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суправентрикулярная
тахикардия:
клинические
рекомендации
eko
2019
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00:00:01
good afternoon, dear colleagues, today we
00:00:04
will talk about supraventricular
00:00:05
tachycardia and what is important for a
00:00:08
primary care doctor to know about this problem, we
00:00:11
will use information from the
00:00:13
clinical recommendations of the European
00:00:15
Society of Cardiology 2019, what is
00:00:20
meant by this rhythm disturbance,
00:00:21
supraventricular tachycardia sct
00:00:24
is tachycardia with pure atrial contraction
00:00:28
over 100 beats per minute at rest with
00:00:31
this source of rhythm located above the
00:00:34
branching of the fasciculus the diagram
00:00:36
shows the conduction system of the heart the
00:00:39
line separates the two sections of the
00:00:43
ventricular conduction system and the
00:00:45
ventricular one and the arrow shows us exactly those
00:00:47
sections that belong to the
00:00:50
conduction system above the ventricles this is the
00:00:52
anatomical separation of patients with
00:00:57
supraventricular tachycardia at an appointment with a
00:00:59
primary care doctor what may
00:01:01
bother them what will lead them to the doctor
00:01:04
what complaints is this rapid heartbeat
00:01:07
one of the most common frequent
00:01:09
problems for which such patients
00:01:11
seek medical help this is a
00:01:15
subjective complaint and it is not always
00:01:16
well tolerated by many patients
00:01:20
discomfort or pressure in the chest is one
00:01:23
of the also frequent complaints that cause
00:01:27
anxiety to patients, even to a large
00:01:31
extent anxiety about the state of health,
00:01:33
it can be shortness of breath, dizziness, shortness of breath
00:01:38
reflects both subjective problems and
00:01:46
hemodynamic features with a high heart rate,
00:01:50
dizziness and can be a manifestation of
00:01:54
cerebral disorders such
00:01:57
restlessness or complaints such as polyuria
00:02:00
can also occur in patients with
00:02:02
supraventricular tachycardia,
00:02:05
most often at the height of a
00:02:08
paroxysm of tachycardia, or at the end of the
00:02:10
end of this attack,
00:02:12
sweating as a manifestation of
00:02:14
autonomic disorders accompanying the
00:02:17
paroxysm, and 1 serious
00:02:21
worrying complaint may be a
00:02:22
faint state or complete
00:02:25
loss consciousness, this is most often
00:02:27
typical for elderly patients,
00:02:29
they do not tolerate paroxysms with a high
00:02:32
frequency of ventricular contraction, it is
00:02:35
often necessary to make a
00:02:37
differential diagnosis with other
00:02:39
conditions and diseases with
00:02:41
supraventricular tachycardia, what may
00:02:45
be similar to this disease, these
00:02:50
diseases are panic anxiety
00:02:52
disorder,
00:02:53
this is postural orthostatic
00:02:55
tachycardia, what is it? the problem is
00:02:59
postural orthostatic tachycardia
00:03:02
develops gradually when moving from a
00:03:04
supine position to a
00:03:06
vertical position, while it is not
00:03:09
accompanied by orthostatic
00:03:11
hypotension. If we measure the pressure of
00:03:13
such a patient, we will conduct a test, for example,
00:03:16
his pressure will not respond to a change in
00:03:19
body position from horizontal to
00:03:21
vertical, so what should we do with the
00:03:25
initial assessment of the patient
00:03:27
supraventricular tachycardia
00:03:28
according to the recommendations of the European
00:03:31
Society of Cardiology in 2019,
00:03:34
examination methods are divided into routine ones,
00:03:37
such as taking anamnesis, physical
00:03:40
examination of the patient,
00:03:42
12-lead electrocardiograms are required,
00:03:45
further laboratory methods include a detailed
00:03:49
general blood test,
00:03:50
biochemical blood test and thyroid
00:03:53
profile, the spectrum of
00:03:55
thyroid hormones must be examined
00:03:59
in this case In addition,
00:04:01
it is desirable that an electrocardiogram be obtained and
00:04:03
recorded
00:04:05
during a paroxysm of tachycardia
00:04:07
directly during this period. In addition,
00:04:10
routine methods also include
00:04:12
transthoracic echocardiography.
