Palpitations and Management of Arrhythmias 1

7/8/2011 Fernando Vega, M.D. 1

Palpitations and Management of Arrhythmias

7/8/2011 Fernando Vega, M.D. 2

yFernando Vega, M.D.

Palpitations• A sensory symptom• An unpleasant awareness of the forceful,

rapid or irregular beating of the heart

7/8/2011 Fernando Vega, M.D. 3

• Can be described as:– Rapid fluttering in the chest– Flip-flopping in the chest– Pounding sensation in chest or neck

Differential Diagnosis

Cardiac Causes-Arrhythmia-Cardiac and extracardiac shunts

7/8/2011 Fernando Vega, M.D. 4

Cardiac and extracardiac shunts-Valvular Heart Disease-Atrial Myxoma-Cardiomyopathy-Pericarditis

Differential Diagnosis

Psychiatric-Panic Attack-Obsessive Disorder

7/8/2011 Fernando Vega, M.D. 5

Obsessive Disorder-Somatization-Depression-Loneliness-Grief

Differential Diagnosis

Medications-Sympathomimmetic Agents-Vasodilators

7/8/2011 Fernando Vega, M.D. 6

Vasodilators-Anticholinergics-Beta Blocker withdrawal

Palpitations and Management of Arrhythmias 2

Differential Diagnosis

Habbits-Caffeine-Nicotine

7/8/2011 Fernando Vega, M.D. 7

Nicotine-Cocaine-Amphetamines

Differential Diagnosis

Metabolic Disorders-Hypoglycemia-Thyrotoxicosis

7/8/2011 Fernando Vega, M.D. 8

Thyrotoxicosis-Pheochromocytoma-Argentaffionoma-Scromboid Food poisoning

Differential Diagnosis

High Output States-Anemia-Pregnancy

7/8/2011 Fernando Vega, M.D. 9

Pregnancy-Paget’s Disease-Fever

HistorySymptoms:• “flip-flopping in chest” – isolated PACs or

PVCs

•Often caused by supraventricular or

7/8/2011 Fernando Vega, M.D. 10

•Often caused by supraventricular or Ventricular premature contraction

ECG - PAC

7/8/2011 Fernando Vega, M.D. 11

HistorySymptoms:• “rapid fluttering in chest”

7/8/2011 Fernando Vega, M.D. 12

•Sustained surpraventricular or ventricular arrhythmia including sinus tachycardia

•May be regular or irregular

Palpitations and Management of Arrhythmias 3

ECG _*

7/8/2011 Fernando Vega, M.D. 13

ECG - VT

7/8/2011 Fernando Vega, M.D. 14

HistorySymptoms:• “pounding in the neck”

•Irregular pounding of the neck is caused by

7/8/2011 Fernando Vega, M.D. 15

arioventricular dissociation where the atriacontract against an occasionlly closed AV valve. Cannon A waves are formed.

•Examples include PVC’s, third degreeheart block or ventricular tachycardia

HistoryMode of Onset:•Abrupt suggests paroxysmal abnormal tachycardia,though sinus tach may start abruptly in anxiety.

7/8/2011 Fernando Vega, M.D. 16

Mode of Termination:•Abrupt suggests paroxysmal arrhythmia,though high adrenergic tone caused by arrhythmia

may result in consequent sinus tach.

HistoryCharacteristics:•Rapid, irregular – AF, AFL, Atrial tachycardia,

multiple PACs or PVCs•Rapid, regular – SVT, VT

7/8/2011 Fernando Vega, M.D. 17

Circumstances:•Panic/anxiety – the chicken or the egg?•Catecholamine excess

–Exercise – idiopathic RVOT VT, AF–Emotional startle – Long QT syndrome

Palpitations• Most patients with Palpitations will have

benign supraventricular or ventricular ectopy

PVC’ d t i d t i l

7/8/2011 Fernando Vega, M.D. 18

•The above are not associated with increased mortality in pts with structurallynormal hearts

•PVC’s and non sustained ventricular tachycardia come in less often.

Palpitations and Management of Arrhythmias 4

Palpitations – Structurally Normal• No history of cardiovascular disease,

congenital anomalies

N l ECG

7/8/2011 Fernando Vega, M.D. 19

•Normal ECG

Palpitations – Other rhythms• Atrial Fibrilation

•Wolf Parkinson White

7/8/2011 Fernando Vega, M.D. 20

•Prolonged Q-T Syndrome

Palpitations – Other rhythms

Atrial Fibrilation

7/8/2011 Fernando Vega, M.D. 21

Palpitations – Atrial Fibrilation

7/8/2011 Fernando Vega, M.D. 22

Palpitations – Atrial Fibrilation

• Hemodynamicaly Stable?

