DIAGNOSING & TREATING PALPITATIONSDIAGNOSING & TREATING PALPITATIONS

Lee GrahamLee GrahamConsultant ElectrophysiologistConsultant ElectrophysiologistYorkshire Heart CentreYorkshire Heart Centre

PALPITATIONSPALPITATIONS

• Definition:

‘an uncomfortable sensation in which a person is aware of their heart beat which may be irregular, pounding, forceful or rapid’

DIAGNOSTIC PATHWAYDIAGNOSTIC PATHWAY

• History

• Examination

• Resting ECG

• Symptom-ECG correlation

• Additional investigations

• Treatment

HISTORYHISTORY

• 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

HISTORYHISTORY

• Red Flag features (referral suggested)

• Exercise induced

• Associated syncope

• Unexplained “seizure”

• Chest pain

• Family history of premature sudden cardiac death

• Underlying structural heart disease

HISTORYHISTORY• Drug history including OTC medicines

• Decongestants

• Alcohol

• Antidepressants

• Psychotropics

• Antibiotics & antifungals

• Antihistamines

• Methadone

• Recreational drugs

EXAMINATIONEXAMINATION

• Cardiovascular• Pulse

• Blood Pressure

• Heart murmurs

• Signs of heart failure

• Features of thyroid disease

RESTING ECGRESTING 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 SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME

BRUGADA SYNDROMEBRUGADA SYNDROME

HYPERTROPHIC CARDIOMYOPATHYHYPERTROPHIC CARDIOMYOPATHY

DIAGNOSTIC YIELD FROM CLINICAL ASSESSMENTDIAGNOSTIC YIELD FROM CLINICAL ASSESSMENT

Thavendiranathan et al. JAMA 2009;302:2135-43

Not sufficiently accurate to exclude clinically significant arrhythmia

SYMPTOM-ECG CORRELATION 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)

• 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

HOLTER MONITORHOLTER MONITOR

• Useful for less frequent symptoms

• Longer duration of symptoms

• Symptoms need to be reasonably well tolerated

EVENT RECORDEREVENT RECORDER

IMPLANTABLE LOOP RECORDERSIMPLANTABLE LOOP RECORDERS

AMBULATORY MONITORING OPTIONSAMBULATORY MONITORING OPTIONS

Time (months)

24h- 7 days

7-30 days

36 months

CASE VIGNETTECASE 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 CORRELATIONILR SYMPTOM – RHYTHM CORRELATION

DIAGNOSTIC YIELD FROM MONITORINGDIAGNOSTIC YIELD FROM MONITORING

Investigation Any arrhythmia Clinically significant arrhythmia

ECG during symptoms 3-26% 2%

Holter 34% 3-24%

Event recorder 30-60% 17-19%

ILR - 73%

Thavendiranathan et al. JAMA 2009;302:2135-43

ADDITIONAL INVESTIGATIONSADDITIONAL INVESTIGATIONS

• Structural cardiac disease

• Echocardiogram

• Cardiac MRI

• Exercise tolerance test

• Cardiac catheterisation

• Electrophysiological study +/- catheter ablation

PALPITATIONS-COMMON CAUSESPALPITATIONS-COMMON CAUSES

• Sinus Tachycardia

• Ectopics (PAC’s / PVC’s)

• Supraventricular tachycardia (AVNRT / AVRT / atrial tachycardia)

• Atrial flutter

• Atrial fibrillation

• Ventricular tachycardia

SINUS TACHYCARDIASINUS 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 TACHYCARDIAINAPPROPRIATE 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

• 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

ECTOPICSECTOPICS

RV OUTFLOW TRACT ECTOPY / VTRV OUTFLOW TRACT ECTOPY / VT

RV OUTFLOW TRACT ECTOPY / VTRV 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 TACHYCARDIASUPRAVENTRICULAR 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

• Short PR interval

• Delta wave

• Ventricular preexcitation

• AVRT most common arrhythmia

• AF more common and may be preexcited

• Small risk of sudden death

WOLFF-PARKINSON-WHITE SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME

No conduction delay

AV node Accessory

pathway

WOLFF-PARKINSON-WHITE SYNDROMEWOLFF-PARKINSON-WHITE SYNDROME

• Usually narrow complex

• Rarely broad complex

• Often frequent episodes starting in childhood

ATRIOVENTRICULAR REENTRANT TACHYCARDIAATRIOVENTRICULAR REENTRANT TACHYCARDIA

Up accessory pathway

Conduction down AV node

AV REENTRANT TACHYCARDIAAV REENTRANT TACHYCARDIA

• AF may conduct rapidly over accessory pathway

• Irregular broad complex tachycardia

• Risk of degeneration to VF

• Avoid AV node blockers

PREEXCITED AFPREEXCITED AF

PREEXCITED AFPREEXCITED AF

• 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

MANAGEMENT OF WPWMANAGEMENT OF WPW

• ~ 60% of all SVT F > M

• Onset often later than in AVRT

• Beta-blockers or verapamil first line antiarrhythmics

• Catheter ablation 95% curative but 1% risk AV node damage

AV NODAL REENTRANT TACHYCARDIAAV NODAL REENTRANT TACHYCARDIASlow pathway

Fast pathway

AV NODAL REENTRANT TACHYCARDIAAV NODAL REENTRANT TACHYCARDIA

• 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)

ATRIAL FLUTTERATRIAL FLUTTER

““TYPICAL” ATRIAL FLUTTERTYPICAL” ATRIAL FLUTTER

CATHETER ABLATION FOR TYPICAL FLUTTERCATHETER ABLATION FOR TYPICAL FLUTTER

ATRIAL FIBRILLATIONATRIAL FIBRILLATION

• Assess symptoms

• Control ventricular rate

• Assess thromboembolic risk

• Rate vs. rhythm control strategy

WHO SHOULD BE OFFERED RHYTHM CONTROLWHO 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 AFRHYTHM CONTROL FOR AF

• Antiarrhythmic drug therapy

• Beta-blockers

• Flecaininde

• Sotalol, amiodarone, dronedarone

• Cardioversion

• Catheter ablation

PULMONARY VEIN TRIGGERS DRIVE PULMONARY VEIN TRIGGERS DRIVE PAROXYSMAL AFPAROXYSMAL AF

RATIONALE FOR AF ABLATIONRATIONALE 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 ?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

• ~ 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

CATHETER ABLATION FOR AFCATHETER ABLATION FOR AF

ANY QUESTIONS?ANY QUESTIONS?