00:04:14
It can
00:04:17
provide detailed information about the structure of the
00:04:21
heart chambers about the pumping function of the
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left ventricle. First of all, this is
00:04:28
also very important. for the initial assessment of
00:04:30
the patient, SVT, an
00:04:32
expanded scope of examinations with you
00:04:35
about the screw of regular tachycardia, these are those
00:04:38
examinations that the patient must
00:04:40
undergo according to indications, well,
00:04:44
stress tests are included here, in some cases, a
00:04:47
reaction to stress is a kind of
00:04:50
provocation; a provocative test is not
00:04:53
often used in Russia for similar
00:04:55
events similar studies of
00:04:57
patients with 24-hour rhythms
00:05:02
Arabic ECG monitoring
00:05:04
electrocardiogram or recording on an
00:05:06
implantable drinking recorder it is
00:05:08
presented on this slide this
00:05:09
device for long-term recording kg not
00:05:13
only several days it is weeks a month
00:05:18
and in some cases even six months or
00:05:21
more depending from the battery charge,
00:05:23
of course, such information is very important,
00:05:28
especially if rhythm disturbances do
00:05:31
not occur often; it is difficult to catch them;
00:05:33
record them; in these cases, a loop
00:05:36
recorder that is implanted
00:05:39
under the patient’s skin in the cardiac area is very
00:05:42
helpful in solving the problem;
00:05:44
tests for myocardial ischemia in patients with
00:05:47
risk factors and bs men
00:05:50
over 40 years of age and postmenopausal women,
00:05:53
well, this is also an examination according to indications,
00:05:58
especially if there is a good reason
00:06:00
to suspect and bs cents an electrophysiological
00:06:04
study of the heart is a kind of gold
00:06:06
standard,
00:06:07
it is considered to confirm the
00:06:09
verification of the diagnosis, as well as in a situation
00:06:11
where catheter ablation is planned about
00:06:15
this study in this manipulation we
00:06:17
will also talk and the indications for it have
00:06:19
greatly expanded, let us
00:06:23
remember the classification of
00:06:25
supraventricular tachycardia, it has not
00:06:27
undergone significant changes, and the
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recommendations of 2019 present in the
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following version the first group of
00:06:37
tachycardia, then sinus tachycardia, which
00:06:40
includes physiological sinus tachycardia, an
00:06:42
adequate response, for example,
00:06:44
to physical stress, an adequate
00:06:47
response of the cardiovascular the vascular system of a
00:06:49
healthy person, along with this,
00:06:51
distinguishes non-physiological or
00:06:53
inadequate sinus tachycardia;
00:06:55
it occurs in situations that are not
00:06:58
accompanied by any example,
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physical activity, not emotional
00:07:03
stress, therefore they are defined as
00:07:06
from the reaction of the sinus node, it is more common;
00:07:12
nevertheless, in the presence of underlying
00:07:14
diseases, a clear example here is
00:07:15
patients with diabetes mellitus, they have
00:07:18
autonomic polyneuropathy, it
00:07:23
can be a manifestation, in particular, yes from the
00:07:27
cardiovascular system,
00:07:28
rapid heartbeat, which does not
00:07:31
depend on the situation, the patient
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is at rest or
00:07:38
undergoes some kind of minimal
00:07:40
physical stress, nevertheless, rapid
00:07:42
heartbeat is present constantly
00:07:44
sinus node variant of heretics Cordi is
00:07:47
another one component of this group of
00:07:50
tachycardia group of atrial tachycardia are
00:07:53
not found more often included here and it is a
00:07:56
focal atrial tachycardia
00:07:58
multi focus on or poly top on and we
00:08:01
know it atrial tachycardia it often
00:08:03
ends in atrial fibrillation
00:08:06
this is a fairly serious harbinger and
00:08:10
serious according to the forecast, rhythm disturbance in the
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macro center atrial tachycardia is in
00:08:17
this group, it is large, but I included
00:08:19
here only atrial flutter
00:08:22
typical typical various options we
00:08:26
continue the classification the third group
00:08:28
is tachycardia and tomorrow the screw of the regular
00:08:31
connection this includes such vessels includes
00:08:34
such options as from rewind regular
00:08:37
nodal n3 tachycardia
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a brevi
00:08:40
round physicist electrophysiology of rhythm lags
00:08:42
know it as
00:08:43
aurt not ren 3 nodal tachycardia, also
00:08:48
several options,
00:08:49
and a separate independent group is
00:08:52
atrioventricular reentrant tachycardia
00:08:55
and rt is only one letter, our
00:08:58
abbreviation has disappeared, a completely different
00:09:00
meaning, if there are additional ways of
00:09:02
conducting the traditional one, they are divided into
00:09:05
ort huge tachycardias and anti-drones and
00:09:09
vrt
00:09:12
on the slide the mechanisms of
00:09:15
various types of supraventricular
00:09:17
tachycardia are presented. A lot of
00:09:19
tachycardias work on the principle
00:09:21
they arise according to the principle of the reentry mechanism of
00:09:24
re-entry of the excitation wave. This
00:09:32
mechanism can be like a small,
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very small dart and,
00:09:38
for example, both situations with nodal
00:09:42
tachycardia and mo - closed n3
00:09:46
large loop where
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additional conduction pathways are carried out
00:09:52
atrioventricular n3 tachycardia
00:09:54
during atrial flutter can
00:09:56
use the
00:09:57
McCrory mechanism
00:09:59
involved n3 large tachycardias are involved goes
00:10:04
around large anatomical structures
00:10:06
this anatomical area in the right
00:10:09
chambers of the heart now I would like to briefly
00:10:14
touch on the history of clinical
00:10:16
recommendations for management patients with
00:10:17
elastic regular tachycardia me,
00:10:19
in fact, it is not that big, but it
00:10:25
affects the period after 2000, this is
00:10:28
2003, when the first
00:10:31
version of clinical recommendations for the
00:10:33
management of such patients with
00:10:35
supraventricular tachycardia me appeared in Europe,
00:10:37
then there was a period when this was no longer only
00:10:41
in but in In 2015, American
00:10:43
clinical guidelines were issued for the
00:10:46
management of patients with SVT in adult patients. In
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2017, our domestic
00:10:53
clinical guidelines for
00:10:55
supraventricular tachycardia appeared.
00:10:57
They were created at the Bakulev Scientific Center of the
00:11:00
Ministry of Health of the Russian Federation. Well,
00:11:02
in the nineteenth year, this document
00:11:07
updated a very long period,
00:11:09
look 16 years since the publication of the
00:11:12
first version of the clinical guidelines, in
00:11:14
2019, an update occurred.
