ARRYTHMIAS IN THE YOUNG Dr Mark Earley, Consultant Cardiologist BMI The London Independent Hospital St Bartholomew’s Hospital

v Wolff Parkinson White Syndrome

v Atria only Atrial tachycardia Typical atrial flutter Atypical atrial flutter Sinus tachycardia Atrial fibrillation Atrial ectopy Ventricle only Ventricular tachycardia Ventricular fibrillation Ventricular ectopy Atria and ventricle AVNRT AVRT Tachycardia

v Bradycardia When? Bradycardia Stop cause! Observe unless CHB which always needs a PPM Symptomatic? Any underlying cause? Pacemaker YES NO YES Drugs BBlockers Digoxin Myocardial infarction Hypothyroidism Hypothermia Drugs BBlockers Digoxin Myocardial infarction Hypothyroidism Hypothermia Sinus node disease AV node disease 1 st degree 2 nd degree 3 rd degree (CHB) His Purkinje disease Bifasicular block Trifasicular block Sinus node disease AV node disease 1 st degree 2 nd degree 3 rd degree (CHB) His Purkinje disease Bifasicular block Trifasicular block

v 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 “ an abnormal awareness of the beating of the heart, whether too slow, too fast, irregular or at its normal frequency ”

v 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”  “Its like someone has their hand inside my chest me tickling my heart”  “……. my heart is fluttering……” PALPITATION = ARRHYTHMIA?

v Palpitation - causes 1 Arrhythmia 2 Sensing normal rhythm 3 Unrelated to the heart NormalPanic attack Hyperdynamic circulation Hyperthyroidism Pregancy Anaemia Fever Depression Anxiety Physiological tachycardia Anxiety Exercise Drugs Caffeine

v 184 patients referred with palpitations Sulfi Mayou et al Q J Med 2003; 96:115–123 Psychiatric assessment: 35% panic attacks 21% major disorder How many patients have arrhythmia?

v Palpitation – patient assessment ASSUME….  Likely to be benign cause  Reassurance all that is needed ….but avoid missing potentially life threatening diagnosis

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v Palpitations – the dangerous  Ventricular tachycardia  Ventricular fibrillation  AF in WPW  AF & stroke  IMPAIRED LV FUNCTION  Ischaemic heart disease  Valvular heart disease  Dilated cardiomyopathy  HYPERTROPHIC CARDIOMYOPATHY  CONGENITAL HEART DISEASE  INHERITED PRIMARY ELECTRICAL DISORDERS  Long QT  Brugada  ARVC  CPVT

v 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 3.Could this be dangerous?

v 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 “…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”

v 1. Is there an arrhythmia?  History ……. Circumstances: Associated symptoms: Exercise Precipitating factors Position Stress/anxiety Syncope Presyncope Chest pain Dyspnoea Appreciate psychological or lifestyle factors

v 1. Is there an arrhythmia?  Electrocardiography (ECG monitoring) Norman “ Jeff ” Holter

v 24 hour Holter monitoring Diagnoses in 2688 patients referred with palpitations Sulfi et al. Ann.Noninvasive.Electrocardiol. 2008;13(1):39–43

v 1. Is there an arrhythmia?  ECG monitoring – frequency of symptoms?  ContinuousECG  2-3 x day or more24 hour Holter  Daily48 hour Holter  2-3 x week7 day Holter  Weekly – monthly Event recorder  Less than monthly Implantable loop recorder (syncope)  Exercise inducedExercise test

v 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.Syncope or near syncope 2.Cardiac disease – heart failure 3.Abnormal ECG 4.Ventricular arrhythmia identified

v Conclusion: Management of palpitations History Examination ECG Syncope Abnormal ECG LV failure Specialist referral Monitoring Echo Other tests Ectopic beats only Very infrequent or mild symptoms Normal ECG Palpitations Manage arrhythmia or other condition identified REASSURE ± Counseling Appropriate monitoring ± Echocardiogram Benign or no arrhythmia Important arrhythmia