Course overview

1Ihab B Abdalrahman

ARRHYTHMIAS THE WAY IT SHOW & THE WAY YOU GO

Dr. Ihab B Abdalrahman, MBBS, MD, ABIM, SSBBSoba University Hospital

SAMA- Founder & VP

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Objectives

To recognize the clinical presentations of arrhythmias

To determine who need immediate intervention.

To know how to capture the rhythm

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The way it show

No Symptom

s

Palpitation &

Dizziness

LOC & Sudden Death

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Message # 1

If your patient get palpitation

Don’t get yourself palpitation


PALPITATIONS COULD BE DUE TO Arrhythmias

Nonarrhythmic cardiac causesExtracardiac causesDrugs and medicationsPsychiatric causes

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ARRHYTHMIC CAUSES

Atrial fibrillation/flutterBradycardia caused by advanced AV block or sinus node dysfunctionBradycardia-tachycardia syndrome(sick sinus syndrome)Multifocal atrial tachycardiaPremature supraventricular or ventricular contractionsSinus tachycardiaSupraventricular tachycardiaVentricular tachycardiaWolff-Parkinson-White syndrome

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Palpitations Nonarrhythmic cardiac causes

Atrial or ventricular septal defect Cardiomyopathy Congenital heart disease Congestive heart failure Mitral valve prolapse Pacemaker-mediated tachycardia Pericarditis Valvular disease (e.g., aortic

insufficiency,stenosis)11Ihab B Abdalrahman

PALPITATIONS /EXTRACARDIAC CAUSES

Anemia, Electrolyte imbalanceFeverHyperthyroidismHypoglycemiaHypovolemiaPheochromocytomaVasovagal syndrome 12Ihab B Abdalrahman

Drug


DRUG-INDUCED ECG ABNORMALITIES


PALPITATIONS/PSYCHIATRIC ETIOLOGY

Anxiety disorderPanic attacks


ANXIETY OR PANIC DISORDER

Prevalence of panic disorder in patients with palpitations is 15 to 31 percent.

Panic disorder and significant arrhythmias are not mutually exclusive,

Cardiac evaluation still may be necessary in patients with suspected panic disorder


Differential Diagnosis of Palpitations/ Drugs and medications Alcohol, Caffeine beta agonists, phenothiazine,

theophylline, isotretinoin, digoxin Cocaine Tobacco


DIETARY SUPPLEMENT CAUSING PALPITATION

ChocolateEphedra/Diet pillsGinsengBitter OrangeValerianHawthorn


Normal Impulse Conduction

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers


Pathophysiology

Enhanced or suppressed automaticity Automaticity is a natural property of all

myocytes. It can be affected +/-vely by:

Ischemia, scarring, electrolyte disturbances, medications, advancing age.


Pathophysiology

Triggered activity, Triggered activity occurs when early

afterdepolarizations and delayed afterdepolarizations initiate spontaneous multiple depolarizations, precipitating ventricular arrhythmias. Examples include torsades de pointes and ventricular arrhythmias caused by digitalis toxicity.


Pathophysiology

Re-entry. Circuit lead to propagation of the rhythm The commonest mechanism Bidirectional or unidirectional block. Micro level re-entry occurs with VT Macro level re-entry occurs via

conduction through (Wolff-Parkinson-White [WPW] syndrome) concealed accessory pathways.


What is arrhythmia

Broadly defined as any abnormality in the normal activation sequence of the myocardium.


There are hundreds of different types of cardiac arrhythmias.


My dream

It would be immensely convenient

if every dysrhythmia had a classic ECG appearance

and every patient with a given dysrhythmia manifested a similar clinical presentation.

In arrhythmias one size does not fit all

CDC have estimated sudden cardiac death rates at more than 600, 000 per year .

Up to 50% of patients have sudden death as the first manifestation of cardiac disease.


The major determinant

In general, the seriousness of cardiac arrhythmias depends on the presence or absence of structural heart disease.


Benign In normal heart

Serious in abnormal heart

APC VPC Lone A fib

Non-sustained VT Syncope In patients with CAD Severe LV dysfunction


Ataa Ataa

Ataa senior (42 years) was an athlete trainer in the army

He won 2 medals He died suddenly in a marathon

race


Ataa Ataa

Ataa Junior is a 26 year football player.

Ataa junior collapsed during a match in Qatar.

Luckily they have and AED.


The way it

Show GoCollapse(Near) Sudden cardiac death

DC shockMay be screening


Najat is a 36 obese female. She delivered her dream baby 3 days

a go. She was brought to ER because of

SOB, pleuritic chest pain and palpitation.


The way it

Show GoPalpitationFeatures of a concomitant disease

Diagnose & Treat the disease


Haj Adam is a 73 male with vascular dementia

Admitted to hospital because of confusion and weakness.

