Palpitations Syncope Dysrrhythmias

Hippocrates“Those who suffer from recurrentFainting die suddenly”

Palpitations and Syncope

Symptoms

Cardiovascular origin

May be related to Cardiac rhythm abnormalities

Multiple causes

Assessment priority-those at risk

Treatment –Reassurance to Intervention

Palpitations

“Awareness of ones heart beat”

History important!!!!

Physical exam

Investigations (Aim)-Correlate symptoms with cardiac rhythm

HistoryA clear description of the palpitation is helpful

-Onset-Duration of symptom-Heart rate estimate-Regularity of rhythm-Trigger factors

PalpitationsCommon Causative

Factors

Sinus TachycardiaGradual onsetAnxiety and panic

PrematureEctopic beats

Tachydysrythmias

Physical Findings and Investigations

Physical FindingsNormal or Abnormal

InvestigationsElectrocardiogramAmbulatory Monitoring

Treatment

Reassurance-Sinus Tachycardia and ectopic beats

Treatment of specific arrhythmias

Syncope

Transient loss of consciousness and postural tone with spontaneous recovery ( Due to decrease cerebral blood flow)Do not confuse with a seizure disorderCommon 6% hospital admissions and 1-2% emergency admissions Can occur at any age - Elderly

Causes

Any cause of decrease cerebral flow particularly to the area of brain know as the *Reticular Activating System*

Classification of causes – Prognosis (cardiac causes mortality 18 to 33%)

“Those who suffer from recurrent fainting die suddenly’’

Causes

Neurally Mediated

Cardiac

Neurological or psychiatric

Syncope of unknown origin*

Neurally Mediated

Disorders of Autonomic control – orthostatic intolerance - syncope Reflex syncope – due to an increased sensitivity of normal reflex responses or autonomic dysfunction where abnormal neurovascular control results in orthostatic hypotension

Neurally Mediated

Reflex Mediated

Vasovagal or neurocardiogenic syncopeCarotid sinus hypersensitivitySituational(micturation, defaecation,cough ,swallow)

Autonomic dysfunction

Pure autonomic failure atrophy(Parkinsonism,cerebellarMultiple system)Postural orthostatic tachycardia syndromeSecondary autonomic failure

Vasovagal commonest cause

Vasovagal Syncope

Commonest causeAffect all age groupsHypersensitivity of the Autonomic System to any StimuliPostural

Pathophysiology

Upright position venous pooling

Decrease CO decrease VR

Increase symp A Activation Mechanoreceptors Withdrawal of symp and activation of ParasympVasodilatation bradycardiaDecrease cerebral flow

Carotid Sinus Hypersensitivity

Abnormal sensitivity of a normal reflex

Carotid sinus massage result in sympathetic withdrawal and parasympathetic activation

Bradycardia prominent feature

Situational reflex-mediated syncope

Autonomic dysfunctionOrthostatic hypotensionUpright posture BP decrease20mmhg systolic or decrease to 90mmhgMore common in the elderlyDo not forget drugs that may ppt syncope

Cardiac syncope

Rhythm DisturbancesBradycardiaAtrioventricular blockSinus node dysfunction

TachycardiaVentricular ArrhythmiaSupraventricular arrhythmia

Structural cardiac disease Aortic stenosisHypertrophic cardiomyopathy

Neurogenic or Psychiatric

NeurologicalMigraineVertebrobasilar disease Subclavian steal

PsychiatricAnxietyDepressionHyperventilation(Psychogenic syncope)

How does one evaluate a patient with syncope ?

