Antony French Consultant Cardiologist & Electrophysiologist

Antony French Consultant Cardiologist & Electrophysiologist

Palpitations Unpleasant awareness of rapid or forceful heart beat Not all tachycardias cause palpitations, and not all palpitations are due to tachy. Wide variety of terms used by patients to describe the phenomenon Associated cardiac symptoms are often important Situational context may sometimes be helpful

Arrhythmia Palpitations

Potential Causes Of Palpitations Non-cardiac PACs/PVCs Sinus tachycardia SANRT Junctional rhythm Atrial Tachycardia Atrial Flutter Atrial Fibrillation AVNRT AVRT VT Bradycardias Pacemaker syndrome

Prognostic Causes Of Palpitations Ischaemic VT (usually in context of severe LV systolic dysfunction: LVEF <35%) Channelopathies (LQTS, Brugada etc) WPW (manifest pre-excitation) Cardiomyopathies: ARVC, LMNA mutations CPVT

The Reassuring Bit For Patients A normal resting ECG and a normal echo (mainly LV function) make a dangerous cause for symptoms EXTREMELY unlikely Even a FHx of inherited cardiac conditions may not indicate a serious cause in that patient The vast majority of treatment is symptom-driven, not prognosis-driven

Red Flags For Palpitations Associated syncope Structurally abnormal heart on echo (especially LV systolic impairment) Abnormal ECG (pre-excited, Brugada, LQTS) FHx of significant inherited arrhythmia (symptoms on exertion)

Pre-excitation Kay NG. Am J of Med. 1996;10:344-356.

LQT 3 Prolonged ST segment

Brugada Syndrome ECG patterns Type-1 2-mm J-point elevation, coved type ST-T segment elevation and inverted T-wave in leads V1 and V2. Type-2 2-mm J-point elevation, 1-mm St segment elevation, saddleback ST-T segment and a positive or biphasic T-wave. Type-3 Same as type 2, except that the ST-segment elevation is <1 mm.

Diagnostic Clues Jumps or pauses suggestive of ectopy Gradual onset/resolution suggestive of sinus tachycardia Abrupt onset/resolution suggestive of paroxysmal rhythm change Irregular pulse suggestive of AF Rate may be helpful, if recorded: 100-140:? Sinus ~150:? Atrial flutter with 2:1 >160:? Reentry tachycardia

Ventricular Ectopics Commonest diagnosis in Arrhythmia Clinic Although benign, can produce intolerable symptom burden Often cyclical in occurrence Medical therapy largely unsatisfactory: B-blockers very rarely of help Class I AAs can be successful, but advanced Rx Omega-3 FAs may help Avoidance of trigger factors usually beneficial

Ventricular Ectopics Generally, have no prognostic significance However, important in ARVD, and in ischaemic dilated cardiomyopathy Ablative intervention occasionally undertaken for extreme symptoms: uses endocardial mapping techniques, and risk of CVA etc. Explanation and reassurance far more valuable: vast majority of patients satisfied

Investigations: ECG: baseline and during tachy if possible Routine bloods inc. TFTs CXR Echo Ambulatory monitoring: Not just 24 hour tapes ILR device (Implantable Loop Recorder) EP studies Rarely: CT, MRI, angiography

Ambulatory Monitoring The infamous 24 Hour Holter Week-long Holter (Novacor) Patient activated event recorders AliveCor device ILRs Detachable patch monitors

AliveCor Commercially available smartphone device Purchased by some NHS Trusts as an alternative form of monitoring technique Retails ~ 90-100 Downloads as PDF file: sent remotely

Implantable Loop Recorders Subcutaneous devices recording EGM continuously Battery lasts approximately 4 years Remotely monitored Minimally invasive: not necessarily hospital environment..

What Monitor? Daily symptoms: 24/48 hour Holter Symptoms most days: Novacor Sustained palpitations every couple of weeks: event recorder, or AliveCor Very infrequent symptoms: ILR, or AliveCor Syncope (regardless of timescale): 24 hour tape:?indication for pacing ILR

Some Helpful Things About Interpreting Holter Results* Minor degree of ectopy is normal physiological variant Ventricular ectopy >5% should have further investigation, but is almost always normal Very brief runs of SVT are almost always atrial tachycardia Young fit people can do very strange things asleep: AV block, junctional escape etc. * Actual contents may differ

Some Helpful Things About Interpreting Holter Results* Broad complex tachycardia may be difficult to definitively diagnose: No prognostic significance unless LV function impaired, or other red flag features If irregular: likely to be atrial rhythm with aberrancy Normal people often have couplets/triplets/runs

Atrial Tachycardia Doesn t necessarily need anticoagulation High CHADS-Vasc? Is almost on a spectrum of normality If asymptomatic: ignore it If you think it s responsible for symptoms, then trial of beta-blockers or Verapamil

Atrial Fibrillation V brief (less than 30 seconds) of AF is probably atrial tachycardia No evidence for anticoagulation if <30 seconds in duration If 30 seconds to 6 minutes: offer anticoagulation to mod/high CHADS-Vasc >6 minutes: treat as any other form of AF CRYSTAL-AF study.

Monitoring & Pacemakers Only prognostic benefit to pacing is in CHB Everything else is essentially symptom-driven Reasonable to anticipate a progression of conduction disease over time, and therefore to consider early pacing to prevent symptoms Echo first: complex device? Nocturnal pauses 3-4 secs v common in AF Nocturnal bradys/block v common in young fit people, and probably not significant

Who Should Be Referred? Anyone you want, basically Unexplained syncope Symptoms with structurally abnormal echo Symptoms with abnormal ECG Asymptomatic WPW Candidates for ablation etc. (AF, SVT etc.) Red flag symptoms Familial screening for Inherited Arrhythmia HF patients under NICE TA314 (complex pacemakers)

NICE Guidance TA314 Complex pacemaker indications Mainly heart failure patients: LVEF <35% QRS duration <120msec potentially ICD QRS duration >120msec potentially CRT-D/-P Relevant even if NYHA 1

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