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Palpitation

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Wide-complex tachycardia of uncertain type should be treated with cardioversion, amiodarone, or procainamide, depending on the chronic heart condition. – PowerPoint PPT presentation

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Title: Palpitation


1
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2
Palpitation
  • definition ?
  • Most probable diagnoses DDX.
  • Important and serious diagnoses.
  • Common pitfalls.

3
Palpitation definition
  • A subjective awareness of ones heartbeat
  • Bradycardia
  • tachycardia

4
  • Spectrum of Patients Descriptions
  • Heart flips or flip-flops
  • Skipped beats
  • Strong beats
  • Irregular beats
  • Heart thumping
  • Bubble sensation in heart or chest
  • Racing or rapid heart beats
  • Pounding in neck or chest
  • Heart jumping out of chest
  • Chest or whole body shaking

5
Most probable diagnoses
  • Anxiety
  • Premature beats (Ectypes PAC / PVC)
  • Sinus tachycardia
  • Drugs, e.g. stimulants
  • Psychogenic
  • Arrhythmia PSVT , AF/afl , VT ,

6
Common Pitfalls
  • Fever / Infection
  • Pregnancy
  • Menopause
  • Drugs, e.g. caffeine, cocaine
  • Mitral valve disease
  • Aortic incompetence
  • Hypoxia / Hypercapnia

7
Masquerade Checklist
  • Depression
  • Diabetes Mellitus
  • Drugs
  • Anemia
  • Thyroid disease
  • Spinal dysfunction
  • Infection (Urinary Tract , )

8
Important and Serious Diagnoses
  • Myocardial infarction / angina
  • Life threatening Arrhythmias
  • -Wolff-Parkinson-White Syndrome
  • -LQTs / SQTs
  • -Burgada sy.
  • Electrolyte disturbances

9
History
  • Keys
  • Characterization of the palpitation
  • Attendant symptoms
  • Cardiac history
  • Arrhythmia history
  • Family history
  • Possible systemic endocrinology disorders
  • Drug use

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1-Characterization of the Palpitation
  • Circumstances at onset
  • Duration of the problem
  • Mode of onset/offset , Trigger factors
  • Heart rate estimate
  • Rhythm regularity vs. irregularity
  • Episode duration
  • Symptom frequency

11
2- Attendant Symptoms
  • Symptoms arising from rhythm disorder
  • Symptoms due to CAD or CHF
  • Neurohormonal responses
  • Psychological symptoms Anxiety disorder , Panic
    attacks

12
3- Cardiac History
  • Ischemic heart disease
  • LV dysfunction
  • Valvular heart disease
  • Atrial or ventricular arrhythmias

13
4-Arrhythmia History
  • Recurrence vs. new onset
  • Recent history of radiofrequency ablation
  • Pacemaker or ICD implantation

14
5- Family History
  • Long QT syndrome
  • Brugadas syndrome
  • Familial cathecolamine-mediated polymorphic V.
    tachycardia
  • Atrial fibrillation

15
6- Possible Endocrine and Metabolic Disorders
  • Hyper or hypothyroidism
  • Pheochromocytoma
  • Diabetes
  • Renal disorders
  • Anemia
  • Electrolyte imbalance
  • Hypoglycemia
  • Hx of rheumatic fever

16
7- Drug Dietary Use
  • Bronchodilator therapy, beta agonists,
  • Caffeine , alcohol , Chocolate
  • Stimulants / substance abuse Cocaine
  • OTC sympathomimetic agents
  • QT-prolonging drugs
  • Thyroid replacement medications
  • phenothiazine, isotretinoin, digoxin
  • Tobacco

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Dietary Supplement Causing Palpitation
  • Chocolate , Caffeine , alcohol
  • Ephedra/Diet pills
  • Ginseng
  • Bitter Orange
  • Valerian
  • Hawthorn

20
Physical Examination
  • Often uninformative in young adults
  • Check for presence of organic heart disease
  • - LV dysfunction
  • - Valvular HD
  • - Congenital HD
  • Evidence of COPD
  • Signs of anemia, thyroid and renal disease
  • Pulse quality, rate, regularity, pauses
  • Orthostatic hypotension

21
Physical Examination
  • Best performed while having palpitations
  • Signs especially to consider
  • Palm signs (sweaty, pallor)
  • Radial pulse (character)
  • Blood Pressure
  • Eye signs (pallor, eye signs of thyrotoxicosis)
  • Goitre
  • Jugular vein pulsations
  • Praecordium abnormalities (e.g. cardiac
    enlargement, murmurs)

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Diagnostic Tests
  • Resting EKG
  • Ambulatory EKG monitoring
  • Echocardiography
  • Exercise testing
  • Event monitor EKG
  • Electrophysiologic testing
  • Implantable loop recorder

