increases a person's risk for developing prolonged runs of VT [1]. In an MI, the damage to the heart muscle creates the necessary conditions for a re-entry VT to develop. Areas of the myocardium die and are replaced with scar tissue. The resulting mix of normal tissue and abnormal scar tissue create adjoining areas of normal and abnormal conduction that allow a re-entry rhythm to occur [29]. Damage from an MI can also impair the ability of one or both ventricles to pump effectively. When the left ventricle is damaged, its ability to pump blood into the systemic circulation is reduced. LVEF describes how well the left ventricle is functioning. LVEF is defined as the percentage of the total volume of blood contained in the left ventricle that is pumped from the ventricle with each heartbeat. A normal LVEF at rest falls between 50% and 75%. EF may be measured noninvasively through the use of an echocardiogram or nuclear medicine study or invasively during a cardiac catheterization procedure [30]. Although polymorphic VT is more common during the acute stage of an MI, sustained monomorphic VT may develop. Aside from coronary artery disease, causes of myocardial ischemia that have been found to trigger monomorphic VT include coronary vasospasm, cocaine-induced vasospasm, severe hypertension, and aortic stenosis [1,3,18].

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  8. A type of idiopathic ventricular tachycardia that may develop in persons with a normal heart is called

    VENTRICULAR TACHYCARDIAS

    Although monomorphic VT occurs more often in people with heart disease, it may also occur in the absence of heart disease. Two types of idiopathic VT that may be seen in persons with normal hearts are right ventricular outflow tract VT and idiopathic left VT. In right ventricular outflow tract VT, exercise or some other hyperadrenergic state may induce repetitive bursts of nonsustained VT or episodes of sustained monomorphic VT. Unlike the VT seen commonly in ischemic heart disease, the VT in right ventricular outflow tract is thought to be caused by abnormal impulse formation in the ventricle. The ventricular arrhythmias seen in right ventricular outflow tract have not been strongly linked to sudden cardiac death episodes but may create debilitating symptoms of palpitations, dizziness, or syncope [35].

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  9. Of the following, which best describes the QRS complexes seen in torsades de pointes?

    VENTRICULAR TACHYCARDIAS

    Torsades de pointes gets its name from the characteristic pattern of its QRS complexes. As the complexes change from upward to a downward deflection, they give the appearance of "twisting" around the baseline [36]. The amplitude of each successive complex gradually increases then decreases, creating an identifiable spindle-shaped pattern. Other ECG characteristics associated with torsades de pointes include [33,36]:

    • A rate of 200 to 250 bpm

    • No P wave or PR interval present

    • An irregular ventricular rhythm

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  10. Ventricular fibrillation is best described as

    VENTRICULAR FIBRILLATION

    The most lethal and disorganized ventricular arrhythmia is ventricular fibrillation. In ventricular fibrillation, electrical activity is completely chaotic. No effective depolarization occurs, and there is absolutely no effective contraction of the heart. Complete circulatory collapse occurs, and emergency intervention is required [39]. Defining ECG characteristics include:

    • An absence of any identifiable P, QRS, or T waves

    • The total absence of any organized rhythm

    • An indiscernible rate

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  11. The single most common etiologic factor predisposing patients to ventricular fibrillation is

    VENTRICULAR FIBRILLATION

    Coronary artery disease (CAD) is the single most common etiologic factor predisposing patients to ventricular fibrillation [40]. Other common causes include the deterioration of VT and severe bradycardia caused by MI [40]. Ventricular fibrillation may also develop in persons with severe heart failure. Other conditions that are linked to ventricular fibrillation include [1,18,36]:

    • Multiple electrolyte imbalances that prolong the relative refractory period

    • Congenital or acquired long QT syndrome

    • Proarrhythmic effect of medications, especially antiarrhythmic medications

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  12. As defined by the "Chain of Survival" concept, early recognition and activation involves which of the following?

    OVERVIEW: AMERICAN HEART ASSOCIATION "CHAIN OF SURVIVAL"

    The first link in the Chain of Survival concept is recognition and activation. In simple terms, this means that a cardiac arrest victim receives help as soon as possible. Two actions are critical: recognition of the emergency and activation of the emergency medical system. Efforts have been made to strengthen the link of early access through increasing public education that targets individuals who are most likely to witness a cardiac arrest in a community or home setting. Research has shown that a person who witnesses a cardiac arrest is more likely to call other people (e.g., friends, neighbors, physicians) before activating the emergency communication system. Consequently, additional public education has been directed toward a "phone first" campaign that instructs people to notify EMS first before making other calls or initiating cardiopulmonary resuscitation (CPR). Other efforts have been directed toward the establishment of an easily dialed emergency dispatch system and toward public education to ensure that people living in any given community are familiar with the local emergency number to call. Healthcare professionals can help to strengthen the link of early access for patients through patient and family education. Pertinent patient/family education may include helping high-risk patients and family members to make plans for emergencies. When to call for emergency help, how to access the emergency medical system in their local area, and identifying an appropriate, easily visible place to post emergency numbers are key points to include. When appropriate, health professionals can encourage family members to enroll in local CPR courses [41,42,43].

