DIAGNOSING & TREATING PALPITATIONS Lee Graham Consultant Electrophysiologist Yorkshire Heart Centre

Palpitations Definition: ‘an uncomfortable sensation in which a person is aware of their heart beat which may be irregular, pounding, forceful or rapid’

Diagnostic pathway History Examination Resting ECG Symptom-ECG correlation Additional investigations Treatment

History Onset / offset characteristics Age of onset Perceived rate Description of regularity Duration and frequency Associated symptoms (e.g. polyuria) Neck pulsations Triggers / relieving factors Nocturnal symptoms

History Red Flag features (referral suggested) Exercise induced Associated syncope Unexplained “seizure” Chest pain Family history of premature sudden cardiac death Underlying structural heart disease

History Drug history including OTC medicines Decongestants Alcohol Antidepressants Psychotropics Antibiotics & antifungals Antihistamines Methadone Recreational drugs

Examination Cardiovascular Features of thyroid disease Pulse Blood Pressure Heart murmurs Signs of heart failure Features of thyroid disease

Consider referral for any abnormal ECG Resting ECG Features to check Sinus rhythm / arrhythmia PR interval (WPW) QRS duration / bundle branch block ST segment shape (LVH / LV aneurysm / brugada) QT interval (long or short) Presence of Q waves (previous infarct) T wave inversion (cardiomyopathy or IHD) Consider referral for any abnormal ECG

Normal 3 to 5 small squares (120 - 200ms) PR interval Normal 3 to 5 small squares (120 - 200ms) QRS duration Normal up to 3 small squares (120ms)

QT interval Depends on heart rate QTc 440 ms men QTc 460 ms women

Wolff-Parkinson-White syndrome

BRUGADA SYNDROME

HYPERTROPHIC CARDIOMYOPATHY

Diagnostic yield from clinical assessment Not sufficiently accurate to exclude clinically significant arrhythmia Thavendiranathan et al. JAMA 2009;302:2135-43

SYMPTOM-ECG CORRELATION 12-lead ECG taken with symptoms Holter monitoring (24h - 7 day) Event recorder with / without looping memory (patient activated device) Implantable loop recorder (ILR)

HOLTER MONITOR Requires typical symptoms during recording Useful if symptoms occur several times per week Asymptomatic arrhythmias Useful for patients who are unable to trigger a monitoring device e.g. syncope

Event recorder Useful for less frequent symptoms Longer duration of symptoms Symptoms need to be reasonably well tolerated

Implantable LoOp recorders Just then to go back to the loop recorder. This is what one looks like if you’ve never seen one. It’s about the size of a typical USB memory stick and is implanted usually in the left parasternal region under LA underneath the skin and subcutaneous fat. This is done as a day case procedure. The device can autoactivate for significant bradycardia or tachycardia (pre-programmable) but the patient also carries an activating device which can be activated by patient or relative following a syncopal event allowing symptom-rhythm correlation

Ambulatory monitoring options 24h- 7 days 7-30 days This graphical representation really just highlights the point about the choice of monitor. As you can see an ILR offers a long-term recording option with the new reveal XT device offering up to a 3 year battery life 36 months Time (months)

Case Vignette ILR implanted 68y old man 10 month history of palpitations Onset with exertion Syncopal on two occasions Normal cardiovascular exam Normal resting ECG ILR implanted

ILR SYMPTOM – RHYTHM CORRELATION

Diagnostic yield from monitoring Investigation Any arrhythmia Clinically significant arrhythmia ECG during symptoms 3-26% 2% Holter 34% 3-24% Event recorder 30-60% 17-19% ILR - 73% Thavendiranathan et al. JAMA 2009;302:2135-43

Additional Investigations Structural cardiac disease Echocardiogram Cardiac MRI Exercise tolerance test Cardiac catheterisation Electrophysiological study +/- catheter ablation

PALPITATIONS-COMMON CAUSES Sinus Tachycardia Ectopics (PAC’s / PVC’s) Supraventricular tachycardia (AVNRT / AVRT / atrial tachycardia) Atrial flutter Atrial fibrillation Ventricular tachycardia

