Palpitations. Julie Martino, MD, FACEP
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1 Palpitations Julie Martino, MD, FACEP Emergency Medicine physician Advocate Illinois Masonic Associate program director, Emergency Medicine residency, University of Illinois at Chicago
2 Disclosures I have no relevant financial relationships with the manufacturer of any commercial product and/or providers of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
3 Objectives 1. Develop a step wise approach to address "palpitations." 2. Integrate best practice management option for these arrhythmias. 3. Learn to better evaluate ECGs and develop management options.
4 Definition
5 Remember to ask: Description of symptoms Triggers During exercise? Standing up straight after bending forward? During sleep? Associated symptoms (syncope) Family hx of sudden cardiac death Medications
6 Differential?
7 Remember to check: Murmurs? Cannon A waves? CHF findings? Signs of systemic disease: pallor, exophthalmos, tremor, mydriasis
8 EBM? Increased probability of arrhythmia: Cardiac hx (LR 2) Palpitations waking pt from sleep (LR 2) Palpitations while at work (LR 2) Resting bradycardia (LR 3) Decreased probability of arrhythmia: Hx panic disorder (LR 0.25) Palpitations duration <5min (LR 0.35)
9 Good history & physical exam EKG
10 Short PR or Delta wave QTc<480 msec LVH with deep Q-waves in lateral leads TWI V1-3 and Epsilon waves RBBB pattern with ST elevation in V1-3 WPW Long QT Syndrome Hypertrophic Cardiomyopathy ARVC Brugada Red Flag EKG findings
11 EKGs What is the diagnosis and/or management?
12 Atrial fibrillation
13 Hyperkalemia
14 Delta Wave Short PR Wolff-Parkinson-White
15 Prolonged QT
16
17 Complete Heart Block
18
19 Brugada
20 Brugada
21 Pulmonary Embolism
22
23 Second degree AV block, Mobitz II
24
25 Dagger Q-waves Hypertrophic Cardiomyopathy
26 Hypertrophic Cardiomyopathy Jonathan A Drezner et al. Br J Sports Med 2013;47:
27 SVT (AVNRT)
28
29 Epsilon Waves
30 Arrhythmogenic Right Ventricular Cardiomyopathy
31 Key points: Thorough H&P Broad differential list Don t miss these scary, subtle EKG findings: EKG finding Short PR or Delta wave QTc >480 msec LVH with deep Q-waves in lateral leads TWI V1-3 and epsilon waves Possible cause WPW Long QT syndrome HCM ARVC RBBB pattern with ST-elevation in leads V1-V3 Brugada
32 References Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100(2): Raviele A, et al. Management of patients with palpitations: a position paper from the European Heart Rhythm Association, EP Europace (7): Zimetbaum P, Josephson, ME. Evaluation of Patients with Palpitations. NEJM 1998; 338: Wilken J. Evidence-based Recommendations for the Evaluation of Palpitations in the Primary Care Setting. Med Clin N Am : Probst MA, Mower WR, Kanzaria HK, et al. Analysis of emergency department visits for palpitations (from the National Hospital Ambulatory Medical Care Survey). Am J Cardiol 2014;113(10): Thavendiranathan P, et al. Does this patient with palpitations have a cardiac arrhythmia? JAMA 2009;302(19): Hoefman E, Boer KR, van Weert HC, et al. Predictive value of history taking and physical examination in diagnosing arrhythmias in general practice. Fam Pract 2007;24(6): Mayou R, Bryant B, Forfar C, et al. Non-cardiac chest pain and benign palpitations in the cardiac clinic. Heart 1994;72: Jamshed N, Dubin J, Eldadah Z. Emergency Management of Palpitations in the Elderly Epidemiology, Diagnostic Approaches, and Therapeutic Options. Clin Geriatr Med :
33 References, part 2 Probst MA, Kanzaria HK, Hoffman JR, et al. Emergency Physicians Perceptions and Decisionmaking Processes Regarding Patients Presenting with Palpitations. J Emerg Med (2): e2 Drezner JA, Ashley E, Baggish AL, et al Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy Br J Sports Med 2013;47: Brugada J. Management of patients with a Brugada ECG pattern An article from the E-Journal of the ESC Council for Cardiology Practice (24) Uberoi A, Stein R, Perez MV, et al. Interpretation of the electrocardiogram of young athletes. Circulation : Jain R, et al. Electrocardiographic features of arrhythmogenic right ventricular dysplasia. Circulation (6); Perez Diez D, Brugada J. Diagnosis and Management of Arrhythmogenic Right Ventricular Dysplasia: An article from the E-Journal of the ESC Council for Cardiology Practice, European Society of Cardiology (6) Kelly BS, Mattu A, Brady WJ. Hypertrophic cardiomyopathy: electrocardiographic manifestations and other important considerations for the emergency physician. American Journal of Emergency Medicine (1): 72-79
34 References cont EKGs courtesy of: Abhi Vallabhaneni, MD Saba Choudhary, MD Teddi Rusinak, MD Jason Gosnell, MD heartpearls.org ECGpedia.org EMS12lead.com thephysiologist.org
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