Palpitations and Management of Arrhythmias. Palpitations. Differential Diagnosis. Differential Diagnosis. Differential Diagnosis
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1 Palpitations and Management of Arrhythmias Fernando Vega, M.D. 7/8/2011 Fernando Vega, M.D. 1 7/8/2011 Fernando Vega, M.D. 2 Palpitations A sensory symptom An unpleasant awareness of the forceful, rapid or irregular beating of the heart 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 -Valvular Heart Disease -Atrial Myxoma -Cardiomyopathy -Pericarditis 7/8/2011 Fernando Vega, M.D. 3 7/8/2011 Fernando Vega, M.D. 4 Differential Diagnosis Differential Diagnosis Psychiatric -Panic Attack -Obsessive Disorder -Somatization -Depression -Loneliness -Grief Medications -Sympathomimmetic Agents -Vasodilators -Anticholinergics -Beta Blocker withdrawal 7/8/2011 Fernando Vega, M.D. 5 7/8/2011 Fernando Vega, M.D. 6 Arrhythmias 1
2 Differential Diagnosis Differential Diagnosis Habbits -Caffeine -Nicotine -Cocaine -Amphetamines Metabolic Disorders -Hypoglycemia -Thyrotoxicosis -Pheochromocytoma -Argentaffionoma -Scromboid Food poisoning 7/8/2011 Fernando Vega, M.D. 7 7/8/2011 Fernando Vega, M.D. 8 Differential Diagnosis High Output States -Anemia -Pregnancy -Paget s Disease -Fever History Symptoms: flip-flopping in chest isolated PACs or PVCs Often caused by supraventricular or Ventricular premature contraction 7/8/2011 Fernando Vega, M.D. 9 7/8/2011 Fernando Vega, M.D. 10 ECG - PAC History Symptoms: rapid fluttering in chest Sustained surpraventricular or ventricular arrhythmia including sinus tachycardia May be regular or irregular 7/8/2011 Fernando Vega, M.D. 11 7/8/2011 Fernando Vega, M.D. 12 Arrhythmias 2
3 ECG _* ECG - VT 7/8/2011 Fernando Vega, M.D. 13 7/8/2011 Fernando Vega, M.D. 14 History Symptoms: pounding in the neck Irregular pounding of the neck is caused by arioventricular dissociation where the atria contract against an occasionlly closed AV valve. Cannon A waves are formed. Examples include PVC s, third degree heart block or ventricular tachycardia 7/8/2011 Fernando Vega, M.D. 15 History Mode of Onset: Abrupt suggests paroxysmal abnormal tachycardia, though sinus tach may start abruptly in anxiety. Mode of Termination: Abrupt suggests paroxysmal arrhythmia, though high adrenergic tone caused by arrhythmia may result in consequent sinus tach. 7/8/2011 Fernando Vega, M.D. 16 History Characteristics: Rapid, irregular AF, AFL, Atrial tachycardia, multiple PACs or PVCs Rapid, regular SVT, VT Circumstances: Panic/anxiety the chicken or the egg? Catecholamine excess Exercise idiopathic RVOT VT, AF Emotional startle Long QT syndrome 7/8/2011 Fernando Vega, M.D. 17 Palpitations Most patients with Palpitations will have benign supraventricular or ventricular ectopy PVC s and non sustained ventricular tachycardia come in less often. The above are not associated with increased mortality in pts with structurally normal hearts 7/8/2011 Fernando Vega, M.D. 18 Arrhythmias 3
4 Palpitations Structurally Normal No history of cardiovascular disease, congenital anomalies Normal ECG Atrial Fibrilation Wolf Parkinson White Prolonged Q-T Syndrome 7/8/2011 Fernando Vega, M.D. 19 7/8/2011 Fernando Vega, M.D. 20 Palpitations Atrial Fibrilation Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 21 7/8/2011 Fernando Vega, M.D. 22 Palpitations Atrial Fibrilation Three Questions to ask: Palpitations Atrial Fibrilation Hemodynamic Stability Hemodynamicaly Stable? Anticoagulate? Rate vs. Rhythm Control? Chest Pain Signs of heart failure Other perfusion Abnormalities 7/8/2011 Fernando Vega, M.D. 23 7/8/2011 Fernando Vega, M.D. 24 Arrhythmias 4
5 Palpitations Atrial Fibrilation Anticoagulation Lone Atrial Fib Intermittent Atrial Fibrilation Atrial Fibrilation Wolf Parkinson White Prolonged Q-T Syndrome Persistent Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 25 7/8/2011 Fernando Vega, M.D. 26 Wolf Parkinson-White Syndrome Characterized by delta wave ECG - WPW Wolf Parkinson-White Syndrome 7/8/2011 Fernando Vega, M.D. 27 7/8/2011 Fernando Vega, M.D. 28 Prolonged QT Interval Increased risk of torsade de pointes Primary Sx: palpitations, p syncope seizures and cardiac arrest Prolonged QT Interval Can be congenital or acquired 7/8/2011 Fernando Vega, M.D. 29 7/8/2011 Fernando Vega, M.D. 30 Arrhythmias 5
