Palpitations and Management of Arrhythmias y Fernando Vega, M.D. - PDF document

Palpitations and Management of Arrhythmias y Fernando Vega, M.D. 7/8/2011 Fernando Vega, M.D. 1 7/8/2011 Fernando Vega, M.D. 2 Palpitations Differential Diagnosis • A sensory symptom • An unpleasant awareness of the forceful, Cardiac Causes -Arrhythmia rapid or irregular beating of the heart -Cardiac and extracardiac shunts Cardiac and extracardiac shunts • Can be described as: -Valvular Heart Disease -Atrial Myxoma – Rapid fluttering in the chest -Cardiomyopathy – Flip-flopping in the chest -Pericarditis – Pounding sensation in chest or neck 7/8/2011 Fernando Vega, M.D. 3 7/8/2011 Fernando Vega, M.D. 4 Differential Diagnosis Differential Diagnosis Psychiatric Medications -Panic Attack -Sympathomimmetic Agents -Obsessive Disorder Obsessive Disorder -Vasodilators Vasodilators -Somatization -Anticholinergics -Depression -Beta Blocker withdrawal -Loneliness -Grief 7/8/2011 Fernando Vega, M.D. 5 7/8/2011 Fernando Vega, M.D. 6 Palpitations and Management of Arrhythmias 1

Differential Diagnosis Differential Diagnosis Habbits Metabolic Disorders -Caffeine -Hypoglycemia -Nicotine Nicotine -Thyrotoxicosis Thyrotoxicosis -Cocaine -Pheochromocytoma -Amphetamines -Argentaffionoma -Scromboid Food poisoning 7/8/2011 Fernando Vega, M.D. 7 7/8/2011 Fernando Vega, M.D. 8 Differential Diagnosis History Symptoms: • “flip-flopping in chest” – isolated PACs or High Output States PVCs -Anemia -Pregnancy Pregnancy •Often caused by supraventricular or •Often caused by supraventricular or -Paget’s Disease Ventricular premature contraction -Fever 7/8/2011 Fernando Vega, M.D. 9 7/8/2011 Fernando Vega, M.D. 10 ECG - PAC History Symptoms: • “rapid fluttering in chest” •Sustained surpraventricular or ventricular arrhythmia including sinus tachycardia •May be regular or irregular 7/8/2011 Fernando Vega, M.D. 11 7/8/2011 Fernando Vega, M.D. 12 Palpitations and Management of Arrhythmias 2

ECG _* ECG - VT 7/8/2011 Fernando Vega, M.D. 13 7/8/2011 Fernando Vega, M.D. 14 History History Symptoms: Mode of Onset: • “pounding in the neck” •Abrupt suggests paroxysmal abnormal tachycardia, though sinus tach may start abruptly in anxiety. •Irregular pounding of the neck is caused by arioventricular dissociation where the atria Mode of Termination: contract against an occasionlly closed AV •Abrupt suggests paroxysmal arrhythmia, valve. Cannon A waves are formed. though high adrenergic tone caused by arrhythmia may result in consequent sinus tach. •Examples include PVC’s, third degree heart block or ventricular tachycardia 7/8/2011 Fernando Vega, M.D. 15 7/8/2011 Fernando Vega, M.D. 16 History Palpitations • Most patients with Palpitations will have Characteristics: •Rapid, irregular – AF, AFL, Atrial tachycardia, benign supraventricular or ventricular multiple PACs or PVCs ectopy •Rapid, regular – SVT, VT •PVC’s and non sustained ventricular PVC’ d t i d t i l Circumstances: tachycardia come in less often. •Panic/anxiety – the chicken or the egg? •Catecholamine excess •The above are not associated with –Exercise – idiopathic RVOT VT, AF increased mortality in pts with structurally –Emotional startle – Long QT syndrome normal hearts 7/8/2011 Fernando Vega, M.D. 17 7/8/2011 Fernando Vega, M.D. 18 Palpitations and Management of Arrhythmias 3

Palpitations – Structurally Normal Palpitations – Other rhythms • No history of cardiovascular disease, • Atrial Fibrilation congenital anomalies •Wolf Parkinson White •Normal ECG N l ECG •Prolonged Q-T Syndrome 7/8/2011 Fernando Vega, M.D. 19 7/8/2011 Fernando Vega, M.D. 20 Palpitations – Other rhythms Palpitations – Atrial Fibrilation Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 21 7/8/2011 Fernando Vega, M.D. 22 Palpitations – Atrial Fibrilation Palpitations – Atrial Fibrilation Three Questions to ask: Hemodynamic Stability • Hemodynamicaly Stable? • Chest Pain •Anticoagulate? • Signs of heart failure •Rate vs. Rhythm Control? • Other perfusion Abnormalities 7/8/2011 Fernando Vega, M.D. 23 7/8/2011 Fernando Vega, M.D. 24 Palpitations and Management of Arrhythmias 4

Palpitations – Atrial Fibrilation Palpitations – Other rhythms Anticoagulation • Atrial Fibrilation •Wolf Parkinson White • Lone Atrial Fib •Prolonged Q-T Syndrome •Intermittent Atrial Fibrilation •Persistent Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 25 7/8/2011 Fernando Vega, M.D. 26 Palpitations – Other rhythms ECG - WPW Wolf Parkinson-White Syndrome Wolf Parkinson-White Syndrome • Characterized by delta wave 7/8/2011 Fernando Vega, M.D. 27 7/8/2011 Fernando Vega, M.D. 28 Palpitations – Other rhythms Palpitations – Other rhythms Prolonged QT Interval Prolonged QT Interval • Increased risk of torsade de pointes •Primary Sx: palpitations, syncope y p p , y p seizures and cardiac arrest •Can be congenital or acquired 7/8/2011 Fernando Vega, M.D. 29 7/8/2011 Fernando Vega, M.D. 30 Palpitations and Management of Arrhythmias 5