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  13. Of the following, which actions would strengthen the link of "early CPR" in the chain of survival?

    OVERVIEW: AMERICAN HEART ASSOCIATION "CHAIN OF SURVIVAL"

    The prompt initiation of CPR as soon as a cardiac arrest is recognized is critical. The structured pattern of chest compressions and ventilations can produce adequate blood flow to the brain and the heart until EMS can arrive and initiate more advanced measures. To strengthen this link, the American Heart Association and American Red Cross have implemented training programs for citizens in an attempt to ensure that bystanders who witness a cardiac arrest will know how to perform CPR. Some data collected suggest that mass training of the civilian population to perform CPR may not be the most effective, because many people who choose to attend training will never see a cardiac arrest. Alternative suggestions for increasing the availability of trained lay rescuers include [41,42,43]:

    • Targeting persons or groups of persons who are most likely to need to perform CPR. Because many victims of sudden cardiac death are middle-aged adults and older, targeted groups would include persons who, as part of their routine family surroundings, work, or social life, are frequently in contact with middle to older age adults. Examples of targeted groups include staff in senior centers and family members and friends of persons who are at risk for cardiac arrest. Training of personnel in gyms or "workout" facilities would be another example of targeted group education.

    • Training EMS dispatchers to give instructions for hands-only CPR (i.e., compression only) over the telephone. Hands-only CPR is substantially easier for EMS dispatchers to instruct and shows similar survival rates among victims when compared with traditional CPR.

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  14. Before pressing the "analyze" button on an AED, the rescuer should

    OVERVIEW: AMERICAN HEART ASSOCIATION "CHAIN OF SURVIVAL"

    If an AED is available, it should be obtained immediately after the rescuer has determined that the victim is unresponsive and the emergency medical system has been activated. Some state legislation governing the use of AEDs requires that the rescuer notify EMS that an AED is available at the site. To use the AED, the rescuer first turns the device on, then attaches the electrodes to the victim in the designated locations. Diagrams showing proper electrode placement are printed on many of the electrode packages to guide the rescuer in determining proper placement. Electrode pads should not be placed directly over implanted pacemaker or ICD sites or over transdermal medication patches. If needed, transdermal patches may be removed and the skin wiped clean before the electrode pads are applied. After the electrodes are attached, the rescuer must make sure that no one is touching the patient. Once the rescuer is sure that the patient is "cleared," the rescuer depresses the "analyze" button on the AED. If prompted that a shock is indicated, the rescuer again verifies that no one is touching the patient and depresses the "shock" button [41,44]. According to CPR guidelines, delivery of the shock should be followed immediately by chest compressions [10,43].

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  15. The definitive treatment of choice for ventricular fibrillation or pulseless ventricular tachycardia is

    EMERGENCY MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    The definitive treatment of choice to suppress ventricular fibrillation or pulseless VT is direct current defibrillation [10,43]. Chest compressions should be initiated while waiting for the defibrillator to be set up and charged. Then, administer a single defibrillation shock. Most defibrillators currently in use deliver a biphasic waveform. The recommended energy dose for biphasic waveform is 120–200 joules (i.e., the specific dose within the range that has been found effective in terminating ventricular fibrillation/pulseless VT with the specific device in use). If the effective dose for a specific biphasic device is unknown, 200 joules should be used. Alternatively, if the defibrillator is monophasic, use 360 joules. Compressions should not be delayed to check the pulse or rhythm immediately after a shock is delivered.

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  16. The initial medication of choice for treatment of stable sustained monomorphic ventricular tachycardia is

    EMERGENCY MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    Class IIa Recommendations

    • Administration of IV procainamide is the initial treatment of choice. For suppression of sustained monomorphic VT, procainamide may be initiated with a loading dose of 20–50 mg/min (or 100 mg every five minutes) until the VT is suppressed, or until a maximum loading dose of 17 mg/kg has been reached or until the patient develops the side effects of hypotension or a widened QRS complex (more than 50% over patient's baseline QRS complex). It may be followed by a maintenance infusion of 1–4 mg/min.

    • Administration of IV lidocaine may be considered for VT specifically associated with acute MI. Lidocaine for suppression of sustained monomorphic VT may be initiated with a 1–1.5 mg/kg bolus IV push. If necessary, a lidocaine infusion may be repeated at a dose of 0.5–0.75 mg/kg every 5 to 10 minutes up to a maximum total dose of 3 mg/kg. A bolus may be followed by a maintenance infusion of 1–4 mg/min.

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  17. Of the following, the immediate treatment of choice for hyperkalemia-induced arrhythmias is

    EMERGENCY MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    Unlike the management of some other ventricular arrhythmias, the management of rhythm changes caused by hyperkalemia must focus on the immediate correction of the potassium level. If the potassium level is not corrected, interventions such as defibrillation and the use of IV medications to restore blood pressure and heart rhythm will be ineffective. Possible urgent/emergency interventions for severe hyperkalemia include the administration of calcium chloride 500–1,000 mg IV or the administration of one ampule of D50W (50% dextrose in water) plus 5–10 units of regular insulin IV to restore a normal serum potassium level [10,19].

