Sun 1040-holters-101- -park

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Palpitations and Holters 101 A quick review in 25 minutes for the Family Physician

Jonathan Tang UBC Division of Cardiology

BCCFP 2014 Spring Family Medicine Conference June 8, 2014

Disclosures

Relationships with commercial interests:

Received financial support:

In-kind support:

Conflict of interest:

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Objectives

1.  To develop an approach to the care of patients with palpitations

2.  To become familiar with the Holter report

Case 1. The case of Willy Maykit.

You see Mr. Maykit, a 70 year old chap, in your office.

He is a gentleman with known ischaemic cardiomyopathy, with a 4-vessel CABG 5 years ago, and an LVEF 40%.

He comes to your office today because he had sudden onset of “heart racing” in his chest, which was associated with lightheadedness, and after a minute, he lost consiousness. He came to after a few minutes, and is now back to normal.

This has occurred once before, about 6 months ago.

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Case 2. The case of Tak Ekardya.

You see Mr. Ekardya, a 28 year old chap, in your office.

He is an otherwise well young athletic individual, who has noted palpitations over the last 6 months.

What he notes is that every 10 weeks or so, he will have, with utter randomness, a feeling of “rapid heart beating”, associated with lightheadedness, but without ever having had loss of consiousness. This will last 10 minutes, and just as abruptly as it started, it will stop.

Case 3. The case of Earl E. deMyse.

You see Mr. deMyse, a 58 year old chap, in your office.

He came to the attention of cardiologists 3 years ago, when he underwent an ECG for insurance purposes demonstrating LVH. A subsequent echocardiogram and cardiac MRI demonstrated findings consistent with hypertrophic cardiomyopathy.

He now has symptoms of “heart pounding hard”, which occurs once every 3 weeks or so, lasts a few seconds at most, and is not associated with lightheadedness or chest pain. He has never had syncope.

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Case 4. The case of Terry Fyde.

You see Miss Fyde, a 26 year old, in your office.

She is an otherwise healthy lady who comes to your attention after having had a syncopal spell.

On this occasion, she was at work at the counter of her university library. She had missed her lunch and the room was full of students. She felt unwell, lightheaded, and after a few minutes, proceeded to go to get a drink of water but lost consciousness at the water cooler.

This type of scenario has occurred a few times before, and she has lost consciousness all times, thankfully without much more than a bruised ego.

Her ECG is normal.

Palpitations - the second most common cardiac symptom

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Definition

an awareness of heart beat a disagreeable sensation of pulsation in the chest and/or adjacent areas

rapid fluttering, irregular

“flip flop” sudden pause - then a “boom”

rapid, regular, fluttering associated with neck pounding sudden on/off “like a switch”

Palpitations - historical features

Substrate risk:

•  known structural or ischaemic heart disease

hypertension, valvular heart disease, previous MI, decreased EF, congenital heart disease, hypertrophic cardiomyopathy, etc.

•  known electrical substrate

Wolff-Parkinson-White, prolonged QT, Brugada, etc.

•  family history of possible inherited heart disease

hypertrophic cardiomyopathy, long QT syndrome, Brugada, ARVC, dilated cardiomyopathy, Fabry’s, unexplained sudden cardiac death in young family member, etc.

Important features to establish

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Palpitations - historical features

Characteristics of palpitations:

regularity, rate, onset and termination

triggers (ie. exercise) and aggravating/alleviating factors

Burden of symptoms

•  frequency and duration of symptoms

•  other associated symptoms (ie. chest pain, nausea, sweating, etc.)

•  haemodynamic impairment (syncope or pre-syncope)

Important features to establish

What is your next step?

a. Get an ECG

b. Get a Holter

c. Send him to ER

d. Tell him to get a will


You see Mr. Maykit, a 70 year old chap, in your office.

He is a gentleman with known ischaemic cardiomyopathy, with a 4-vessel CABG 5 years ago, and an LVEF 40%.

