atrial fibrillation and exercise: part 7: case study and summary of interventions
Hi i’m steve sally founder of fit test and in part seven of my series on atrial fibrillation and exercise i’m going to present a another case study with a very important take-home message and also i’ve been asked to provide a summary of all of the interventions that i’ve talked about in this series into one slide which is coming up on the very next slide so the
Medical interventions for our tool fibrillation consists of the heart rhythm controlling medications and the goal of these treatments used to return the patient back to sinus rhythm in other words a regular rhythm from their atrial fibrillation arrhythmia and the main drugs that are used to try and achieve this outcome of the calcium channel blockers amiodarone
And sotalol and occasionally you’ll see flicka nod i don’t see flicking i’d much in my practice as an exercise physiologist because it’s more used in the acute setting and i only see post acute clients and also some many of the conditions that i see flicka nod is contraindicated so i don’t see that much but i’m just mentioning it here the heart rate controlling
Medication is leader blockers and that’s easy to remember because they end in lol of which the main ones that are used to control heart rate and by controlling usually that means reducing heart rhodes in people with atrial fibrillation who have heart rates at rest and almost certainly in during exercise that are considered to be too high so there are a lot of
Therapeutic reasons for reducing heart rate in people without real fibrillation the main three beta blockers that you’ll see here attend along which i prolong and we also see sewed along which we saw here as a counseling channel blocker or a membrane stabilizer it’s also a beta blocker now how this works in the setting of atrial fibrillation i think it’s worth just
Mentioning this so an atrial fibrillation the scientists know the sun electron no it is in fact not in action because the chaotic electrical activity is occurring actually consumes the electrical activity of the upper chambers the atria and effectively blocks out any action from the sinus node so these chaotic a rhythmic wavelets of electrical energy occurring all
Over the atria and effectively knock out the main post maker tissue the sinus node and as i said in part one of this series these chaotic wavelets of electrical activity can then get through the atrioventricular node into to stimulate the ventricles the lower chambers the pumping chambers but at a chaotic rhythm hence the arrhythmia you know through fibrillation
Now in the setting where the only arrhythmia persists in other words heart with heart rhythm and controlling medications or other interventions were not successful or haven’t been tried in someone without real fibrillation then the next important therapeutic goal is to try and control heart rate and the medications as i said the main ones of the buda blockers a10
Along the top are also long and some other beta blockers the calcium channel blockers come up again for controlling heart rate their membrane stabilizers and digoxin also works directly on the av node as an av node blocker h a ventricular node to block here now the beta blockers in the av nodal node or blocker to toxin work by slowing the conduction or letting less
Electrical activity less events of electrical activity known as action potentials through this filter and so the av node effectively acts as a filter to prevent a very high heart rate coming from this chaos in the upper tumors we still have the arrhythmia in the lower chambers but at a more controlled rate and that’s the key of the beta blockers the first-line
Drugs for arterial fibrillation for people who are permanently in the arrhythmia so then moving on to the anti-clotting medications which i won’t talk about a great length here the main ones and the reason for giving anti-clotting medications as i said in part one is that clots can form in the oak tree at a very low amount of pumping activity and those clots
Can break off and go to the brain where they can cause a stroke for example so the main anti clotting agents to be used are the oral anticoagulants or oac s the most commonly prescribed of those are burns the 10a burns it’s easy to remember because they block factor 10 a 10 in roman numerals which is one of the key enzymes in the enzymatic thrombogenic pathway to
Produce thrombin and blood clots so there’s our bands it’s easy to remember they’ve blocked that enzyme and the most common of those is rivaroxaban or xarelto then apixaban or eliquis i don’t see your doctor burn much my practise dabigatran as an alternative to these and this is a direct thrombin inhibitor then you’ve got the vitamin k antagonists which warfarin
Is the most commonly prescribed or coumadin but this is really only used these days mainly used these days for bella atrial fibrillation and so these are in this should be in the minority of the anti clotting agents that are given to a true fibrillation clients then we move on the cardioversion which is some elective deep revelation while the person is under light
Anaesthetic to try and restore the rhythm i’ve got a question mark there because it doesn’t always work if it does work it often does revert back to arial fibrillation at some point in the next usually in the next few months then we have ablation which again question mark rhythm if this is successful and in another presentation i went over these two methods which
You can look at another presentation in this series and the two main ablation methods of pulmonary vein isolation or atrioventricular nodal ablation when the av node is ablated then this electrically separates out the chaos in the upper chambers from the what’s going on in the lower chambers then the lower chambers can be pasted into a rhythm and an appropriate
Rate so that’s a very successful treatment that’s often used now i come on to my case study of which there’s a very good learning moment coming up and this is a 65 year old male that then in on the 10th of june 2011 was diagnosed with new atrial fibrillation presented to me as an exercise physiologist and just about 2 weeks later and that’s the key point here in
This case medications he was on just a started dose of so little old and i certainly missed that that he was on a low dose soda law and that was not enough to control his heart rate as you will see in a minute he was also not on a first-line oral anticoagulant such as rivaroxaban xarelto or even dabigatran so that wasn’t there he wasn’t on warfarin either so there
Was no real strong anticoagulant therapy going on there so pretty exercised he’s clearly the ventricles are clearly out of rhythm and you can see the arrhythmia running along the baseline which is the atrial fibrillation so that is very typical of atrial fibrillation the heart rate was quite high in another video in my series on total fibrillation i talked about
Lenient road control versus versus strict road control this you would look at and say lenient road control but really the key is had come back to these low dose of soda law which will become important to you to the his case study in a minute so again after seeing this high heart rate we really try to get him to relax for a while and although heart rate came down