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  18. Which of the following should be included in a patient history for a person who has had a ventricular arrhythmia?

    LONG-TERM MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    Key points to cover in a patient history include:

    • Has the patient experienced an arrhythmia episode before? If so, when? What happened? What symptoms did the patient have? How was it treated?

    • Is the patient taking any antiarrhythmic medications at this time? If so, which ones? At what dose? Has the patient missed doses? Is there any indication that the patient might have been taking extra doses? In some cases, evaluation of serum drug levels may be indicated to check for the presence of therapeutic or toxic levels.

    • What other medications is the patient taking? Have there been any recent changes in the medications that the patient takes? Do any of the patient's noncardiac medications have cardiac side effects? Inquire about prescribed, over-the-counter, and natural or herbal medications that the patient may be taking.

    • Does the patient have any history of heart disease? Coronary artery disease? Stents? Percutaneous transluminal coronary angioplasty (PTCA)? CABG? Heart valve disease, especially mitral valve or aortic valve disease? Has the patient had an MI? Does the patient have congestive heart failure? Cardiomyopathy? If heart disease is present, how is it being treated? How well are the patient's symptoms controlled?

    • What symptoms is the patient experiencing? Does the patient have any symptoms of reduced cardiac output, such as weakness, light-headedness, unexplained falls or near falls, syncopal episodes, dyspnea, or reduced activity tolerance? Do family members report any changes in the patient's usual functioning?

    • Does the patient have a history of a close family member (e.g., parent, sibling) who died unexpectedly at a young age or who has/had a history of unexplained syncopal episodes or a known history of sudden cardiac death episodes?

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  19. Which of the following is a class I recommendation regarding the management of incessant VT?

    LONG-TERM MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    RECOMMENDED THERAPIES FOR MANAGEMENT OF VT

    ECG PresentationRecommendationsComments

    Sustained monomorphic VT

    Class I

    If tachycardia is wide complex, presume VT if diagnosis uncertain. Direct current cardioversion if patient is unstable

    Class IIa
    Consider IV procainamide.
    For repetitive monomorphic VT in patients with coronary heart disease or idiopathic VT, use of IV amiodarone, beta blockers, procainamide may be useful.
    Class IIb
    Consider IV amiodarone for VT that is unstable, refractory to counter-shock, or recurrent despite procainamide.
    Polymorphic VT (QT interval normal during intervening SR) Class I Polymorphic VT with a normal QT interval is most commonly seen during acute ischemia or myocardial infarct, but it may also occur in cardiomyopathy and heart failure.
    If unstable, suppress arrhythmias with direct current cardioversion.
    Consider IV beta blockers if ischemia is present or suspected.
    Consider loading with IV amiodarone.
    Consider urgent angiography leading to revascularization if acute MI cannot be ruled out.
    Class IIb
    IV lidocaine may be reasonable when acute MI cannot be ruled out.
    Torsades de pointes Emergent treatment When replenishing potassium, a target level of 4.5–5.0 mmol/L may be considered.
    Direct current cardioversion or defibrillation, followed by consideration of IV magnesium when secondary to a long QT interval
    Isoproterenol infusion and/or ventricular pacing to increase heart rate in patients with bradycardia and drug-induced prolonged QT
    Class I
    Stop offending drugs and correct electrolyte abnormalities.
    Consider acute and long-term pacing for patients with torsades de pointes due to heart block and symptomatic bradycardia.
    Class IIa
    IV magnesium is not likely to be effective for patients with normal QT interval.
    Acute and long-term pacing is reasonable for recurrent pause-dependent torsades de pointes.
    Use of beta blockers combined with pacing is reasonable acute therapy for patients in torsades de pointes who have sinus bradycardia.
    Isoproterenol is a reasonable temporary treatment for pause-dependent torsades de pointes in patients who do not have congenital long QT syndrome
    Incessant VT Class I
    For patients with incessant or recurrent polymorphic VT due to myocardial ischemia, use IV amiodarone followed by VT ablation.
    Class IIa
    IV amiodarone followed by VT ablation may be used in the management of recurring or incessant monomorphic VT storm.
    ACLS=advanced cardiovascular life support; MI=myocardial infarction; VT=ventricular tachycardia.
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  20. The abrupt development of PVCs may indicate