He comes to your office today because he had sudden onset of “heart racing” in his chest, which was associated with lightheadedness, and after a minute, he lost consiousness. He came to after a few minutes, and is now back to normal.

This has occurred once before, about 6 months ago.

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Why do we worry about palpitations?

The management strategy depends on:

•  the suspected arrhythmic diagnosis

•  the ability to obtain definitive ECG diagnosis

•  the risk of a malignant arrhythmia

•  the impairment in quality of life

Manifestations of possible death

What is the cause of his syncope?

a. Ventricular tachycardia

b. Can’t be sure

c. SVT

d. Vasovagal (from pretty GP)


Mr. Maykit is seen in the Emergency. His ECG demonstrates sinus rhythm with a prior inferior infarct. He is admitted to a monitored bed.

He is asymptomatic and reading his book, when the telemetry alarm bells go off. The strip shows the following:

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Diagnosis: the need for rhythm-symptom correlation

The only means to achieve a definitive diagnosis behind a patient’s symptoms is to obtain an ECG at the time of palpitations.

However, in the absence of a diagnosis, one can infer the likely cause of symptoms, and the risk associated with the suspected arrhythmia.

Risk: what to look for on monitoring

the word “normal” narrow-complex

not too fast short

infrequent

wide-complex fast

sustained frequent

associated with syncope

THE BAD

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Diagnosis: what method to choose?

HOLTER IMPLANTABLE LOOP

RECORDER Easily available

Limited duration (24 - 48 hrs)

Useful for frequent symptoms

Diagnostic yield: up to 10%

EVENT/LOOP RECORDER

Longer duration (1 to 4 weeks)

Useful for less frequent symptoms

Needs patient self-activation

Diagnostic yield: 25%

Longest duration (up to 3 years)

For infrequent but debilitating symptoms with suspected cardiac

cause

Diagnostic yield: 70%


Mr. Maykit was referred to a cardiologist for further management for his high-risk palpitations/syncope with ventricular tachycardia suspected to be the underlying cause.

A dual-chamber ICD was placed.

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a. Get an ECG

b. Get a Holter

c. Get an event monitor

d. Tell him to stop whining


You see Mr. Ekardya, a 28 year old chap, in your office.

He is an otherwise well young athletic individual, who has noted palpitations over the last 6 months.

What he notes is that every 10 weeks or so, he will have, with utter randomness, a feeling of “rapid heart beating”, associated with lightheadedness, but without ever having had loss of consiousness. This will last 10 minutes, and just as abruptly as it started, it will stop.


His ECG is interpreted as normal.

You are cognizant that it will be difficult to obtain a diagnosis for this gentleman as his symptoms are relatively short and infrequent.

While a diagnosis is not possible at this time, with a normal history, examination, and ECG, you attempt to reassure him that his symptoms do not confer any high-risk features. You give him instructions to seek medical attention and get an ECG if his symptoms become protracted.

He looks at you with a doubtful face, but duly states that he will do as instructed.

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You see him back in the office after 3 months.

He tells you know that with his examinations, his symptoms are occurring longer and more frequently (once every few days, 30 minutes each time now). You note that he is drinking more coffee as well.

You arrange for a Holter monitor.

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HOLTER REPORT NAME: TAK EKARDYA DOB: 04/31/1986

REPORT: Predominant sinus rhythm with frequent PACs Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial tachycardia; longest run 551 beats at 185 bpm Symptoms of “palpitations” correlated with runs of SVT

IMPRESSION: Symptomatic SVT; long RP tachycardia, atypical AVNRT or atrial tachycardia

HOLTER MONITOR PATIENT DIARY

TIME ACTIVITY SYMPTOMS TIME ACTIVITY SYMPTOMS 0920 Eating 0950 Watching TV 1000 Bathroom 1030 Driving to work 1055 Meeting 1100 Sitting at desk 1130 Coffee 1200 Lunch 1300 Angry 1320 Feel better 1350 Coffee 1500 Email 1600 Leaving work 1730 In accident 1750 Bathroom 1800 Making dinner 1850 Sitting 1910 Bus to friends 1920 Watching TV 2000 Chatting 2100 Talking to mom 2200 Going to sleep 0800 Breakfast 0900 Return Holter

