Download PDF
Semin Respir Crit Care Med 2006; 27(3): 221-229
DOI: 10.1055/s-2006-945525
Copyright © 2006 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Cardiac Arrhythmias in the Intensive Care Unit

Daniel J. Tarditi1 , Steven M. Hollenberg1
  • 1Divisions of Cardiovascular Disease and Critical Care Medicine, Cooper University Hospital, Camden, New Jersey
Further Information

Publication History

Publication Date:
21 June 2006 (online)

    Permissions and Reprints

ABSTRACT

Cardiac arrhythmias are a common problem encountered in the intensive care unit (ICU) and represent a major source of morbidity. Arrhythmias are most likely to occur in patients with structural heart disease. The inciting factor for an arrhythmia in a given patient may be an insult such as hypoxia, infection, cardiac ischemia, catecholamine excess (endogenous or exogenous), or an electrolyte abnormality. Management includes correction of these imbalances as well as medical therapy directed at the arrhythmia itself. The physiological impact of arrhythmias depends on ventricular response rate and duration, and the impact of a given arrhythmia in a given situation depends on the patient's cardiac physiology and function. Similarly, urgency and type of treatment are determined by the physiological impact of the arrhythmia as well as by underlying cardiac status. The purpose of this review is to provide an update regarding current concepts of diagnosis and acute management of arrhythmias in the ICU. A systematic approach to diagnosis and evaluation will be presented, followed by consideration of specific arrhythmias.

KEYWORDS

Arrhythmia - ICU - ventricular tachycardia - AV nodal reentrant tachycardia - atrial fibrillation - atrial flutter - sinus tachycardia - Wolff-Parkinson-White syndrome - electrical storm - bradycardia

