1. A Different Beat: Arrhythmias and Heart Palpitations Bobbi L. Hoppe, M.D. North Memorial Heart & Vascular Institute
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3. Autonomic Blockade in Men and Women * P < 0.05 * * 1400 1300 1200 1100 1000 900 800 700 600 500 400 Women Men Women Men Baseline Post Blockade Cycle Length Burke JH, et al. Am J Med. 1996;100:537-543.
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11. Catheter Ablation of Accessory Pathways, AVNRT, and AV Junction: Accessory Pathways AVNRT AV Junction Women Men Calkins H, et al. Circ. 1999;99:262-270. Gender Distribution % 42% 58% 70% 30% 52% 48%
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13. Cyclical Variation in Tachycardia (SVT) in Women 28 Rosano GMC, et al. The Lancet. 1996;347:786-788. 12 25 11 36 27 49* 38* * = p < 0.02 Number of Episodes Day (Menstrual Cycle)
22. Pregnancy and the Long QT Syndrome Rashba EJ, et al. Circ. 1998;97:451-456. 0.0% 1.8% 9.0%* % New 0nset Cardiac Events * p<0.02 vs the pregnancy or prepregnancy interval
36. Atrial Fibrillation and Risk of Death Adapted from Benjamin EJ, et al. Circ. 1998;98:946-952. 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 Percent of Subjects Dead in Follow-up Years of Follow-up Age 55 - 74 yrs Men AF Women AF Men no AF Women no AF
37. Atrial Fibrillation and Risk of Death Benjamin EJ, et al. Circ. 1998;98:946-952. 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 0.5 1 1.5 42 2.5 3 3.5 4 4.5 5 Percent of Subjects Dead in Follow-up Years of Follow-up Age 75 - 94 yrs Men AF Women AF Men no AF Women no AF
Burke JH, et al. evaluated 43 (20 male and 23 female) healthy volunteers. The graph represents sinus cycle length before and after autonomic blockade in men and women. Each value plotted on the graph represents an individual RR value. Both at rest and following autonomic blockade, men had a significantly slower heart rate than women. 1 J. Larsen and A. Kadish in their review of the literature on gender differences in cardiac arrhythmias conclude that differences in autonomic tone and menstrual cycle variability at rest do not appear to be responsible for the gender differences in the QT interval. 2 1 Burke JH, Goldberger JJ, Ehlert FA, et al. Gender differences in heart rate before and after autonomic blockade: Evidence against an intrinsic gender effect. Am J Med. 1996;100:537-543. 2 Larsen JA, Kadish AH, Effects of Gender on Cardiac Arrhythmias. J Cardiovasc Electrophysiol. 1998:9:655-664.
Palpitation is a symptom, often due to a cardiac arrhythmia, and should be considered as such. Common cardiac causes of arrhythmia include acute and chronic coronary artery disease, valvular heart disease, cardiomyopathies, acute myocardial infarction and its sequelae, and in children, congenital heart disease. 6 6 Rosano GMC, Rillo M, Leonardo F, et al. Palpitations: What is the Mechanism, and When should We Treat Them? In J Fertil. 1997;42:94-100.
This graph from the paper published by John Hopkins University School of Medicine represents 500 patients who participated in the Atakar Ablation System (Medtronic CardioRhythm) clinical trial and who had undergone catheter ablation of a single Accessory Pathway (AP); 373 patients who underwent ablation of AVNRT, and 121 who underwent ablation or the AVJ between 1992 and 1995. Patients who underwent ablation of AVNRT were more likely to be female (70%) than were patients who underwent ablation of an AP (42%) or the AVJ (52%, p<0.001). 4 4 Calkins H, Yong P, Miller JM, et al. Catheter Ablation of Accessory Pathways, Atrioventricular Nodal Reentrant Tachycardia, and the Atrioventricular Junction: Final Results of a Prospective, Multicenter Clinical Trial. Circ. 1999;99:262-270.
Studies of canine coronary arteries treated with 17 -estradiol has led to the suggestion that the hormone acts by increasing K + conduction. Recent studies on cardiac myocytes have shown that estradiol has calcium-antagonistic properties. Ovarian hormones exhibit a cyclic variation in their plasma levels during the menstrual cycle and these changes seem to be associated with changes in plasma catecholamine levels and adrenergic activity, such that catecholamines are higher during the luteal phase of the menstrual cycle. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is The Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
This slide represents data from a study of 26 young women complaining of palpitations and diagnosed with SVT. All patients underwent 48-hour ambulatory ECG monitoring and measurement of plasma concentrations of estradiol and progesterone on days 7, 14, 21, and 28 of their menstrual cycle. A significant increase in the number and duration of episodes of arrhythmia was recorded on day 28. Patients also complained of a higher incidence of symptomatic episodes on day 28 as opposed to day 7 (77% versus 43%, p<0.05). The higher incidence of arrhythmia during the luteal phase of the menstrual cycle may be related to the electrophysiological effects of ovarian hormones or increased sympathetic activity, which often occurs at this time in the menstrual cycle. 6 6 Rosano GMC, Leonardo F, Sarrel PM, et al. Cyclical variation in paroxysmal supraventricular tachycardia in women. Lancet. 1996;347:786-788.