00:11:20
European cardiologists have developed a new
00:11:25
version of the recommendations for the management of these
00:11:28
patients, and today the
00:11:30
Russian Society of Cardiology,
00:11:32
together with the Arrhythmologist Society of
00:11:35
Cardiovascular Surgeons of the Russian
00:11:36
Federation, has prepared a draft
00:11:39
clinical guidelines for
00:11:40
supraventricular tachycardia. has
00:11:42
not yet been officially adopted, but in the
00:11:45
likely twentieth year this will happen,
00:11:48
that is, the evolution of clinical
00:11:51
recommendations for supraventricular
00:11:52
tachycardia is moving quite
00:11:56
slowly, this is due to the fact that it is difficult to
00:11:59
recruit groups of patients large enough from the point of
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view of evidence-based medicine
00:12:03
to prove the effectiveness of
00:12:05
certain interventions, the use of certain
00:12:08
other
00:12:09
antiarrhythmic drugs, including shock groups of
00:12:12
patients, but nevertheless, today we
00:12:14
have a fresh document on the management of such
00:12:17
patients, I will remind you that in clinical
00:12:20
practice, supraventricular tachycardias
00:12:23
are tachycardias with a narrow
00:12:26
or wide complex qrs,
00:12:28
what is it again, let us recall the term
00:12:32
tachycardia with a narrow complex qrs is
00:12:33
the duration of this element and kg,
00:12:36
we know that the ventricular cortex in the
00:12:38
complex is 120 milliseconds or
00:12:41
less; the slide shows
00:12:43
a fragment of an electrocardiogram of tachycardia
00:12:45
with a narrow qrs complex;
00:12:48
narrow qrs complexes are caused by rapid
00:12:52
activation of the ventricles using the porteño system;
00:12:54
this indicates
00:12:57
that the source of the rhythm is located above or
00:13:00
inside the bundle of his on the first slide, we
00:13:03
saw this in the diagram,
00:13:04
yes, just the source is above the line
00:13:06
separating above and above the ventricular
00:13:10
conduction system, the term
00:13:13
tachycardia with a wide qrs complex
00:13:16
is used in situations when its
00:13:18
duration is more than 100
00:13:20
20 milliseconds fragments when also
00:13:23
is presented on the slide and immediately visually
00:13:26
we pay attention to the width and
00:13:28
qrs complexes
00:13:30
during tachycardia, why does this happen
00:13:34
with supraventricular tachycardia, what is the
00:13:36
reason for
00:13:37
this, there may be several reasons,
00:13:39
several explanations, firstly, there may be a
00:13:43
concomitant blockade of the bundle branches, there
00:13:45
may be an operant effect
00:13:49
that is, in a roundabout way of conducting
00:13:51
impulses, the widening of the qrs complexes
00:13:55
may be associated with a drug-
00:13:57
induced slowdown, and
00:13:59
conduction conduction may take
00:14:04
place anterogrodno and
00:14:06
conduction along additional conduction
00:14:09
paths, and finally, during ventricular stimulation,
00:14:11
when the pacemaker
00:14:14
perceives its own atrial
00:14:17
impulses, the electrical intrinsic
00:14:18
activity of the complexes
00:14:20
in all In these cases, the qrs complexes may
00:14:22
be wide, of course,
00:14:24
either a functional diagnostics specialist or an arrhythmologist cardiologist can understand this in detail,
00:14:32
but however, we will keep in mind all
00:14:35
tachycardias with a wide qrs complex
00:14:37
should be regarded as ventricular
00:14:40
until the contrary is proven,
00:14:44
respectively, we and
00:14:46
we choose the tactics for administering such patients as in case of
00:14:48
ventricular tachycardia, the
00:14:51
website presents the differential and
00:14:53
the algorithm. The algorithm is a differential
00:14:57
diagnosis of tachycardia with a narrow complex of
00:14:59
heart failure, and when its duration is no
00:15:02
more than 120 milliseconds, it is quite
00:15:05
informative, it is taken into account here, I
00:15:08
will not comment on it in detail, we will
00:15:10
now see what parameters are in the
00:15:13
differential in the diagnosis of
00:15:15
narrow complex tachycardia, what is taken into account is the
00:15:18
regularity of
00:15:19
the rhythm, this presence is visible and the presence, yes,
00:15:22
when we see the pkg wave with the eye,
00:15:24
this is the ratio of the frequency of atrial contraction
00:15:27
and the purity of ventricular contraction is
00:15:30
also important, this is the assessment of the
00:15:33
duration of the
00:15:34
intervals r t y p on the
00:15:37
electrocardiogram if we return to the
00:15:39
algorithm you can see that each of
00:15:42
these parameters is important and,
00:15:44
accordingly, reaching a certain
00:15:46
rhythm disturbance,
00:15:47
although purely pathognomonic
00:15:50
when in general there are no signs and criteria, it is
00:15:54
necessary to understand each specific case,
00:15:56
so we see we are reaching a
00:15:59
whole group of
00:16:00
arrhythmia having one or another set of
00:16:03
electrocardiographic signs
00:16:06
Well, what can we say about changes in
00:16:09
approaches to the treatment of such patients, taking into
00:16:11
account the
00:16:13
European recommendations of the nineteenth year, the draft
00:16:15
Russian recommendations, the
00:16:18
following principles emerge today
00:16:21
in the first place is the
00:16:23
assessment of the stability of the hemodynamics of a
00:16:25
patient with supraventricular
00:16:27
tachycardia, if the hemodynamics
00:16:30
are unstable then they resort to
00:16:32
electrical pulse therapy, this is in all of
00:16:37
these situations,
00:16:38
if there are no signs of
00:16:41
hemodynamic instability, then we follow this
00:16:45
algorithm in the first place of this gusno, I’m talking
00:16:47
about us now, I’ll dwell on them in more detail
00:16:49
later, the introduction of ATP drugs in Russia
00:16:53
is trifon adenine before Nazim we are not
00:16:55
registered, we use triphosphate
00:16:58
names dosage 10 20 30 milligrams
00:17:01
gradually with increasing progress, you will be on I for a
00:17:04
therapeutic or diagnostic purpose,
00:17:06