He was still in atrial fibrillation obviously with the ventricle ventricular arrhythmia are very obvious from these large spots when we went to exercise we had quite a lot of arrhythmia but you’ll notice that it’s suddenly accelerated at this point where we stopped exercise and this instantaneous heart rate here was in fact 250 beats 254 beats per minute actually
So in here the heart rate was 254 and remained way over 200 all the way through here and this was a 65 year old male now i did have the advantage of having an ecg for this but you could also pick this up with a dramatic rise in heart rate as i’ll show you a later on in this slide recovery at 10 seconds he was actually this very high heart rate of 250 plus persisted
All the way through this record so all the way through here heart rate above 250 think about that for a minute this is a 65 year old male with a heart rate above 250 he was conscious we were getting him off the ergometer but he was conscious and talking to us and we were trying to not excite him further recovery at 25 seconds there was a change in rhythm here
And in a minute you’ll see that there was somewhat of a rhythm restored in fact we can start to see it here so now we’ve got from from away with me all the way through here back to a rhythm here but the very fast heart round he is sitting on a chair here with a heart rate of about 180 plus so this is already well above his age predicted heart rate max all the way
Through here recovery way above so there’s something very excitable going on but the interesting thing is that the the rhythm was now was now a rhythmical and you can actually see the p waves in most of these complexes there which means the asado atrial node has taken up the rhythm again which wasn’t either a good outcome or a better outcome it’s just i’m just
Noting in here with the hard road very high still at 180 plus a 10 minutes 30 he jumped out of that rhythm of 180 and look almost flatline for a while which is not a very pleasant thing to be seen because i’m responsible for his safety so almost cardiac standstill for a bit of this but then he jumped back into something of a rhythm at half a minute after this
And here we can see p waves again so he’s back in sinus rhythm here with but these pauses here are quite disconcerting if you’re in charge of this situation so at 17 minutes in fact he went left the facility with a rhythmical heart which was interesting and you can see the p waves there and the heart rate was in fact back to way below the pre exercise levels so you
Know stupid way i could say that the exercise that we gave to my client actually triggered him to revert from the arrhythmia to sinus rhythm but i’m certainly not going to be arrogant enough to claim that benefit of exercise it didn’t exist this was purely a coincidence now that now i just want to show you the heart rates here so the if you didn’t have an ecg then
You would be able to get a heart rate record that would also be extremely useful so this is a heart rate record over the whole of the exercise test here and all of the recovery here so there’s about 8 to 10 minutes of exercise in about 17 minutes of recovery clearly through the early parts of exercise the hard road was was tracking a long crime well admittedly out
Of rhythm that’s the fact that it’s not going up in a straight line but lots of jagged curve parts of the curve here which is really reflected in the arrhythmia but then this heart rate going above 250 which caused us to stop exercise coming down after about one minute in the first minute coming down to this constant rate of 180 plus boots for about 10 minutes
Until recovery 10 minutes 30 then he jumped right back down to below 40 heart rate and came up and settled at a heart rate of about 70 by the time he left the facility so you could get all of this of course with a good decent heart rate monitor most of modern smartwatches and so on with the apps will give you a record a little bit like this and it would still
Be extremely useful of course we’re not diagnosing without an ecg but this would still be an extremely useful record to pass on to the primary care medical practitioner to show that heart rate was not under control so we don’t have rhythm under control although i said here he left with rhythm but at rest pre exercise he was not he did not have rhythm control and
During exercise he certainly did not have rate control so we don’t have either rhythm or rate control now coming back to the start of dose and the take-home message for me was that this client was really in knew atrial fibrillation and he was not medically stable and he was also only on a starter dose of rhythm control and rate control remember so delong does both
It’s both a beta blocker and a kelson channel and a potassium channel blocker which means it is a membrane stabilizer for rhythm and also for right now the soda law was not doing the job adequately clearly in this case so then going on with his case a few months later in that year he had hired a personal trainer so i’ve obviously remarked on this and presumably i
Wasn’t seen as a client but presumably he was going up in the dose of soda law but he had had recent episodes of feeling funny after exercise and he was aware of palpitations during those personal training sessions a month after that he collapsed at home and was admitted to coronary care unit and had a permanent pacemaker fitted i just want to show you what happened
To the pacemaker that i actually got to test him over the next few years after this he wasn’t an ongoing client of mine but i was able to tell him once a year for his reagan rhythm so you’ve already seen the pre post mocha when he had our regulation that was my first exercise assessment of my client in 2014 a couple of years after three years after his pacemaker
Was fitted you can see here that the pacemaker was over triggering here a little bit in early exercise and we had some triggering occurring in at in recovery and you’ll notice here this flat line here this is completely desirable and expected for someone with a pacemaker the pacemaker is working perfectly here which means he has been placed and exactly i think it
Was 70 beats and modern man 80 beats but anyway let’s say it was 70 absolutely constant pacing at 70 which is the main indication for the post maker to stop the heart rate going too low the heart rate and the pacing can also help to prevent it from going too high but that’s really the beta blocker more than the pacemaker there was another triggering event here in
Recovery when i tested him a year after that we had almost no triggering during exercise or over triggering during exercise and we only had one over triggering event in recovery and then finally in 2016 which was the last time i tested him we had a nice characteristic post-motor increase in the heart rate here but not over triggering very very typical heart rate
Response to exercise with a pacemaker and then we just had one very small over triggering event in recovery and he flatlined all the way through him which means he was think post all the way through there so thank you for listening and watching this short video on an important case study with an important take-home message and also i’ve fulfilled my goal of trying
To revise the interventions all on one slide for those who are interested in in that so you can contact me info admire just comment on our youth and have a great day bye for now bye
Transcribed from video
atrial fibrillation and exercise: part 7: case study and summary of interventions By Steve Selig