    MANAGEMENT OF PVCs AND NONSUSTAINED VT

    In persons with structurally normal hearts, isolated PVCs can occur normally and without symptoms. These PVCs carry minimal risk of producing sudden cardiac death and do not require treatment. If the patient experiences symptoms such as palpitations, light-headedness, near syncope, or reduced activity tolerance, treatment to control the PVCs to decrease symptoms may be implemented. Initial treatment may focus on explanation of what the arrhythmia is and why it is causing symptoms coupled with reassurance that the arrhythmia is not dangerous and will not lead to serious problems. Given the serious side effects associated with antiarrhythmic drug therapy, antiarrhythmics are often not the first treatment of choice for these patients. The patient may be assessed for the use of substances such as caffeine, nicotine, cocaine, and some over-the-counter medications that have been known to trigger PVCs. Often, reduction or elimination of the offending substance(s) is sufficient to eliminate the PVCs and related symptoms. For persons whose symptoms persist, the use of antiarrhythmic medications or radiofrequency ablation may be considered. Particularly in hospitalized patients (or persons who are ill), the abrupt occurrence of PVCs or nonsustained VT in persons without heart disease may be triggered by electrolyte imbalances such as hypokalemia or hypomagnesemia. Often, correction of the electrolyte imbalance eliminates the arrhythmias [1,3,25].

    In persons with known risk factors for heart disease, the abrupt occurrence of PVCs or nonsustained VT may be an indicator of myocardial ischemia or infarction. In these cases, further assessment is necessary. If ischemia is present, measures to reduce the ischemia are indicated. If the arrhythmias are severe, medications such as IV lidocaine may be used to suppress them. In persons with known heart disease who are not experiencing acute ischemia, the occurrence of PVCs and nonsustained VT does not usually lead directly to the development of a sudden cardiac arrest; however, their occurrence may be an indication that the patient's underlying disease has progressed to the point that the patient's overall risk of developing sudden cardiac death has increased. In these patients, the long-term goal of therapy is not the suppression of the PVCs or the nonsustained VT but rather the prevention of sudden cardiac death [1,3,25].

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  21. According to the AHA, ACC, and NASPE device-based therapy guidelines, ICD implantation is indicated for persons

    IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY

    Guidelines from the AHA, ACCF, and HRS regarding device-based therapy for cardiac rhythm abnormalities make extensive recommendations for the appropriate use of ICD therapy. In brief, the strongest (i.e., category I) indications for ICD implantation includes [59]:

    • Persons who have LVEF ≤35%, sinus rhythm, left bundle branch block with a QRS duration ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on guideline-directed medical therapy

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  22. The lead system for an ICD is most commonly implanted

    IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY

    The ICD lead is a small, flexible insulated wire that connects the ICD generator to the patient's myocardium. An ICD lead is used to relay information about electrical activity in the heart and to deliver electrical therapy when indicated. Most commonly, ICD leads are inserted transvenously and positioned into the endocardium. Leads may have a small amount of a steroid in a reservoir at the tip of the lead. When the lead is positioned and attached, the steroid is released. The steroid, through its anti-inflammatory action, reduces the amount of inflammation and scar tissue that could develop around the tip of the lead. Minimizing scar tissue allows the electrode at the end of the lead to deliver electrical pacing impulses more effectively. Lead systems in an ICD can be very complex. For basic ICD function, a single lead, consisting of sense/pace electrodes and defibrillation electrode(s), is implanted into the right ventricle. For dual-chamber systems, both atrial and ventricular leads are implanted. ICD systems that provide dual-chamber biventricular pacing may use three leads, one positioned in each ventricle and one in the right atrium. The specific configuration of ICD leads may vary from manufacturer to manufacturer.

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  23. The usual power source for new generation ICDs is a

    IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY

    To function as a defibrillator, an ICD must have the capability of building up a high-energy charge rapidly. ICDs use lithium vanadium pentoxide or lithium silver vanadium pentoxide batteries. The batteries are sealed in titanium to prevent leakage. The average battery life is 8 years or longer and is influenced by the type and frequency of electrical therapy delivered [58]. As with a permanent pacemaker, when the battery is depleted the entire ICD generator must be replaced.

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  24. A pacing option available with ICD therapy is

    IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY

    A routine feature in any modern ICD is back-up ventricular demand pacing. Sometimes referred to as VVI pacing, back-up ventricular demand pacing was primarily designed to pace the heart if a slow heart rate occurred following the heart's recovery from a defibrillation shock. In persons whose ventricular arrhythmias were thought to result when the patient's heart rate dropped, the VVI function in the ICD could also provide intermittent pacing. However, back-up bradycardic pacing was never designed to function as a full-time pacemaker for the heart. One of the primary limiting factors was battery life; continuous pacing would significantly decrease the battery life of the ICD. For a period of time, if a patient required ICD therapy and pacemaker therapy, two separate devices were implanted. This worked adequately, but device interactions created some programming problems. Now ICDs are designed to provide both full pacemaker and ICD therapies. Options include [8,58]:

    • Dual-chamber sensing that monitors electrical activity in both atria and ventricles.

    • Dual-chamber pacing that provides a pacing impulse to trigger depolarization in the atrium, the ventricle, or both in proper sequence.

    • Rate-responsive feature that triggers the pacemaker to pace the heart at a faster or slower rate (within programmed parameters) in response to the body's metabolic demands.

