DIAGNOSING & TREATING PALPITATIONS

1. DIAGNOSING & TREATING PALPITATIONS Lee Graham Consultant Electrophysiologist Yorkshire Heart Centre

2. Palpitations • Definition: ‘an uncomfortable sensation in which a person is aware of their heart beat which may be irregular, pounding, forceful or rapid’

3. Diagnostic pathway • History • Examination • Resting ECG • Symptom-ECG correlation • Additional investigations • Treatment

4. History • Onset / offset characteristics • Age of onset • Perceived rate • Description of regularity • Duration and frequency • Associated symptoms (e.g. polyuria) • Neck pulsations • Triggers / relieving factors • Nocturnal symptoms

5. History • Red Flag features (referral suggested) • Exercise induced • Associated syncope • Unexplained “seizure” • Chest pain • Family history of premature sudden cardiac death • Underlying structural heart disease

6. History • Drug history including OTC medicines • Decongestants • Alcohol • Antidepressants • Psychotropics • Antibiotics & antifungals • Antihistamines • Methadone • Recreational drugs

7. Examination • Cardiovascular • Pulse • Blood Pressure • Heart murmurs • Signs of heart failure • Features of thyroid disease

8. Resting ECG • Features to check • Sinus rhythm / arrhythmia • PR interval (WPW) • QRS duration / bundle branch block • ST segment shape (LVH / LV aneurysm / brugada) • QT interval (long or short) • Presence of Q waves (previous infarct) • T wave inversion (cardiomyopathy or IHD) Consider referral for any abnormal ECG

9. PR interval Normal 3 to 5 small squares (120 - 200ms) QRS duration Normal up to 3 small squares (120ms)

10. QT interval Depends on heart rate QTc 440 ms men QTc 460 ms women

11. Wolff-Parkinson-White syndrome

12. BRUGADA SYNDROME

13. HYPERTROPHIC CARDIOMYOPATHY

14. Diagnostic yield from clinical assessment Not sufficiently accurate to exclude clinically significant arrhythmia Thavendiranathan et al. JAMA 2009;302:2135-43

15. SYMPTOM-ECG CORRELATION • 12-lead ECG taken with symptoms • Holter monitoring (24h - 7 day) • Event recorder with / without looping memory (patient activated device) • Implantable loop recorder (ILR)

16. HOLTER MONITOR • Requires typical symptoms during recording • Useful if symptoms occur several times per week • Asymptomatic arrhythmias • Useful for patients who are unable to trigger a monitoring device e.g. syncope

17. Event recorder • Useful for less frequent symptoms • Longer duration of symptoms • Symptoms need to be reasonably well tolerated

18. Implantable LoOprecorders

19. Ambulatory monitoring options 24h- 7 days 7-30 days 36 months Time (months)

20. Case Vignette • 68y old man • 10 month history of palpitations • Onset with exertion • Syncopal on two occasions • Normal cardiovascular exam • Normal resting ECG ILR implanted

21. ILR SYMPTOM – RHYTHM CORRELATION

23. Diagnostic yield from monitoring Thavendiranathan et al. JAMA 2009;302:2135-43

24. Additional Investigations • Structural cardiac disease • Echocardiogram • Cardiac MRI • Exercise tolerance test • Cardiac catheterisation • Electrophysiological study +/- catheter ablation

25. PALPITATIONS-COMMON CAUSES • Sinus Tachycardia • Ectopics (PAC’s / PVC’s) • Supraventricular tachycardia (AVNRT / AVRT / atrial tachycardia) • Atrial flutter • Atrial fibrillation • Ventricular tachycardia

26. SINUS TACHYCARDIA • Onset and termination are gradual (i.e. not paroxysmal) • Perceived rate relatively slow • May persist for several hours or days • Normal P wave morphology • Physiological • sensitive to autonomic modulation • Inappropriate • Usually resting rate >100bpm ;mean >95bpm on 24h Holter

27. Poorly understood Young women most commonly affected Associated symptoms of dyspnoea, pre-syncope & fatigue Association with Postural Orthostatic Tachycardia Syndrome Treatment unsatisfactory Beta-blockers or rate limiting Ca antagonist Ivabradine Catheter modification of the sinus node can be attempted INAPPROPRIATE SINUS TACHYCARDIA

28. ECTOPICS • Usually sudden onset • Perceived as ‘missed beats’ often followed by thud & fluttering • rate relatively slow • More commonly noticeable at rest or in bed • Often described as persistent for several hours or days • Sporadic • Reassurance • Treatment usually not required although beta-blockers can be helpful

29. RV OUTFLOW TRACT ECTOPY / VT

30. Frequent ectopics / salvos Catecholamine sensitive Treat with beta-blockers Catheter ablation offers 80% chance of cure if remains symptomatic 1% risk tamponade RV OUTFLOW TRACT ECTOPY / VT

31. SUPRAVENTRICULAR TACHYCARDIA • Usually sudden onset / offset (except atrial tachycardia) • Perceived rate rapid and regular • Pounding pulsation in neck (AVNRT) • Variable duration • Vagal manoeuvres may terminate • Usually adenosine sensitive • Reentry most common mechanism (except atrial tachycardia) • AVRT/AVNRT/atrial tachy

32. No conduction delay AV node Accessory pathway Wolff-Parkinson-White syndrome • Short PR interval • Delta wave • Ventricular preexcitation • AVRT most common arrhythmia • AF more common and may be preexcited • Small risk of sudden death

33. Wolff-Parkinson-White syndrome

34. Conduction down AV node Up accessory pathway ATRIOVENTRICULAR REENTRANT TACHYCARDIA • Usually narrow complex • Rarely broad complex • Often frequent episodes starting in childhood

35. Av reentrant tachycardia

36. Preexcited AF • AF may conduct rapidly over accessory pathway • Irregular broad complex tachycardia • Risk of degeneration to VF • Avoid AV node blockers

37. Preexcited AF

38. Management of wpw • Refer to an electrophysiologist • EPS and catheter ablation if symptomatic • 95% curative (<1% risk) • Reasonable to offer asymptomatic patients EPS • Flecainide antiarrhythmic drug of choice

39. Slow pathway Fast pathway Av nodal reentrant tachycardia • ~ 60% of all SVT F > M • Onset often later than in AVRT • Beta-blockers or verapamil first line antiarrhythmics • Catheter ablation 95% curative but 1% risk AV node damage

40. Av nodal reentrant tachycardia

41. Atrial flutter • Regular or irregular palpitations • Paroxysmal or persistent • Saw tooth baseline • Atrial rate usually 300 min • Ventricular rate variable 2:1 block common • Often difficult to rate (or rhythm) control • Catheter ablation 90-95% curative and should be offered as first line (<1% risk)

42. “Typical” Atrial flutter

43. Catheter ablation for typical flutter

44. Atrial Fibrillation • Assess symptoms • Control ventricular rate • Assess thromboembolic risk • Rate vs. rhythm control strategy

45. Who should be offered rhythm control • Symptomatic AF despite adequate rate control • Young symptomatic patients • AF related heart failure • AF secondary to corrected trigger or cause EHRA. EHJ 2010;31:2369-2429

46. Rhythm control for AF • Antiarrhythmic drug therapy • Beta-blockers • Flecaininde • Sotalol, amiodarone, dronedarone • Cardioversion • Catheter ablation

47. Pulmonary vein triggers drive paroxysmal AF

48. Electrical isolation of the pulmonary veins Prevents “triggers” and “drivers” of AF Creates electrically inexcitable “scar” around the PV’s which blocks PV ectopics from entering the left atrium More effective in paroxysmal than in persistent AF RATIONALE FOR AF ABLATION

49. The ideal patient for AF ablation ? • Arrhythmia related symptoms • Refractory or intolerant to at least one class 1 or 3 drug • ? Young age • Paroxysmal rather than persistent AF • Short duration of symptoms • Structurally normal heart • Informed and motivated

50. Catheter ablation for af • ~ 70% success rates • Often multiple procedures required • 3-4 hour procedure • 3-4% risk major complication • Stroke 0.5-1% • Cardiac tamponade 1-2% • Usually second line