REFERENCES

  • 1 Imrie J R, Yee R, Klein G J, Sharma A D. Incidence and clinical significance of ST segment depression in supraventricular tachycardia.  Can J Cardiol. 1990;  6 323-326
    PubMedGoogle Scholar
  • 2 Tebbenjohanns J, Pfeiffer D, Schumacher B, Jung W, Manz M, Luderitz B. Intravenous adenosine during atrioventricular reentrant tachycardia: induction of atrial fibrillation with rapid conduction over an accessory pathway.  Pacing Clin Electrophysiol. 1995;  18 743-746
    PubMedGoogle Scholar
  • 3 Pelleg A, Pennock R S, Kutalek S P. Proarrhythmic effects of adenosine: one decade of clinical data.  Am J Ther. 2002;  9 141-147
    PubMedGoogle Scholar
  • 4 Winniford M D, Fulton K L, Hillis L D. Long-term therapy of paroxysmal supraventricular tachycardia: a randomized, double-blind comparison of digoxin, propranolol and verapamil.  Am J Cardiol. 1984;  54 1138-1139
    CrossrefPubMedGoogle Scholar
  • 5 Lown B. Electrical reversion of cardiac arrhythmias.  Br Heart J. 1967;  29 469-489
    PubMedGoogle Scholar
  • 6 Ellenbogen K A, Stambler B S, Wood M A et al.. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study.  J Am Coll Cardiol. 1996;  28 130-136
    CrossrefPubMedGoogle Scholar
  • 7 Stambler B S, Wood M A, Ellenbogen K A, Perry K T, Wakefield L K, VanderLugt J T. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators.  Circulation. 1996;  94 1613-1621
    PubMedGoogle Scholar
  • 8 Sung R J, Tan H L, Karagounis L et al.. Intravenous sotalol for the termination of supraventricular tachycardia and atrial fibrillation and flutter: a multicenter, randomized, double-blind, placebo-controlled study. Sotalol Multicenter Study Group.  Am Heart J. 1995;  129 739-748
    CrossrefPubMedGoogle Scholar
  • 9 Kingma J H, Suttorp M J. Acute pharmacologic conversion of atrial fibrillation and flutter: the role of flecainide, propafenone, and verapamil.  Am J Cardiol. 1992;  70 56A-60A , discussion A-1A
    CrossrefPubMedGoogle Scholar
  • 10 Suttorp M J, Kingma J H, Jessurun E R, Lie A HL, van Hemel N M, Lie K I. The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm.  J Am Coll Cardiol. 1990;  16 1722-1727
    PubMedGoogle Scholar
  • 11 Trappe H J, Brandts B, Weismueller P. Arrhythmias in the intensive care patient.  Curr Opin Crit Care. 2003;  9 345-355
    PubMedGoogle Scholar
  • 12 Feinberg W M, Blackshear J L, Laupacis A, Kronmal R, Hart R G. Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications.  Arch Intern Med. 1995;  155 469-473
    CrossrefPubMedGoogle Scholar
  • 13 Kannel W B, Abbott R D, Savage D D, McNamara P M. Epidemiologic features of chronic atrial fibrillation: the Framingham study.  N Engl J Med. 1982;  306 1018-1022
    CrossrefPubMedGoogle Scholar
  • 14 Davidson E, Weinberger I, Rotenberg Z, Fuchs J, Agmon J. Atrial fibrillation: cause and time of onset.  Arch Intern Med. 1989;  149 457-459
    CrossrefPubMedGoogle Scholar
  • 15 Koh K K, Song J H, Kwon K S et al.. Comparative study of efficacy and safety of low-dose diltiazem or betaxolol in combination with digoxin to control ventricular rate in chronic atrial fibrillation: randomized crossover study.  Int J Cardiol. 1995;  52 167-174
    CrossrefPubMedGoogle Scholar
  • 16 Phillips B G, Gandhi A J, Sanoski C A, Just V L, Bauman J L. Comparison of intravenous diltiazem and verapamil for the acute treatment of atrial fibrillation and atrial flutter.  Pharmacotherapy. 1997;  17 1238-1245
    PubMedGoogle Scholar
  • 17 Ellenbogen K A, Dias V C, Plumb V J, Heywood J T, Mirvis D M. A placebo-controlled trial of continuous intravenous diltiazem infusion for 24-hour heart rate control during atrial fibrillation and atrial flutter: a multicenter study.  J Am Coll Cardiol. 1991;  18 891-897
    PubMedGoogle Scholar
  • 18 Jordaens L, Trouerbach J, Calle P et al.. Conversion of atrial fibrillation to sinus rhythm and rate control by digoxin in comparison to placebo.  Eur Heart J. 1997;  18 643-648
    PubMedGoogle Scholar
  • 19 Arnold A Z, Mick M J, Mazurek R P, Loop F D, Trohman R G. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter.  J Am Coll Cardiol. 1992;  19 851-855
    PubMedGoogle Scholar
  • 20 Bjerkelund C J, Orning O M. The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation.  Am J Cardiol. 1969;  23 208-216
    CrossrefPubMedGoogle Scholar
  • 21 Ommen S R, Odell J A, Stanton M S. Atrial arrhythmias after cardiothoracic surgery.  N Engl J Med. 1997;  336 1429-1434
    CrossrefPubMedGoogle Scholar
  • 22 Hashimoto K, Ilstrup D M, Schaff H V. Influence of clinical and hemodynamic variables on risk of supraventricular tachycardia after coronary artery bypass.  J Thorac Cardiovasc Surg. 1991;  101 56-65
    PubMedGoogle Scholar
  • 23 Crystal E, Connolly S J, Sleik K, Ginger T J, Yusuf S. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis.  Circulation. 2002;  106 75-80
    CrossrefPubMedGoogle Scholar
  • 24 Stebbins D, Igidbashian L, Goldman S M et al.. Clinical outcome of patients who develop atrial fibrillation after coronary artery bypass surgery [abstract].  PACE. 1995;  18 798
    PubMedGoogle Scholar
  • 25 Gage B F, Waterman A D, Shannon W, Boechler M, Rich M W, Radford M J. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.  JAMA. 2001;  285 2864-2870
    CrossrefPubMedGoogle Scholar
  • 26 Wang K, Goldfarb B L, Gobel F L, Richman H G. Multifocal atrial tachycardia.  Arch Intern Med. 1977;  137 161-164
    CrossrefPubMedGoogle Scholar
  • 27 Wagner G. Marriott's Practical Electrocardiography. Philadelphia, PA; Lippincott Williams and Wilkins 2001
    Google Scholar
  • 28 Shenasa M, Borggrefe M, Haverkamp W, Hindricks G, Breithardt G. Ventricular tachycardia.  Lancet. 1993;  341 1512-1519
    CrossrefPubMedGoogle Scholar
