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Bao Xiaoming Huantai County People's Hospital
Bao Xiaoming
Master's degree candidate, attending physician, graduated from Nanchang University in 2010 and is now working in Huantai County People's Hospital. Engaged in the diagnosis and treatment of common diseases and multiple diseases in cardiology, the main professional direction is the drug treatment of arrhythmias.
At noon on January 5th, the 68th session of the cardiovascular disease management ability assessment and improvement project - "Famous Artists Face to Face" online rounds course was successfully held.
Today Xiaobian takes you back to the second case of this course - a case of sick sinus node.
Medical history
The patient, Wu XX, female, 71 years old, farmer, married.
Main complaint: Episodic palpitation, chest tightness for 1.5 years, another 3 days of hospitalization
Current medical history: patients 1.5 years ago night sleep when the chest tightness, panic, nausea, no blackness, syncope, lasting about 2 hours without relief, to the local hospital for treatment, ECG examination shows atrial fibrillation, myocardial ischemia, no use of drugs, self-conversion to sinus rhythm. In the early morning before November, the above symptoms appeared again, came to our hospital for treatment, the electrocardiogram suggested "coronary heart disease, atrial fibrillation", and the Holter electrocardiogram showed "sinus bradycardia, atrial premature beat, short burst of room rate". In the early morning of March, I had dizziness and blackness, and came to our hospital again for a Holter electrocardiogram to show "sinus bradycardia with unevenness, atrial premature beats, short bursts of atrial tachycardia, R-R long intervals, up to 3.82s". Before February, he performed "permanent double-chamber pacemaker implantation" at a higher-level hospital. In the past 3 days, I have had repeated episodes of palpitation and chest tightness.
Past history: "coronary heart disease" medical history, usually oral "clopidogrel hydrogen sulfate, heart treasure pills" drugs. The complaint had been performed with coronary CT, the specific results of which are unknown. He has been treated with gastroscopy for "gastric ulcer and gastric polyps", and has complained that the gastroscopic ulcer has healed 3 years ago, and has a history of hypothyroidism, and is currently taking "levothyroxine tablets 100ug qd"
Personal history: Smokeless alcohol and drinking habits.
Family history: Denial of a family history of similar diseases.
Admission to the hospital: pulse 84 times / min, body temperature 36.8 ° C, blood pressure 120/ 68 mmHg, breathing 19 times / min, both lungs breathing sounds clear, no smell and dry and wet rales, heart rate 84 times / min, heart rhythm, heart sounds can be, no murmur and additional heart sounds, abdomen, nervous system examination negative, lower limbs are not swollen.
Adjunctive testing
24-hour Holter (2021-09-26): 24-hour total heart beats 76633 beats, the slowest heart rate 29 beats per minute, the fastest heart rate 79 beats per minute. Sinus bradycardia with acess, atrial premature beats, short bursts of atrial tachycardia, R-R long intervals, up to 3.82 s, occurring at 7:25 a.m., the whole ST-T change.
Electrocardiogram after admission:
Review of Holter electrocardiogram after admission:
24-hour Holter ECG diagram: total heart beats 88491 times, the maximum caution rate is 61 times, and the maximum heart rate is 101 times. Diagnostic conclusions: 1. Sinus rhythm + pacing rhythm 2. Occasional atrial premature beats 3, short paroxysmal atrial tachycardia 4.Bi-chamber pacemaker, visible mode conversion 5.Pacemaker sensor perception function is normal, sometimes poor atrial pacing function 6.Autonomic rhythm with ST changes.
