‫آریتمی‬
‫دکتر محمد رضا تابان‬
‫متخصص داخلی و فوق تخصص قلب و عروق‬
‫مرکز قلب شهید مدنی تبریز‬
‫اسفند ‪91‬‬
Palpitation
- definition ?
– Most probable diagnoses & DDX.
– Important and serious diagnoses.
– Common pitfalls.
Palpitation
definition
• A subjective awareness of one’s
heartbeat
• # Bradycardia
• # tachycardia
Spectrum of Patients’ Descriptions
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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
Most probable diagnoses
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Anxiety
Premature beats (Ectypes= PAC / PVC)
Sinus tachycardia
Drugs, e.g. stimulants
Psychogenic
Arrhythmia: PSVT , AF/afl , VT ,…
Common Pitfalls
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Fever / Infection
Pregnancy
Menopause
Drugs, e.g. caffeine, cocaine
Mitral valve disease
Aortic incompetence
Hypoxia / Hypercapnia
Masquerade Checklist
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Depression
Diabetes Mellitus
Drugs
Anemia
Thyroid disease
Spinal dysfunction
Infection (Urinary Tract , …)
Important and Serious Diagnoses
• Myocardial infarction / angina
• Life threatening Arrhythmias
-Wolff-Parkinson-White Syndrome
-LQTs / SQTs
-Burgada sy.
• Electrolyte disturbances
History
Keys:
• Characterization of the palpitation
• Attendant symptoms
• Cardiac history
• Arrhythmia history
• Family history
• Possible systemic & endocrinology disorders
• Drug use
1-Characterization of the Palpitation
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Circumstances at onset
Duration of the problem
Mode of onset/offset , Trigger factors
Heart rate estimate
Rhythm regularity vs. irregularity
Episode duration
Symptom frequency
2- Attendant Symptoms
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Symptoms arising from rhythm disorder
Symptoms due to CAD or CHF
Neurohormonal responses
Psychological symptoms: Anxiety disorder ,
Panic attacks
3- Cardiac History
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Ischemic heart disease
LV dysfunction
Valvular heart disease
Atrial or ventricular arrhythmias
4-Arrhythmia History
• Recurrence vs. new onset
• Recent history of radiofrequency ablation
• Pacemaker or ICD implantation
5- Family History
• Long QT syndrome
• Brugada’s syndrome
• Familial cathecolamine-mediated
polymorphic V. tachycardia
• Atrial fibrillation
6- Possible Endocrine and
Metabolic Disorders
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Hyper or hypothyroidism
Pheochromocytoma
Diabetes
Renal disorders
Anemia
Electrolyte imbalance
Hypoglycemia
Hx of rheumatic fever
7- Drug & Dietary Use
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Bronchodilator therapy, beta agonists,
Caffeine , alcohol , Chocolate
Stimulants / substance abuse: Cocaine
OTC sympathomimetic agents
QT-prolonging drugs
Thyroid replacement medications
phenothiazine, isotretinoin, digoxin
Tobacco
Dietary Supplement Causing
Palpitation
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Chocolate , Caffeine , alcohol
Ephedra/Diet pills
Ginseng
Bitter Orange
Valerian
Hawthorn
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
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)
Diagnostic Tests
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Resting EKG
Ambulatory EKG monitoring
Echocardiography
Exercise testing
Event monitor EKG
Electrophysiologic testing
Implantable loop recorder
A 48 year old man with palpitation
Atrial Premature Beat
A 50 year old man with DM & palpitation for 2-4
hours
A 73 year old woman with palpitation &
dizziness.
2 to 1 AV block
An 82 year old lady with palpitation & dizzy
spells + hx of AF & Digoxin
AF+ complete heart block
A 57 year old woman with palpitations
Atrial flutter
A 68 year old women on Digoxin complaining
of palpitation & fatigue
Atrial flutter
A 60 year old woman with HTN crisis &
palpitation
A 58 year old man on hemodialysis presents
with palpitation & weakness
Hyperkalaemia
A 39 year old woman with palpitation
Hx of LD
Acute pulmonary embolus
A 69 year old man
2weeks post MI
Holter monitor VS Event monitor
ECG
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1- QT (long QT , short QT)
2- burgada syndrome
3- WPW
4- ARVD ( epsilon wave)
5- HCM
6- MI
A woman with Hx of palpitation
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
Ventricular tachycardia in the arrhythmogenic right ventricular dysplasia
A 25 year old man with periodic
palpitation
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
A 47 year old man with a long history of
palpitations and blackouts.
