Palpitations Julie Martino, MD, FACEP Emergency Medicine physician Advocate Illinois Masonic Associate program director, Emergency Medicine residency, University of Illinois at Chicago
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.
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.
Definition
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
Differential?
Remember to check: Murmurs? Cannon A waves? CHF findings? Signs of systemic disease: pallor, exophthalmos, tremor, mydriasis
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)
Good history & physical exam EKG
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
EKGs What is the diagnosis and/or management?
Atrial fibrillation
Hyperkalemia
Delta Wave Short PR Wolff-Parkinson-White
Prolonged QT
Complete Heart Block
Brugada
Brugada
Pulmonary Embolism
Second degree AV block, Mobitz II
Dagger Q-waves Hypertrophic Cardiomyopathy
Hypertrophic Cardiomyopathy Jonathan A Drezner et al. Br J Sports Med 2013;47:137-152
SVT (AVNRT)
Epsilon Waves
Arrhythmogenic Right Ventricular Cardiomyopathy
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
References Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100(2):138 48 Raviele A, et al. Management of patients with palpitations: a position paper from the European Heart Rhythm Association, EP Europace 2011. 13 (7): 920 934. Zimetbaum P, Josephson, ME. Evaluation of Patients with Palpitations. NEJM 1998; 338:1369-1373 Wilken J. Evidence-based Recommendations for the Evaluation of Palpitations in the Primary Care Setting. Med Clin N Am 2016. 100: 981 989 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):1685 90. Thavendiranathan P, et al. Does this patient with palpitations have a cardiac arrhythmia? JAMA 2009;302(19):2135 43. 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):636 41. Mayou R, Bryant B, Forfar C, et al. Non-cardiac chest pain and benign palpitations in the cardiac clinic. Heart 1994;72:548-553. Jamshed N, Dubin J, Eldadah Z. Emergency Management of Palpitations in the Elderly Epidemiology, Diagnostic Approaches, and Therapeutic Options. Clin Geriatr Med 2013. 29: 205 230
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. 2015. 49(2): 236 243.e2 Drezner JA, Ashley E, Baggish AL, et al Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy Br J Sports Med 2013;47:137-152. Brugada J. Management of patients with a Brugada ECG pattern An article from the E-Journal of the ESC Council for Cardiology Practice 2009. 7 (24) Uberoi A, Stein R, Perez MV, et al. Interpretation of the electrocardiogram of young athletes. Circulation 2011. 124:746 57. Jain R, et al. Electrocardiographic features of arrhythmogenic right ventricular dysplasia. Circulation. 2009. 120 (6); 477-87 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 2008. 7 (6) Kelly BS, Mattu A, Brady WJ. Hypertrophic cardiomyopathy: electrocardiographic manifestations and other important considerations for the emergency physician. American Journal of Emergency Medicine 2007. 25 (1): 72-79
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