    • Cardiac resynchronization therapy that uses pacing stimuli to recoordinate the depolarization and contraction of the right and left ventricles (referred to as biventricular pacing). Cardiac resynchronization therapy is a rapidly expanding treatment option for some patients with severe congestive heart failure.

    • A dual-chamber ICD that is capable of treating atrial and ventricular arrhythmias.

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  25. Appropriate patient education prior to ICD implantation should include which of the following?

    IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY

    Education for the patient and the patient's family begins in the preoperative period and continues throughout the patient's life. Patient education in the preoperative period focuses on addressing the patient's immediate questions and concerns and on providing the patient and family with information about what to expect during implantation and in the period immediately following implantation. Many patients and their families are very anxious about ICD implantation. They may express fears of the ICD firing or the ICD failing to fire when needed. When interacting with them, there are some general points to keep in mind. Many patients who receive ICDs have had a sudden cardiac arrest; this usually represents a major crisis to the patient and to the patient's family. Similarly, because implantation of an ICD is often a graphic reminder that the patient has a life-threatening condition, ICD implantation is also often a time of crisis for the patient and family. During crisis, people do not learn new information or new skills well. They require time to adapt to the changes in the patient's health status and in his or her lifestyle. The short length of stay permitted for ICD implantation limits the amount of information that can be presented or learned. Written instructions should be provided as well as information on outside resources and community support groups (Resources). Patients and their families often have specific concerns about how an ICD may interfere with their normal activities or with their ability to use certain types of equipment. Eliciting any concerns or questions the patient has and responding specifically to those during the preoperative period is very important. Providing specific information about what the patient can expect before, during, and immediately after ICD implantation may also help to reduce the patient's anxiety. The following topics are often helpful to cover in the preoperative period [60,61,62]:

    • A brief explanation of how an ICD works

    • A brief discussion about why the device is necessary for the patient. The explanation should not be overly technical and should be directly linked to the patient's specific situation. It is important to stress that the ICD does not prevent arrhythmias from occurring but it monitors the heart continuously and will provide immediate treatment should a life-threatening arrhythmia occur.

    • A brief description of what sensations the patient may experience when the ICD discharges. Patients have described the high-energy shock as "very painful" or like a "kick in the chest."

    • A brief description of what the patient's partner or family may experience when the patient's ICD fires. With a high-energy shock, the patient may appear startled, go limp and fall, lose consciousness briefly, or have some body movements that look similar to seizure activity. Following discharge of the ICD, some patients may be disoriented for a short period of time. If someone is touching the patient when the ICD delivers a high-energy shock, he or she may feel a tingling sensation.

    • A brief description of what an ICD generator and lead system look like. ICD manufacturers are a good source of pictures and diagrams of their products. Some also provide informational videos directed at patients and their families.

    • A brief discussion about where the ICD will be implanted and how the leads will be attached

    • A brief discussion about the use of moderate sedation during the procedure to minimize discomfort

    • A brief description of the usual preoperative preparation procedures

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  26. For a person with an implanted defibrillator, which of the following is correct about the use of a cell phone?

    MANAGING WITH AN ICD AT HOME

    Portable cordless telephones and many cell phones do not interfere with ICDs. However, as cellular phone technology is constantly changing, it is prudent to instruct patients to use some precautions when using or carrying a cell phone. Consider covering the following points [72]:

    • Maintain at least a 6-inch distance between the cell phone and the device. Use the ear on the opposite side from the device when talking on a cell phone.

    • Carry the cell phone in a pocket away from the generator; avoid carrying the phone in the pocket that is right over the generator site when the phone is turned on.

    • Cordless household telephones are not the same as cellular phones and should not interfere with the device's function.

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  27. A patient's emotional response to implantation of an ICD may include

    MANAGING WITH AN ICD AT HOME

    Research has shown that patients with ICDs report strong feelings of fear, terror, and anxiety [58]. If the patient experiences a shock from the ICD, his or her anxiety and fear may increase. If the ICD fires without warning, patients may become additionally anxious and fearful. Common fears include fear of a shock, fear that the device will fail, and fear of death. Persons with an ICD also have been found to experience a strong sense of loss of control. They struggle with the realization that the device may fire without warning and that they have no control over when the device fires. Some people who experience a shock may respond by restricting their activities in an attempt to avoid "triggering" the device another time. They may repeatedly analyze the circumstances of the initial shock, attempting to establish a "cause and effect" that will help them avoid a future shock. Occasionally, people with an ICD develop the phenomenon of a "phantom shock." Briefly defined, a phantom shock occurs when the patient feels that the ICD has fired although the device actually has not discharged an electrical shock. People may experience anger and depression over their loss of independence and their decline in health status [58]. Other issues include employability, maintenance of their current job, obtaining a different job, eligibility and maintenance of insurance coverage, and the costs involved in ICD follow-up and medical care. Patients also report that they experience a variety of physical complaints during the months following ICD implantation. These include insomnia and sleep disturbances, lack of energy, dizziness, weakness, decreased exercise tolerance, and weight loss or gain. Short-term memory loss, difficulties in coping, and problems with family functioning may be experienced. The patient's partner and close family and friends also report anxiety and fear related to the implantation of the ICD. Some express the fear that they "will not know what to do if the ICD fires." Some partners report changes in sexual activity brought about by the fear that such activity will trigger the ICD. Some people are concerned that they might experience a shock if they are touching the patient when the patient's ICD fires. Persons with ICDs report that their partners and other family members often become overprotective [58,60,62,67,68]. Interventions that are helpful to the patient and family include:

