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ARRYTHMIAS IN THE YOUNG

ARRYTHMIAS IN THE YOUNG. Dr Mark Earley , Consultant Cardiologist BMI The London Independent Hospita l St Bartholomew’s Hospital. Wolff Parkinson White Syndrome. Atria and ventricle AVNRT AVRT. Ventricle only Ventricular tachycardia Ventricular fibrillation Ventricular ectopy.

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ARRYTHMIAS IN THE YOUNG

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  1. ARRYTHMIAS IN THE YOUNG Dr Mark Earley, Consultant Cardiologist BMI The London Independent Hospital St Bartholomew’s Hospital

  2. Wolff Parkinson White Syndrome

  3. Atria and ventricle • AVNRT • AVRT • Ventricle only • Ventricular tachycardia • Ventricular fibrillation • Ventricular ectopy Tachycardia • Atria only • Atrial tachycardia • Typical atrial flutter • Atypical atrial flutter • Sinus tachycardia • Atrial fibrillation • Atrial ectopy

  4. Bradycardia Bradycardia • Sinus node disease • AV node disease • 1st degree • 2nd degree • 3rd degree (CHB) • His Purkinje disease • Bifasicular blockTrifasicular block Any underlying cause? YES Stop cause! NO Symptomatic? Observe unless CHB which always needs a PPM NO • Drugs • BBlockers • Digoxin • Myocardial infarction • Hypothyroidism • Hypothermia YES Pacemaker When?

  5. Presentation of arrhythmia • Cardiac arrest • ALS guidelines • Syncope • Near syncope • Pre syncope (dizziness) • Chest pain • Dyspnoea • Palpitations • Fatigue • Asymptomatic • incidental discovery

  6. Presentation of arrhythmia • Cardiac arrest • ALS guidelines • Syncope • Near syncope • Pre syncope (dizziness) • Chest pain • Dyspnoea • Palpitations • Fatigue • Asymptomatic • incidental discovery

  7. Palpitation - definition 'For every passion of the mind which troubles men's spirits, either with grief, joy, hope, or anxiety, and gets access to the heart, there makes it to change from its natural constitution, by distemperature, pulsation, and the rest.. .‘De MotuCordis 1628 William Harvey 1578-1657 “an abnormal awareness of the beating of theheart, whether too slow, too fast, irregularor at its normal frequency”

  8. Symptoms • “my heart stops ….. it skips a beat • “ …… a large bang in my chest…..” • “my heart was flip flopping in my chest” • “…….it was going crazy, all over the place • “…it’s thumping in my chest” • “Its like someone has their hand inside my chest me tickling my heart” • “……. my heart is fluttering……” PALPITATION = ARRHYTHMIA?

  9. Palpitation - causes

  10. How many patients have arrhythmia? 184 patients referred with palpitations • Psychiatric assessment: • 35% panic attacks • 21% major disorder Sulfi Mayou et al Q J Med 2003; 96:115–123

  11. Palpitation – patient assessment ASSUME…. • Likely to be benign cause • Reassurance all that is needed ….but avoid missing potentially life threatening diagnosis

  12. Ventricular tachycardia Ventricular fibrillation AF in WPW AF & stroke IMPAIRED LV FUNCTION Ischaemic heart disease Valvular heart disease Dilated cardiomyopathy HYPERTROPHIC CARDIOMYOPATHY CONGENITAL HEART DISEASE INHERITED PRIMARY ELECTRICAL DISORDERS Long QT Brugada ARVC CPVT Palpitations – the dangerous

  13. Palpitation – patient assessment • Is there an arrhythmia? • History • Appreciate psychological or lifestyle factors • Cardiac monitoring • Is there evidence of cardiac disease? • History • ECG • Echo • Could this be dangerous?

  14. 1. Is there an arrhythmia? • History ……. • “my heart stops ….. it skips a beat • “ …… a large bang in my chest…..” • “my heart was flip flopping in my chest” • “…….it was going crazy, all over the place • “…it’s thumping in my chest” • “It’s like someone has their hand inside my chest me tickling my heart” • “……. my heart is fluttering……” • “ there was pounding in my neck”

  15. 1. Is there an arrhythmia? • History ……. Circumstances: Associated symptoms: • Exercise • Precipitating factors • Position • Stress/anxiety Appreciate psychological or lifestyle factors • Syncope • Presyncope • Chest pain • Dyspnoea

  16. 1. Is there an arrhythmia? • Electrocardiography (ECG monitoring) Norman “Jeff” Holter 1914-1983

  17. 24 hour Holter monitoring Diagnoses in 2688 patients referred with palpitations Sulfi et al. Ann.Noninvasive.Electrocardiol. 2008;13(1):39–43

  18. 1. Is there an arrhythmia? • ECG monitoring – frequency of symptoms? • Continuous ECG • 2-3 x day or more 24 hour Holter • Daily 48 hour Holter • 2-3 x week 7 day Holter • Weekly – monthly Event recorder • Less than monthly Implantable loop recorder (syncope) • Exercise induced Exercise test

  19. 2 Is there evidence of cardiac disease? • History • Family history • Examination • Investigations • 12 lead ECG • TFTs, FBC • Cardiac imaging

  20. 3 Could this be dangerous? • Syncope or near syncope • Cardiac disease – heart failure • Abnormal ECG • Ventricular arrhythmia identified

  21. Conclusion: Management of palpitations Palpitations • History • Examination • ECG • Ectopic beats only • Very infrequent or mild symptoms • Normal ECG • Syncope • Abnormal ECG • LV failure Appropriate monitoring ± Echocardiogram • Specialist referral • Monitoring • Echo • Other tests Benign orno arrhythmia Important arrhythmia REASSURE ± Counseling Manage arrhythmiaor other condition identified

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