1. DIAGNOSING & TREATING PALPITATIONS
Lee Graham
Consultant Electrophysiologist
Yorkshire Heart Centre

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

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

4. 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

5. 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

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

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

8. 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

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

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

11. Wolff-Parkinson-White syndrome

12. BRUGADA SYNDROME

13. HYPERTROPHIC CARDIOMYOPATHY

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

15. 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)

16. 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

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

18. 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

19. 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)

20. 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

21. ILR SYMPTOM – RHYTHM CORRELATION

23. 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:

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

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

26. 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

27. 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

28. 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

29. RV OUTFLOW TRACT ECTOPY / VT

30. 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

31. 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

32. 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

33. Wolff-Parkinson-White syndrome

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

35. Av reentrant tachycardia

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

37. Preexcited AF
Antidromic SVT

38. 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

39. 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

40. Av nodal reentrant tachycardia

41. 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)

42. “Typical” Atrial flutter

43. Catheter ablation for typical flutter

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

45. 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:

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

47. Pulmonary vein triggers drive paroxysmal AF

48. 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

49. 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

50. 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

51. Any questions?