Cardiac ultrasound:
Diagnosis and treatment ideas
Current diagnosis:
arrhythmia
Pathological sinus node syndrome
Paroxysmal atrial fibrillation
Short burst room speed
One-degree AV block
After pacemaker implantation
Coronary atherosclerotic heart disease
Hypothyroidism
After gastric polyp removal
Treatment Options:
1. Anticoagulation: Rivaroxaban 15mg qd
2. Lipid regulation, stable plaque: atorvastatin 20mg qd
3. Sinus rhythm: amiodarone hydrochloride injection, oral amiodarone is given after conversion, atrial fibrillation still occurs, and oral amiodarone is stopped
4. Control arrhythmias: Dunedalon 400mg bid
Metoprolol succinate 47.5 mg qd
5. Acid suppression, protection of gastric mucosa: omeprazole 10mg bid
6. Correction of hypothyroidism: levothyroxine tablets 100ug qd
Problem thinking
First, the patient's initial onset of rapid atrial fibrillation consider the disease sinus syndrome, slow syndrome, the double-chamber pacemaker solves the problem of slowness in patients, some patients no longer have atrial fibrillation, but some patients still have atrial fibrillation: for this part of the patient who still has atrial fibrillation within half a year after pacemaker surgery, is it continued to observe, or is it recommended to perform ablation surgery as soon as possible?
Second, the patient's current oral dronedarone combined with metoprolol oral administration, compared with the previous ELECTROCARDI, the proportion of ventricular pacing is significantly increased, will it offset the benefits brought by the drug, how to adjust the next antiarrhythmic drug?
3. The permanent pacemaker is an ultra-long-range Holter, if the patient has a rhythmic pacemaker from six months to one year after ambulatory ablation, and no more episodes of atrial fibrillation are recorded, even if the CHA2DS2-VASc score ≥ 3 points, stop oral anticoagulation or long-term oral anticoagulation after 3 months?
IV. For patients with high-risk atrial fibrillation with BOTH CHA2DS2-VASC and HAS-BLED scores, how to choose the type and dose of anticoagulant drugs? Especially > 75-year-old patients, does the dose of anticoagulant drugs need to be adjusted?
Expert reviews
Professor Chen Lianghua of Shandong Provincial Hospital: The case report is relatively complete, and the patient's first history of coronary heart disease needs to be clear, because the patient's ECG has obvious ST-T ischemic changes, which can aggravate ischemia during the onset of atrial fibrillation, and in the CHA2DS2-VASc score, coronary heart disease is 1 point, which is important for evaluating the patient's thrombotic risk. Secondly, it is difficult to diagnose slow and fast syndrome in this patient, slow and fast are two problems, and if atrial fibrillation is repeated, catheter ablation is necessary.
Professor Wu Yongquan of Beijing Anzhen Hospital affiliated to Capital Medical University: If this patient has recurrent episodes of atrial fibrillation, catheter ablation should be performed as soon as possible, and there is no need to take dronedarone and metoprolol after surgery, but the pacemaker electrode should be paid attention to during the operation. In addition, in the process of pacemaker programming, it is found that the proportion of ventricular pacing is high, the pacing frequency can be lowered, and there is no problem with the patient's atrioventricular node function, as long as the patient does not have dizziness and syncope symptoms.
Professor Ma Changsheng of Beijing Anzhen Hospital affiliated to Capital Medical University: The case report is very good, because there are many problems for elderly women. First of all, the patient pacemaker pacing frequency does not need to be so high, the ventricular pacing frequency > 48% is useless, the pacing frequency can be adjusted to 40-45 times / min, you need to pay attention to the pacemaker function, to ensure that there is no R-R long interval. Transesophageal ultrasound is the gold standard for evaluating left atrial appendage thrombosis, pulmonary vein intensive CT can not be compared with transesophageal ultrasound, but the former is still high for the negative predictive value of left atrial appendage thrombosis, for patients with paroxysmal atrial fibrillation can replace transesophageal ultrasound, but for patients with persistent atrial fibrillation, left atrial ear blood flow is slow, poor perfusion, there will be false positives. For the next step, I agreed with the two professors and recommended catheter ablation. Patients have no history of stroke and can be discontinued 3 months after surgery. For elderly patients, if there is no contraindication, try to be anticoagulated, the risk of bleeding is not contraindicated, and the dose adjustment should be considered comprehensively in combination with the patient's renal function.
Welcome to forward, welcome to participate!
CDQI
National Cardiovascular Disease Management Capacity Assessment and Improvement Project