sometimes this
00:17:07
will be the introduction of a drug, then
00:17:11
drugs that belong to the classes of
00:17:14
antiarrhythmic therapy,
00:17:15
it is aimed either at rhythm control
00:17:18
during supraventricular tachycardia or
00:17:20
purity, ventricular contraction
00:17:22
is involved if we carefully look at
00:17:24
almost all classes of antiarrhythmic
00:17:26
drugs to achieve this goal of these
00:17:28
goals and 1 1 c 2 3 4 but once again
00:17:34
almost everything is according to the Williams classification
00:17:37
and finally, invasive methods of treating
00:17:41
tachycardia are catheter ablation,
00:17:43
which today has been widely
00:17:45
introduced into practical arrhythmology and,
00:17:48
in general, it has had some success and
00:17:50
also provides emergency care to the
00:17:53
patient supraventricular tachycardia
00:17:56
to stop tachycardia with a narrow
00:17:58
qrs complex
00:17:59
with stable hemodynamics, we chose the
00:18:03
conditions when we have such maps with a narrow
00:18:05
hemodynamic complex consistently
00:18:06
used by the first stage of the sailing
00:18:09
test, one of the most common
00:18:11
is the valsalva maneuver, it has long been known that
00:18:15
specialists working in ambulance
00:18:18
use this technique, what it is
00:18:21
represents the Valsalva maneuver,
00:18:22
this is straining, an attempt to exhale with
00:18:25
the nose pinched
00:18:26
and the glottis closed, the
00:18:30
Valsalva maneuver is presented in front of you on the
00:18:31
slide, the first thing you need to do is
00:18:34
tell the patient to pinch your nose,
00:18:37
pinch your nose, then close your mouth, second
00:18:39
stage, third stage, try to
00:18:42
exhale sharply, let’s make a reservation right away that such a
00:18:46
maneuver
00:18:47
is recommended it is preferable to carry out
00:18:49
in the supine position with the
00:18:51
legs elevated; this recommendation even has a
00:18:54
class and level of evidence of 1b,
00:18:59
but the maneuvers do not always help in
00:19:02
regional tests;
00:19:03
therefore, there is a further algorithm for
00:19:06
providing assistance, taking into account the
00:19:10
medical effects of medications,
00:19:11
drug relief of tachycardia with a
00:19:14
narrow qrs complex
00:19:16
if the mechanic
00:19:19
does not have supraventricular tachycardia obvious a,
00:19:22
etc. for differential diagnosis
00:19:24
this is often the case at the
00:19:26
prehospital stage,
00:19:27
even at the stage of providing assistance in the emergency
00:19:31
department, the patient is recommended
00:19:32
to use the medicinal guests
00:19:34
adenosine triphosphate ATP
00:19:36
trifon adenine, we said it again, this is a
00:19:39
bolus injection intravenous
00:19:42
ATP 10 20 30 milligrams class level
00:19:46
of evidence for this method high one in
00:19:50
response for the introduction of ATP
00:19:54
here on the slide is adenosine, which
00:19:56
is used in Europe, it is
00:19:58
registered there, the answer may be different
00:20:02
if we have a tachycardia of regular
00:20:05
tachycardia with a narrow core with a complex, then
00:20:08
the situation may be the following effect
00:20:10
no possible dose small
00:20:12
may be gasoline delivery to Nazin yes
00:20:16
it can be carried out this is an option, a
00:20:19
special case of
00:20:20
high ventricular tachycardia, high
00:20:22
in location, the source of arrhythmia if there
00:20:26
is a gradual slowdown
00:20:29
with subsequent restoration of the
00:20:30
heart rate, it could be
00:20:33
sinus tachycardia,
00:20:35
it could be focal atrial
00:20:36
tachycardia or nodal
00:20:39
tachycardia, and you have nodal tachycardia, that is,
00:20:41
sinus rhythm is restored regularly
00:20:43
after administration the test gradually if it
00:20:47
suddenly stopped
00:20:48
matters to the fact of the
00:20:51
recovery factor of the rhythm soup mission it
00:20:53
could be atrial and you have nodal
00:20:56
tachycardia reentry recognize the sinus in
00:21:01
this basket, there are also their varieties and there
00:21:03
may be a last option when, in
00:21:05
response to the introduction, wearing a continuation of
00:21:09
atrial tachycardia with transient
00:21:11
separation from the regular one high
00:21:13
degree blockade occurs, this is typical
00:21:17
for atrial flutter, I
00:21:18
would like to draw your attention to the fact that the introduction of ATF does not
00:21:21
restore the rhythm of the nutrition of the atria,
00:21:24
it can change
00:21:28
when the picture of rhythm disturbance is
00:21:32
therefore used
00:21:35
as a diagnostic test, not only as a
00:21:37
therapeutic one, but if the administration of tf
00:21:42
did not help in any way we go further according to
00:21:45
the algorithm of drug relief of
00:21:47
riccardi with a narrow qrs complex, what
00:21:49
can be used among medications
00:21:51
drugs are listed here
00:21:56
in order of preference for
00:21:58
use in the first place beta 1
00:22:02
adrenergic blockers, that is, cardio-
00:22:03
selective drugs of this class
00:22:06
beta blockers belong to the second
00:22:07
class of antiarrhythmic drugs further
00:22:10
in that it can also be used this is not
00:22:15
hydra pyridine you and calcium antagonists
00:22:18
verapamil diltiazem class 4 he is the theorist
00:22:20
of further class 1 representative of
00:22:26
procainamide of mine we know as novocainamide or
00:22:30
class 1 theorists propafenone amiodarone
00:22:34
esata lol these are reserve drugs class 3
00:22:38
antiarrhythmic drugs from 2019
00:22:41
in clinical recommendations appear and
00:22:43
in the form of one single representative of
00:22:46
inhibitors of aif canals of sinus nodes, the
00:22:49
only one registered in Russia,
00:22:51
what are the indications for its use
00:22:54
since it appeared taxes and
00:22:59
as a pre-drug in control, we recently
00:23:02
for patients with sinus tachycardia for
00:23:05
whom it is indicated for patients with sinus
00:23:06
tachycardia after excluding reversible
00:23:09
causes, if symptoms are present,
00:23:12
therapy is recommended and in the form of us or
00:23:15
its combination with beta-blockers,
00:23:16
