Palpitations in general practice

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DIAGNOSING & TREATING PALPITATIONS
Lee Graham
Consultant Electrophysiologist
Yorkshire Heart Centre
PALPITATIONS
• Definition:
‘an uncomfortable sensation in which a person is aware of their
heart beat which may be irregular, pounding, forceful or rapid’
DIAGNOSTIC PATHWAY
• History
• Examination
• Resting ECG
• Symptom-ECG correlation
• Additional investigations
• Treatment
HISTORY
• Onset / offset characteristics
• Age of onset
• Perceived rate
• Description of regularity
• Duration and frequency
• Associated symptoms (e.g. polyuria)
• Neck pulsations
• Triggers / relieving factors
• Nocturnal symptoms
HISTORY
• Red Flag features (referral suggested)
• Exercise induced
• Associated syncope
• Unexplained “seizure”
• Chest pain
• Family history of premature sudden cardiac death
• Underlying structural heart disease
HISTORY
• Drug history including OTC medicines
• Decongestants
• Alcohol
• Antidepressants
• Psychotropics
• Antibiotics & antifungals
• Antihistamines
• Methadone
• Recreational drugs
EXAMINATION
• Cardiovascular
• Pulse
• Blood Pressure
• Heart murmurs
• Signs of heart failure
• Features of thyroid disease
RESTING ECG
• Features to check
• Sinus rhythm / arrhythmia
• PR interval (WPW)
• QRS duration / bundle branch block
• ST segment shape (LVH / LV aneurysm / brugada)
• QT interval (long or short)
• Presence of Q waves (previous infarct)
• T wave inversion (cardiomyopathy or IHD)
Consider referral for any abnormal ECG
PR interval
Normal 3 to 5 small squares
(120 - 200ms)
QRS duration
Normal up to 3 small squares
(120ms)
QT interval
Depends on heart rate
QTc 440 ms men
QTc 460 ms women
WOLFF-PARKINSON-WHITE SYNDROME
BRUGADA SYNDROME
HYPERTROPHIC CARDIOMYOPATHY
DIAGNOSTIC YIELD FROM CLINICAL ASSESSMENT
Not sufficiently accurate to exclude clinically significant arrhythmia
Thavendiranathan et al. JAMA 2009;302:2135-43
SYMPTOM-ECG CORRELATION
• 12-lead ECG taken with symptoms
• Holter monitoring (24h - 7 day)
• Event recorder with / without looping memory (patient
activated device)
• Implantable loop recorder (ILR)
HOLTER MONITOR
• Requires typical symptoms
during recording
• Useful if symptoms occur
several times per week
• Asymptomatic arrhythmias
• Useful for patients who are
unable to trigger a
monitoring device e.g.
syncope
EVENT RECORDER
• Useful for less frequent
symptoms
• Longer duration of
symptoms
• Symptoms need to be
reasonably well tolerated
IMPLANTABLE LOOP RECORDERS
AMBULATORY MONITORING OPTIONS
24h- 7 days
7-30 days
36 months
Time (months)
CASE VIGNETTE
• 68y old man
• 10 month history of palpitations
• Onset with exertion
• Syncopal on two occasions
• Normal cardiovascular exam
• Normal resting ECG
ILR implanted
ILR SYMPTOM – RHYTHM CORRELATION
DIAGNOSTIC YIELD FROM MONITORING
Investigation
ECG during symptoms
Holter
Event recorder
ILR
Any arrhythmia
Clinically significant arrhythmia
3-26%
2%
34%
3-24%
30-60%
17-19%
-
73%
Thavendiranathan et al. JAMA 2009;302:2135-43
ADDITIONAL INVESTIGATIONS
• Structural cardiac disease
• Echocardiogram
• Cardiac MRI
• Exercise tolerance test
• Cardiac catheterisation
• Electrophysiological study +/- catheter ablation
PALPITATIONS-COMMON CAUSES
• Sinus Tachycardia
• Ectopics (PAC’s / PVC’s)
• Supraventricular tachycardia (AVNRT / AVRT / atrial
tachycardia)
• Atrial flutter
• Atrial fibrillation
• Ventricular tachycardia
SINUS TACHYCARDIA
• Onset and termination are gradual (i.e. not paroxysmal)
• Perceived rate relatively slow
• May persist for several hours or days
• Normal P wave morphology
• Physiological
• sensitive to autonomic modulation
• Inappropriate
• Usually resting rate >100bpm ;mean >95bpm on 24h Holter
INAPPROPRIATE SINUS TACHYCARDIA
• Poorly understood
• Young women most commonly affected
• Associated symptoms of dyspnoea, pre-syncope & fatigue
