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Palpitations and Management of Arrhythmias 1

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Palpitations and Management of Arrhythmias

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yFernando Vega, M.D.

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

rapid or irregular beating of the heart

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• 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

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

Differential Diagnosis

Psychiatric-Panic Attack-Obsessive Disorder

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Obsessive Disorder-Somatization-Depression-Loneliness-Grief

Differential Diagnosis

Medications-Sympathomimmetic Agents-Vasodilators

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Vasodilators-Anticholinergics-Beta Blocker withdrawal

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Differential Diagnosis

Habbits-Caffeine-Nicotine

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Nicotine-Cocaine-Amphetamines

Differential Diagnosis

Metabolic Disorders-Hypoglycemia-Thyrotoxicosis

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Thyrotoxicosis-Pheochromocytoma-Argentaffionoma-Scromboid Food poisoning

Differential Diagnosis

High Output States-Anemia-Pregnancy

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Pregnancy-Paget’s Disease-Fever

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

PVCs

•Often caused by supraventricular or

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•Often caused by supraventricular or Ventricular premature contraction

ECG - PAC

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HistorySymptoms:• “rapid fluttering in chest”

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•Sustained surpraventricular or ventricular arrhythmia including sinus tachycardia

•May be regular or irregular

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ECG _*

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ECG - VT

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HistorySymptoms:• “pounding in the neck”

•Irregular pounding of the neck is caused by

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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.

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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

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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

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

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

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Palpitations – Structurally Normal• No history of cardiovascular disease,

congenital anomalies

N l ECG

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•Normal ECG

Palpitations – Other rhythms• Atrial Fibrilation

•Wolf Parkinson White

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•Prolonged Q-T Syndrome

Palpitations – Other rhythms

Atrial Fibrilation

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Palpitations – Atrial Fibrilation

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Palpitations – Atrial Fibrilation

• Hemodynamicaly Stable?

Three Questions to ask:

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•Rate vs. Rhythm Control?

•Anticoagulate?

Palpitations – Atrial Fibrilation

• Chest Pain

Hemodynamic Stability

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• Other perfusion Abnormalities

• Signs of heart failure

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Palpitations – Atrial Fibrilation

• Lone Atrial Fib

Anticoagulation

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•Persistent Atrial Fibrilation

•Intermittent Atrial Fibrilation

Palpitations – Other rhythms• Atrial Fibrilation

•Wolf Parkinson White

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•Prolonged Q-T Syndrome

Palpitations – Other rhythms

• Characterized by delta wave

Wolf Parkinson-White Syndrome

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ECG - WPWWolf Parkinson-White Syndrome

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Palpitations – Other rhythms

• Increased risk of torsade de pointes

•Primary Sx: palpitations, syncope

Prolonged QT Interval

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•Can be congenital or acquired

y p p , y pseizures and cardiac arrest

Palpitations – Other rhythmsProlonged QT Interval

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Palpitations – Other rhythmsProlonged QT Interval

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Palpitations – Other rhythms

QTc = QT interval / square root of RR

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

QT is not always prolonged and varies over time

Palpitations – Other rhythmsProlonged QT Interval

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Palpitations – Other rhythmsProlonged QT Interval

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Palpitations – Prolonged QT

Antiarrhythmics:•Amniodarone

Drugs that cause prolonged Q-T Intervals:

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

Palpitations – Prolonged QT

ANTIHISTAMINES:

Drugs that cause prolonged Q-T Intervals:

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•Astemizole•Terfenadine

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Palpitations – Prolonged QT

ANTIMICROBIALS:E h i i h l i h

Drugs that cause prolonged Q-T Intervals:

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

mefloquine

Palpitations – Prolonged QT

•Anorexia nervosa•Hypocalcemia

Metabolic Disorders:

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

Palpitations:oth Considerations• Mitral Valve Prolapse

•Organic Heart Disease

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•Obsession

Palpitations:oth Considerations• Mitral Valve Prolapse

•Organic Heart Disease

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•Obsession

Palpitations-other ConsiderationsMitral Valve Prolapse

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

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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

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•Exaggerated heart rate response to phenylephrine

•Decreased bradycardic response to dive reflex

•Isoproterenol reproduces symptoms

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Palpitations-Main Points•Symptoms sometimes characterizes the arrhythmia

•Arrhythmia is almost always benign in healthy pts.

•A normal ECG supports above

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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

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g

•CXR

•EPS Mapping

Palpitations - Management•Caffeine, caffeine, caffeine

•Nutritional support of the heart

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•Hepatodoron, donkey thistle, aurum stibium hyosciamus

•Beta blockade may not supress arrhythmia but associated symptoms

•Other antiarrhythmics

Palpitations: Baseline ECG

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Palpitations: Baseline ECG

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Palpitations: Baseline ECG

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Old ASMI

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Palpitations: Baseline ECG

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Long Q-T interval

Palpitations: Baseline ECG

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Atrial Fibrilation

Palpitations: Brief Discussion on Atrial Fib

Common, especially in middle age

Rule out Hyperthyroidism

“Lone Atrial Fibrlation” – No pharmacological treatment necessary

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“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

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“Intermitt

“Persistent Atrial

Palpitations: Baseline ECG

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Normal ECG

Palpitations: ECG with Symptoms

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Palpitations: Narrow QRS Tachycardia

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

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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”

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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

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Wide QRS Tachycardia

Palpitations: Wide QRS Tachycardia

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

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• 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

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

Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

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• Antiarrhythmic therapy• Catheter ablation

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Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

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• Antiarrhythmic therapy• Catheter ablation

Palpitations: Management

• Reassurance• AV node blocking meds• Antiarrhythmic therapy

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• Antiarrhythmic therapy• Catheter ablation

AF 1/3

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AF 2/3

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AF 3/3

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Palpitations: Management

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