None None None None

Pounding heart “Blip”

Heart racing None

Heart racing None

Heart racing Tired Happy

Chest pain None None None None None None None None None

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Going through a Holter report

HOLTER REPORT NAME: TAK EKARDYA DOB: 04/31/1986

REPORT: Predominant sinus rhythm with frequent PACs Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial tachycardia; longest run 551 beats at 185 bpm Symptoms of “palpitations” correlated with runs of SVT


NAME

HEART RATES TYPES OF ECTOPICS

SUBDIVISIONS OF ECTOPY Isolated, Couplets, Runs, Duration, Rate

REPORT Predominant sinus rhythm with frequent PACs Runs of regular, narrow complex, long RP tachycardia, possible atypical AVNRT or atrial tachycardia; longest run 551 beats at 185 bpm Symptoms of “palpitations” correlated with runs of SVT


Bare facts:

Diagnostic Holter with rhythm symptom correlation

Diagnosis: SVT

Non-lethal

Significant impairment in quality of life


Mr. Ekardya’s Holter report was reviewed.

He was reassured that his new diagnosis of SVT was not life-threatening.

The possible management options were discussed. Given that he had significant impairment in quality of life, a referral was made for him to undergo an electrophysiology study and ablation.

He underwent ablation for AVNRT and has not had any further episodes since.

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a. Get an ECG

b. Get a Holter

c. Get an event monitor

d. Send him to a cardiologist


You see Mr. deMyse, a 58 year old chap, in your office.

He came to the attention of cardiologists 3 years ago, when he underwent an ECG for insurance purposes demonstrating LVH. A subsequent echocardiogram and cardiac MRI demonstrated findings consistent with hypertrophic cardiomyopathy.

He now has symptoms of “heart pounding hard”, which occurs once every 3 weeks or so, lasts a few seconds at most, and is not associated with lightheadedness or chest pain. He has never had syncope.

Patients with hypertrophic cardiomyopathy are at increased risk of sudden cardiac death

Therefore, suspicion of any possible arrhythmic symptoms should come to the attention of a cardiologist

The cardiologist reviews Mr. deMyse and feels that on history and review of his recent tests, there are no high risk features to suggest a further increased risk of a ventricular arrhythmia.

However, to further delineate his risk, Mr. deMyse undergoes a Holter.


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HOLTER REPORT NAME: EARL DEMYSE DOB: 13/30/1956

REPORT: Sinus rhythm throughout Only one PAC noted No arrhythmias. No symptoms noted.

IMPRESSION: Normal Holter

Bare facts:

This is a reassuring Holter (ie. favourable prognosis)

He is still at increased risk of sudden cardiac death given his known diagnosis of hypertrophic

cardiomyopathy

However, there are no high-risk features to suggest that he is at further increased risk

We still don’t know the actual etiology behind his “heart pounding” given the lack of rhythm-symptom

correlation

In patients with hypertrophic cardiomyopathy, the presence of nonsustained ventricular tachycardia, even if asymptomatic, would be considered to be a feature of increased risk for sudden cardiac death

The cardiologist reviews Mr. deMyse again. He is still concerned that his “heart pounding” could still represent a ventricular dysrhythmia (ie. PVC).

He arranges for an event monitor.

Before the event monitor is arranged, Mr. deMyse notes that he is under more financial stress and that he is now having these “heart pounding” almost daily. Therefore, his cardiologist arranges for a Holter.


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HOLTER REPORT NAME: EARL DEMYSE DOB: 13/30/1956

REPORT: Sinus rhythm throughout Frequent, isolated PVCs. No runs. Symptoms of “heart pounding” corresponded to sinus rhythm

IMPRESSION: Sinus rhythm with frequent PVCs. No rhythm symptom correlation.

PVCs: what to do about them?

