Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Netherlands Heart Journal
Published in: Netherlands Heart Journal 4/2018

Open Access 01-04-2018 | Review Article

A clinical approach to arrhythmias revisited in 2018

From ECG over noninvasive and invasive electrophysiology to advanced imaging

Author: L. Jordaens

Published in: Netherlands Heart Journal | Issue 4/2018

Login to get access

Abstract

Understanding arrhythmias and their treatment is not always easy. The current straightforward approach with catheter ablation and device therapy is an amazing achievement, but does not make management of underlying or other cardiac disease and pharmacological therapy unnecessary. The goal of this paper is to describe how much of the knowledge of the 1980s and early 1990s can and should still be applied in the modern treatment of patients with arrhythmias. After an introduction, this review will focus on paroxysmal atrial fibrillation and a prototype of ‘idiopathic’ ventricular arrhythmias, two diseases with a striking similarity, and will discuss the arrhythmogenesis. The ECG continues to play an important role in diagnostics. Both diseases are associated with a structurally normal heart; the autonomic nervous system plays an important role in triggering arrhythmias at both the atrial and ventricular level.
Literature
1.
2.
Coumel P. The management of clinical arrhythmias. An overview on invasive versus non-invasive electrophysiology. Eur Heart J. 1987;8:92–9.CrossRefPubMed
3.
Coumel P. Autonomic influences in atrial tachyarrhythmias. J Cardiovasc Electrophysiol. 1996;7:999–1007.CrossRefPubMed
4.
5.
Moe GK, Abildskov JA. Atrial fibrillation as a self-sustaining arrhythmia independent of focal discharge. Am Heart J. 1959;58:59–70.CrossRefPubMed
6.
Durrer D, Schoo L, Schuilenburg RM, Wellens HJ. The role of premature beats in the initiation and the termination of supraventricular tachycardia in the Wolff-Parkinson-White syndrome. Circulation. 1967;36:644–62.CrossRefPubMed
7.
Lie KI, Wellens HJ, van Capelle FJ, Durrer D. Lidocaine in the prevention of primary ventricular fibrillation. A double-blind, randomized study of 212 consecutive patients. N Engl J Med. 1974;291:1324–6.CrossRefPubMed
8.
The Task Force of the Working Group on Arrhythmias of the European Society of Cardiology. The ‘Sicilian Gambit’. A new approach to the classification of antiarrhythmic drugs based on their actions on arrhythmogenic mechanisms. Eur Heart J. 1991;12:1112–31.CrossRef
9.
Cox JL, Gallagher JJ, Cain ME. Experience with 118 consecutive patients undergoing operation for the Wolff-Parkinson-White syndrome. J Thorac Cardiovasc Surg. 1985;90:490–501.PubMed
10.
Defauw JJ, Guiraudon GM, van Hemel NM, Vermeulen FE, Kingma JH, de Bakker JM. Surgical therapy of paroxysmal atrial fibrillation with the ‘corridor’ operation. Ann Thorac Surg. 1992;53:564–70.CrossRefPubMed
11.
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.CrossRef
12.
Mirowski M, Reid PR, Mower MM, et al. Clinical performance of the implantable cardioverter-defibrillator. Pacing Clin Electrophysiol. 1984;7:1345–50.CrossRefPubMed
13.
Jordaens L, Waleffe A, Derom F, Rodriguez LM, Clement DL, Kulbertus H. First experience with the implantable cardioverter-defibrillator: 90 patient-months of follow-up. Acta Clin Belg. 1988;43:209–18.CrossRefPubMed
14.
Calkins H, Sousa J, el-Atassi R, Rosenheck S, de Buitleir M, Kou WH, Kadish AH, Langberg JJ, Morady F. Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test. N Engl J Med. 1991;324:1612–8.CrossRefPubMed
15.
Evans GT, Scheinman MM, the Executive Committee of the Registry. The percutaneous cardiac mapping and ablation registry: final summary of results. Pacing Clin Electrophysiol. 1988;11:1621–6.CrossRefPubMed
16.
Hook BG, Marchlinski FE. Value of ventricular electrogram recordings in the diagnosis of arrhythmias precipitating electrical device shock therapy. J Am Coll Cardiol. 1991;17:985–90.CrossRefPubMed
17.
Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace. 2016;18:1455–90.CrossRefPubMed
18.
Lieve KV, Wilde AA. Inherited ion channel diseases: a brief review. Europace. 2015;17(Suppl 2):1–6.CrossRef
19.
Suzuki T, Nazarian S, Jerosch-Herold M, Chugh SS. Imaging for assessment of sudden death risk: current role and future prospects. Europace. 2016;18:1491–500.CrossRefPubMedPubMedCentral
20.