  • 29 Wellens H J, Brugada P. Diagnosis of ventricular tachycardia from the 12-lead electrocardiogram.  Cardiol Clin. 1987;  5 511-525
    PubMedGoogle Scholar
  • 30 Josephson M E, Wellens H J. Differential diagnosis of supraventricular tachycardia.  Cardiol Clin. 1990;  8 411-442
    PubMedGoogle Scholar
  • 31 Wellens H J, Bar F W, Lie K I. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.  Am J Med. 1978;  64 27-33
    CrossrefPubMedGoogle Scholar
  • 32 Brugada P, Brugada J, Mont L, Smeets J, Andries E W. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex.  Circulation. 1991;  83 1649-1659
    PubMedGoogle Scholar
  • 33 Tchou P, Young P, Mahmud R, Denker S, Jazayeri M, Akhtar M. Useful clinical criteria for the diagnosis of ventricular tachycardia.  Am J Med. 1988;  84 53-56
    PubMedGoogle Scholar
  • 34 Kostis J B, McCrone K, Moreyra A E et al.. Premature ventricular complexes in the absence of identifiable heart disease.  Circulation. 1981;  63 1351-1356
    PubMedGoogle Scholar
  • 35 Raftery E B, Cashman P M. Long-term recording of the electrocardiogram in a normal population.  Postgrad Med J. 1976;  52(Suppl 7) 32-38
    PubMedGoogle Scholar
  • 36 Fleg J L, Kennedy H L. Cardiac arrhythmias in a healthy elderly population: detection by 24-hour ambulatory electrocardiography.  Chest. 1982;  81 302-307
    CrossrefPubMedGoogle Scholar
  • 37 Anderson K P, DeCamilla J, Moss A J. Clinical significance of ventricular tachycardia (3 beats or longer) detected during ambulatory monitoring after myocardial infarction.  Circulation. 1978;  57 890-897
    PubMedGoogle Scholar
  • 38 Buxton A E, Marchlinski F E, Waxman H L, Flores B T, Cassidy D M, Josephson M E. Prognostic factors in nonsustained ventricular tachycardia.  Am J Cardiol. 1984;  53 1275-1279
    CrossrefPubMedGoogle Scholar
  • 39 Larsen L, Markham J, Haffajee C I. Sudden death in idiopathic dilated cardiomyopathy: role of ventricular arrhythmias.  Pacing Clin Electrophysiol. 1993;  16 1051-1059
    PubMedGoogle Scholar
  • 40 Gregoratos G, Abrams J, Epstein A E et al.. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines).  Circulation. 2002;  106 2145-2161
    CrossrefPubMedGoogle Scholar
  • 41 Kligfield P, Levy D, Devereux R B, Savage D D. Arrhythmias and sudden death in mitral valve prolapse.  Am Heart J. 1987;  113 1298-1307
    CrossrefPubMedGoogle Scholar
  • 42 Kligfield P, Hochreiter C, Niles N, Devereux R B, Borer J S. Relation of sudden death in pure mitral regurgitation, with and without mitral valve prolapse, to repetitive ventricular arrhythmias and right and left ventricular ejection fractions.  Am J Cardiol. 1987;  60 397-399
    CrossrefPubMedGoogle Scholar
  • 43 Wolfe R R, Driscoll D J, Gersony W M et al.. Arrhythmias in patients with valvar aortic stenosis, valvar pulmonary stenosis, and ventricular septal defect: results of 24-hour ECG monitoring.  Circulation. 1993;  87 I89-101
    PubMedGoogle Scholar
  • 44 Newby K H, Thompson T, Stebbins A, Topol E J, Califf R M, Natale A. Sustained ventricular arrhythmias in patients receiving thrombolytic therapy: incidence and outcomes. The GUSTO Investigators.  Circulation. 1998;  98 2567-2573
    PubMedGoogle Scholar
  • 45 Trujillo T C, Nolan P E. Antiarrhythmic agents: drug interactions of clinical significance.  Drug Saf. 2000;  23 509-532
    CrossrefPubMedGoogle Scholar
  • 46 Kossmann C E. Torsade de pointes: an addition to the nosography of ventricular tachycardia.  Am J Cardiol. 1978;  42 1054-1056
    CrossrefPubMedGoogle Scholar
  • 47 Banai S, Tzivoni D. Drug therapy for torsade de pointes.  J Cardiovasc Electrophysiol. 1993;  4 206-210
    PubMedGoogle Scholar
  • 48 Campbell R W, Smith R A, Gallagher J J, Pritchett E L, Wallace A G. Atrial fibrillation in the preexcitation syndrome.  Am J Cardiol. 1977;  40 514-520
    CrossrefPubMedGoogle Scholar
  • 49 Exner D V, Pinski S L, Wyse D G et al.. Electrical storm presages nonsudden death: the antiarrhythmics versus implantable defibrillators (AVID) trial.  Circulation. 2001;  103 2066-2071
    CrossrefPubMedGoogle Scholar
  • 50 Greene M, Geist M, Paquette M et al.. Long-term follow-up of implantable defibrillator therapy in patients with electrical storm [abstract].  Pacing Clin Electrophysiol. 1997;  20 1207
    PubMedGoogle Scholar
  • 51 O'Donoghue S, Patia E V, Waclawski S et al.. Transient electrical storm: prognostic significance of very numerous automatic defibrillator discharges [abstract].  J Am Coll Cardiol. 1997;  17 352A
    PubMedGoogle Scholar
  • 52 Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes.  Med Clin North Am. 2001;  85 321-341
    CrossrefPubMedGoogle Scholar
  • 53 Tschaidse O, Graboys T B, Lown B, Lampert S, Ravid S. The prevalence of proarrhythmic events during moricizine therapy and their relationship to ventricular function.  Am Heart J. 1992;  124 912-916
    CrossrefPubMedGoogle Scholar
  • 54 Kowey P R. An overview of antiarrhythmic drug management of electrical storm.  Can J Cardiol. 1996;  12(Suppl B) 3B-8B discussion 27B-28B
    PubMedGoogle Scholar
  • 55 Brugada J, Berruezo A, Cuesta A et al.. Nonsurgical transthoracic epicardial radiofrequency ablation: an alternative in incessant ventricular tachycardia.  J Am Coll Cardiol. 2003;  41 2036-2043
    CrossrefPubMedGoogle Scholar
  • 56 Gregoratos G, Cheitlin M D, Conill A et al.. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation).  J Am Coll Cardiol. 1998;  31 1175-1209
    CrossrefPubMedGoogle Scholar

Steven M HollenbergM.D. 

Divisions of Cardiovascular Disease and Critical Care Medicine, Cooper University Hospital

One Cooper Plaza, 366 Dorrance, Camden, NJ 08103

Email: Hollenberg-Steven@cooperhealth.edu

      >