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A 48 year old man with palpitation
Atrial Premature Beat
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A 50 year old man with DM palpitation for 2-4
hours
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A 73 year old woman with palpitation dizziness.
2 to 1 AV block
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An 82 year old lady with palpitation dizzy
spells hx of AF Digoxin
AF complete heart block
35
A 57 year old woman with palpitations
Atrial flutter
36
A 68 year old women on Digoxin complaining of
palpitation fatigue
Atrial flutter
37
A 60 year old woman with HTN crisis palpitation
38
A 58 year old man on hemodialysis presents with
palpitation weakness
Hyperkalaemia
39
A 39 year old woman with palpitationHx of LD
Acute pulmonary embolus
40
A 69 year old man 2weeks post MI
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Holter monitor VS Event monitor
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ECG
  • 1- QT (long QT , short QT)
  • 2- burgada syndrome
  • 3- WPW
  • 4- ARVD ( epsilon wave)
  • 5- HCM
  • 6- MI

45
A woman with Hx of palpitation
46
Tracing from a young boy with congenital long-QT
syndrome. The QTU interval in the sinus beats is
at least 600 milliseconds. Note TU wave alternans
in the first and second complexes. A late
premature complex occurring in the downslope of
the TU wave initiates an episode of ventricular
tachycardia
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Ventricular tachycardia in the arrhythmogenic
right ventricular dysplasia
49
A 25 year old man with periodic palpitation
50
Wolf-Parkinson-White syndrome
  • short PR interval, less than 3 small squares (120
    ms)
  • slurred upstroke to the QRS indicating
    pre-excitation (delta wave)
  • broad QRS
  • secondary ST and T wave changes
  • Localising the accessory pathway
  • An accessory pathway, bundle of Kent, exists
    between atria and ventricles and causes
  • early depolarisation of the ventricle. The
    location of the pathway may be deduced as
    follows-
  • LOCATION V1 V2 QRS axis
  • left posteroseptal (type A) ve ve left
  • right lateral (type B) -ve -ve left
  • left lateral (type C) ve ve inferior
    (90 degrees)
  • right posteroseptal -ve -ve left
  • anteroseptal -ve -ve normal

51
A 47 year old man with a long history of
palpitations and blackouts.
52
A 23 year old male with palpitations
WPW AF
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WQRST ????? ???? ?????
57
Wide Complex Tachycardia--Sinus tach
aberrancy.--SVT (PSVT, AF, flutter)
aberrancy.--Ventricular tachycardia
  • Pretest probability
  • Majority of wide complex tachycardia is
    ventricular tachycardia
  • REMEMBER VT does not invariably cause
    hemodynamic collapse patients may be conscious
    and stable

58
Clinical Cluesfor Regular Wide QRS Tachycardia
  • History of heart disease, especially prior MI ?
    suggests VT
  • Occurrence in a young patient with no known heart
    disease ? SVT
  • 12-lead EKG (if patient stable) should be obtained

59
5 Questions in tachyarrhythmia
  • 1- QRS
  • Wide or Narrow?
  • Axis?
  • Shap?
  • 2- Regularity?
  • Regular
  • Regularly irregular
  • Irregularly irregular
  • 3- P-waves?
  • 4- Rate?
  • HR?
  • 5- Rate change sudden or gradual?

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1- QRS Wide or Narrow
  • Narrow
  • Sinus, PSVT, A flutter, A fib
  • (All without aberrancy)
  • Wide
  • SVT aberrancy
  • Ventricular tachycardia

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Aberrancy - SVT with wide complex
  • Abnormal ventricular conduction
  • Anatomical RBBB or LBBB
  • Functional Rate-related BBB
  • Antidromic Reciprocating
  • Goes down through bypass tract

63
Suggest VT
  • In RBBB pattern gt 140 ms
  • In LBBB pattern gt 160 ms

64
1- QRS Shape? Typical or atypical LBBB/RBBB
  • true bundle branch block pattern
  • Right or left (sinus or SVT with aberrancy)
  • absence of RS complex in all leads V1-V6
    (negative Concordance)

65
Morphology criteria for VT
RBBB
V1
V6
LBBB
V6
V1
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1-QRS Axis
  • gt45 degree
  • R in aVR

69
1- QRS Fusion beats / capture beats
  • Fusion beats (occasional narrow complex fused
    with wide one)
  • Capture beats

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2- P waves
  • If p waves, and associated with QRS, then sinus
    (or, rarely, atrial tachycardia)
  • PSVT generally no p wave visible
  • PR short
  • P wave hidden in QRS, inverted
  • A fib and flutter
  • No p waves, but flutter may fool you
  • V tach
  • May rarely see P waves, but with no association
  • (AV dissociation) or retrograde

73
AV Dissociation
ATRIA AND VENTRICLES ACT INDEPENDENTLY
SA Node
Ventricular Focus
74
More R-Waves Than P-Waves Implies VT!
II
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  • P-waves in front of QRS?