A 23 year old male with palpitations
WPW + AF
‫تشخیص تاکی کاردی ‪WQRST‬‬
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
Clinical Clues:
for 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
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?
1- QRS: Wide or Narrow
• Narrow
– Sinus, PSVT, A flutter, A fib
• (All without aberrancy)
• Wide
– SVT + aberrancy
– Ventricular tachycardia
Aberrancy - SVT with wide complex
• Abnormal ventricular conduction
– Anatomical : RBBB or LBBB
– Functional : Rate-related BBB
– Antidromic Reciprocating
• Goes down through bypass tract
Suggest VT
• In RBBB pattern > 140 ms
• In LBBB pattern > 160 ms
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)
Morphology criteria for VT
RBBB
V1
V6
LBBB
V1
V6
1-QRS: Axis
• >45 degree
R in aVR
1- QRS : Fusion beats / capture
beats
• Fusion beats (occasional narrow complex fused
with wide one)
• Capture beats
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
AV
Dissociation
SA
Node
ATRIA AND
VENTRICLES
ACT
INDEPENDENTLY
Ventricular
Focus
More R-Waves Than P-Waves Implies
VT!
II
• P-waves in front of QRS?
Ventricular Tachycardia
(VT)
V1
• Rates range from 100-250 beats/min
• Non-sustained or sustained
• P waves often dissociated (as seen here)
3- Regularity in tachycardia
• Regular
– VT, Sinus, PSVT, flutter,
• Regularly irregular
– Atrial flutter / AT
• Irregularly irregular
– AF, MAT
4- rate
• Rate: the faster, the less likely it is sinus
(260 beats/min)
5- Sudden vs. Gradual change
(Re-entry vs. automaticity)
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Sinus: gradual
PSVT: sudden
Atrial flutter: sudden
AF: always changing, but sudden onset
Ventricular tachycardia: Sudden
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 > 100 msec (0.10 sec) in any
precordial leads?
– If yes, then rhythm is VT.
> 0.10 sec?
• 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
:‫چند تمرین‬
Regular Wide QRS Tachycardia:
VT or SVT with Aberrant Conduction?
Ventricular Tachycardia
Concordance
Step 1: Absence of RS in all precordial leads
Ventricular Tachycardia
Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)
Step 2: RS in V5 > 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
V tach
RS > 0.10 sec
What is it?
What is it?
What is it?
Sinus Rhythm and PACs
With Aberrant Conduction
What is it?
Artifact Mimicking “Ventricular
Tachycardia”
QRS complexes “march through”
the pseudo-tachyarrhythmia
Artifact
precedes
“VT”
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.
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.
Ventricular
Flutter
• VT  250 beats/min, without clear isoelectric line
• Note “sine wave”-like appearance
Ventricular Fibrillation (VF)
• Totally chaotic rapid ventricular rhythm
• Often precipitated by VT
• Fatal unless promptly terminated (DC shock)
Sustained VT  Degeneration to VF
Accelerated idioventricular
rhythm
A 36 year old woman with recurrent blackouts
Rx
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/Sx’s & rapid HR due to something else?
– I.e., is it sinus tach due to sepsis, hemorrhage, PE,
tamponade, dehydration, etc.
Treatment when in doubt
Stable or unstable-Electricity
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If possible, get 12-lead ECG first
If electricity does not work
– Automatic rhythm
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Sinus, accelerated junctional, accelerated idioventricular,
automatic atrial, MAT—treatment of underlying disorder
– Chronic atrial fib
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Be sure it is not physiologic tachycardia
Amiodarone for conversion
Diltiazem or Digoxin to control rate
– Refractory ventricular tachycardia
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Amiodarone
– 150 mg, may repeat several times
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Treat underlying ischemia
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 don’t shock sinus tachycardia!!