Camm AJ, Al-Khatib SM, Calkins H, et al. A proposal for new clinical concepts in the management of atrial fibrillation. Am Heart J. 2012;164:292–302.CrossRefPubMed
21.
Alings M, Smit MD, Moes ML, Crijns HJ, Tijssen JG, Brügemann J, et al. Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure, the RACE 3 study. Neth Heart J. 2013;21:354–63. https://​doi.​org/​10.​1007/​s12471-013-0428-5.
22.
Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18:1609–78.CrossRefPubMed
23.
Janse PA, Van Belle YL, Theuns DAMJ, Rivero-Ayerza M, Scholten MF, Jordaens LJ. Symptoms versus objective rhythm monitoring in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation. Eur J Cardiovasc Nurs. 2008;7:147–51.CrossRefPubMed
24.
Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27:949–53.CrossRefPubMed
25.
Kalbfleisch SJ, El-Atassi R, Calkins H, Langberg JJ, Morady F. Association between atrioventricular node re-entrant tachycardia and inducible atrial flutter. J Am Coll Cardiol. 1993;22:80–4.CrossRefPubMed
26.
Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–66.CrossRefPubMed
27.
Verma A, Jiang C, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372:1812–22.CrossRefPubMed
28.
Ausma J, Wijffels M, Thoné F, Wouters L, Allessie M, Borgers M. Structural changes of atrial myocardium due to sustained atrial fibrillation in the goat. Circulation. 1997;96:3157–63.CrossRefPubMed
29.
Steinberg JS, Palekar R, Sichrovsky T, et al. Very long-term outcome after initially successful catheter ablation of atrial fibrillation. Heart Rhythm. 2014;11:771–6.CrossRefPubMed
30.
Calvo N, Brugada J, Sitges M, Mont L. Atrial fibrillation and atrial flutter in athletes. Br J Sports Med. 2012;46(Suppl 1):i37–43.CrossRefPubMed
31.
Dimmer C, Jordaens L, Gorgov N, et al. Analysis of the P wave with signal averaging to assess the risk of atrial fibrillation after coronary artery bypass grafting. Cardiology. 1998;89:19–24.CrossRefPubMed
32.
Marrouche NF, Wilber D, Hindricks G, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. 2014;311:498–506.CrossRefPubMed
33.
34.
de Vos CB, Nieuwlaat R, Crijns HJ, et al. Autonomic trigger patterns and anti-arrhythmic treatment of paroxysmal atrial fibrillation: data from the Euro Heart Survey. Eur Heart J. 2008;29:632–9.CrossRefPubMed
35.
Dimmer C, Tavernier R, Gjorgov N, Van Nooten G, Clement DL, Jordaens L. Variations in autonomic tone before onset of atrial fibrillation. Am J Cardiol. 1998;82:22–5.CrossRefPubMed
36.
Pokushalov E, Kozlov B, Romanov A, et al. Long-term suppression of atrial fibrillation by botulinum toxin injection into epicardial fat pads in patients undergoing cardiac surgery: one-year follow-up of a randomized pilot study. Circ Arrhythm Electrophysiol. 2015;8:1334–41.PubMed
37.
Driessen AH, Berger WR, Krul SP, et al. Ganglion plexus ablation in advanced atrial fibrillation: the AFACT Study. J Am Coll Cardiol. 2016;68:1155–65.CrossRefPubMed
38.
Scholten MF, Thornton AS, Mekel J, Rivero-Ayerza MJ, Marrouche NF, Jordaens LJ. Pulmonary vein antrum isolation guided by phased-array intracardiac echocardiography. Neth Heart J. 2005;13:439–43.PubMedPubMedCentral
39.
40.
Køber L, Thune JJ, Nielsen JC, al Investigators DANISH. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med. 2016;375:1221–30.CrossRefPubMed
41.
Wellens HJJ, Schwartz PJ, Lindemans FW, et al. Risk stratification for sudden cardiac death: current status and challenges for the future. Eur Heart J. 2014;35:1642–51.CrossRefPubMedPubMedCentral
42.
Remme WJ, Cleland JG, Erhardt L, et al. Effect of carvedilol and metoprolol on the mode of death in patients with heart failure. Eur J Heart Fail. 2007;9:1128–35.CrossRefPubMed
43.
Herring N, Paterson DJ. Neuromodulators of peripheral cardiac sympatho-vagal balance. Exp Physiol. 2009;94:46–53.CrossRefPubMed
44.
Coumel P, Lecercq JF, Attuel P, et al. Tachycardies ventriculaires en salves. Etude électrophysiologique et thérapeutique. Arch Mal Cœur. 1980;73:153–64.PubMed
45.
Liu CF, Cheung JW, Thomas G, Ip JE, Markowitz SM, Lerman BB. Ubiquitous myocardial extensions into the pulmonary artery demonstrated by integrated intracardiac echocardiography and electroanatomic mapping: changing the paradigm of idiopathic right ventricular outflow tract arrhythmias. Circ Arrhythm Electrophysiol. 2014;7:691–700.CrossRefPubMed
46.