History Important++++

Eye witness description if possible

Physical examination (Neurological Exam)

Logical approach to investigations

History

Description of syncopal episode

Provocative factors

Preceding symptoms

Recovery period

Family history

Associated injury

Clinical Findings

Investigations

Electrocardiogram*

Ambulatory Monitoring*

Tilt Testing

Electrophysiological Testing (Specialized Tests)

Other – Echocardiography*

Electrocardiography

Mandatory in ALL patients

May offer clues to cause (Underlying structural heart disease arrhythmia, Inherited disorders)

ECG recording coupled with certain maneuvers

Ambulatory Monitoring

Holter Monitoring - 24 or 48hr ECG recording- Limitations(Intermittent)

Event recorders – Limitations (Patient Activation)

Tilt Testing

Very useful in confirming diagnosis in vasovagal syncope

Availability of the necessary hardware

Electrophysiological Testing

Highly specialized

Restricted to a specific category of patients

Other

Echocardiography- Clinical clues

TreatmentDepends on the cause*

Vasovagal syncopeReassurance Avoid provocative factors

Carotid sinus Hypersensitivity(Pacing)

Dysrhythmia

Abnormality of cardiac rhythm

Range - benign to malignant (Extrasystoles to ventricular fibrillation and asystole)

Dysrhythmias (Cont)

Symptoms – Varied. Brady episodes may present with syncope, presyncope and even sudden death – other –fatigue, memory impairment and dyspnoea. Tachy episodes may present with angina, palpitations , syncope and sudden death

Dysrhythmia (cont)

Role of the following in the assessment – Important

HISTORY*****

ECG************* Must be of good quality

BradycardiasVentricular rate less than 60/min(Physiological and Pathological)

Bradycardia

Results from : reduction in the rate of normal sinus rhythm : Disturbances of Atrioventrcular conduction

Pathological causes

Degeneration of the sinus node , AV node or conduction system.

Extrinsic factors – vagal stimulation drugs,myocardial infarction ischaemia,infitration,hypothyroidism, hypothermia, jaundice and raised intracranial pressure

A-V Conduction Disturbances

First degree – prolongation of the PR interval.Delayed conduction from A to V.

Second degree – Intermittent of failure in conduction from the atria to ventricle.2 types.Type I - Progressive prolongation of PR interval followed by a non conducted P wave.Type II – Normal PR internal with sudden failure of Conduction.

A-V conduction disturbance (cont)

Third degree A-V block – Complete

Complete dissociation of atrial and ventricular activity(Atria and ventricle beating at different rates)

There is an escape rhythm(His bundle 50/min, Purkinje – 20 to 30/min)

Varying degrees of A-v block

A-V Conduction disturbances

Causes

Which ones need treatment

Treatment Strategies

Role of pacing in Prognosis

Sinus Node Dysfunction(Sino atrial node disease)

InappropriateSinusbradycardia

Sinus pauses

ProneTo Tachy

Treatment : Symptoms

TACHYCARDIASTACYARRHYTHMIAS

Tachycardias

Origins :Atria: Ventricle:AV junction

Mechanisms

QRS morphology and duration

Role of antiarrhythmic therapy in Rx

Atrial Arrhythmias

Atrial FibrillationSinus TachycardiaAtrial FlutterAtrial TachycardiasJunctional tachycardiasother

Atrial Fibrillation

Common

Mechanism – re-entry

Prevalence increases with age(5%)

Multiple causes (“Lone”A F )

Increased risk of stroke

Classification :Paroxysmal,Persistent, Permanent

Treatment strategies linked to duration and clinical presentation

Atrial Fibrillation

Clinical features (underlying cause and those related to AF)ECG – Recent onset AF - Rapid irregular “f” waves at a rate of 350 to 600. Irregular ventricular response rate due to variable conduction.Chronic atrial fibrillation –Absence of atrial waves with an irregular R- R interval

Treatment

Onset and duration

Presence of organic disease/ppt factors

Haemodynamic Status

Anticoagulation

Antiarrhythmics

Other

Atrial Flutter

Re- entry RA

Saw tooth pattern on ECG – Flutter waves(300/min)

Termination cardioversion ( medical or Chemical)

Progression to atrial fibrillation

Ventricular Tachyarrhythmias

Ventricular tachycardia

Ventricula fibrillation

Ventricular Tachycardia

Sustained or nonsustained ( Duration)

Monomorphic or polymorphic(Related to constant or change of the QRS morphology)

Multiple causes – Myocardial infarction,CMO,HCM,ARVD,

Treatment Strategies( ECV,Drugs)

LQTS-Torsades*