PALPITASI

Pembimbing : dr. Yuddy, Sp.EM

Jeffri Prasetyo UtomoTania Putri ZahraEvanti Tansil

INTRODUCTION

Definition Perceptible unpleasant forcible pulsation of the heart, usually with

an increase in frequency or force, with or without irregularity in rhythm.

Presentation

• Most common outpatient complaint in patients presenting to PCP and cardiologists

• 16% in one study of 500 patients

• TermiAnology used:• Rapid fluttering in the chest

• Flop-flopping in the chest

• Pounding in the neck

Etiology• Cardiac:• Arrhythmias

• Cardiac and extracardiac shunts

• Valvular heart disease

• Pacemaker

• Atrial myxoma

• Cardiomyopathy

• Psychiatric:• Panic disorders

• Anxiety disorders

• Somatization

• Depression

Etiology• Medication:• Sympathomimetic

• Vasodilators

• Anticholinergic

• -blocker withdrawal

• Catecholamine Stress:• Exercise

• Stress

• Habits:• Cocaine

• Amphetamines

• Caffeine

• Nicotine

Etiology

• Metabolic disorders:• Hypoglycemia

• Thyrotoxicosis

• Pheochromocytoma

• Mastocytosis

• Scombroid Food Poisoning

• High output states:• Anemia

• Pregnancy

• Fever

• Paget’s disease

Arrhythmic Etiologies

• PAC/PVC

• Sinus arrhythmias

• SVT (AF, Aflutter, ORT, AVNRT, AT)

• Idiopathic ventricular arrhythmias (RVOT, LVOT, fascicular VT)

• Life-threatening ventricular arrhythmias (MMVT, PMVT, TdP, VFlutter, VF)

Predictors of Cardiac Etiology

• Male gender

• Reporting irregular heart beats

• History of heart disease

• Event duration > 5 minutes

History

• Circumstances:• Association with anxiety or panic (20% of palpitations are

due to panic attacks and 67% of patients with SVT where diagnosed at some point with panic disorder)

• Association with stress (arrhythmias benign and fatal)

• Association with position (AVNRT pr PAC/PVC)

• Association with syncope or near-syncope (high level of suspicion for VA)

Evaluation

• Detailed History:• Age • Onset• Duration• Circumstances • Symptoms• Termination • Maneuvers (CSM, valsalva)• Regularity (tap out the rhythm)• Medications• Habits• Psychiatric disorders

Evaluation• Physical Exam:• Rarely during palpitations

• Auscultation (MVP, HCM, chronic AF)

• Evidence of CMP, valvular disease, congenital abnormalities

Evaluation• 12-Lead ECG:

• PAC/PCV/SVT/VT

• WPW

• LVH/LAE/RAE

• Long QT, Brugada, ARVD

• Old MI

• Conduction abnormalities predisposing to TdP

CASE REPORT

Identitas

• Nama : Ny. LS

• Register : 1123xxxx

• Jenis Kelamin : Perempuan

• Umur : 42 th

• Alamat : Karanganyar, Poncokusumo

• MRS : 10 April 2015, pukul 11.25

Primary Survey• A : Patent

• B : Gerakan dada simetris, RR 22 x/menit reguler, retraksi (-), Sat 02 96%.

• C : TD: 150/90 mmHg, Nadi 96 x/menit iregular, akral hangat, T.ax: 36,0 C, CRT <2’

• D : GCS 456

Triage: P2

Intervensi Awal

A : -

B : O2 NC 4 lpm

C : IVFD NaCl 2000cc/24 jam

Anamnesa

• Keluhan Utama: Berdebar

Pasien mengeluhkan dada berdebar debar sejak tadi pagi jam 08.00 saat istirahat/ tidak beraktifitas, timbul tiba tiba. Nyeri dada (-), sesak nafas (-), tiba tiba terasa seperti mau pingsan. Riwayat debar debar sebelumnya (+) 1 tahun yang lalu, kadang kadang, timbul tiba tiba tanpa sebab, hilang dengan istirahat. Riwayat DOE (-), PND (-), kaki bengkak (-)

Riwayat HT (+) sejak 6 bulan yang lalu, TDS 150/…, tidak rutin kontrol

Riwayat Penyakit Keluarga: HT (-), DM (-), Asma (-), TB (-)

Riwayat Alergi: pasien tidak memiliki alergi

Secondary SurveyPalpitasi

No history for allergy

Never consume any medication before

Gejala yang sama 1 tahun yang lalu

4 jam SMRS

SAMPLE

Physical ExaminationBP = 130/90 mmHg PR =

97x/menit iregular

RR = 20x/menit Tax : 36.5°C

General : Tampak sakit sedang GCS 456

Head Anemis (-/-)

Icterik (-/-)

Pupil isokor 3mm/3mm

Reflek Cahaya +/+

Neck JVP R + 0 cmH2O 30Q

Thorax Cor: Ictus invisible palpable at ICS 5, MCL S

LHM ≈ ictus

RHM: SL D

S1, S2 single regular, murmur -, gallop -

Pulmo: Simetris D=S, SF D=S v|v rh - | - wh - | -

v|v - | - - | -

v|v - | - - | -

Abdomen Datar, Soefl, traube space timpani, shifting dullness (-)

