تابان آریتمی رضا محمد دکترو قلب تخصص فوق و داخلی متخصص

عروقتبریز مدنی شهید قلب مرکز

91اسفند

Palpitation

- definition ?

– Most probable diagnoses & DDX.

– Important and serious diagnoses.

– Common pitfalls.

Palpitation definition

• A subjective awareness of one’s heartbeat

• # Bradycardia• # tachycardia

Spectrum of Patients’ Descriptions

• Heart flips or flip-flops• Skipped beats• Strong beats• Irregular beats• Heart thumping• Bubble sensation in heart or chest• Racing or rapid heart beats• Pounding in neck or chest• Heart jumping out of chest• Chest or whole body shaking

Most probable diagnoses

• Anxiety• Premature beats (Ectypes= PAC / PVC)• Sinus tachycardia• Drugs, e.g. stimulants• Psychogenic • Arrhythmia: PSVT , AF/afl , VT ,…

Common Pitfalls

• Fever / Infection• Pregnancy• Menopause• Drugs, e.g. caffeine, cocaine• Mitral valve disease• Aortic incompetence• Hypoxia / Hypercapnia

Masquerade Checklist

• Depression• Diabetes Mellitus• Drugs• Anemia• Thyroid disease• Spinal dysfunction• Infection (Urinary Tract , …)

Important and Serious Diagnoses

• Myocardial infarction / angina• Life threatening Arrhythmias-Wolff-Parkinson-White Syndrome-LQTs / SQTs-Burgada sy. • Electrolyte disturbances

HistoryKeys:• Characterization of the palpitation• Attendant symptoms• Cardiac history• Arrhythmia history• Family history• Possible systemic & endocrinology disorders• Drug use

1-Characterization of the Palpitation1. Circumstances at onset2. Duration of the problem3. Mode of onset/offset , Trigger factors4. Heart rate estimate5. Rhythm regularity vs. irregularity6. Episode duration7. Symptom frequency

2- Attendant Symptoms• Symptoms arising from rhythm disorder• Symptoms due to CAD or CHF• Neurohormonal responses• Psychological symptoms: Anxiety disorder ,

Panic attacks

3- Cardiac History• Ischemic heart disease• LV dysfunction• Valvular heart disease• Atrial or ventricular arrhythmias

4-Arrhythmia History• Recurrence vs. new onset• Recent history of radiofrequency ablation• Pacemaker or ICD implantation

5- Family History• Long QT syndrome• Brugada’s syndrome• Familial cathecolamine-mediated

polymorphic V. tachycardia• Atrial fibrillation

6- Possible Endocrine and Metabolic Disorders

• Hyper or hypothyroidism• Pheochromocytoma• Diabetes• Renal disorders• Anemia• Electrolyte imbalance• Hypoglycemia• Hx of rheumatic fever

7- Drug & Dietary Use• Bronchodilator therapy, beta agonists, • Caffeine , alcohol , Chocolate• Stimulants / substance abuse: Cocaine • OTC sympathomimetic agents • QT-prolonging drugs• Thyroid replacement medications• phenothiazine, isotretinoin, digoxin• Tobacco

Dietary Supplement Causing Palpitation

• Chocolate , Caffeine , alcohol • Ephedra/Diet pills• Ginseng• Bitter Orange• Valerian• Hawthorn

Physical ExaminationOften uninformative in young adults

• Check for presence of organic heart disease - LV dysfunction - Valvular HD - Congenital HD• Evidence of COPD• Signs of anemia, thyroid and renal disease• Pulse quality, rate, regularity, pauses• Orthostatic hypotension

Physical Examination

• Best performed while having palpitations• Signs especially to consider

– Palm signs (sweaty, pallor)– Radial pulse (character)– Blood Pressure– Eye signs (pallor, eye signs of thyrotoxicosis)– Goitre– Jugular vein pulsations– Praecordium abnormalities (e.g. cardiac

enlargement, murmurs)

Diagnostic Tests • Resting EKG• Ambulatory EKG monitoring• Echocardiography• Exercise testing• Event monitor EKG• Electrophysiologic testing• Implantable loop recorder

A 48 year old man with palpitation

Atrial Premature Beat

A 50 year old man with DM & palpitation for 2-4 hours

A 73 year old woman with palpitation & dizziness.

