Palpitations and Common Arrhythmias J. Philip Saul, M.D. West Virginia University Morgantown, WV

Outline Definitions Normal cardiac conduction/rhythm Review common arrhythmias –Irregular rhythms –Tachycardias When to worry Initial evaluation and management

59 yo male with palpitations

Arrhythmia Features Rate – tachycardia, bradycardia Regularity QRS complex – narrow or wide P waves – axis, rate, synchrony with QRS A:V ratio –>1atrial rhythm –<1ventricular or junctional rhythm –1atrial, junctional or ventricular rhythm

59 yo male with palpitations

Palpitations - Definition Sensation of the heartbeat Typically related to either a change in cardiac rhythm or a change in beat intensity

Arrhythmia - Definition Abnormality of cardiac rhythm –Premature beat/s –Blocked beat –Tachycardia –Bradycardia –Escape beat/rhythm –Asystole May or may not cause palpitations

Specialized Cardiac Conduction System Sinus node AV node

Days Months Years HR vs Age Beats / Min ( ) Age Davignon % 95% 75% 50% 5% 25% 2% N Min Max

Arrhythmias in “Normal” Patients

Sinus Bradycardia/Sinus Arrhythmia Does Not Cause Symptoms

Skipped Beats

Premature Beat or Extrasystole Definition Depolarization of the atria, AV-node, or ventricles More premature than expected Depolarization (or beat) vs systole or contraction May be hard to differentiate by PE from marked sinus arrhythmia

Atrial Premature Beat

APB Sinus node

Atrial Premature Beat Definition Premature P wave Morphology different from sinus P wave QRS usually looks like sinus Can occur with bundle branch block (aberrancy), or AV block Sinus rhythm is reset, usually not fully compensatory

Atrial Premature Beat

APB with Aberrancy Bundle Branch Block

APB with Aberrancy APB Sinus node

Blocked Atrial Bigeminy

APB with Block APB Sinus node

APB’s 220 ms 320 ms 260 ms

Junctional Premature Beat

JPB Sinus node

Junctional Premature Beat Definition Premature QRS Morphology identical to conducted sinus QRS No identifiable conductable P wave Cannot diagnose as JPB in presence of bundle branch block (aberrancy)

Junctional Escape Beat vs Junctional Premature Beat

Ventricular Premature Beats

Ventricular Premature Beat VPB Sinus node

Ventricular Premature Beat Definition Premature QRS Morphology different from conducted sinus QRS No identifiable conductable P wave Typically sinus rhythm not reset fully compensatory

Ventricular Premature Beats 920 ms900 ms Fully Compensatory Fusion

Ventricular Premature Beats

Ventricular Trigeminy

1 o Degree AV Block

2 o AV Block, Mobitz Type I (Wenckebach)

Second Degree AV Block 2:1

2 o AV Block, Type I (Wenckebach)

2 o AV Block, Type II

AV Block - 2 o Degree Type I and Type II Sinus node AV node Type I Wenckebach Type II

3 o AV Block (Complete Heart Block)

1 st degree 2 nd degree Type 1 2 nd degree Type 2 3 rd degree complete

The Fast Beat “Rapid heart beat” “Racing heart” “Heart beeping” “Heart beating out of her chest” “Too fast to count” “Pulse was 235 beats/minute” Not!

Concerns Supraventricular tachycardia (SVT) Ventricular tachycardia (VT) vs Sinus tachycardia Normal rate with increased beat sensation/intensity

Supraventricular Tachycardia (SVT)

Valsalva Maneuver

Wolff-Parkinson-White (WPW)

WPW

Ventricular Tachycardia (VT)

When to Worry Dizziness, syncope or “seizure” Known heart disease - congenital/acquired Arrhythmia on exam - rapid or irregular Not respiratory related Family hx sudden death, LQTS Abnormal ECG

8 yo with Hx seizures presents to ER with new onset syncope

Torsades de Pointes

Congenital Long QT Syndrome QTc 590 msec

6 yo with hx of seizure and new onset dizzyness and fatigue

17 yo male with a strong family history of sudden death

Brugada Syndrome

When to Worry Less Gradual onset/gradual termination No associated symptoms Normal exam or respiratory arrhythmia Normal ECG Associated hyperventilation

Asymptomatic 18 year old sports evaluation

Evaluation - Initial Careful history of events Physical exam ECG –WPW, long QT, dilated or hypertrophic cardiomyopathy –Premature beats –Rarely see tachycardia –Lots of false positives

ECG Documentation > once/day Holter > once/2 wks (non-sust) Event - looping > once/2 wks (sust) Event - nonlooping < once/mo (unclear) Pulse check/ECG < once/mo (clear) Esoph EPS

Transtelephonic Event Monitors Memory: non-looping Memory: looping

Smart Phone/Watch Based

Event Recordings During Palpitations

14 yo s/p surgery for Tetralogy of Fallot with palpitations

Malignant Symptoms Admission for telemetry Intracardiac EPS if telemetry unclear

Arrhythmias & Palpitations Summary Most are benign - sinus tachycardia, isolated premature beats, … Benign asymptomatic arrhythmias are frequent in children ECG documentation during palpitations is critical Syncope or known heart disease demand more extensive evaluation