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DIAGNOSING & TREATING PALPITATIONSDIAGNOSING & TREATING PALPITATIONS
Lee GrahamLee GrahamConsultant ElectrophysiologistConsultant ElectrophysiologistYorkshire Heart CentreYorkshire Heart Centre
PALPITATIONSPALPITATIONS
• Definition:
‘an uncomfortable sensation in which a person is aware of their heart beat which may be irregular, pounding, forceful or rapid’
DIAGNOSTIC PATHWAYDIAGNOSTIC PATHWAY
• History
• Examination
• Resting ECG
• Symptom-ECG correlation
• Additional investigations
• Treatment
HISTORYHISTORY
• Onset / offset characteristics
• Age of onset
• Perceived rate
• Description of regularity
• Duration and frequency
• Associated symptoms (e.g. polyuria)
• Neck pulsations
• Triggers / relieving factors
• Nocturnal symptoms
HISTORYHISTORY
• Red Flag features (referral suggested)
• Exercise induced
• Associated syncope
• Unexplained “seizure”
• Chest pain
• Family history of premature sudden cardiac death
• Underlying structural heart disease
HISTORYHISTORY• Drug history including OTC medicines
• Decongestants
• Alcohol
• Antidepressants
• Psychotropics
• Antibiotics & antifungals
• Antihistamines
• Methadone
• Recreational drugs
EXAMINATIONEXAMINATION
• Cardiovascular• Pulse
• Blood Pressure
• Heart murmurs
• Signs of heart failure
• Features of thyroid disease
RESTING ECGRESTING ECG
• Features to check• Sinus rhythm / arrhythmia
• PR interval (WPW)
• QRS duration / bundle branch block
• ST segment shape (LVH / LV aneurysm / brugada)
• QT interval (long or short)
• Presence of Q waves (previous infarct)
• T wave inversion (cardiomyopathy or IHD)
Consider referral for any abnormal ECG
PR interval
Normal 3 to 5 small squares
(120 - 200ms)
QRS duration
Normal up to 3 small squares
(120ms)
QT interval
Depends on heart rate
QTc 440 ms men
QTc 460 ms women
WOLFF-PARKINSON-WHITE SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME
BRUGADA SYNDROMEBRUGADA SYNDROME
HYPERTROPHIC CARDIOMYOPATHYHYPERTROPHIC CARDIOMYOPATHY
DIAGNOSTIC YIELD FROM CLINICAL ASSESSMENTDIAGNOSTIC YIELD FROM CLINICAL ASSESSMENT
Thavendiranathan et al. JAMA 2009;302:2135-43
Not sufficiently accurate to exclude clinically significant arrhythmia
SYMPTOM-ECG CORRELATION SYMPTOM-ECG CORRELATION
• 12-lead ECG taken with symptoms
• Holter monitoring (24h - 7 day)
• Event recorder with / without looping memory (patient
activated device)
• Implantable loop recorder (ILR)
• Requires typical symptoms during recording
• Useful if symptoms occur several times per week
• Asymptomatic arrhythmias
• Useful for patients who are unable to trigger a monitoring device e.g. syncope
HOLTER MONITORHOLTER MONITOR
• Useful for less frequent symptoms
• Longer duration of symptoms
• Symptoms need to be reasonably well tolerated
EVENT RECORDEREVENT RECORDER
IMPLANTABLE LOOP RECORDERSIMPLANTABLE LOOP RECORDERS
AMBULATORY MONITORING OPTIONSAMBULATORY MONITORING OPTIONS
Time (months)
24h- 7 days
7-30 days
36 months
CASE VIGNETTECASE VIGNETTE
• 68y old man
• 10 month history of palpitations
• Onset with exertion
• Syncopal on two occasions
• Normal cardiovascular exam
• Normal resting ECG
ILR implanted
ILR SYMPTOM – RHYTHM CORRELATIONILR SYMPTOM – RHYTHM CORRELATION
DIAGNOSTIC YIELD FROM MONITORINGDIAGNOSTIC YIELD FROM MONITORING
Investigation Any arrhythmia Clinically significant arrhythmia
ECG during symptoms 3-26% 2%
Holter 34% 3-24%
Event recorder 30-60% 17-19%
ILR - 73%
Thavendiranathan et al. JAMA 2009;302:2135-43
ADDITIONAL INVESTIGATIONSADDITIONAL INVESTIGATIONS
• Structural cardiac disease
• Echocardiogram
• Cardiac MRI
• Exercise tolerance test
• Cardiac catheterisation
• Electrophysiological study +/- catheter ablation
PALPITATIONS-COMMON CAUSESPALPITATIONS-COMMON CAUSES
• Sinus Tachycardia
• Ectopics (PAC’s / PVC’s)
• Supraventricular tachycardia (AVNRT / AVRT / atrial tachycardia)
• Atrial flutter
• Atrial fibrillation
• Ventricular tachycardia
SINUS TACHYCARDIASINUS TACHYCARDIA
• Onset and termination are gradual (i.e. not paroxysmal)
• Perceived rate relatively slow
• May persist for several hours or days
• Normal P wave morphology
• Physiological
• sensitive to autonomic modulation
• Inappropriate
• Usually resting rate >100bpm ;mean >95bpm on 24h Holter
INAPPROPRIATE SINUS TACHYCARDIAINAPPROPRIATE SINUS TACHYCARDIA
• Poorly understood
• Young women most commonly affected
• Associated symptoms of dyspnoea, pre-syncope & fatigue
• Association with Postural Orthostatic Tachycardia Syndrome