here is its clinical niche of
00:23:19
use, while calcium
00:23:21
channel blockers and catheter ablation are not
00:23:24
mentioned at all in the treatment of sinus
00:23:26
tachycardia section, that is, just the situation with
00:23:30
inadequate sinus non-
00:23:32
physiological tachycardia can be controlled by
00:23:35
the use of its brody mothers, and finally,
00:23:39
catheter ablation, which I have already
00:23:41
mentioned several times today for
00:23:44
supraventricular tachycardia, it is
00:23:49
presented by experts of the
00:23:51
European Society of Cardiology
00:23:53
as the main method of treatment for
00:23:55
supraventricular tachycardia when this is a
00:23:58
symptom of its nodal and
00:23:59
reciprocal tachycardia focal
00:24:01
atrial tachycardia atrial flutter
00:24:04
in some cases, if there are
00:24:08
high-risk signs associated with the presence of an
00:24:10
additional conduction pathway, also the
00:24:13
method of choice and for this is catheter
00:24:15
ablation, a
00:24:16
high class of evidence, the first
00:24:19
today, catheter ablation is
00:24:21
also recommended for asymptomatic
00:24:23
patients in the presence of
00:24:25
excitation and dysfunction of the left
00:24:27
ventricle, that is, situations when
00:24:29
arrhythmogenic has developed cardiomyopathy,
00:24:32
therefore, during the lecture we will dwell in
00:24:38
such a way that is included in the algorithm for
00:24:42
urgent treatment of
00:24:44
supraventricular tachycardia with a narrow
00:24:46
qrs complex
00:24:47
when the diagnosis is final, that is, the
00:24:50
type of arrhythmia has not been definitively established has
00:24:52
not been determined,
00:24:53
we have already listed and now we will summarize the list of
00:24:56
these measures
00:24:58
in case of hemodynamic instability this is
00:25:00
synchronized electropulse
00:25:02
therapy with which it is synchronized; the
00:25:04
discharge corresponding to the electric
00:25:07
discharge must be synchronized with the
00:25:09
qrs complex on the ECG in order to
00:25:12
successfully restore, interrupt tachycardia,
00:25:16
restore sinus rhythm,
00:25:18
if there is no instability, then we go to the
00:25:22
next step, I can use dreams and techniques, if they are
00:25:25
ineffective, intravenous administration of
00:25:27
adenosine or
00:25:30
ATP in Russia, if this is ineffective, the
00:25:33
following options are possible: either
00:25:36
intravenous administration of 1 pomelo or
00:25:38
do and Azimov calcium antagonists are not
00:25:40
hydra in front of a new series or
00:25:42
beta blockers
00:25:43
parenterally, well, if all these
00:25:46
measures are not effective, then again
00:25:48
consider electropulse therapy
00:25:52
as a change compared to
00:25:53
recommendations of 2003,
00:25:55
it should be noted that amiodarone and digoxin are
00:25:58
not mentioned in the section of
00:26:01
emergency care for patients with
00:26:03
ventricular tachycardia with a narrow
00:26:05
qrs complex,
00:26:09
if we have
00:26:10
supraventricular tachycardia with a wide
00:26:12
qrs complex
00:26:13
and the final diagnosis is also not clear,
00:26:16
what kind of rhythm disturbance is this, then the
00:26:20
algorithms are as follows,
00:26:22
starting again from the assessment of hemodynamics, if
00:26:26
it is unstable, then only
00:26:27
synchronized electropulse
00:26:29
therapy for emergency indications, if there
00:26:31
is no instability, again, the steps are the
00:26:33
following in regional techniques if they are
00:26:37
ineffective, parenteral administration of
00:26:38
ATP, but here with a big reservation, if there
00:26:42
are no signs of excitement on and kg
00:26:44
rest, therefore, for patients with suspected
00:26:46
additional pathways or with
00:26:48
evidence of their presence if the
00:26:50
patient already has and as well as signs of
00:26:53
additional pathways of
00:26:54
syndromes, for example, administration of tf is not
00:26:58
indicated, it will suppress the activity of
00:27:02
its own conduction system, these are the nodes
00:27:05
and you are the node in the first place
00:27:07
and will lead to a high frequency of
00:27:13
atrial contraction discharge
00:27:15
and the ventricles are fraught with the development of
00:27:18
life-threatening arrhythmias in
00:27:20
such patients, if this
00:27:23
measure is ineffective, we can consider
00:27:24
parenteral administration of
00:27:26
praca and us to class 1a or amiodarone
00:27:29
here it is lowered to class 2b, we
00:27:31
will immediately note that in comparison with and
00:27:34
clinical recommendations 3 years
00:27:37
the introduction of emergency management patients with
00:27:41
daughter tachycardia with a wide speed
00:27:44
complex, the class of evidence has been lowered
00:27:46
for me, I need 2b,
00:27:48
but Lol or Dicaine, these drugs are
00:27:51
not mentioned at all in 2019, in the
00:27:54
recommendations updated, if
00:27:57
drug therapy is ineffective,
00:27:58
electropulse is again considered for
00:28:03
another slide, rhythm disturbance, I
00:28:07
specifically brought this to a separate slide
00:28:10
she quite recognizable, familiar to a
00:28:13
primary care physician, I am a cardiologist,
00:28:15
especially a doctor of functional
00:28:16
diagnostics, this is atrial flutter, the
00:28:20
correct form is three to one about atrial
00:28:26
flutter, in the recommendations
00:28:29
there is a separate section, a fairly
00:28:31
large section, an
00:28:32
algorithm for providing emergency care to
00:28:35
patients with atrial flutter, even
00:28:38
wet n3 atrial
00:28:39
tachycardia is included he also starts from the
00:28:43
initial condition of the patient, is the
00:28:45
hemodynamics stable, if it is
00:28:47
unstable, synchronized
00:28:49
electropulse therapy, if there is
00:28:50
no instability, we are considering tactics
00:28:53
to control the rhythm, restore
00:28:56
and maintain sinus rhythm, and then, in the
00:28:58
essence of nutrition, the atrium is
00:28:59
preferable to electropulse
00:29:01
therapy; after all,
00:29:02
if there is no urgency, a strategy is chosen to
00:29:05
control the purity of the contraction of the ventricles.
