Diagnosis and Management of Cardiac Rhythm Disorders

Module details

Title

Diagnosis and Management of Cardiac Rhythm Disorders

Type

Specialist

Module code

SPS122

Credits

30

Requirement

Optional

Aim of this module

This rotation will enable trainees to manage a range of patients with cardiac rhythm disorders, and to support and undertake the long-term follow-up of patients, demonstrating safe, patient-centred practice. Trainees will be expected to build practical skills in setting up and maintaining the equipment used, produce reports, interpret results, explain procedures to patients and gain consent, while developing and building their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1,2,3,4,5,6,7	Competency Control infection risks in accordance with departmental protocols.	Action View
# 2	Learning outcome 1,2,3,4,5,6,7	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 3	Learning outcome 1,2,3,4,5,6	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality at all times.	Action View
# 4	Learning outcome 1,2,3,4,5,6,7	Competency Review a suitably completed request form. Greet the patient, check patient identity and ensure that the patient’s identity is confirmed as correct and fully identified on each type of recording system for each procedure.	Action View
# 5	Learning outcome 1,2,3,4,5,6,7	Competency Select suitable technology for the procedure, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer for each patient.	Action View
# 6	Learning outcome 1,2,3,4,5,6,7	Competency Set up appropriate equipment in preparation for each type of procedure, including resuscitation equipment where appropriate. Calibrate where necessary.	Action View
# 7	Learning outcome 1,2,3,4,5,6	Competency Explain the full procedure to the patient and address any questions they may have relating to the procedure, including the process after the procedure and how the patient will be informed of the results.	Action View
# 8	Learning outcome 1,2,3,4,5,6	Competency Gain informed consent.	Action View
# 9	Learning outcome 1,2,3,4,5,6,7	Competency Obtain and evaluate a clinical history as appropriate for each procedure.	Action View
# 10	Learning outcome 1,2,3,4,5,6,7	Competency Check and assess wound site and escalate any abnormal findings.	Action View
# 11	Learning outcome 1,2,3,4,5,6,7	Competency Check ECG and patient status throughout the procedure and report any adverse changes as necessary.	Action View
# 12	Learning outcome 1,2,3,4,5,6,7	Competency Interrogate cardiac device and perform and interpret standard measurements appropriate to device undertaking testing to ensure lead integrity and stability, assessing stored diagnostics and histograms and the standard parameters of the device to establish and program appropriate safety margins.	Action View
# 13	Learning outcome 1,2,3,4,5,6	Competency Optimise rate modulation, blanking periods, refractory periods and mode switching as required.	Action View
# 15	Learning outcome 1,2,3,4,5,6,7	Competency Perform advanced testing as necessary, for example provocation manoeuvres in unipolar leads.	Action View
# 16	Learning outcome 1,2,3,4,5,6,7	Competency Take appropriate action to respond to the specific needs of the patient, as defined by department protocol.	Action View
# 17	Learning outcome 1,2,3,4,5,6,7	Competency Review the results from each test, taking into account artefacts, necessary adjustments of values and planned/unplanned events occurring during the test.	Action View
# 18	Learning outcome 1,2,3,4,5,6	Competency Compare the values/traces obtained with the normal range/values related to the procedure.	Action View
# 19	Learning outcome 1,2,3,4,5,6	Competency Complete relevant documentation in line with national and local policies and produce a clear written report of the procedure.	Action View
# 20	Learning outcome 1,2,3,4,5,6	Competency Inform the patient of the follow-up procedures and advise and inform them of the relevant information needed for their device type and functionality.	Action View
# 21	Learning outcome 8	Competency Present the findings of a critical review of current published research literature for the diagnosis and treatment of cardiac rhythm disorders and related topics, incorporating evidence-based practice at your local departmental meeting.	Action View
# 14	Learning outcome 1,2,3,4,5,6,7	Competency Assess implanted device for arrhythmias and set appropriate algorithm to monitor or provide treatment appropriate to patient symptomology, referring for additional diagnostic testing relevant to any anomalies found.	Action View

Assessments

You must complete:

• 4 case-based discussion(s)
• 4 of the following DOPS/ OCEs:

Select suitable equipment and consumables for an ICD implantation procedure.	DOPS
Select suitable equipment and consumables for a biventricular device implantation procedure.	DOPS
Complete relevant documentation in line with national and local policies and produce a clear written report of the procedure.	DOPS
Check and assess wound site and escalate any abnormal findings.	OCE
Programme and optimise a dual chamber bradycardia device.	OCE
Programme and optimise a dual chamber tachycardia device.	OCE
Programme and optimise a CRT P device.	OCE
Programme and optimise a CRT D device.	OCE
Interrogate an ICD and undertake testing to ensure lead integrity and stability, assessing stored diagnostics and histogramsto establish and programme appropriate safety margins.	OCE
Optimise rate modulation, blanking periods, refractory periods and mode switching as required.	OCE