• Association with Postural Orthostatic Tachycardia Syndrome
• Treatment unsatisfactory
• Beta-blockers or rate limiting Ca antagonist
• Ivabradine
• Catheter modification of the sinus node can be attempted
ECTOPICS
• Usually sudden onset
• Perceived as ‘missed beats’ often followed by thud & fluttering
• rate relatively slow
• More commonly noticeable at rest or in bed
• Often described as persistent for several hours or days
• Sporadic
• Reassurance
• Treatment usually not required although beta-blockers can be
helpful
RV OUTFLOW TRACT ECTOPY / VT
RV OUTFLOW TRACT ECTOPY / VT
• Frequent ectopics / salvos
• Catecholamine sensitive
• Treat with beta-blockers
• Catheter ablation offers 80%
chance of cure if remains
symptomatic
• 1% risk tamponade
SUPRAVENTRICULAR TACHYCARDIA
• Usually sudden onset / offset (except atrial tachycardia)
• Perceived rate rapid and regular
• Pounding pulsation in neck (AVNRT)
• Variable duration
• Vagal manoeuvres may terminate
• Usually adenosine sensitive
• Reentry most common mechanism (except atrial tachycardia)
• AVRT/AVNRT/atrial tachy
WOLFF-PARKINSON-WHITE SYNDROME
• Short PR interval
No conduction
delay
• Delta wave
• Ventricular preexcitation
• AVRT most common
arrhythmia
• AF more common and may
be preexcited
• Small risk of sudden death
AV
node
Accessory
pathway
WOLFF-PARKINSON-WHITE SYNDROME
ATRIOVENTRICULAR REENTRANT
TACHYCARDIA
Conduction down AV
node
• Usually narrow complex
• Rarely broad complex
• Often frequent episodes
starting in childhood
Up accessory
pathway
AV REENTRANT TACHYCARDIA
PREEXCITED AF
• AF may conduct rapidly
over accessory pathway
• Irregular broad complex
tachycardia
• Risk of degeneration to VF
• Avoid AV node blockers
PREEXCITED AF
MANAGEMENT OF WPW
• Refer to an electrophysiologist
• EPS and catheter ablation if
symptomatic
• 95% curative (<1% risk)
• Reasonable to offer
asymptomatic patients EPS
• Flecainide antiarrhythmic drug
of choice
AV NODAL REENTRANT TACHYCARDIA
• ~ 60% of all SVT F > M
Slow pathway
• Onset often later than in
AVRT
• Beta-blockers or verapamil
first line antiarrhythmics
• Catheter ablation 95%
curative but 1% risk AV
node damage
Fast pathway
AV NODAL REENTRANT TACHYCARDIA
ATRIAL FLUTTER
• Regular or irregular palpitations
• Paroxysmal or persistent
• Saw tooth baseline
• Atrial rate usually 300 min
• Ventricular rate variable 2:1 block
common
• Often difficult to rate (or rhythm) control
• Catheter ablation 90-95% curative and
should be offered as first line (<1% risk)
“TYPICAL” ATRIAL FLUTTER
CATHETER ABLATION FOR TYPICAL FLUTTER
ATRIAL FIBRILLATION
• Assess symptoms
• Control ventricular rate
• Assess thromboembolic risk
• Rate vs. rhythm control strategy
WHO SHOULD BE OFFERED RHYTHM CONTROL
• Symptomatic AF despite adequate rate control
• Young symptomatic patients
• AF related heart failure
• AF secondary to corrected trigger or cause
EHRA. EHJ 2010;31:2369-2429
RHYTHM CONTROL FOR AF
• Antiarrhythmic drug therapy
• Beta-blockers
• Flecaininde
• Sotalol, amiodarone, dronedarone
• Cardioversion
• Catheter ablation
PULMONARY VEIN TRIGGERS DRIVE
PAROXYSMAL AF
RATIONALE FOR AF ABLATION
• Electrical isolation of the pulmonary veins
• Prevents “triggers” and “drivers” of AF
• Creates electrically inexcitable “scar” around the PV’s which
blocks PV ectopics from entering the left atrium
• More effective in paroxysmal than in persistent AF
THE IDEAL PATIENT FOR AF ABLATION ?
• Arrhythmia related symptoms
• Refractory or intolerant to at least one class 1 or 3 drug
• ? Young age
• Paroxysmal rather than persistent AF
• Short duration of symptoms
• Structurally normal heart
• Informed and motivated
CATHETER ABLATION FOR AF
• ~ 70% success rates
• Often multiple procedures
required
• 3-4 hour procedure
• 3-4% risk major complication
• Stroke 0.5-1%
• Cardiac tamponade 1-2%
• Usually second line
ANY QUESTIONS?
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