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Ventricular Tachycardia (VT)
V1
  • Rates range from 100-250 beats/min
  • Non-sustained or sustained
  • P waves often dissociated (as seen here)

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3- Regularity in tachycardia
  • Regular
  • VT, Sinus, PSVT, flutter,
  • Regularly irregular
  • Atrial flutter / AT
  • Irregularly irregular
  • AF, MAT

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4- rate
  • Rate the faster, the less likely it is sinus

(260 beats/min)
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5- Sudden vs. Gradual change(Re-entry vs.
automaticity)
  • Sinus gradual
  • PSVT sudden
  • Atrial flutter sudden
  • AF always changing, but sudden onset
  • Ventricular tachycardia Sudden

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Identify ventricular tachycardia
Regular and wide
  • Step 1 Is there absence of RS complex in all
    leads V1-V6? (Concordance)
  • If yes, then rhythm is VT
  • Step 2 Is interval from onset of R wave to nadir
    of the S gt 100 msec (0.10 sec) in any precordial
    leads?
  • If yes, then rhythm is VT.
  • Step 3 Is there AV dissociation?
  • If yes, then rhythm is VT.
  • Step 4 Are morphology criteria for VT present
    (not typical BBB)?
  • If yes, then VT

gt 0.10 sec?
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??? ?????
Regular Wide QRS Tachycardia VT or SVT
with Aberrant Conduction?
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Ventricular Tachycardia Concordance
Step 1 Absence of RS in all precordial leads
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Ventricular Tachycardia
Step 1 there is no absence of RS in all
precordial leads (no concordance) (V5, V6) Step
2 RS in V5 gt 0.10 ms, therefore v tach Step 3
No AV dissociation Step 4 RBBB pattern (tall R
in V1). Notching of this monophasic R indicates
VT
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V tachRS gt 0.10 sec
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What is it?
90
What is it?
91
What is it?
92
Sinus Rhythm and PACsWith Aberrant Conduction
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What is it?
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Artifact Mimicking Ventricular Tachycardia
QRS complexes march through the
pseudo-tachyarrhythmia
Artifact precedes VT
95
Ventricular tachycardia originating from the
right ventricular outflow tract. This tachycardia
is characterized by a left bundle branch block
contour in lead V1 and an inferior axis.
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Left septal ventricular tachycardia. This
tachycardia is characterized by a right bundle
branch block contour. In this instance, the axis
was rightward. The site of the ventricular
tachycardia was established to be in the left
posterior septum by electrophysiological mapping
and ablation.
97
Ventricular Flutter
  • VT ? 250 beats/min, without clear isoelectric
    line
  • Note sine wave-like appearance

98
Ventricular Fibrillation (VF)
  • Totally chaotic rapid ventricular rhythm
  • Often precipitated by VT
  • Fatal unless promptly terminated (DC shock)

99
Sustained VT ? Degeneration to VF
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Accelerated idioventricular rhythm
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A 36 year old woman with recurrent blackouts
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Rx
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Is patient stable or unstable?
  • Patient has serious signs or symptoms? Look for
  • Chest pain (ischemic? possible ACS?)
  • Shortness of breath (lungs wet? possible CHF?)
  • Hypotension
  • Decreased level of consciousness
  • (poor cerebral perfusion?)
  • Clinical shock
  • (cool and clammy -- peripheral vaso-constriction?)
  • Are the signs symptoms due to the rapid heart
    rate?
  • Or are S/Sxs rapid HR due to something else?
  • I.e., is it sinus tach due to sepsis, hemorrhage,
    PE, tamponade, dehydration, etc.

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Treatment when in doubtStable or
unstable-Electricity
  • If possible, get 12-lead ECG first
  • If electricity does not work
  • Automatic rhythm
  • Sinus, accelerated junctional, accelerated
    idioventricular, automatic atrial, MATtreatment
    of underlying disorder
  • Chronic atrial fib
  • Be sure it is not physiologic tachycardia
  • Amiodarone for conversion
  • Diltiazem or Digoxin to control rate
  • Refractory ventricular tachycardia
  • Amiodarone
  • 150 mg, may repeat several times
  • Treat underlying ischemia

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Conclusion When in doubt
  • Shock a fast rhythm
  • Pace a slow rhythm
  • In anterior STEMI
  • Be certain that transcutaneous pacing will
    capture if there is high grade block
  • But dont shock sinus tachycardia!!

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