Learning outcomes

1. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with single chamber bradycardia, recognising the clinical signs and symptoms of device complications.
2. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with single chamber tachycardia, recognising the clinical signs and symptoms of device complications.
3. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with dual chamber bradycardia, recognising the clinical signs and symptoms of device complications. 
4. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with dual chamber tachycardia, recognising the clinical signs and symptoms of device complications.
5. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with CRT-P (cardiac resynchronization therapy with pacemaker), recognising the clinical signs and symptoms of device complications.
6. Perform and interpret procedures to assess implanted cardiac devices and, using appropriate algorithms, program and optimise the device to monitor or provide treatment appropriate to patients with CRT-D (cardiac resynchronization therapy with defibrillator function) recognising the clinical signs and symptoms of device complications.
7. Perform long-term follow-up procedures for patients with implanted cardiac devices, ensuring the safe and effective functioning of each device and highlighting devices that may need replacement.
8. Critically appraise current literature/research studies that address the issues of the diagnosis and management of cardiac rhythm disorders, incorporating evidence-based practice.

Learning outcomes

1. Recall the anatomy and physiology of the heart and explain, in depth, the anatomy and physiology of the heart relevant to cardiac rhythm management.
2. Describe the mechanisms of arrhythmia generation.
3. Explain the indications for device implantation and placement and the evidence-based current guidelines.
4. Describe the cardiac physical examination, including auscultation, measurement of jugular venous pressure and blood pressure.
5. Recognise ECG changes associated with inherited arrhythmia syndromes, channelopathies/Brugada syndrome, long QT and short QT.
6. Describe the underpinning physics of the instrumentation/equipment used in electrophysiology studies, including the functionality of amplifiers.
7. Identify implanted devices and lead systems from a chest X-ray
8. Describe programming possibilities for atrial arrhythmia suppression.
9. Describe product specific algorithms for atrial anti-tachycardia pacing.
10. Explain the principles behind tachycardia detection and redetection.
11. Explain the definitions and terminology of tachycardia discrimination software.
12. Describe the hardware used in ICD implantation.
13. Explain the process of wound healing process.
14. Describe the clinical signs and symptoms associated with heart failure.
15. Describe the possible symptoms associated with tachy and brady arrhythmias.
16. Explain and justify the DVLA requirements for patients with abnormalities of cardiac rhythm.
17. Compare current guidelines with respect to cardiac rhythm management.

Indicative content

Electrophysiology and Arrhythmia Management 

High energy shock leads

• Electrodes
• Different types of lead insulation
• Single and dual coil electrodes
• Subcutaneous array lead
• Multilumen vs conventional coaxial design
• Connectors

Use of CRT devices

• Appropriate use of CRT devices
• Underlying medical conditions
• Long-term implication

Use of timing cycles

• Relationship between mechanical and physiological timing cycles
• Relative and absolute refractory
• Blanking period
• Atrial-based timing vs ventricular-based timing
• V-V timing in CRT devices with relation to inter- and intraventricular delay
• Mechanical timing limitations

Rate modulation

• Rate response mechanisms within pulse generators
• Technology of rate response sensors
• Implications of single vs dual sensors
• Rate smoothing algorithms
• Limitations of rate modulation

Sensing

• Cardiac signals A/V/T wave/injury currents/pericardial signals
• Intracardiac signals of basic electrophysiology (EP)

Stimulation

• Anodal/cathodal stimulation
• Stimulation/defibrillation threshold
• Ohm’s law; current, voltage and impedance (calculation of)
• Strength duration; stimulation threshold. Rheobase and chronaxie time
• Power and energy

Timing cycles

• Single chamber
• Dual chamber – atrial based and ventricular based
• Rate modulation – rate responsive AV delay and PVARP
• CRT (bivent) V-V timing

Algorithms

• Bradycardia/tachycardia pacing therapy
• Tachycardia detection
• SVT discrimination
• ATP pacing

Hardware used in ICD implantation

• Seldinger technique
• Introducer sheaths
• LV lead introduction hardware
• Transeptal equipment
• Transeptal technique

Programming possibilities for atrial arrhythmia suppression

• Mechanism of action
• Rate stabilisation
• Automatic atrial rate increase algorithms
• Overdrive

Product-specific algorithms for atrial anti-tachycardia pacing

Individual company/product-specific algorithms

Principles behind tachycardia detection and redetection

Individual company/product-specific algorithms

Definitions and terminology of tachycardia discriminator software

• Stability
• Onset
• Morphology
• VT-ST boundary

Battery technology

• Pacemaker battery chemical composition and depletion characteristics
• ICD battery chemical composition and depletion characteristics
• Battery impedance, voltage, battery charge
• Elective replacement indicators

Function and connection of circuitry components

• Capacitors – structure and function
• Band pass filtering – intracardiac EGM frequency
• Sense amplifiers
• Output pulse square wave

Acceptable measurements at implant

• Battery voltage
• Pacing threshold
• Lead impedance
• Current drain
• Sensing threshold
• Slew rate

Normal parameter changes over time 

• First week
• First three months
• Lead/device lifetime

Lead hardware problems

• Fracture
• Insulation break
• Perforation
• Poor header connection
• Leads reversed in header

Device hardware problems

• Header connection
• Deformation of can

Assessment of implanted system to ascertain potential problems

• Provocative manoeuvres
• EMI
• Lead impedance, pacing and sensing threshold
• Oversensing
• Undersensing
• Upper rate behaviour
• Inappropriate ICD detection and therapy
• EGM assessment

Basic electrophysiology

• Anatomy and physiology of the heart, to include detail of the conduction system
• Electrophysiological anatomy of the normal conduction system
• Electrophysiology of abnormal conduction, to include slow and fast pathways
• Baseline measurements of electrograms (AV, AH, VA, CL)
• Action potentials, gates and channels: channelopathies
• Differences of action potentials at differing anatomical locations
• Abnormalities of the conduction system: failure to initiate, failure to propagate

Mechanisms of arrhythmia

• Re-entry
• Triggered
• Automaticity
• Anisotropy
• Process of induction
• Arrhythmia behaviours
• Pacing mechanisms during arrhythmia to aid diagnosis
• Termination behaviours of arrhythmias

Remote entry

• Familiarisation with different remote monitoring applications
• Clinical use of remote monitoring applications
• Limitations of remote monitoring

Clinical assessment

• Indications for device therapy, placement, associated trials and NICE guidelines
• Brady arrhythmias
• Tachy arrhythmias
• Chronic congestive heart failure
• Syncope

Basic pharmacology

• Types of drugs commonly used in rhythm management
• Major cardiovascular responses; pharmacokinetics
• Drug effects on the action potentials
• Drug effects on cardiac rhythm and conduction

Radiation associated with X-rays and fluoroscopy

• Measurement of radiation for chest X-ray
• Measurement of radiation for fluroscopy
• Radiation safety regulations
• Lateral/PA X-rays

Recognition of devices using X-ray

• Type of device from X-ray
• Identifying manufacturer from X-ray
• Type of lead
• Type of lead – ICD
• Site of implant

 

Normal positions of leads on X-ray and fluoroscopy.

RA – appendage/free wall

RV – septal/apical

LV – mid-lateral free wall

Abnormal lead positions and lead problems

• Displacement
• Perforation
• Fracture
• Pneumothorax
• Subclavian crush

Anatomical landmarks from fluoroscopy

• CS ostium
• CS venous anatomy
• MV/AV/TV
• AV ring

EP catheter positions from fluoroscopy

• RAO
• LAO
• Lateral
• AP

Clinical electrophysiology

• Initial assessment and diagnostic work-up
• Pre-assessment of patient
• MRSA screening
• ECG assessment
• Arrhythmia recognition
• Pacing stimulators
• Sensing/oversensing
• Outputs and thresholds
• Coupling intervals
• Risks associated with the procedure
• Different protocols for induction and overdrive pacing

Clinical evaluation of arrhythmia

• Response to drugs
• Response to vagal manoeuvres
• Emergency management

Patient and Device Follow-Up 

Clinical signs and symptoms associated with heart failure

• Shortness of breath
• Increasing peripheral oedema
• Increased weight
• Decreased exercise tolerance
• Relationship between diagnostic data and devices
• Possible symptoms associated with tachy/brady arrhythmias

Communication with patients and carers

• Proactive verbal investigation of symptoms
• Careful listening to description of symptoms
• Organisation and explanation of further investigation if deemed necessary
• Core questions: evaluation of box site, dizziness, palpitations, breathlessness, timing and duration of any symptoms, chest pain

Guidelines including:

• Driver and Vehicle Licensing Agency (DVLA)
• Heart Rhythm United Kingdom (HRUK)
• American Heart Association (AHA)
• European Society of Cardiology (ESC)

 

Activities

• Identify a patient with a disorder of cardiac rhythm requiring electrophysiology and arrhythmia management and, with permission, follow the progress of the patient from the initial consultation, through procedures and follow-up appointment, and reflect on your learning from this process.
• Observe a range of electrophysiological (EP) mapping and ablation procedures, including ventricular tachycardia (VT), typical atrial flutter, atrioventricular nodal reentry tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT) and atrial fibrillation (AF) ablation.
• Identify two patients with disorders of cardiac rhythm requiring electrophysiology and arrhythmia management and critically reflect on the effect on the lifestyle of the patient and the role of the healthcare scientist in the diagnosis and treatment of patients.
• Observe a series of patients reviewed as new and follow-up patients in an outpatient clinic and critically appraise the process of referral, diagnosis and treatment, including the range of healthcare professionals who contribute to the care of each patient and how the interprofessional team work together.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with disorders of cardiac rhythm requiring electrophysiology and arrhythmia management.
• Observe the treatment of children with disorders of cardiac rhythm requiring electrophysiology studies/ablation and arrhythmia management and discuss your experience with your trainer.