Boukens BJ, Christoffels VM, Coronel R, Moorman AF. Developmental basis for electrophysiological heterogeneity in the ventricular and outflow tract myocardium as a substrate for life-threatening ventricular arrhythmias. Circ Res. 2009;104:19–31.CrossRefPubMed
47.
Zang M, Zhang T, Mao J, Zhou S, He B. Beneficial effects of catheter ablation of frequent premature ventricular complexes on left ventricular function. Heart. 2014;100:787–93.CrossRefPubMed
48.
Sung RJ, Keung EC, Nguyen NX, Huycke EC. Effects of beta-adrenergic blockade on verapamil-responsive and verapamil-irresponsive sustained ventricular tachycardias. J Clin Invest. 1988;81:688–99.CrossRefPubMedPubMedCentral
49.
Lerman BB. Mechanism, diagnosis, and treatment of outflow tract tachycardia. Nat Rev Cardiol. 2015;12:597–608.CrossRefPubMed
50.
Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC), Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Europace. 2015;17:1601–87.
51.
Lemery R, Brugada P, Bella DP, Dugernier T, van den Dool A, Wellens HJ. Nonischemic ventricular tachycardia. Clinical course and long-term follow-up in patients without clinically overt heart disease. Circulation. 1989;79:990–9.CrossRefPubMed
52.
Haïssaguerre M, Shoda M, Jaïs P, et al. Mapping and ablation of idiopathic ventricular fibrillation. Circulation. 2002;106:962–7.CrossRefPubMed
53.
Valk SD, Dabiri-Abkenari L, Theuns DA, Thornton AS, Res JC, Jordaens L. Ventricular fibrillation and life-threatening ventricular tachycardia in the setting of outflow tract arrhythmias—the place of ICD therapy. Int J Cardiol. 2013;165:385–7.CrossRefPubMed
54.
Jordaens L. Sudden death and tachyarrhythmias in athletes. In: Oto AM, editor. Practice and progress in cardiac pacing and electrophysiology. Dordrecht: Kluwer Academic Publishing; 1996. pp. 13–21.CrossRef
55.
Kazmierczak J, de Sutter J, Tavernier R, Cuvelier C, Dimmer C, Jordaens L. Electrocardiographic and morphometric features in patients with ventricular tachycardia from right ventricular origin. Heart. 1998;79:388–93.CrossRefPubMedPubMedCentral
56.
Jordaens L, Missault L, Pelleman G, Duprez D, De Backer G, Clement DL. Comparison of athletes with life-threatening ventricular arrhythmias with two groups of healthy athletes and a group of normal control subjects. Am J Cardiol. 1994;74:1124–8.CrossRefPubMed
57.
Coumel P. Mécanismes des arythmies ventriculaires. In: Saoudi N, Deharo JC, editors. Précis de Rythmologie. Montpellier: Sauramps Medical; 2004. pp. 107–26.
58.
Mäkikallio TH, Koistinen J, Jordaens L, et al. Heart rate dynamics before the spontaneous onset of ventricular fibrillation in patients with healed myocardial infarcts. Am J Cardiol. 1999;83:880–4.CrossRefPubMed
59.
Ventura R, Steven D, Klemm HU, et al Decennial follow-up in patients with recurrent tachycardia originating from the right ventricular outflow tract: electrophysiologic characteristics and response to treatment. Eur Heart J. 2007;28:2338–45.CrossRefPubMed
60.
Valk SD, de Groot NM, Szili-Torok T, Van Belle YL, Res JC, Jordaens L. Clinical characteristics and acute results of catheter ablation for outflow tract ventricular tachycardia or premature beats. J Interv Card Electrophysiol. 2012;35:301–9.CrossRefPubMed
Metadata
Title
A clinical approach to arrhythmias revisited in 2018
From ECG over noninvasive and invasive electrophysiology to advanced imaging
Author
L. Jordaens
Publication date
01-04-2018
Publisher
Bohn Stafleu van Loghum
Published in
Netherlands Heart Journal / Issue 4/2018
Print ISSN: 1568-5888
Electronic ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-018-1089-1

Other articles of this Issue 4/2018

Netherlands Heart Journal 4/2018 Go to the issue

Special Article

What topics caught your attention in 2017?

Heart Beat

First dutch experience of the accurate neo self-expanding supra-annular valve for valve-in-valve transcatheter aortic valve implantation

Letter to the Editor

Cardiac arrest during sports activity is difficult to recognise? Let the AED do the job!

Original Article - E‑Learning

Predictors of severe stenosis at invasive coronary angiography in patients with normal myocardial perfusion imaging

Letter to the Editor

Reply to the letter from Damman et al.: Heart transplantation in the Netherlands: a national achievement

Original Article

Catheter ablation of symptomatic idiopathic ventricular arrhythmias

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits