Download Arrhythmias in the young

ARRYTHMIAS IN THE YOUNG
Dr Mark Earley, Consultant Cardiologist
BMI The London Independent Hospital
St Bartholomew’s Hospital
Wolff Parkinson White Syndrome
v
Tachycardia
Atria only
•Atrial tachycardia
•Typical atrial flutter
•Atypical atrial flutter
Atria and ventricle
•Sinus tachycardia
•AVNRT
•Atrial fibrillation
•Atrial ectopy
Ventricle only
•Ventricular tachycardia
•Ventricular fibrillation
•Ventricular ectopy
•AVRT
v
Bradycardia
Bradycardia
YES
Stop cause!
•Sinus node disease
•AV node disease
1st degree
2nd degree
3rd degree (CHB)
Any
underlying
cause?
•His Purkinje disease
Bifasicular block
Trifasicular block
NO
•Drugs
BBlockers
Digoxin
•Myocardial infarction
•Hypothyroidism
•Hypothermia
v
Symptomatic?
NO
YES
Pacemaker
When?
Observe
unless CHB
which always
needs a PPM
Presentation of arrhythmia
 Cardiac arrest
 ALS guidelines
 Syncope
 Near syncope
 Pre syncope (dizziness)





Chest pain
Dyspnoea
Palpitations
Fatigue
Asymptomatic
 incidental discovery
v
Presentation of arrhythmia
 Cardiac arrest
 ALS guidelines
 Syncope
 Near syncope
 Pre syncope (dizziness)





Chest pain
Dyspnoea
Palpitations
Fatigue
Asymptomatic
 incidental discovery
v
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 Motu Cordis 1628
William Harvey 1578-1657
v
“an abnormal awareness of the beating of the
heart, whether too slow, too fast, irregular
or at its normal frequency”
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”
v
 “Its like someone has their hand
inside my chest me tickling my
heart”

“……. my heart is fluttering……”
PALPITATION = ARRHYTHMIA?
Palpitation - causes
2 Sensing normal
rhythm
1 Arrhythmia
3 Unrelated to the
heart
Normal
Panic attack
Hyperdynamic
circulation
Depression
•
•
•
•
Hyperthyroidism
Pregancy
Anaemia
Fever
v
Physiological
tachycardia
•
•
•
•
Anxiety
Exercise
Drugs
Caffeine
Anxiety
How many patients have arrhythmia?
184 patients referred with palpitations
Ectopic
beats
Psychiatric assessment:
•35% panic attacks
•21% major disorder
v
PAF
Sinus
rhythm
SVT
VT
Sulfi Mayou et al Q J Med 2003; 96:115–123
NSVT
Palpitation – patient assessment
ASSUME….
 Likely to be benign cause
 Reassurance all that is needed ….but
avoid missing potentially life threatening diagnosis
v
v
v
Palpitations – the dangerous
 IMPAIRED LV FUNCTION
 Ischaemic heart disease
 Ventricular
tachycardia
 Ventricular fibrillation
 Valvular heart disease
 Dilated cardiomyopathy
 HYPERTROPHIC CARDIOMYOPATHY
 CONGENITAL HEART DISEASE
 AF in WPW
 AF & stroke
v
 INHERITED PRIMARY ELECTRICAL
DISORDERS
 Long QT
 Brugada
 ARVC
 CPVT
Palpitation – patient assessment
1. Is there an arrhythmia?
1. History
2. Appreciate psychological or lifestyle factors
3. Cardiac monitoring
2. Is there evidence of cardiac disease?
1. History
2. ECG
3. Echo
v
3. Could this be dangerous?
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
v
• “…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”
1. Is there an arrhythmia?
 History …….
Circumstances:
• Exercise
• Precipitating factors
• Position
• Stress/anxiety
Associated symptoms:
v
• Syncope
• Presyncope
• Chest pain
• Dyspnoea
Appreciate psychological
or lifestyle factors
1. Is there an arrhythmia?
 Electrocardiography (ECG monitoring)
v
Norman “Jeff” Holter 1914-1983
24 hour Holter monitoring
Diagnoses in 2688 patients referred with palpitations
100
90
80
70
60
50
40
v
30
20
10
0
Normal
Frequent
ectopics
All
PAF
SVT
VT
< 50 years old
Sulfi et al. Ann.Noninvasive.Electrocardiol. 2008;13(1):39–43
1. Is there an arrhythmia?
 ECG monitoring – frequency of symptoms?






Continuous
2-3 x day or more
Daily
2-3 x week
Weekly – monthly
Less than monthly
 Exercise induced
ECG
24 hour Holter
48 hour Holter
7 day Holter
v
Event recorder
Implantable loop recorder (syncope)
Exercise test
2 Is there evidence of cardiac disease?
 History
 Family history
 Examination
 Investigations
 12 lead ECG
 TFTs, FBC
 Cardiac imaging
v
3 Could this be dangerous?
1.
2.
3.
4.
Syncope or near syncope
Cardiac disease – heart failure
Abnormal ECG
Ventricular arrhythmia identified
v
Conclusion: Management of palpitations
Palpitations
•History
•Examination
•ECG
•Ectopic beats only
•Very infrequent or
mild symptoms
•Normal ECG
Appropriate monitoring
± Echocardiogram
v
Benign or
no arrhythmia
REASSURE ±
Counseling
Important
arrhythmia
•Syncope
•Abnormal ECG
•LV failure
Specialist referral
•Monitoring
•Echo
•Other tests
Manage arrhythmia
or other condition identified