SINUS TACHYCARDIA Onset and termination are gradual (i.e. not paroxysmal) Perceived rate relatively slow May persist for several hours or days Normal P wave morphology Physiological sensitive to autonomic modulation Inappropriate Usually resting rate >100bpm ;mean >95bpm on 24h Holter

INAPPROPRIATE SINUS TACHYCARDIA Poorly understood Young women most commonly affected Associated symptoms of dyspnoea, pre-syncope & fatigue Association with Postural Orthostatic Tachycardia Syndrome Treatment unsatisfactory Beta-blockers or rate limiting Ca antagonist Ivabradine Catheter modification of the sinus node can be attempted

ECTOPICS Usually sudden onset Perceived as ‘missed beats’ often followed by thud & fluttering rate relatively slow More commonly noticeable at rest or in bed Often described as persistent for several hours or days Sporadic Reassurance Treatment usually not required although beta-blockers can be helpful

RV OUTFLOW TRACT ECTOPY / VT

RV OUTFLOW TRACT ECTOPY / VT Frequent ectopics / salvos Catecholamine sensitive Treat with beta-blockers Catheter ablation offers 80% chance of cure if remains symptomatic 1% risk tamponade

SUPRAVENTRICULAR TACHYCARDIA Usually sudden onset / offset (except atrial tachycardia) Perceived rate rapid and regular Pounding pulsation in neck (AVNRT) Variable duration Vagal manoeuvres may terminate Usually adenosine sensitive Reentry most common mechanism (except atrial tachycardia) AVRT/AVNRT/atrial tachy

Wolff-Parkinson-White syndrome Short PR interval Delta wave Ventricular preexcitation AVRT most common arrhythmia AF more common and may be preexcited Small risk of sudden death No conduction delay AV node Accessory pathway

Wolff-Parkinson-White syndrome

ATRIOVENTRICULAR REENTRANT TACHYCARDIA Up accessory pathway Conduction down AV node Usually narrow complex Rarely broad complex Often frequent episodes starting in childhood

Av reentrant tachycardia

Preexcited AF AF may conduct rapidly over accessory pathway Irregular broad complex tachycardia Risk of degeneration to VF Avoid AV node blockers

Preexcited AF Antidromic SVT

Management of wpw Refer to an electrophysiologist EPS and catheter ablation if symptomatic 95% curative (<1% risk) Reasonable to offer asymptomatic patients EPS Flecainide antiarrhythmic drug of choice

Av nodal reentrant tachycardia Slow pathway Fast pathway ~ 60% of all SVT F > M Onset often later than in AVRT Beta-blockers or verapamil first line antiarrhythmics Catheter ablation 95% curative but 1% risk AV node damage

Av nodal reentrant tachycardia

Atrial flutter Regular or irregular palpitations Paroxysmal or persistent Saw tooth baseline Atrial rate usually 300 min Ventricular rate variable 2:1 block common Often difficult to rate (or rhythm) control Catheter ablation 90-95% curative and should be offered as first line (<1% risk)

“Typical” Atrial flutter

Catheter ablation for typical flutter

Atrial Fibrillation Assess symptoms Control ventricular rate Assess thromboembolic risk Rate vs. rhythm control strategy

Who should be offered rhythm control Symptomatic AF despite adequate rate control Young symptomatic patients AF related heart failure AF secondary to corrected trigger or cause EHRA. EHJ 2010;31:2369-2429

Rhythm control for AF Antiarrhythmic drug therapy Beta-blockers Flecaininde Sotalol, amiodarone, dronedarone Cardioversion Catheter ablation

Pulmonary vein triggers drive paroxysmal AF

RATIONALE FOR AF ABLATION Electrical isolation of the pulmonary veins Prevents “triggers” and “drivers” of AF Creates electrically inexcitable “scar” around the PV’s which blocks PV ectopics from entering the left atrium More effective in paroxysmal than in persistent AF

The ideal patient for AF ablation ? Arrhythmia related symptoms Refractory or intolerant to at least one class 1 or 3 drug ? Young age Paroxysmal rather than persistent AF Short duration of symptoms Structurally normal heart Informed and motivated

Catheter ablation for af ~ 70% success rates Often multiple procedures required 3-4 hour procedure 3-4% risk major complication Stroke 0.5-1% Cardiac tamponade 1-2% Usually second line

Any questions?