Palpitations & Common Arrhythmias PDF

INTERNAL MEDICINE Palpitations & Common Arrhythmias Palpitations Palpitations refer to the perception of an abnormal or irregular heartbeat (sensation often described as feeling like the heart is pounding, racing, fluttering, skipping beats, o...

INTERNAL MEDICINE Palpitations & Common Arrhythmias Palpitations Palpitations refer to the perception of an abnormal or irregular heartbeat (sensation often described as feeling like the heart is pounding, racing, fluttering, skipping beats, or beating too hard/too fast)  Could be due to something normal or something abnormal Palpitations can be a symptom of underlying cardiac & noncardiac disease… Arrhythmia Supraventricular arrhythmias – a variety of abnormal heart rhythms that originate above the Classification ventricles  Atrial fibrillation  Atrial flutter  Premature atrial contractions (PACs)  Supraventricular Tachycardia (SVT) o Atrial tachycardia o AVNRT o AVRT Ventricular arrhythmias - a variety of abnormal heart rhythms that originate in the ventricles  Ventricular tachycardia (VT)  Ventricular Fibrillation (VFib)  Premature ventricular contractions (PVCs) Approaching Approach to Palpitations Palpitations  ECG diagnosis (symptom rhythm correlation)  Diagnose & treat underlying cardiac and extra-cardiac diseases  Diagnose & treat factors that modify the risk of future events  It is important to get a chronological sense of the symptoms, duration, onset/offset, etc. (different patterns are suggestive of different arrythmias) HPI PMHx  INTERNAL MEDICINE Palpitations & Common Arrhythmias Social Hx  Caffeine consumption  Recreational drug use (specifically cocaine & amphetamine use) Family Hx  Family history of heritable cardiomyopathy Physical exam  Pulse – rate & regularity  Evidence of structural heart disease – murmurs, CHF (peripheral edema, JVP, rales/rhonchi), scars from cardiac surgery  Hyperthyroidism (tremor, goitre, lid lag, exophthalmos, hyperhidrosis) Investigations Ambulatory Monitors  Continuous recording monitors (Holter monitor)  Continuous recording patch monitor  Event recorder (non-looping) – Kardia  Implantable loop recorder Other Tests 12 lead ECG Transthoracic echo (atrial dilation, ventricular dysfunction, valvular heart disease) Blood work (low TSH, anemia, electrolyte disturbances) Other (urine tox screen) Approach to Treatment options Therapeutics  Medications Important to consider:  Catheter ablation  Is there prognostic benefit?  Device therapy  How troublesome are the symptoms?  Treat underlying disease  Is the patient willing to accept the risk of side effects/complications of the therapy for the possibility of symptomatic or prognostic benefit? INTERNAL MEDICINE Palpitations & Common Arrhythmias Management of SVT (AVNRT/AVRT)  Valsalva maneuver – can be effective in terminating certain episodes of SVT by stimulating the vagus nerve increasing parasympathetic tone and slowing the heart rate and potentially interrupting the re-entrant circuit  Calcium channel blockers/beta blockers – can be used to slow heart rate and terminate SVT episodes (rate control)  Electrophysiology Study – evaluates the electrical conduction system of the heart and identifies abnormal rhythms or arrythmias (if abnormal electrical pathways or areas causing arrhythmias are identified, catheter ablation may be performed) Management of Atrial Fibrillation Management of Sinus Tachycardia  Identify & treat underlying causes  Explanation and reassurance regarding the benign nature of the rhythm Management of PVCs and PACs  Identify & treat underlying causes  Explanation & reassurance regarding the benign nature of the rhyth  Medication o B-blocker or Ca blocker o Catheter ablation an option if frequent/incessant o Anti-arrhythmic drugs