    • Referral to a local support group for ICD patients and their families

    • Assistance in helping the patient and family develop and rehearse a plan for what to do when the patient receives a shock and what to do in the event of an emergency

    • Recommendation that partners or family members take a community-based CPR course

    • Referral for professional counseling for management of anxiety and depression and development of increased skills in coping with a life-threatening illness

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  28. Which of the following is an indication of impaired healing following ICD implantation?

    MANAGING WITH AN ICD AT HOME

    Following ICD implantation, the generator site should be carefully assessed for indications of impaired healing or signs of complications. Complications that may occur include infection in the pocket, development of a hematoma in the pocket site, and erosion of the generator or the lead through the tissue and skin. Persons with diabetes are more at risk to develop an infection. Persons taking anticoagulants are at risk to form a hematoma in the generator pocket [73]. Signs of impaired healing may include:

    • Subjective complaint of increased pain at the generator site

    • Increased swelling present in the pocket area

    • Elevated temperature or other signs of systemic infection

    • Purulent drainage from the incision site

    • Failure of the incision line to heal

    • Warmth or redness around the incision line or pocket

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  29. Inappropriate ICD shocks may result from

    LONG-TERM MANAGEMENT OF ICD FUNCTION

    In the past, a large number of people with ICDs received inappropriate electrical shocks for rhythms other than VT or ventricular fibrillation [75,76]. Non-life-threatening rhythms that the ICD commonly mistook for VT included sinus tachycardia and supraventricular tachycardia [57,77]. Given the enhancements incorporated into current generation ICDs, the risk of shocks for sinus tachycardia or supraventricular tachycardias is much less. In addition, the use of dual-chamber ICDs that can sense electrical activity in the atria has improved the device's ability to discriminate between VT and rapid atrial fibrillation or atrial flutter. When the patient suspects an inappropriate shock in the absence of persisting severe symptoms (e.g., chest pain, shortness of breath, rapid palpitations), he/she should contact the physician and schedule an appointment for interrogation of the device for stored data and testing of lead function [77]. Device problems that may result in delivery of inappropriate shocks include EMI, T-wave oversensing, a dislodged lead, a fractured lead, or a break in the insulation covering the lead [57]. Replacement of the lead may be required.

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  30. ICD "electrical storm" may be defined as

    LONG-TERM MANAGEMENT OF ICD FUNCTION

    In an "electrical storm," a patient receives multiple appropriate shocks from his or her ICD for VT or ventricular fibrillation within a relatively short period of time. Most sources define an ICD storm more precisely as at least three or more appropriate shocks within 24 hours [79,80,81,82]. Factors that may trigger electrical storm include modification of or noncompliance to drug therapy, worsening of heart failure, early postoperative period, emotional stress and anger, alcohol excess, electrolyte abnormalities, and myocardial ischemia. Most cases, however, occur without any apparent cause [77]. More than 80% of cases of electrical storm are caused by episodes of monomorphic VT; however, it can also occur due to polymorphic VT/ventricular fibrillation. Knowledge of the type of underlying arrhythmia is important when selecting a management strategy. Electrical storm has been reported in 10% to 40% of patients in secondary prevention; the incidence is lower in primary prevention [77].

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  31. The treatment of choice for the management of ICD storm is

    LONG-TERM MANAGEMENT OF ICD FUNCTION

    After ICD interrogation confirms that the shocks were appropriate and that no device malfunction occurred, clinical management focuses on strategies to prevent high-energy shocks through other means of arrhythmia control. The treatment option of choice is the addition of antiarrhythmic medications. Although some antiarrhythmic medications have been linked to increased mortality in patients with heart disease who do not have an ICD, many antiarrhythmic medications may be safely used in persons with an ICD to prevent repeated defibrillation shocks [5]. Antiarrhythmic drugs may be used in persons with an ICD to suppress episodes of nonsustained VT, suppress episodes of sustained VT, slow the rate of VT and increase the efficacy of ATP in terminating the arrhythmia, and prevent the syncope that may be associated with faster rates of VT.

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  32. Which of the following is considered a Class Ia antiarrhythmic drug?