00:29:07
rhythm degrading drugs
00:29:12
beta blockers or
00:29:14
verapamil or diltiazem intravenously
00:29:17
one of these drugs
00:29:20
and further tactics are already chosen
00:29:24
depending on the specific clinical
00:29:29
picture and the patient I want to note that
00:29:32
Rif Rolon appeared in the recommendations,
00:29:34
here it is and this is one of the new
00:29:37
Russian antiarrhythmics drugs,
00:29:40
but its use is possible only in
00:29:43
the conditions of an intensive care unit;
00:29:44
it is quite
00:29:47
aggressive; it has a model effect;
00:29:49
therefore, at the outpatient stage, it is necessary to in-
00:29:53
hospital; in no
00:29:55
case are changes compared to the
00:29:58
clinical recommendations of 2003 for the
00:30:01
management of patients with atrial flutter
00:30:03
and the urgent on and treatment provided
00:30:06
emergency assistance involving nutrition,
00:30:08
what changes have occurred? The class of
00:30:11
evidence for verapamil
00:30:13
and diltiazem A has been lowered to 2, and the class of
00:30:16
evidence for beta-blockers has also been lowered for
00:30:20
atrial or water stimulation through food.
00:30:24
Propafenone is categorically not
00:30:26
recommended in providing emergency
00:30:28
care to patients with atrial flutter,
00:30:30
we see the class of evidence 3 this
00:30:33
means that this effect
00:30:35
is ineffective
00:30:36
or harmful and digoxin, let’s say right away, is
00:30:39
not mentioned at all in the recommendations of the
00:30:41
nineteenth year in relation to atrial
00:30:43
flutter, if we talk about the
00:30:46
long-term administration of such patients for
00:30:50
the treatment of atrial flutter,
00:30:53
here we look at what form of symptom on
00:30:56
and recurrent rhythm disturbances symptom
00:30:59
on and recurrent if yes, then the
00:31:03
last patient and the solution to the question of the
00:31:05
possibility of catheter ablation, if this is
00:31:11
well tolerated by the patient, the situation
00:31:14
or rare relapses practically does not
00:31:16
recur, then drug
00:31:19
therapy is in accordance with the recommendations of the
00:31:21
arrhythmologist, and we see that here there is
00:31:23
also a place for catheter ablation, it
00:31:26
depends on the wishes of the patient, the
00:31:28
real possibilities of carrying out this
00:31:30
manipulations, but also among drug
00:31:34
therapy, these are beta-blocker drugs from
00:31:38
calcium agonists, not hyper advanced, it is
00:31:40
possible to use Midarona, but the class of
00:31:42
evidence is once again lowered. How do
00:31:45
you solve the question of whether anticoagulants are needed for
00:31:47
patients with manage regular
00:31:49
tachycardia mem Chotka we know what is the
00:31:52
algorithm for choosing
00:31:53
an anticoagulant for a patient in the center with
00:31:55
fibrillation of the atria, as is already suitable here, the
00:31:58
following concept has been accepted today:
00:32:00
anticoagulants
00:32:02
are necessary for patients with
00:32:04
atrial flutter and concomitant atrial fibrillation,
00:32:06
class level of evidence is high, level of evidence is
00:32:07
high 1b,
00:32:09
if flutter and
00:32:12
fibrillation are accompanied, we prescribe anticoagulants
00:32:15
in accordance with the algorithm on a scale of an
00:32:17
hour or two, we calculate the score and evaluate the
00:32:20
need to prescribe these drugs
00:32:23
if isolated
00:32:28
atrial flutter occurs, clear criteria for
00:32:30
starting therapy have not yet been identified,
00:32:32
although there is a recommendation to consider anticoagulant therapy,
00:32:36
it has a class of evidence of 2 and
00:32:39
level C, that is, there have been no
00:32:42
special studies yet, this is only an opinion of
00:32:44
expert committees on this problem,
00:32:46
in addition, in the recommendations
00:32:48
nineteenth year, it is noted that the risk of
00:32:51
thromboembolic complications in the
00:32:53
presence of a hall frame and food without
00:32:55
fibrillation, only this food is probably
00:32:57
lower than when combined with fibrillation, once again
00:33:01
this problem requires additional
00:33:03
research study and in the future there will
00:33:06
probably be a recommendation for special
00:33:10
clinical situations that are
00:33:11
presented in the recommendations for
00:33:13
supraventricular tachycardia 2019 This is the
00:33:16
management of patients with
00:33:18
asymptomatic during agitation, the phenomenon of SVC,
00:33:21
this is the vision of adult patients with
00:33:24
supraventricular tachycardia against the background of
00:33:25
congenital heart defects, the management of
00:33:28
pregnant women with
00:33:29
supraventricular tachycardia, as well as the
00:33:32
diagnosis and treatment of
00:33:34
tachycardic cardiomyopathy with SVT. I will dwell on
00:33:37
some of these situations,
00:33:40
what you need to remember about
00:33:44
patients with asymptomatic presentations of the
00:33:46
ppv phenomenon,
00:33:47
but we all know that if and when
00:33:51
there are signs of the syndrome, we drink this is a
00:33:56
shortened interval pekun delta wave
00:33:58
and a widened qrs complex,
00:34:01
but there are no rhythm disturbances, then this
00:34:04
clinical situation is considered as a
00:34:06
phenomenon if,
00:34:10
in addition to the presence of
00:34:13
changes in their playing, there are also
00:34:15
rhythm disturbances then the situation
00:34:19
is regarded as a ready syndrome, so
00:34:22
taking into account the development of catheter methods for
00:34:24
diagnosing and treating arrhythmias associated with
00:34:27
additional conduction pathways,
00:34:30
today it has been proven that in order to
00:34:32
stratify the risk, patients with the
00:34:35
phenomenon B are shown an
00:34:38
electrophysiological study and
00:34:39
film, even if they are asymptomatic, that
00:34:42
is, there are no rhythm disturbances
00:34:45
signs of nike game paw syndrome
00:34:48
occur for athletes, this situation
00:34:52