2 to 1 AV block

An 82 year old lady with palpitation & dizzy spells + hx of AF & Digoxin

AF+ complete heart block

A 57 year old woman with palpitations

Atrial flutter

A 68 year old women on Digoxin complaining of palpitation & fatigue

Atrial flutter

A 60 year old woman with HTN crisis & palpitation

A 58 year old man on hemodialysis presents with palpitation & weakness

Hyperkalaemia

A 39 year old woman with palpitationHx of LD

Acute pulmonary embolus

A 69 year old man 2weeks post MI

Holter monitor VS Event monitor

ECG

• 1- QT (long QT , short QT)• 2- burgada syndrome• 3- WPW • 4- ARVD ( epsilon wave)• 5- HCM• 6- MI

A woman with Hx of palpitation

Tracing from a young boy with congenital long-QT syndrome. The QTU interval in the sinus beats is at least 600 milliseconds. Note TU wave alternans in the first and second complexes. A late premature complex occurring in the downslope of the TU wave initiates an episode of ventricular tachycardia

Ventricular tachycardia in the arrhythmogenic right ventricular dysplasia

A 25 year old man with periodic palpitation

short PR interval, less than 3 small squares (120 ms)

slurred upstroke to the QRS indicating pre-excitation (delta wave)

broad QRS

secondary ST and T wave changes

Localising the accessory pathway

An accessory pathway, bundle of Kent, exists between atria and ventricles and causes

early depolarisation of the ventricle. The location of the pathway may be deduced as follows:- LOCATION V1 V2 QRS axisleft posteroseptal (type A) +ve +ve leftright lateral (type B) -ve -ve leftleft lateral (type C) +ve +ve inferior (90 degrees)right posteroseptal -ve -ve leftanteroseptal -ve -ve normal

Wolf-Parkinson-White syndrome

A 47 year old man with a long history of palpitations and blackouts.

A 23 year old male with palpitations

WPW + AF

WQRST تاکی تشخیص کاردی

Wide Complex Tachycardia--Sinus tach + aberrancy.

--SVT (PSVT, AF, flutter) + aberrancy.

--Ventricular tachycardia

• Pretest probability: – Majority of wide complex tachycardia is

ventricular tachycardiaREMEMBER: VT does not invariably cause

hemodynamic collapse; patients may be conscious and stable

Clinical Clues:for Regular Wide QRS Tachycardia

• History of heart disease, especially prior MI suggests VT

• Occurrence in a young patient with no known heart disease SVT

• 12-lead EKG (if patient stable) should be obtained

5 Questions in tachyarrhythmia• 1- QRS:Wide or Narrow?Axis?Shap?• 2- Regularity?

– Regular– Regularly irregular– Irregularly irregular

• 3- P-waves? • 4- Rate?HR?• 5- Rate change sudden or gradual?

1- QRS: Wide or Narrow

• Narrow– Sinus, PSVT, A flutter, A fib

• (All without aberrancy)

• Wide– SVT + aberrancy

– Ventricular tachycardia

Aberrancy - SVT with wide complex

• Abnormal ventricular conduction– Anatomical : RBBB or LBBB

– Functional : Rate-related BBB

– Antidromic Reciprocating• Goes down through bypass tract

Suggest VT

• In RBBB pattern > 140 ms

• In LBBB pattern > 160 ms

1- QRS: Shape? Typical or atypical LBBB/RBBB

• true bundle branch block pattern– Right or left (sinus or SVT with aberrancy)

• absence of RS complex in all leads V1-V6 (negative Concordance)

Morphology criteria for VTRBBB

LBBB

V1 V6

V1 V6

1-QRS: Axis

• >45 degree

R in aVR

1- QRS : Fusion beats / capture beats

• Fusion beats (occasional narrow complex fused with wide one)

• Capture beats

2- P waves

• If p waves, and associated with QRS, then sinus (or, rarely, atrial tachycardia)

• PSVT: generally no p wave visible– PR short– P wave hidden in QRS, inverted

• A fib and flutter:– No p waves, but flutter may fool you

• V tach– May rarely see P waves, but with no association(AV dissociation) or retrograde

SANode

Ventricular Focus

ATRIA AND VENTRICLESACT INDEPENDENTLY

AV Dissociation

More R-Waves Than P-Waves Implies VT!