Extremities Akral hangat, edema - | -

- | -

Laboratory FindingsFindings Result Unit Normal value

Complete Blood Count

Hemoglobin 14,60 g/dL 13,4-17,7

Erythrocyte 4,71 104/mikroL 4,0-5,5

Leucocyte 6,39 103/mikroL 4,3-10,3

Hematocryte 41,20 % 40-47

Trombocyte 299 103/mikroL 142-424

MCV 87,50 fL 80-93

MCH 31,00 pg 27-31

MCHC 35,40 g/dL 32-36

Diff Count

-Eos 0,0 % 0-4

-Ba 0,2 % 0-1

-Neu 75,8 % 51-67

-Lim 18,5 % 25-33

-Mono 5,5 % 2-5

GDS 86 Mg/dL <200

Electrolyte

Natrium 139 Mmol/L 136-145

Kalium 4,15 Mmol/L 3,5-5,0

Chloride 116 Mmol/L 98-106

Laboratory FindingsFindings Result Unit Normal value

Faal Hati

SGOT 10 U/L 0-40

SGPT 11 U/L 0-41

Albumin - g/dL 3,5-5,5

Faal Ginjal

Ureum 15,80 mg/dL 16,6-48,5

Kreatinin 0,64 mg/dL <1,2

Analisa Gas Darah

pH 7,38 7,35 - 7,45

pCO2 27,2 mmHg 35-45

pO2 127,5 mmHg 80-100

HCO3 16,4 mmol/L 21-28

BE -8,9 mmol/L (-3) – (+3)

Saturasi O2 98,8 % >95

Hb 13,3 g/dL

Suhu 37,0 ◦C

Enzim Jantung

Troponin I 0,37 Mikrog/L <1

CK-NAC 50 U/L 26-192

CK-MB 18 U/L 7-25

EKG 10 April 2015 jam 7.10

EKG 10 April 2015 jam 10.19

10 april 2015 11.25

10 april 2015 13.15-13.21

10 april 2015 18.05 pasca drip amiodarone 1 jam

19.40

Thorax

Diagnose

• Supraventricular Tachycardi

Theraphy

• O2 2-4 lpm NC

• IVFD NS 0,9% 2000 cc/24 jam

• Loading amiodarone->

Monitoring

• Vital Sign

• Subjective

• ECG serial

DISCUSSION

1. Perempuan, 42 tahun mengalami berdebar 3 jam SMRS, riwayat berdebar sejak 1 tahun yang lalu, sesak (-), PND (-), DOE (-), bengkak (-), riwayat DM dan HT(-).

2. Pemeriksaan fisik: TD 150/90 mmHg, N 96x/menit iregular, RR 22x/menit, Tax 36,0 0C.

3. EKG: SVT

4. Lab: -

5. Terapi: O2 4 lpm via Nasal canul, IV line IVFD NaCl 0.9% maintanance 2000cc?24 jam

• Berdasarkan data dari primary dan secondary survey, kita membuat kesimpulan pasien mengalami palpitasi dt SVT

• Tachycardia refers to a heart rate >100 bpm. The tachycardia may be supraventicular or ventricular depending of the origin og the arrithmya.

• SVT is a narrow complex tachycardia originating in propagation outside the sinus node but above the bifurcation of the bundle of His, with rate that exceed 100 bpm.

Therapy

Pharmacological therapy • ABCD are the drug of choice (adenosin, beta blocker, CCB, digoxin)

• Adenosin should not be given if the patient have bronchospastic pulmonary disease because can precipitate asthma. Initial dose is 6 mg given IV bolus. The injectiion should given rapidly in 1 to 2 second follow by saline flush. If not converted to normal synus 12mg bolus is given IVthird and final dose 0f 12 mg may be repeated if the tachycardia has not responded.

• Beta Blocker ( metoprolol, atenolol, propanolol, esmolol). Should not be given if there is congestive heart failure.

• CCB verapamil or diltiazem. If the patient is not hypitnesis 2.5 – 5 mg of verapamil is give on IV slowly over to minute under carefull ECG and blood pressure monotoring, if there is no response and the patient remain stable, additional dose of 5-10 mg maybe given every 15 – 30 minutes until total dose of 20 mg is given.

• Digoxin has slowe onset of action and is not as effective as previously discussed agents. The initial dose of digoxin agent in a patient who is not on oral digoxin is 0.5 mg given slowly IV for 5 minutes or longer. Subsecuent doses of 0.25 mg IV should be given after 4hr and repeated if needed for a total dose of no more than 1.5 mg over 24 hr period.

• Other Antiarhtymia agent that should be considered include type 1A (procainamide) 1C (propafenon) or type 3 agent (amiodaron, ibutilit). The use of this agent. Requires expert consultation. This agent should be considered only if SVT is resistant to above pharmacologic agent.

Discussion

• Primary survey

• 1. A : -

2. B : O2 NC 4 lpm

3. C : IVFD NaCl 2000cc/24 jam

Klinis

• Jantung berdebar debar, dan riwayat berdebar-debar sejak 1 tahun lalu

• Tiba-tiba terasa seperti mau pingsan

• Lemas

Theory • Palpitation - greater than

96 %

• Dizziness - 75%

• Shortness of breath - 47%

• Syncope -20%

• Chest pain -35%

• Fatigue - 23%

• Diaphoresis – 17%

• Nausea – 13 %

Found

Therapy

• O2 2-4 lpm NC

• IVFD NS 0,9% 2000 cc/24 jam

• Loading amiodarone-> 150 mg IV bolus in 10 minute( 15mg/minute), followed by 360 mg over next 6 hours (1mg/minute).

Lesson Learnt

• Palpitasi merupakan perasaan subjektif pasien berupa rasa tidak nyaman/ bergetar/ nyeri di dada atau daerah anatomis disekitarnya yang dapat terjadi mendadak atau perlahan

• Palpitasi dapat disebabkan oleh karena gangguan pada jantung, kondisi psikologis, penggunaan obat-obatan, maupun gangguan elektrolit

• Tatalaksana dari palpitasi yaitu antiaritmia (amiodarone), calsium channel blocker (verapamil/diltiazem)

TERIMA KASIH