1. Palpitations Syncope Dysrrhythmias Hippocrates “Those who suffer from recurrent Fainting die suddenly”

3. Palpitations and Syncope Symptoms Cardiovascular origin May be related to Cardiac rhythm abnormalities Multiple causes Assessment priority-those at risk Treatment –Reassurance to Intervention

4. Palpitations “Awareness of ones heart beat” History important!!!! Physical exam Investigations (Aim)-Correlate symptoms with cardiac rhythm

5. History A clear description of the palpitation is helpful -Onset -Duration of symptom -Heart rate estimate -Regularity of rhythm -Trigger factors

6. Palpitations Common Causative Factors Sinus Tachycardia Gradual onset Anxiety and panic Premature Ectopic beats Tachydysrythmias

7. Physical Findings and Investigations Physical Findings Normal or Abnormal Investigations Electrocardiogram Ambulatory Monitoring

8. Treatment Reassurance-Sinus Tachycardia and ectopic beats Treatment of specific arrhythmias

9. Syncope Transient loss of consciousness and postural tone with spontaneous recovery ( Due to decrease cerebral blood flow) Do not confuse with a seizure disorder Common 6% hospital admissions and 1-2% emergency admissions Can occur at any age - Elderly

10. Causes Any cause of decrease cerebral flow particularly to the area of brain know as the *Reticular Activating System* Classification of causes – Prognosis (cardiac causes mortality 18 to 33%) “Those who suffer from recurrent fainting die suddenly’’

11. Causes Neurally Mediated Cardiac Neurological or psychiatric Syncope of unknown origin*

12. Neurally Mediated Disorders of Autonomic control – orthostatic intolerance - syncope Reflex syncope – due to an increased sensitivity of normal reflex responses or autonomic dysfunction where abnormal neurovascular control results in orthostatic hypotension

13. Neurally Mediated Reflex Mediated Vasovagal or neurocardiogenic syncope Carotid sinus hypersensitivity Situational(micturation, defaecation,cough,swallow) Autonomic dysfunction Pure autonomic failure atrophy(Parkinsonism,cerebellar Multiple system) Postural orthostatic tachycardia syndrome Secondary autonomic failure Vasovagal commonest cause

14. Vasovagal Syncope Commonest cause Affect all age groups Hypersensitivity of the Autonomic System to any Stimuli Postural

15. Pathophysiology Upright position venous pooling Decrease CO decrease VR Increase symp A Activation Mechanoreceptors Withdrawal of symp and activation of Parasymp Vasodilatation bradycardia Decrease cerebral flow

16. Carotid Sinus Hypersensitivity Abnormal sensitivity of a normal reflex Carotid sinus massage result in sympathetic withdrawal and parasympathetic activation Bradycardia prominent feature

17. Situational reflex-mediated syncope Autonomic dysfunction Orthostatic hypotension Upright posture BP decrease 20mmhg systolic or decrease to 90mmhg More common in the elderly Do not forget drugs that may ppt syncope

18. Cardiac syncope Rhythm Disturbances Bradycardia Atrioventricular block Sinus node dysfunction Tachycardia Ventricular Arrhythmia Supraventricular arrhythmia Structural cardiac disease Aortic stenosis Hypertrophic cardiomyopathy

19. Neurogenic or Psychiatric Neurological Migraine Vertebrobasilar disease Subclavian steal Psychiatric Anxiety Depression Hyperventilation(Psychogenic syncope)

20. How does one evaluate a patient with syncope ? History Important++++ Eye witness description if possible Physical examination (Neurological Exam) Logical approach to investigations

21. History Description of syncopal episode Provocative factors Preceding symptoms Recovery period Family history Associated injury

22. Clinical Findings

23. Investigations Electrocardiogram* Ambulatory Monitoring* Tilt Testing Electrophysiological Testing (Specialized Tests) Other – Echocardiography*

24. Electrocardiography Mandatory in ALL patients May offer clues to cause (Underlying structural heart disease arrhythmia, Inherited disorders) ECG recording coupled with certain maneuvers