II

• P-waves in front of QRS?

V1

Ventricular Tachycardia (VT)

• Rates range from 100-250 beats/min• Non-sustained or sustained • P waves often dissociated (as seen here)

3- Regularity in tachycardia

• Regular– VT, Sinus, PSVT, flutter,

• Regularly irregular– Atrial flutter / AT

• Irregularly irregular– AF, MAT

4- rate

• Rate: the faster, the less likely it is sinus

(260 beats/min)

5- Sudden vs. Gradual change(Re-entry vs. automaticity)

• Sinus: gradual• PSVT: sudden• Atrial flutter: sudden• AF: always changing, but sudden onset• Ventricular tachycardia: Sudden

Identify ventricular tachycardia

• Step 1: Is there absence of RS complex in all leads V1-V6? (Concordance)– If yes, then rhythm is VT

• Step 2: Is interval from onset of R wave to nadir of the S > 100 msec (0.10 sec) in any precordial leads?– If yes, then rhythm is VT.

• Step 3: Is there AV dissociation?– If yes, then rhythm is VT.

• Step 4: Are morphology criteria for VT present (not typical BBB)? – If yes, then VT

> 0.10 sec?

Regular and wide

تم,رین :چند

Regular Wide QRS Tachycardia: VT or SVT with Aberrant Conduction?

Ventricular Tachycardia Concordance

Step 1: Absence of RS in all precordial leads

Ventricular Tachycardia

Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)

Step 2: RS in V5 > 0.10 ms, therefore v tachStep 3: No AV dissociation

Step 4: RBBB pattern (tall R in V1). Notching of this monophasic R indicates VT

V tachRS > 0.10 sec

What is it?

What is it?

What is it?

Sinus Rhythm and PACsWith Aberrant Conduction

What is it?

Artifact Mimicking “Ventricular Tachycardia”

Artifact precedes“VT”

QRS complexes “march through”the pseudo-tachyarrhythmia

Ventricular tachycardia originating from the right ventricular outflow tract. This tachycardia is characterized by a left bundle branch block contour in lead V1 and an inferior axis.

Left septal ventricular tachycardia. This tachycardia is characterized by a right bundle branch block contour. In this instance, the axis was rightward. The site of the ventricular tachycardia was established to be in the left posterior septum by electrophysiological mapping and ablation.

Ventricular Flutter

• VT 250 beats/min, without clear isoelectric line• Note “sine wave”-like appearance

Ventricular Fibrillation (VF)

• Totally chaotic rapid ventricular rhythm• Often precipitated by VT• Fatal unless promptly terminated (DC shock)

Sustained VT Degeneration to VF

Accelerated idioventricular rhythm

A 36 year old woman with recurrent blackouts

Rx

Is patient stable or unstable?• Patient has serious signs or symptoms? Look for

– Chest pain (ischemic? possible ACS?)– Shortness of breath (lungs ‘wet’? possible CHF?)– Hypotension– Decreased level of consciousness

• (poor cerebral perfusion?)– Clinical shock

• (cool and clammy -- peripheral vaso-constriction?)

• Are the signs & symptoms due to the rapid heart rate?

• Or are S/Sx’s & rapid HR due to something else?

– I.e., is it sinus tach due to sepsis, hemorrhage, PE, tamponade, dehydration, etc.

Treatment when in doubtStable or unstable-Electricity

• If possible, get 12-lead ECG first• If electricity does not work

– Automatic rhythm• Sinus, accelerated junctional, accelerated idioventricular,

automatic atrial, MAT—treatment of underlying disorder– Chronic atrial fib

• Be sure it is not physiologic tachycardia• Amiodarone for conversion• Diltiazem or Digoxin to control rate

– Refractory ventricular tachycardia• Amiodarone

– 150 mg, may repeat several times• Treat underlying ischemia

Conclusion: When in doubt

• Shock a fast rhythm• Pace a slow rhythm• In anterior STEMI

– Be certain that transcutaneous pacing will capture if there is high grade block

• But don’t shock sinus tachycardia!!