received a class of evidence of 1 1 the
00:34:54
highest for other patients 2a
00:34:57
in case of presence of high-risk signs,
00:35:00
catheter ablation
00:35:03
is recommended for such patients, no matter whether they are athletes or
00:35:06
not, nevertheless, a high-
00:35:09
class recommendation class 1 regarding such a
00:35:13
difficult situation such as SVT tachycardia and
00:35:17
supraventricular tachycardia in pregnant women, the
00:35:22
approaches are quite clearly prescribed today, if a
00:35:26
woman has recurrent
00:35:28
supraventricular tachycardia at the stage of
00:35:30
pregnancy planning, then
00:35:32
catheter ablation should be considered, high
00:35:34
class of evidence c this is the level of
00:35:38
evidence, expert opinion, since
00:35:40
studies are not carried out on pregnant women,
00:35:43
this is difficult recruit an appropriate
00:35:45
group and provide a study if we are
00:35:50
talking about emergency therapy to
00:35:53
assist a pregnant woman
00:35:55
with unstable hemodynamics, we
00:35:58
should certainly resort to immediate
00:36:00
electrical cardioversion if
00:36:03
hemodynamics are stable, then in regional
00:36:05
tests the algorithm is exactly the same as in
00:36:08
general cases if they are ineffective,
00:36:10
administering tf parenterally
00:36:12
with for the purpose of emergency relief of
00:36:14
tachycardia,
00:36:16
what else can be used if it does not help
00:36:18
and tf, you can consider beta 1
00:36:21
adrenergic blockers, besides you tell
00:36:24
us the recommendations for emergency
00:36:25
relief or control of the frequency of
00:36:28
ventricular contractions in
00:36:30
supraventricular tachycardia, it is possible to
00:36:33
use digoxin intravenously to
00:36:35
control the frequency of ventricular contractions
00:36:37
in atrial tachycardia if not
00:36:40
beta-blockers are effective, but even in
00:36:43
years it has a low class of evidence in
00:36:45
Russia, this drug is not registered
00:36:47
in relation to the long-term management of
00:36:50
pregnant women with the saint, it is recommended to
00:36:52
avoid any antiarrhythmic drugs in the first
00:36:55
trimester of pregnancy in order to
00:36:57
prevent supraventricular
00:37:00
tachycardia in patients without EP syndrome,
00:37:03
it should be considered in this alone
00:37:05
selective beta-blockers
00:37:09
besides navala or verapamil or
00:37:12
beta-blockers other than ethanol or
00:37:14
verapamil if the patient has SVC
00:37:18
syndrome but there is no structural pathology of the heart, it
00:37:21
is possible for the purpose of prevention to prescribe
00:37:23
propafenone and which is not registered in Russia,
00:37:26
and further tactics
00:37:31
are
00:37:33
categorically not recommended individually in
00:37:34
pregnant women, amiodarone,
00:37:38
and regarding catheter ablation,
00:37:42
if such a need still
00:37:44
arises in a pregnant patient,
00:37:46
it is recommended to consider this
00:37:48
intervention without radiation exposure in a
00:37:50
specialized center if
00:37:53
supraventricular tachycardia is allowed,
00:37:55
reflex drug treatment
00:37:57
or is poorly tolerated, some
00:38:01
special situations are possible for tourists,
00:38:05
well statement of tachycardia tic
00:38:08
cardiomyopathy also has a second
00:38:10
name for the rhythm of the gene accordion for those
00:38:13
against the background of SVT it is recommended to consider the
00:38:17
probable diagnosis of caused tachycardia
00:38:21
or we say arrhythmogenic
00:38:22
cardiomyopathy in patients with a reduced
00:38:25
left ventricular ejection fraction in the
00:38:28
presence of constant
00:38:29
or recurrent tachycardia with more than
00:38:31
100 beats per minute after excluding
00:38:34
other possible causes of cardiomyopathy,
00:38:38
the definition is given in accordance with
00:38:40
European recommendations,
00:38:42
level of evidence is one b.n.
00:38:44
how to make such a diagnosis of tachycardic
00:38:47
tic cardiomyopathy, here
00:38:50
several conditions must be met, firstly, this is a
00:38:52
diagnosis of exclusion by exclusion and
00:38:54
without valve defects in the heart,
00:38:57
arterial hypertension,
00:38:59
alcohol abuse and other causes,
00:39:01
it is necessary to exclude the second condition
00:39:03
of demonstrating restoration of
00:39:06
left ventricular function after eliminating the rhythm
00:39:07
or a significant decrease in heart rate,
00:39:10
or we stop the rhythm or
00:39:11
control the heart rate,
00:39:13
but this allows you to restore the
00:39:16
ejection fraction, usually the following condition
00:39:20
for tachycardia-induced cardiomyopathy, the
00:39:22
ejection fraction of the left ventricle
00:39:24
is less than 30 percent, the
00:39:26
end-diastolic diameter of the left
00:39:29
ventricle is less than 65 millimeters and the
00:39:31
end-systolic diameter is less than 50
00:39:35
if there is a large delegation of
00:39:38
the ventricles when suggest the presence of
00:39:40
dilated cardiomyopathy, such an
00:39:43
approach today is
00:39:46
that it is recommended to treat
00:39:51
supraventricular tachycardia in
00:39:53
patients with probable or
00:39:54
diagnosed heart
00:39:56
failure due to this
00:39:58
cardial cardiomyopathy in the first place
00:40:01
if we look at catheter ablation for the
00:40:04
treatment of tachycardia tic
00:40:06
cardiomyopathy first class and the level of
00:40:09
evidence is high this is catheter
00:40:11
ablation,
00:40:15
if it is ineffective or
00:40:18
not feasible, then it is recommended to
00:40:20
prescribe beta-blockers with
00:40:22
proven effectiveness, as in
00:40:25
heart failure with low ejection
00:40:26
fraction, drugs that we already
00:40:30
know and use in patients with
00:40:32
reduced left ventricular ejection fraction;
00:40:34
in addition, the solution is recommended to
00:40:36
consider the diagnosis of tachycardia-tic
00:40:39
cardiomyopathy patients with reduced
00:40:41
left ventricular ejection fraction with a
00:40:43