Three Questions to ask:

7/8/2011 Fernando Vega, M.D. 23

•Rate vs. Rhythm Control?

•Anticoagulate?

Palpitations – Atrial Fibrilation

• Chest Pain

Hemodynamic Stability

7/8/2011 Fernando Vega, M.D. 24

• Other perfusion Abnormalities

• Signs of heart failure

Palpitations and Management of Arrhythmias 5

Palpitations – Atrial Fibrilation

• Lone Atrial Fib

Anticoagulation

7/8/2011 Fernando Vega, M.D. 25

•Persistent Atrial Fibrilation

•Intermittent Atrial Fibrilation

Palpitations – Other rhythms• Atrial Fibrilation

•Wolf Parkinson White

7/8/2011 Fernando Vega, M.D. 26

•Prolonged Q-T Syndrome

Palpitations – Other rhythms

• Characterized by delta wave

Wolf Parkinson-White Syndrome

7/8/2011 Fernando Vega, M.D. 27

ECG - WPWWolf Parkinson-White Syndrome

7/8/2011 Fernando Vega, M.D. 28

Palpitations – Other rhythms

• Increased risk of torsade de pointes

•Primary Sx: palpitations, syncope

Prolonged QT Interval

7/8/2011 Fernando Vega, M.D. 29

•Can be congenital or acquired

y p p , y pseizures and cardiac arrest

Palpitations – Other rhythmsProlonged QT Interval

7/8/2011 Fernando Vega, M.D. 30

Palpitations and Management of Arrhythmias 6

Palpitations – Other rhythmsProlonged QT Interval

7/8/2011 Fernando Vega, M.D. 31

Palpitations – Other rhythms

QTc = QT interval / square root of RR

7/8/2011 Fernando Vega, M.D. 32

QT is measured in lead II, maybe V2-3, V56

QT is not always prolonged and varies over time

Palpitations – Other rhythmsProlonged QT Interval

7/8/2011 Fernando Vega, M.D. 33

Palpitations – Other rhythmsProlonged QT Interval

7/8/2011 Fernando Vega, M.D. 34

Palpitations – Prolonged QT

Antiarrhythmics:•Amniodarone

Drugs that cause prolonged Q-T Intervals:

7/8/2011 Fernando Vega, M.D. 35

•Disopyramide•Dofetilide, sematilide, ibutilide•Quinidine•Sotalol

Palpitations – Prolonged QT

ANTIHISTAMINES:

Drugs that cause prolonged Q-T Intervals:

7/8/2011 Fernando Vega, M.D. 36

•Astemizole•Terfenadine

Palpitations and Management of Arrhythmias 7

Palpitations – Prolonged QT

ANTIMICROBIALS:E h i i h l i h

Drugs that cause prolonged Q-T Intervals:

7/8/2011 Fernando Vega, M.D. 37

•Erythromycin, azithro, clarithro•Some flouroquinones•TMP/SMZ•Other: Pentamidine, chloroquine

mefloquine

Palpitations – Prolonged QT

•Anorexia nervosa•Hypocalcemia

Metabolic Disorders:

7/8/2011 Fernando Vega, M.D. 38

Hypocalcemia•Hypockalemia•Hypomagnesemia•Hypothyroidism (sporadic case reports)•Liquid protein diets•Starvation

Palpitations:oth Considerations• Mitral Valve Prolapse

•Organic Heart Disease

7/8/2011 Fernando Vega, M.D. 39

•Obsession

Palpitations:oth Considerations• Mitral Valve Prolapse

•Organic Heart Disease

7/8/2011 Fernando Vega, M.D. 40

•Obsession

Palpitations-other ConsiderationsMitral Valve Prolapse

Framingham Heart Study compared 84 patients with MVP to 3403 control subjects;

7/8/2011 Fernando Vega, M.D. 41

with MVP to 3403 control subjects;

Chest pain, dyspnea, syncope, CHF, AF and ECG abnormalities were equally prevalent in matched controls.