    ANTIARRHYTHMIC DRUG THERAPY

    CLASSIFICATION OF ANTIARRHYTHMIC MEDICATIONS

    ClassAction/PropertiesClass Proarrhythmic EffectsSpecific Agents
    Ia
    Blocks the rapid influx of sodium
    Slows rate of development of phase 0 of the action potential
    Slows conduction velocity; QRS complex widens
    Prolongs repolarization; QT interval lengthens
    Torsades de pointes (quinidine)
    Ventricular fibrillation or asystole
    Second degree heart block
    Quinidine
    Procainamide
    Disopyramide
    Ib
    Sodium channel blocker
    Shortens action potential duration
    Shortens repolarization
    Used only for management of ventricular arrhythmias
    Increased premature ventricular contractions (rare)
    Atrioventricular block/conduction disturbances
    Lidocaine
    Mexiletine
    Ranolazinea
    Ic
    Significant block of sodium channel
    Slows conduction velocity; QRS complex widens
    Has no effect on repolarization; QT interval unaffected
    Re-entry arrhythmias
    Flecainide
    Propafenone
    II
    Beta adrenergic blockers
    Slows AV node conduction
    Slows sinus rate
    Decreases myocardial oxygen consumption
    Sinus bradycardia
    Atrioventricular block
    Metoprolol
    Acebutolol
    Sotalol
    III
    Blocks outward movement of potassium ions in phase 3 of the action potential
    Prolongs repolarization; lengthens QT interval
    Prolongs cardiac action potential and effective refractory period
    At increased heart rates, has reduced ability to affect/slow the cardiac action potential
    Sinus bradycardia
    Torsades de pointes
    Amiodarone
    Dofetilide
    Sotalol
    Dronedaroneb
    IV
    Calcium channel blockers
    Blocks slow inward movement of calcium ions into myocardial and vascular smooth muscle
    Slows conduction through sinoatrial, atrioventricular nodes
    Prolongs atrioventricular node refractory period
    Sinus bradycardia
    Atrioventricular block
    Verapamil
    Diltiazem
    aRanolazine is a novel antianginal drug with potent ion channel blocking effect and is thus considered a class Ib agent. Based on limited clinical experiences, it appears to be beneficial as add-on therapy in patients with recurrent VT while on a class III antiarrhythmic.
    bShown to be effective in suppressing VT in case reports of patients with refractory VT/VF episodes; concerns exist about its safe use in patients with structural heart disease
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  33. According to the antiarrhythmic medications classification system, diltiazem is considered to be Class

    ANTIARRHYTHMIC DRUG THERAPY

    CLASSIFICATION OF ANTIARRHYTHMIC MEDICATIONS

    ClassAction/PropertiesClass Proarrhythmic EffectsSpecific Agents
    Ia
    Blocks the rapid influx of sodium
    Slows rate of development of phase 0 of the action potential
    Slows conduction velocity; QRS complex widens
    Prolongs repolarization; QT interval lengthens
    Torsades de pointes (quinidine)
    Ventricular fibrillation or asystole
    Second degree heart block
    Quinidine
    Procainamide
    Disopyramide
    Ib
    Sodium channel blocker
    Shortens action potential duration
    Shortens repolarization
    Used only for management of ventricular arrhythmias
    Increased premature ventricular contractions (rare)
    Atrioventricular block/conduction disturbances
    Lidocaine
    Mexiletine
    Ranolazinea
    Ic
    Significant block of sodium channel
    Slows conduction velocity; QRS complex widens
    Has no effect on repolarization; QT interval unaffected
    Re-entry arrhythmias
    Flecainide
    Propafenone
    II
    Beta adrenergic blockers
    Slows AV node conduction
    Slows sinus rate
    Decreases myocardial oxygen consumption
    Sinus bradycardia
    Atrioventricular block
    Metoprolol
    Acebutolol
    Sotalol
    III
    Blocks outward movement of potassium ions in phase 3 of the action potential
    Prolongs repolarization; lengthens QT interval
    Prolongs cardiac action potential and effective refractory period
    At increased heart rates, has reduced ability to affect/slow the cardiac action potential
    Sinus bradycardia
    Torsades de pointes
    Amiodarone
    Dofetilide
    Sotalol
    Dronedaroneb
    IV
    Calcium channel blockers
    Blocks slow inward movement of calcium ions into myocardial and vascular smooth muscle
    Slows conduction through sinoatrial, atrioventricular nodes
    Prolongs atrioventricular node refractory period
    Sinus bradycardia
    Atrioventricular block
    Verapamil
    Diltiazem
    aRanolazine is a novel antianginal drug with potent ion channel blocking effect and is thus considered a class Ib agent. Based on limited clinical experiences, it appears to be beneficial as add-on therapy in patients with recurrent VT while on a class III antiarrhythmic.
    bShown to be effective in suppressing VT in case reports of patients with refractory VT/VF episodes; concerns exist about its safe use in patients with structural heart disease
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  34. The usual loading dose for oral amiodarone is

    ANTIARRHYTHMIC DRUG THERAPY

    It is recommended that amiodarone therapy be initiated in the hospital setting with continuous ECG monitoring. A loading dose may be administered initially by IV or by mouth, followed by decreasing oral doses at a set interval. Usual dosing includes [1,91,92]:

    • Rapid IV loading dose: 150 mg IV in 100 mL of D5W administered over 10 minutes

    • Oral loading dose: 400 mg every 8 to 12 hours for one to two weeks

    • Followed by: 300–400 mg per day in single or divided doses

    • Reduce to: 200–400 mg/day

    • Followed by: 200 mg per day as a maintenance dose

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  35. The maximum recommended daily oral dose of sotalol is

    ANTIARRHYTHMIC DRUG THERAPY

    Only the oral form of sotalol is approved for use in the United States. The initial oral dose is 80–120 mg twice a day. The dose may be gradually increased to a maintenance dose of 160–320 mg in divided doses. The maximum recommended oral dose is 320 mg per day [37,91,93].

