Palpitation

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Palpitation

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

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Palpitation definition

• A subjective awareness of ones heartbeat
• Bradycardia
• tachycardia

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• 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

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Most probable diagnoses

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

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Common Pitfalls

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

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Masquerade Checklist

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

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Important and Serious Diagnoses

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

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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

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2- Attendant Symptoms

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

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3- Cardiac History

• Ischemic heart disease
• LV dysfunction
• Valvular heart disease
• Atrial or ventricular arrhythmias

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4-Arrhythmia History

• Recurrence vs. new onset
• Recent history of radiofrequency ablation
• Pacemaker or ICD implantation

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5- Family History

• Long QT syndrome
• Brugadas syndrome
• Familial cathecolamine-mediated polymorphic V.
  tachycardia
• Atrial fibrillation

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6- Possible Endocrine and Metabolic Disorders

• Hyper or hypothyroidism
• Pheochromocytoma
• Diabetes
• Renal disorders
• Anemia
• Electrolyte imbalance
• Hypoglycemia
• Hx of rheumatic fever

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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

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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

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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
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A 57 year old woman with palpitations
Atrial flutter
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A 68 year old women on Digoxin complaining of
palpitation fatigue
Atrial flutter
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A 60 year old woman with HTN crisis palpitation
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A 58 year old man on hemodialysis presents with
palpitation weakness
Hyperkalaemia
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A 39 year old woman with palpitationHx of LD
Acute pulmonary embolus
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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

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A woman with Hx of palpitation
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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
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A 25 year old man with periodic palpitation
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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

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A 47 year old man with a long history of
palpitations and blackouts.
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A 23 year old male with palpitations
WPW AF
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WQRST ????? ???? ?????
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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

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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

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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

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Suggest VT

• In RBBB pattern gt 140 ms
• In LBBB pattern gt 160 ms

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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)

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Morphology criteria for VT
RBBB
V1
V6
LBBB
V6
V1
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1-QRS Axis

• gt45 degree
• R in aVR

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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

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AV Dissociation
ATRIA AND VENTRICLES ACT INDEPENDENTLY
SA Node
Ventricular Focus
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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?
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What is it?
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What is it?
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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
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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.
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Ventricular Flutter

• VT ? 250 beats/min, without clear isoelectric
  line
• Note sine wave-like appearance

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Ventricular Fibrillation (VF)

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

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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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