25. Ambulatory Monitoring Holter Monitoring - 24 or 48hr ECG recording- Limitations(Intermittent) Event recorders – Limitations (Patient Activation)

26. Tilt Testing Very useful in confirming diagnosis in vasovagal syncope Availability of the necessary hardware

27. Electrophysiological Testing Highly specialized Restricted to a specific category of patients

28. Other Echocardiography- Clinical clues

29. Treatment Depends on the cause* Vasovagal syncope Reassurance Avoid provocative factors Carotid sinus Hypersensitivity (Pacing)

30. Dysrhythmia Abnormality of cardiac rhythm Range - benign to malignant (Extrasystoles to ventricular fibrillation and asystole)

31. Dysrhythmias (Cont) Symptoms – Varied. Brady episodes may present with syncope, presyncope and even sudden death – other –fatigue, memory impairment and dyspnoea. Tachy episodes may present with angina, palpitations, syncope and sudden death

32. Dysrhythmia (cont) Role of the following in the assessment – Important HISTORY***** ECG************* Must be of good quality

33. Bradycardias Ventricular rate less than 60/min( Physiological and Pathological)

34. Bradycardia Results from : reduction in the rate of normal sinus rhythm : Disturbances of Atrioventrcular conduction

35. Pathological causes Degeneration of the sinus node, AV node or conduction system. Extrinsic factors – vagal stimulation drugs,myocardial infarction ischaemia,infitration,hypothyroidism, hypothermia, jaundice and raised intracranial pressure

36. A-V Conduction Disturbances First degree – prolongation of the PR interval. Delayed conduction from A to V. Second degree – Intermittent of failure in conduction from the atria to ventricle.2 types.Type I - Progressive prolongation of PR interval followed by a non conducted P wave.Type II – Normal PR internal with sudden failure of Conduction.

37. A-V conduction disturbance (cont) Third degree A-V block – Complete Complete dissociation of atrial and ventricular activity(Atria and ventricle beating at different rates) There is an escape rhythm(His bundle 50/min, Purkinje – 20 to 30/min) Varying degrees of A-v block

38. A-V Conduction disturbances Causes Which ones need treatment Treatment Strategies Role of pacing in Prognosis

39. Sinus Node Dysfunction (Sino atrial node disease) Inappropriate Sinus bradycardia Sinus pauses Prone To Tachy Treatment : Symptoms

40. TACHYCARDIAS TACYARRHYTHMIAS

41. Tachycardias Origins :Atria: Ventricle:AV junction Mechanisms QRS morphology and duration Role of antiarrhythmic therapy in Rx

42. Atrial Arrhythmias Atrial Fibrillation Sinus Tachycardia Atrial Flutter Atrial Tachycardias Junctional tachycardias other

43. Atrial Fibrillation Common Mechanism – re-entry Prevalence increases with age(5%) Multiple causes (“Lone”A F ) Increased risk of stroke Classification :Paroxysmal,Persistent, Permanent Treatment strategies linked to duration and clinical presentation

44. Atrial Fibrillation Clinical features (underlying cause and those related to AF) ECG – Recent onset AF - Rapid irregular “f” waves at a rate of 350 to 600. Irregular ventricular response rate due to variable conduction.Chronic atrial fibrillation – Absence of atrial waves with an irregular R- R interval

45. Treatment Onset and duration Presence of organic disease/ppt factors Haemodynamic Status Anticoagulation Antiarrhythmics Other

46. Atrial Flutter Re- entry RA Saw tooth pattern on ECG – Flutter waves(300/min) Termination cardioversion ( medical or Chemical) Progression to atrial fibrillation

47. Ventricular Tachyarrhythmias Ventricular tachycardia Ventricula fibrillation

49. Ventricular Tachycardia Sustained or nonsustained ( Duration) Monomorphic or polymorphic(Related to constant or change of the QRS morphology) Multiple causes – Myocardial infarction,CMO,HCM,ARVD, Treatment Strategies( ECV,Drugs) LQTS-Torsades*