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  36. A proarrhythmia commonly caused by quinidine therapy is

    ANTIARRHYTHMIC DRUG THERAPY

    As mentioned, quinidine can have significant proarrhythmic effects, including the development of torsades de pointes. Side effects may be extremely troublesome and cause the patient to discontinue the medication independently. Side effects include nausea, anorexia, abdominal cramping, and diarrhea [37].

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  37. One risk associated with VT ablation performed in the electrophysiology laboratory is

    ABLATION OF VENTRICULAR TACHYCARDIA

    The preparation for radiofrequency ablation is similar to that for cardiac catheterization. The physician should explain the procedure and obtain informed consent. Risks associated with radiofrequency ablation include bleeding at the insertion site(s), hematoma formation, pneumothorax, and risk of death from arrhythmias that are invoked during the test and not terminated. Prior to the procedure, the electrophysiologist will review any antiarrhythmic medications that the patient is taking and make a recommendation about stopping those medications before the study. The patient should be NPO for six to eight hours prior to the procedure. Routine lab work, including a CBC, electrolyte panel, prothrombin time/international normalized ratio, and urinalysis should be done. A chest x-ray and ECG are also performed [7,9,27,95]. The ECG is usually performed to assess the location of scarring, if any, and to assess the overall pumping function of the heart [95,96].

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  38. The purpose of left ventricular reconstruction surgery is to

    SURGICAL RECONSTRUCTION

    Surgery to resect or reconstruct a left ventricle that has been severely damaged from a MI has been used to improve the heart's pumping ability and to reduce ventricular arrhythmias. When the left ventricle is damaged by an MI, an area of scar tissue forms; the size of the scar depends on the extent or severity of the MI. The presence of scar tissue in the heart interferes with the heart's ability to contract normally, producing signs of reduced cardiac output. The scar tissue also interferes with normal conduction of electrical impulses and creates conditions for ventricular arrhythmias to develop. Theoretically, reconstruction of the ventricle to remove the scar tissue permanently from the areas of functioning myocardium should improve the heart's pumping ability and reduce the incidence of arrhythmias. Various techniques have been developed to identify and separate the area of scar. If the area of scar is large, the dead tissue may be surgically removed and a patch applied. In some cases, at least two rows of circulation stitches may be placed around the border of the scar tissue; the stitches are pulled together so the scarred area is permanently separated from the functioning tissue. Reconstructive surgery is a high-risk procedure involving heart-lung bypass and is not indicated for all patients who have reduced left ventricular function following MI. Other names for reconstructive surgery (or similar procedures) include endoventricular circular patch plasty repair, Dor procedure, surgical ventricular restoration, and left ventricular aneurysmectomy reconstruction [102,103,104].

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  39. A key factor in managing medical costs associated with ICD therapy is

    TRENDS AND ISSUES IN THE MANAGEMENT OF VENTRICULAR ARRHYTHMIAS

    Long-term follow-up studies have shown that medical care costs are higher in patients with ICDs than in those without [4]. Some clinical trials have included measurements of both cost and clinical effectiveness. Based on available data, the Writing Group for Device-Based Therapy notes that [4]:

    • Proper patient selection is crucial to cost-effective device therapy. Improper patient selection increases medical care costs.

    • Theoretically, ICD therapy will be more cost effective when used for patients who have an increased risk for sudden cardiac death but a low risk for death from other causes.

    • For patients with reduced left ventricular function, additional risk stratification to better identify specific groups of patients who would benefit from ICD therapy might improve cost effectiveness.

    • Further improvement of the reliability and length of life of the device itself coupled with a reduction in cost of the device would also improve cost effectiveness.

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  40. In Case Study I, Patient CC's risk factors for sudden cardiac death include

    SIMULATED CASE STUDIES

    Rationale and comments: Patient CC has risk factors for sudden cardiac death, including reduced left ventricular function, ischemic heart disease, the continued presence of PVCs, and episodes of nonsustained VT after CABG surgery. Electrophysiology is indicated to determine if he is at high risk. If he is, implantation of an ICD is indicated. Some patients with heart failure who require an ICD may benefit from cardiac resynchronization therapy as well. In cardiac resynchronization therapy, a biventricular pacemaker is implanted, leads are placed in the right and left ventricles, and the device is programmed to coordinate the contraction of the right and left ventricles to restore a more normal pattern of ventricular contraction. Re-synchronizing ventricular contraction has been shown to improve functional status.

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