Palpitations – Other rhythms Palpitations – Other rhythms Prolonged QT Interval QTc = QT interval / square root of RR QT is measured in lead II, maybe V2-3, V56 QT is not always prolonged and varies over time 7/8/2011 Fernando Vega, M.D. 31 7/8/2011 Fernando Vega, M.D. 32 Palpitations – Other rhythms Palpitations – Other rhythms Prolonged QT Interval Prolonged QT Interval 7/8/2011 Fernando Vega, M.D. 33 7/8/2011 Fernando Vega, M.D. 34 Palpitations – Prolonged QT Palpitations – Prolonged QT Drugs that cause prolonged Q-T Intervals : Drugs that cause prolonged Q-T Intervals : Antiarrhythmics: •Amniodarone ANTIHISTAMINES: •Astemizole •Disopyramide •Terfenadine •Dofetilide, sematilide, ibutilide •Quinidine •Sotalol 7/8/2011 Fernando Vega, M.D. 35 7/8/2011 Fernando Vega, M.D. 36 Palpitations and Management of Arrhythmias 6

Palpitations – Prolonged QT Palpitations – Prolonged QT Drugs that cause prolonged Q-T Intervals : Metabolic Disorders : •Anorexia nervosa ANTIMICROBIALS: •Hypocalcemia Hypocalcemia •Erythromycin, azithro, clarithro E h i i h l i h •Hypockalemia •Some flouroquinones •Hypomagnesemia •TMP/SMZ •Hypothyroidism (sporadic case reports) •Other: Pentamidine, chloroquine •Liquid protein diets mefloquine •Starvation 7/8/2011 Fernando Vega, M.D. 37 7/8/2011 Fernando Vega, M.D. 38 Palpitations:oth Considerations Palpitations:oth Considerations • Mitral Valve Prolapse • Mitral Valve Prolapse •Organic Heart Disease •Organic Heart Disease •Obsession •Obsession 7/8/2011 Fernando Vega, M.D. 39 7/8/2011 Fernando Vega, M.D. 40 Palpitations-other Considerations Palpitations-other Considerations Mitral Valve Prolapse Mitral Valve Prolapse • Elevated urine and plasma catecholamine levels Framingham Heart Study compared 84 patients with MVP to 3403 control subjects; with MVP to 3403 control subjects; • Exaggerated heart rate response to phenylephrine • Decreased bradycardic response to dive reflex Chest pain, dyspnea, syncope, CHF, AF and ECG abnormalities were equally prevalent in • Isoproterenol reproduces symptoms matched controls. 7/8/2011 Fernando Vega, M.D. 41 7/8/2011 Fernando Vega, M.D. 42 Palpitations and Management of Arrhythmias 7

Palpitations-Main Points Palpitations-Further Workup • Symptoms sometimes characterizes the arrhythmia • Holter Monitoring • Arrhythmia is almost always benign in healthy pts. • Event Monitoring • A normal ECG supports above • Echocardiogram pp g • Look out for atrial fib, prolonged QT intervals, WPW • CXR • Look out for other signs of organic disease: Q waves, • EPS Mapping ST changes, hypertrophy 7/8/2011 Fernando Vega, M.D. 43 7/8/2011 Fernando Vega, M.D. 44 Palpitations - Management Palpitations: Baseline ECG • Caffeine, caffeine, caffeine • Nutritional support of the heart • Hepatodoron, donkey thistle, aurum stibium hyosciamus • Beta blockade may not supress arrhythmia but associated symptoms • Other antiarrhythmics Wolff-Parkinson-White 7/8/2011 Fernando Vega, M.D. 45 7/8/2011 Fernando Vega, M.D. 46 Palpitations: Baseline ECG Palpitations: Baseline ECG Old ASMI LVH with strain and LAE 7/8/2011 Fernando Vega, M.D. 47 7/8/2011 Fernando Vega, M.D. 48 Palpitations and Management of Arrhythmias 8

Palpitations: Baseline ECG Palpitations: Baseline ECG Long Q-T interval Atrial Fibrilation 7/8/2011 Fernando Vega, M.D. 49 7/8/2011 Fernando Vega, M.D. 50 Palpitations: Brief Discussion on Palpitations: Brief Discussion on Atrial Fib Atrial Fib Common, especially in middle age Rhyhm vs. Rate control Rule out Hyperthyroidism Rule “Lone Atrial Fibrlation” – No pharmacological treatment necessary “Lone “Intermittent Atrial Fibrilation”- Studies show high likelyhood “Intermitt Of mural thrombi and possible embolization “Persistent Atrial Fibrilation” – Requires anticoagulation “Persistent Atrial 7/8/2011 Fernando Vega, M.D. 51 7/8/2011 Fernando Vega, M.D. 52 Palpitations: ECG with Symptoms Palpitations: Baseline ECG Normal ECG Narrow QRS Tachycardia 7/8/2011 Fernando Vega, M.D. 53 7/8/2011 Fernando Vega, M.D. 54 Palpitations and Management of Arrhythmias 9