Palpitations-other ConsiderationsMitral Valve Prolapse

•Elevated urine and plasma catecholamine levels

7/8/2011 Fernando Vega, M.D. 42

•Exaggerated heart rate response to phenylephrine

•Decreased bradycardic response to dive reflex

•Isoproterenol reproduces symptoms

Palpitations and Management of Arrhythmias 8

Palpitations-Main Points•Symptoms sometimes characterizes the arrhythmia

•Arrhythmia is almost always benign in healthy pts.

•A normal ECG supports above

7/8/2011 Fernando Vega, M.D. 43

pp

•Look out for atrial fib, prolonged QT intervals, WPW

•Look out for other signs of organic disease: Q waves,

ST changes, hypertrophy

Palpitations-Further Workup•Holter Monitoring

•Event Monitoring

•Echocardiogram

7/8/2011 Fernando Vega, M.D. 44

g

•CXR

•EPS Mapping

Palpitations - Management•Caffeine, caffeine, caffeine

•Nutritional support of the heart

7/8/2011 Fernando Vega, M.D. 45

•Hepatodoron, donkey thistle, aurum stibium hyosciamus

•Beta blockade may not supress arrhythmia but associated symptoms

•Other antiarrhythmics

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 46Wolff-Parkinson-White

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 47LVH with strain and LAE

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 48

Old ASMI

Palpitations and Management of Arrhythmias 9

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 49

Long Q-T interval

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 50

Atrial Fibrilation

Palpitations: Brief Discussion on Atrial Fib

Common, especially in middle age

Rule out Hyperthyroidism

“Lone Atrial Fibrlation” – No pharmacological treatment necessary

7/8/2011 Fernando Vega, M.D. 51

“Intermittent Atrial Fibrilation”- Studies show high likelyhoodOf mural thrombi and possible embolization

“Persistent Atrial Fibrilation” – Requires anticoagulation

Palpitations: Brief Discussion on Atrial Fib

Rhyhm vs. Rate control

Rule

“Lone

7/8/2011 Fernando Vega, M.D. 52

“Intermitt

“Persistent Atrial

Palpitations: Baseline ECG

7/8/2011 Fernando Vega, M.D. 53

Normal ECG

Palpitations: ECG with Symptoms

7/8/2011 Fernando Vega, M.D. 54Narrow QRS Tachycardia

Palpitations and Management of Arrhythmias 10

Palpitations: Narrow QRS Tachycardia

• Regular? No → AF AT/AFL with variable block MAT

7/8/2011 Fernando Vega, M.D. 55

Regular? No → AF, AT/AFL with variable block, MAT• Visible P waves? No → AVNRT• Atrial rate greater than ventricular rate? Yes → AT/AFL• Short RP interval? AVNRT, AVRT, AT• Long RP interval? AT, PJRT, Atypical AVNRT

Palpitations: Narrow QRS Tachycardia

Take the “Adenosine Challenge”Take the “Adenosine Challenge”

7/8/2011 Fernando Vega, M.D. 56

gg

• Sudden termination → AVNRT, AVRT, SNRT• Persistent Atach, high-degree AV block → AFL, AT• Gradual slowing, then reacceleration → ST, JT• No change in rate → inadequate dose, VT

Palpitations: ECG with Symptoms

7/8/2011 Fernando Vega, M.D. 57

Wide QRS Tachycardia

Palpitations: Wide QRS Tachycardia

• Regular? No → AF/AFL/AT with BBB or AP

7/8/2011 Fernando Vega, M.D. 58

• Is QRS identical to that of SR? Yes → SVT with BBB, antidromic AVRT

• A-V dissociation or fusion beats? Yes → VT• QRS morphology? Bizarre → VT• Previous MI or structural heart disease? Yes → VT

Palpitations: Workup

• 24 hour Holter monitor• Continuous loop event recorder

7/8/2011 Fernando Vega, M.D. 59

• Echocardiogram• Treadmill test (for sxs with or after exercise)• E.P. testing

Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

7/8/2011 Fernando Vega, M.D. 60

• Antiarrhythmic therapy• Catheter ablation

Palpitations and Management of Arrhythmias 11

Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

7/8/2011 Fernando Vega, M.D. 61

• Antiarrhythmic therapy• Catheter ablation

Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

7/8/2011 Fernando Vega, M.D. 62

• Antiarrhythmic therapy• Catheter ablation

AF 1/3

7/8/2011 Fernando Vega, M.D. 63

AF 2/3

7/8/2011 Fernando Vega, M.D. 64

AF 3/3

7/8/2011 Fernando Vega, M.D. 65

Palpitations: Management

7/8/2011 Fernando Vega, M.D. 66