In the presence of a reassuring history and physical examination, normal ECG, and normal cardiac structure, PVCs are considered to be benign.

That means:

•  reassuring history: •  no family history of sudden cardiac death •  no genetic predisposition (ie. no family history of hypertrophic cardiomyopathy, Brugada, etc.) •  no history to suggest angina or syncope

•  normal physical examination: •  normal ECG:

•  no evidence of WPW, LVH, long QT, Brugada, etc.

•  normal echocardiogram: •  no significant ventricular or valvular disease

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PVC-induced cardiomyopathy: a new entity

Do the number of PVCs matter?

“PVC-induced cardiomyopathy” as a diagnosis is still a new entity in its infancy and more is still yet to be known

The higher the PVC burden, the further the risk of depressed EF

PVCs: in a nutshell

1.  PVCs are extremely common, and in the majority of cases, considered to be benign.

2.  In the setting of isolated PVCs without sinister findings (on history, examination, and ECG), all that is needed is reassurance.

3.  In the setting of suspected frequent PVCs, then in addition to the history, examination, and ECG, a Holter (to demonstrate PVC burden) and echocardiogram is valuable.

Definitions of frequent PVCs vary: > 60/hr, > 1% of total QRS complexes, > 1000 per 24 hours

4. There is a new entity of “PVC-induced cardiomyopathy”

5.  A cardiology referral should be considered for patients who are:

a) symptomatic, or;

b) if they have frequent PVCs, to delineate the best management

strategy for further serial evaluation

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The cardiologist determines that Mr. deMyse has “heart pounding” palpitations that is non-arrhythmic in origin.

He has frequent PVCs, but these are asymptomatic. There is no evidence of nonsustained ventricular tachycardia on his Holter monitor reports.

Given that Mr. deMyse has hypertrophic cardiomyopathy, the cardiologist decides to follow Mr. deMyse closely, and informs him of possible symptoms that would warrant urgent evaluation.

A followup visit is arranged for 3 month’s time.



a. Get a Holter

b. Get an event monitor

c. Reassure her, it’s vasovagal

d. Tell her to stop working


You see Miss Fyde, a 26 year old, in your office.

She is an otherwise healthy lady who comes to your attention after having had a syncopal spell.

On this occasion, she was at work at the counter of her university library. She had missed her lunch and the room was full of students. She felt unwell, lightheaded, and after a few minutes, proceeded to go to get a drink of water but lost consciousness at the water cooler.

This type of scenario has occurred a few times before, and she has lost consciousness all times, thankfully without much more than a bruised ego.

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HOLTER REPORT NAME: TERRY FYDE DOB: 02/30/1986

REPORT: Sinus rhythm throughout Episodes of sinus slowing and junctional escape rhythm One episode occurred during daytime hours, with associated “dizziness and nausea”, suggesting intrinsic sinus node disease

IMPRESSION: Sinus node dysfunction. Abnormal Holter.

A referral was made to have Terry see a cardiologist.

The cardiologist agreed that her symptoms were most likely vasovagal. Further understudy of the Holter was taken.


It turns out that she had both a Holter and lab work requested. Her labs were drawn while Holter on. Being terrified of needles, she felt vagal at the time of her needle puncture. Her Holter was consistent with high vagal tone.

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Terry was reassured of the benign nature of her vasovagal syncope and the reassuring Holter results.

She was advised of the conservative treatment measures with regards to her vasovagal events.

She has continued working in the library and while a few more episodes of “feeling unwell” have occurred, these are self-limiting and she has not had any further syncope.


Summary

1.  Many people have palpitations.

2.  An assessment of palpitations includes a detailed history, physical examination, and ECG, to determine the underlying risk of a possible sinister arrhythmia.

3.  The need for further investigations, and the type of ambulatory ECG monitoring, is aimed towards achieving a definitive diagnosis and assessment of prognosis.

4.  This depends on the frequency of symptoms, the need for diagnosis, and the underlying perceived risk.

5.  Remember that your friendly neighbourhood cardiologist is always available!

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Thank you

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