• Treatment unsatisfactory
• Beta-blockers or rate limiting Ca antagonist
• Ivabradine
• Catheter modification of the sinus node can be attempted
• Usually sudden onset
• Perceived as ‘missed beats’ often followed by thud & fluttering
• rate relatively slow
• More commonly noticeable at rest or in bed
• Often described as persistent for several hours or days
• Sporadic
• Reassurance
• Treatment usually not required although beta-blockers can be helpful
ECTOPICSECTOPICS
RV OUTFLOW TRACT ECTOPY / VTRV OUTFLOW TRACT ECTOPY / VT
RV OUTFLOW TRACT ECTOPY / VTRV OUTFLOW TRACT ECTOPY / VT
• Frequent ectopics / salvos
• Catecholamine sensitive
• Treat with beta-blockers
• Catheter ablation offers 80% chance of cure if remains symptomatic
• 1% risk tamponade
SUPRAVENTRICULAR TACHYCARDIASUPRAVENTRICULAR TACHYCARDIA
• Usually sudden onset / offset (except atrial tachycardia)
• Perceived rate rapid and regular
• Pounding pulsation in neck (AVNRT)
• Variable duration
• Vagal manoeuvres may terminate
• Usually adenosine sensitive
• Reentry most common mechanism (except atrial tachycardia)
• AVRT/AVNRT/atrial tachy
• Short PR interval
• Delta wave
• Ventricular preexcitation
• AVRT most common arrhythmia
• AF more common and may be preexcited
• Small risk of sudden death
WOLFF-PARKINSON-WHITE SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME
No conduction delay
AV node Accessory
pathway
WOLFF-PARKINSON-WHITE SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME
• Usually narrow complex
• Rarely broad complex
• Often frequent episodes starting in childhood
ATRIOVENTRICULAR REENTRANT TACHYCARDIAATRIOVENTRICULAR REENTRANT TACHYCARDIA
Up accessory pathway
Conduction down AV node
AV REENTRANT TACHYCARDIAAV REENTRANT TACHYCARDIA
• AF may conduct rapidly over accessory pathway
• Irregular broad complex tachycardia
• Risk of degeneration to VF
• Avoid AV node blockers
PREEXCITED AFPREEXCITED AF
PREEXCITED AFPREEXCITED AF
• Refer to an electrophysiologist
• EPS and catheter ablation if symptomatic
• 95% curative (<1% risk)
• Reasonable to offer asymptomatic patients EPS
• Flecainide antiarrhythmic drug of choice
MANAGEMENT OF WPWMANAGEMENT OF WPW
• ~ 60% of all SVT F > M
• Onset often later than in AVRT
• Beta-blockers or verapamil first line antiarrhythmics
• Catheter ablation 95% curative but 1% risk AV node damage
AV NODAL REENTRANT TACHYCARDIAAV NODAL REENTRANT TACHYCARDIASlow pathway
Fast pathway
AV NODAL REENTRANT TACHYCARDIAAV NODAL REENTRANT TACHYCARDIA
• Regular or irregular palpitations
• Paroxysmal or persistent
• Saw tooth baseline
• Atrial rate usually 300 min
• Ventricular rate variable 2:1 block common
• Often difficult to rate (or rhythm) control
• Catheter ablation 90-95% curative and should be offered as first line (<1% risk)
ATRIAL FLUTTERATRIAL FLUTTER
““TYPICAL” ATRIAL FLUTTERTYPICAL” ATRIAL FLUTTER
CATHETER ABLATION FOR TYPICAL FLUTTERCATHETER ABLATION FOR TYPICAL FLUTTER
ATRIAL FIBRILLATIONATRIAL FIBRILLATION
• Assess symptoms
• Control ventricular rate
• Assess thromboembolic risk
• Rate vs. rhythm control strategy
WHO SHOULD BE OFFERED RHYTHM CONTROLWHO SHOULD BE OFFERED RHYTHM CONTROL
• Symptomatic AF despite adequate rate control
• Young symptomatic patients
• AF related heart failure
• AF secondary to corrected trigger or cause
EHRA. EHJ 2010;31:2369-2429
RHYTHM CONTROL FOR AFRHYTHM CONTROL FOR AF
• Antiarrhythmic drug therapy
• Beta-blockers
• Flecaininde
• Sotalol, amiodarone, dronedarone
• Cardioversion
• Catheter ablation
PULMONARY VEIN TRIGGERS DRIVE PULMONARY VEIN TRIGGERS DRIVE PAROXYSMAL AFPAROXYSMAL AF
RATIONALE FOR AF ABLATIONRATIONALE FOR AF ABLATION
• Electrical isolation of the pulmonary veins
• Prevents “triggers” and “drivers” of AF
• Creates electrically inexcitable “scar” around the PV’s which blocks
PV ectopics from entering the left atrium
• More effective in paroxysmal than in persistent AF
THE IDEAL PATIENT FOR AF ABLATION ?THE IDEAL PATIENT FOR AF ABLATION ?
• Arrhythmia related symptoms
• Refractory or intolerant to at least one class 1 or 3 drug
• ? Young age
• Paroxysmal rather than persistent AF
• Short duration of symptoms
• Structurally normal heart
• Informed and motivated
• ~ 70% success rates
• Often multiple procedures required
• 3-4 hour procedure
• 3-4% risk major complication
• Stroke 0.5-1%
• Cardiac tamponade 1-2%
• Usually second line
CATHETER ABLATION FOR AFCATHETER ABLATION FOR AF
ANY QUESTIONS?ANY QUESTIONS?