ventricular contraction frequency of more than 100
00:40:45
beats per minute at rest, such
00:40:47
recommendations also use
00:40:52
24-hour or multi-day monitoring for this diagnosis
00:40:56
in order to identify subclinical or
00:40:58
online ru rhythm forms, and
00:41:02
further recommendations relate to
00:41:04
catheter ablation separation from the regular
00:41:08
node, subsequent stimulation of either
00:41:14
Bevin regular or the His bundle if
00:41:18
tachycardia cannot be eliminated by
00:41:20
conventional ablation or controlled with
00:41:22
medications, I would
00:41:27
also like to note recommendations for participation in
00:41:29
sports competitions for athletes
00:41:31
with supraventricular arrhythmias,
00:41:33
today mass sports have
00:41:35
quite widely
00:41:36
entered into our lives, there are many
00:41:39
mass sporting events where
00:41:41
not only professional athletes participate,
00:41:45
but also athletes and
00:41:48
amateurs, young athletes,
00:41:51
veteran athletes participate a lot, they can
00:41:54
very often be the first to apply for
00:41:57
admission to a convenient event, a race, a
00:41:59
swim, and other events, how to
00:42:03
approach this situation if we have a
00:42:06
patient with atrial extrasystole an
00:42:08
athlete who wants to participate in
00:42:10
sports competitions, he has no
00:42:13
symptoms, no organic heart pathology,
00:42:15
of course, as a
00:42:18
professional suitability, all sports are available to him
00:42:20
if the patient has
00:42:23
ventricular reciprocal tachycardia
00:42:25
or atrial fibrillation or,
00:42:29
excuse me, yes,
00:42:33
atrial fibrillation is all right
00:42:36
associated with the presence of SVC syndrome,
00:42:38
necessarily catheter ablation
00:42:40
sports are allowed approximately a
00:42:42
month after this manipulation if the
00:42:44
rhythm recurs also
00:42:46
professional suitability is all sports
00:42:48
available in this case if there is an
00:42:52
asymptomatic presentation of the ventricles, that
00:42:54
is, the ppv phenomenon
00:42:55
in high-risk patients,
00:42:58
catheter ablation is necessary to
00:43:00
decide what risk group
00:43:04
the patient is This is the only thing the film will allow us
00:43:06
to do today, where we can
00:43:07
highlight high-risk criteria:
00:43:09
sports activity is allowed one
00:43:11
month after catheter ablation if there is no
00:43:14
relapse; also, all sports are available
00:43:17
if we are talking about paroxysmal
00:43:20
supraventricular tachycardia avrt
00:43:26
and vrt in the presence of hidden additional
00:43:28
conduction pathways and atrial
00:43:31
tachycardia and atrial tachycardia,
00:43:33
if it occurs, then the
00:43:36
means of choice is also recommended: this
00:43:39
catheter ablation, sports activity
00:43:42
is allowed one month after ablation in the
00:43:45
absence of relapses, all types of sports are
00:43:48
available, if this manipulation is
00:43:51
undesirable or impracticable, then
00:43:54
those sports are allowed
00:43:57
where there is no high risk of loss of consciousness,
00:43:59
as a rule these are static loads and
00:44:02
some types of high-
00:44:05
intensity sports, here a
00:44:09
sports doctor can already clarify the situation and a
00:44:11
sports cardiologist
00:44:12
regarding problems and restrictions on
00:44:15
driving for patients with
00:44:17
driving regular tachycardia me
00:44:22
if the patient has
00:44:26
atrial fibrillation or flutter or focal atrial
00:44:28
tachycardia driving a
00:44:30
vehicle possible in the absence of
00:44:32
pineapple for syncope, the
00:44:33
first group of patients, if there are
00:44:37
syncope, the banality of
00:44:39
driving is prohibited from
00:44:40
achieving control over the
00:44:41
patient’s condition or until extraction and the second
00:44:46
option of driving a vehicle
00:44:47
is possible in the absence of a van because of
00:44:49
8 dads and adherence to the recommendations of
00:44:52
pointe coagulation in the presence of
00:44:56
syncope
00:44:58
again in the medical history, driving is prohibited
00:45:00
until the cause is eliminated, until the
00:45:02
risk is achieved and until the risk of relapse is reduced,
00:45:06
adequate control purity must be achieved,
00:45:09
ventricular contraction after reassessment in an
00:45:11
additional assessment of
00:45:12
this world, the restriction is lifted,
00:45:16
driving can be allowed
00:45:20
in conclusion, I would like to say about the nuances of
00:45:22
managing patients with supraventricular
00:45:24
tachycardia in In outpatient practice,
00:45:27
patients newly diagnosed with
00:45:30
focal atrial extrasystoles,
00:45:33
monofocal atrial tachycardia, and
00:45:36
especially with pollen atrial
00:45:39
tachycardia are recommended to conduct a
00:45:41
comprehensive examination to
00:45:42
exclude
00:45:43
background diseases from the
00:45:45
cardiovascular system,
00:45:47
pulmonary diseases and other
00:45:49
potential etiological factors of
00:45:50
the rhythm,
00:45:51
high class and level of danger but this is the
00:45:55
opinion of experts, class recommendation one,
00:45:57
if such patients, on routine
00:45:59
outpatient visits, contact
00:46:04
a doctor about the future,
00:46:05
then it is recommended to examine them,
00:46:09
including mandatory examination in
00:46:11
12 leads,
00:46:13
as well as monitoring of general and biochemical
00:46:15
analysis in the blood; it is also recommended for these patients
00:46:18
to conduct daily or
00:46:20
multi-daily our conditions, this 3-
00:46:24
day monitor is the maximum that can be
00:46:26
given monitoring ECG and
00:46:29
echocardiography, as
00:46:32
well as blood tests for thyroid hormones at
00:46:34
least once a
00:46:37
year
00:46:38
recommendations one level of evidence c
00:46:41
thank you for your attention
00:46:44
our lecture is over

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Суправентрикулярная тахикардия: клинические рекомендации EKO, 2019

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