آریتمی

1. آریتمی دکتر محمد رضا تابان متخصص داخلی و فوق تخصص قلب و عروق مرکز قلب شهید مدنی تبریز اسفند 91

2. Palpitation • definition ? • Most probable diagnoses & DDX. • Important and serious diagnoses. • Common pitfalls.

3. Palpitation definition A subjective awareness of one’s heartbeat # Bradycardia # tachycardia

4. Spectrum of Patients’ Descriptions Heart flips or flip-flops Skipped beats Strong beats Irregular beats Heart thumping Bubble sensation in heart or chest Racing or rapid heart beats Pounding in neck or chest Heart jumping out of chest Chest or whole body shaking

5. Most probable diagnoses • Anxiety • Premature beats (Ectypes= PAC / PVC) • Sinus tachycardia • Drugs, e.g. stimulants • Psychogenic • Arrhythmia: PSVT , AF/afl , VT ,…

6. Common Pitfalls • Fever / Infection • Pregnancy • Menopause • Drugs, e.g. caffeine, cocaine • Mitral valve disease • Aortic incompetence • Hypoxia / Hypercapnia

7. Masquerade Checklist • Depression • Diabetes Mellitus • Drugs • Anemia • Thyroid disease • Spinal dysfunction • Infection (Urinary Tract , …)

8. Important and Serious Diagnoses • Myocardial infarction / angina • Life threatening Arrhythmias -Wolff-Parkinson-White Syndrome -LQTs / SQTs -Burgada sy. • Electrolyte disturbances

9. History Keys: Characterization of the palpitation Attendant symptoms Cardiac history Arrhythmia history Family history Possible systemic & endocrinology disorders Drug use

10. 1-Characterization of the Palpitation Circumstances at onset Duration of the problem Mode of onset/offset , Trigger factors Heart rate estimate Rhythm regularity vs. irregularity Episode duration Symptom frequency

11. 2- Attendant Symptoms Symptoms arising from rhythm disorder Symptoms due to CAD or CHF Neurohormonal responses Psychological symptoms: Anxiety disorder , Panic attacks

12. 3- Cardiac History Ischemic heart disease LV dysfunction Valvular heart disease Atrial or ventricular arrhythmias

13. 4-Arrhythmia History Recurrence vs. new onset Recent history of radiofrequency ablation Pacemaker or ICD implantation

14. 5- Family History Long QT syndrome Brugada’s syndrome Familial cathecolamine-mediated polymorphic V. tachycardia Atrial fibrillation

15. 6- Possible Endocrine and Metabolic Disorders Hyper or hypothyroidism Pheochromocytoma Diabetes Renal disorders Anemia Electrolyte imbalance Hypoglycemia Hx of rheumatic fever

16. 7- Drug & Dietary Use Bronchodilator therapy, beta agonists, Caffeine , alcohol , Chocolate Stimulants / substance abuse: Cocaine OTC sympathomimetic agents QT-prolonging drugs Thyroid replacement medications phenothiazine, isotretinoin, digoxin Tobacco

19. Dietary Supplement Causing Palpitation Chocolate , Caffeine , alcohol Ephedra/Diet pills Ginseng Bitter Orange Valerian Hawthorn

20. Physical Examination Often uninformative in young adults Check for presence of organic heart disease - LV dysfunction - Valvular HD - Congenital HD Evidence of COPD Signs of anemia, thyroid and renal disease Pulse quality, rate, regularity, pauses Orthostatic hypotension

21. Physical Examination • Best performed while having palpitations • Signs especially to consider • Palm signs (sweaty, pallor) • Radial pulse (character) • Blood Pressure • Eye signs (pallor, eye signs of thyrotoxicosis) • Goitre • Jugular vein pulsations • Praecordium abnormalities (e.g. cardiac enlargement, murmurs)

23. Diagnostic Tests Resting EKG Ambulatory EKG monitoring Echocardiography Exercise testing Event monitor EKG Electrophysiologic testing Implantable loop recorder

30. A 48 year old man with palpitation Atrial Premature Beat

31. A 50 year old man with DM & palpitation for 2-4 hours

32. A 73 year old woman with palpitation & dizziness. 2 to 1 AV block

34. An 82 year old lady with palpitation & dizzy spells + hx of AF & Digoxin • AF+ complete heart block

35. A 57 year old woman with palpitations Atrial flutter

36. A 68 year old women on Digoxin complaining of palpitation & fatigue • Atrial flutter

37. A 60 year old woman with HTN crisis & palpitation

38. A 58 year old man on hemodialysis presents with palpitation & weakness Hyperkalaemia

39. A 39 year old woman with palpitationHx of LD • Acute pulmonary embolus

40. A 69 year old man 2weeks post MI

42. Holter monitor VS Event monitor

44. ECG • 1- QT (long QT , short QT) • 2- burgada syndrome • 3- WPW • 4- ARVD ( epsilon wave) • 5- HCM • 6- MI

45. A woman with Hx of palpitation

46. Tracing from a young boy with congenital long-QT syndrome. The QTU interval in the sinus beats is at least 600 milliseconds. Note TU wave alternans in the first and second complexes. A late premature complex occurring in the downslope of the TU wave initiates an episode of ventricular tachycardia

48. Ventricular tachycardia in the arrhythmogenic right ventricular dysplasia

49. A 25 year old man with periodic palpitation

50. Wolf-Parkinson-White syndrome • short PR interval, less than 3 small squares (120 ms) • slurred upstroke to the QRS indicating pre-excitation (delta wave) • broad QRS • secondary ST and T wave changes • Localising the accessory pathway • An accessory pathway, bundle of Kent, exists between atria and ventricles and causes • early depolarisation of the ventricle. The location of the pathway may be deduced as follows:- • LOCATION V1 V2 QRS axis • left posteroseptal (type A) +ve +ve left • right lateral (type B) -ve -ve left • left lateral (type C) +ve +ve inferior (90 degrees) • right posteroseptal -ve -ve left • anteroseptal -ve -ve normal