6 Prolonged QT Interval QTc = QT interval / square root of RR QT is measured in lead II, maybe V2-3, V56 QT is not always prolonged and varies over time 7/8/2011 Fernando Vega, M.D. 31 7/8/2011 Fernando Vega, M.D. 32 Prolonged QT Interval Prolonged QT Interval 7/8/2011 Fernando Vega, M.D. 33 7/8/2011 Fernando Vega, M.D. 34 Palpitations Prolonged QT Drugs that cause prolonged Q-T Intervals: Antiarrhythmics: Amniodarone Disopyramide Dofetilide, sematilide, ibutilide Quinidine Sotalol Palpitations Prolonged QT Drugs that cause prolonged Q-T Intervals: ANTIHISTAMINES: Astemizole Terfenadine 7/8/2011 Fernando Vega, M.D. 35 7/8/2011 Fernando Vega, M.D. 36 Arrhythmias 6
7 Palpitations Prolonged QT Drugs that cause prolonged Q-T Intervals: ANTIMICROBIALS: Erythromycin, azithro, clarithro Some flouroquinones TMP/SMZ Other: Pentamidine, chloroquine mefloquine 7/8/2011 Fernando Vega, M.D. 37 Palpitations Prolonged QT Metabolic Disorders: Anorexia nervosa Hypocalcemia Hypockalemia Hypomagnesemia Hypothyroidism (sporadic case reports) Liquid protein diets Starvation 7/8/2011 Fernando Vega, M.D. 38 Palpitations:oth Considerations Mitral Valve Prolapse Organic Heart Disease Obsession Palpitations:oth Considerations Mitral Valve Prolapse Organic Heart Disease Obsession 7/8/2011 Fernando Vega, M.D. 39 7/8/2011 Fernando Vega, M.D. 40 Palpitations-other Considerations Mitral Valve Prolapse Palpitations-other Considerations Mitral Valve Prolapse Framingham Heart Study compared 84 patients with MVP to 3403 control subjects; Chest pain, dyspnea, syncope, CHF, AF and ECG abnormalities were equally prevalent in matched controls. Elevated urine and plasma catecholamine levels Exaggerated heart rate response to phenylephrine Decreased bradycardic response to dive reflex Isoproterenol reproduces symptoms 7/8/2011 Fernando Vega, M.D. 41 7/8/2011 Fernando Vega, M.D. 42 Arrhythmias 7
8 Palpitations-Main Points Symptoms sometimes characterizes the arrhythmia Arrhythmia is almost always benign in healthy pts. A normal ECG supports above 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 Echocardiogramg CXR EPS Mapping 7/8/2011 Fernando Vega, M.D. 43 7/8/2011 Fernando Vega, M.D. 44 Palpitations - Management Palpitations: Baseline ECG Caffeine, caffeine, caffeine Nutritional support of the heart Hepatodoron, donkey thistle, aurum stibium hyosciamus Beta blockade may not supress arrhythmia but associated symptoms Other antiarrhythmics 7/8/2011 Fernando Vega, M.D. 45 Wolff-Parkinson-White 7/8/2011 Fernando Vega, M.D. 46 Palpitations: Baseline ECG Palpitations: Baseline ECG LVH with strain and LAE 7/8/2011 Fernando Vega, M.D. 47 Old ASMI 7/8/2011 Fernando Vega, M.D. 48 Arrhythmias 8
9 Palpitations: Baseline ECG Palpitations: Baseline ECG Long Q-T interval Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 49 7/8/2011 Fernando Vega, M.D. 50 Palpitations: Brief Discussion on Atrial Fib Common, especially in middle age Rule out Hyperthyroidism Lone Atrial Fibrlation No pharmacological treatment necessary Intermittent Atrial Fibrilation - Studies show high likelyhood Of mural thrombi and possible embolization Persistent Atrial Fibrilation Requires anticoagulation Palpitations: Brief Discussion on Atrial Fib Rhyhm vs. Rate control Rule Lone Intermitt Persistent Atrial 7/8/2011 Fernando Vega, M.D. 51 7/8/2011 Fernando Vega, M.D. 52 Palpitations: Baseline ECG Palpitations: ECG with Symptoms Normal ECG 7/8/2011 Fernando Vega, M.D. 53 Narrow QRS Tachycardia 7/8/2011 Fernando Vega, M.D. 54 Arrhythmias 9
10 Palpitations: Narrow QRS Tachycardia Palpitations: Narrow QRS Tachycardia 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 7/8/2011 Fernando Vega, M.D. 55 Take the Adenosine Challenge 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 7/8/2011 Fernando Vega, M.D. 56 Palpitations: ECG with Symptoms Palpitations: Wide QRS Tachycardia Wide QRS Tachycardia 7/8/2011 Fernando Vega, M.D. 57 Regular? No AF/AFL/AT with BBB or AP 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 7/8/2011 Fernando Vega, M.D. 58 Palpitations: Workup Palpitations: Management 24 hour Holter monitor Continuous loop event recorder Echocardiogram Treadmill test (for sxs with or after exercise) E.P. testing Reassurance AV node blocking meds Antiarrhythmic therapy Catheter ablation 7/8/2011 Fernando Vega, M.D. 59 7/8/2011 Fernando Vega, M.D. 60 Arrhythmias 10
11 Palpitations: Management Palpitations: Management Reassurance AV node blocking meds Antiarrhythmic therapy Catheter ablation Reassurance AV node blocking meds Antiarrhythmic therapy Catheter ablation 7/8/2011 Fernando Vega, M.D. 61 7/8/2011 Fernando Vega, M.D. 62 AF 1/3 AF 2/3 7/8/2011 Fernando Vega, M.D. 63 7/8/2011 Fernando Vega, M.D. 64 AF 3/3 Palpitations: Management 7/8/2011 Fernando Vega, M.D. 65 7/8/2011 Fernando Vega, M.D. 66 Arrhythmias 11
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