No other symptoms. Diagnosed with CAP The resident noticed irregular pulse.


The way it

Show GoAsymptomaticFeatures of a concomitant disease

Treat the diseaseStratify your patient (CHADS2)


Abdalsatar know to have DM, HTN admitted to CCU with ACS

Treated with ASA, BB, ACE, heparin, atrova

12 hour later he had a brief run of He reported some palpitation. He remained conscious with a BP of

110/70, sat 94%


The way it

Show GoSymptomaticFeatures of a concomitant disease Hemodynamic ally stable

Treat the diseaseCorrect K, MGAdjust meds


Abdalwahid has frequent palpitation. He always feel an extra beat in his

pulse No chest pain, DM, HTN, smoking Exam, ECG, Echo all were normal He demanded Holter monitoring

which was negative


The way it

Show GoSymptomaticRecurrent Normal Heart

Reassurance No Further testing


22 year male reported recurrent attack of palpitation.

He was admitted to CCU twice and diagnosed as VT. One episode required DC shock.

Physical exam was normal While searching on his records, you

found this tracing


WOLFF-PARKINSON-WHITE SYNDROME


Clues in the way it shows

The presence of sustained regular palpitations or heart racing in young patients without any evidence of structural heart disease suggests the presence of a SVT caused by AV nodal re-entry or SVT caused by an accessory pathway.


The way it

Show GoSymptomaticRecurrent Normal Heart Suspicious RT

EP study Radiofrequency catheter


The way it shows

In general, severe symptoms are

more likely to occur in the presence of structural heart disease.


Syncope in the setting of noxious stimuli such as pain, prolonged standing, or venipuncture, particularly when preceded by vagal-type symptoms (e.g., diaphoresis, nausea, vomiting) suggests neurocardiogenic (vasovagal) syncope.


Occasionally, patients report abrupt syncope without prodromal symptoms, suggesting the possibility of the malignant variety of neurocardiogenic syncope.


Suzan is a 54 female, high school English-teacher.

Had 3 episodes of syncope in the last 2 month

2 days ago she passed out while watching TV

Exam, electrolytes , TNI, ECG and 36 hours monitoring were normal

Echo EF 30%


The way it

Show GoSymptomaticRecurrent & disabling Structural cardiac abnormality

Further testing


Way you goPrinciples

It is important to proceed with a stepwise approach.

The goal is to obtain a correlation between symptoms and the underlying arrhythmia .

To identify underlying abnormalities To initiate appropriate therapy.


Way you go Assessment for Structural Heart Disease History of CAD or MIs, Risk factors for CAD, Family history of sudden cardiac

death are extremely important. Cardiac exam may detect an

irregular rhythm or premature beats.


Way you go Assessment of Structural Heart Disease Examine the ECG for

conduction system delays, QRS widening, previous MI, PVCs.

Echo CAD, LV dysfunction, valvular disease

Stress testing can demonstrate the presence of CAD.


Way you goClues in ECG EVALUATION

All patients who complain of palpitations

ECG findings warrant further cardiac investigation evidence of previous myocardial infarction, left or right ventricular hypertrophy, atrial enlargement, AV block, short PR interval and delta waves (Wolff-

Parkinson-White syndrome), prolonged QT interval


WAY YOU GOWHEN YOU GO FOR STRESS ECG

ECG exercise testing is appropriate in patients who have palpitations with physical exertion and patients with suspected coronary artery disease or myocardial ischemia.


Capturing the rhythm


FURTHER DIAGNOSTIC TESTING

CONTINUOUS ECG MONITORS (Holter monitor)- continuously to record data for 24 or 48 hours- diary of any symptoms that occur during the monitoring- most expensive

TRANSTELEPHONIC EVENT MONITORS- save data only for the previous and subsequent few minutes when the patient manually activates the monitor


HOLTER MONITOR VS EVENT MONITOR


Choosing an AmbulatoryMonitoring Device Diagnostic yield was

66 to 83% for event monitors 33 to 35% for Holter monitors


Case study

Rapid heart palpitations with associated dyspnea develop suddenly in a 40-year-old man.

His symptoms are acute and progressive.

In ER


The way it

Show GoHRBP RR Temp

DC AVN blocker


Which one of the following signs will determine the way you go?

In a patient with heart palpitations and dyspnea, what piece of clinical history is critical in guiding the initial management?

A. Recent cardiac stress test B. Length of time of current

symptoms C. Lack of chest pain during

symptoms D. History of prior hospitalization for

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Take home

Determine if you need immediate action

Good H & P Examine the ECG Is it in a good heart or structurally

abnormal Think outside the heart Do you need to capture it

Recording devices 70Ihab B Abdalrahman

This is the way it show

Please determine the way you go

Thank you for going the right way


Course overview

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