A study of 68 consecutive patients (42 women and 26 men) referred because of symptomatic paroxysmal SVT was evaluated to determine the prevalence of perimenstrual clustering of spontaneous SVT in women. The study was designed to test the hypothesis that women with a history of perimenstrual clustering would be less inducible during testing at high estrogen states (midcycle or with estrogen replacement therapy) than at low estrogen states (perimenstrual or without estrogen replacement). Those patients with a history of perimenstrual clustering who had negative electrophysiologic studies at midcycle or while receiving ERT had repeat procedures premenstrual or after stopping estrogen replacement therapy. Six patients who were non-inducible at higher estrogen states were inducible at low estrogen states. Successful ablations were then performed in five of these six patients (four AVNRT, one both AVNRT and reciprocating atrial tachycardia, and one with atrial tachycardia). Among women with a history of perimenstrual clustering and of paroxysmal SVT, scheduling elective electrophysiologic procedures at the time of low estrogen levels (premenstrual or off ERT) may facilitate the probability of a successful procedure. 7 7 Myerburg RJ, Cox MM, Interian Jr A, et al. Cycling of Inducibility of Paroxysmal Supraventricular Tachycardia in Women and Its Implications for Timing of Electrophysiologic Procedures. Am J Cardiol. 1999;83:1049-1054
At menopause there is marked decline in ovarian estradiol production, which has been associated with increased, and uncontrolled adrenergic activity. Palpitations are the most common cardiovascular complaint and often associated with vasomotor symptoms. Palpitations during the perimenstrual period are primarily due to sinus tachycardia and seem related to an increased sympathetic drive. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is the Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
Although palpitations do not require treatment, symptoms can be minimized with -blockers if estrogen replacement therapy is not effective in controlling symptoms, or if estrogen replacement therapy is not preferred. If progesterone often given in association with estrogen, triggers arrhythmias, it is recommended to reduce the dose of progesterone or to change to a different one. Natural progesterone may prove helpful for those patients with palpitations worsened by synthetic progesterone. 6 6 Rosano GMC, Rillo M, Leonardo F,et al. Palpitations: What Is the Mechanism, and When Should We Treat Them? Int J Fertil. 1997;42:94-100.
Percentage of LQTS probands with new-onset cardiac events before, during, and after pregnancy. New-onset cardiac events were significantly more common among probands during the postpartum interval. 14 14 Rashba EJ, Zareba W, Moss AJ, et al. Influence of Pregnancy on the Risk for Cardiac Events in Patients With Hereditary Long QT Syndrome. Circ. 1998;97:451-456.
The patient was subsequently brought to the electrophysiology lab and her RVOT ventricular tacycardia was successfully ablated. She has had no reoccurrence of symptoms after three years.
A 29 year old female complaining for two years of increased fatigue and being unable to water-ski and play tennis for long periods as she previously been able to do. Admitted to the emergency room after a minor auto accident caused by feeling “light-headed” and “dizzy”. No LOC. The ECG showed RVOT ventricular tachycardia at a rate of 187 bpm. The patient was sedated and successfully cardioverted to sinus rhythm.
Miyasaka Y. Barnes ME. Gersh BJ. Cha SS. Bailey KR. Abhayaratna WP. Seward JB. Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.[erratum appears in Circulation. 2006 Sep 12;114(11):e498]. [Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't] Circulation. 114(2):119-25, 2006 Jul 11. bstract Background—: Limited data exist on trends in incidence of atrial fibrillation (AF). We assessed the community-based trends in AF incidence for 1980 to 2000 and provided prevalence projections to 2050. Methods and Results—: The adult residents of Olmsted County, Minnesota, who had ECG-confirmed first AF in the period 1980 to 2000 (n=4618) were identified. Trends in age-adjusted incidence were determined and used to construct model-based prevalence estimates. The age- and sex-adjusted incidence of AF per 1000 person-years was 3.04 (95% CI, 2.78 to 3.31) in 1980 and 3.68 (95% CI, 3.42 to 3.95) in 2000. According to Poisson regression with adjustment for age and sex, incidence of AF increased significantly (P=0.014), with a relative increase of 12.6% (95% CI, 2.1 to 23.1) over 21 years. The increase in age-adjusted AF incidence did not differ between men and women (P=0.84). According to the US population projections by the US Census Bureau, the number of persons with AF is projected to be 12.1 million by 2050, assuming no further increase in age-adjusted incidence of AF, but 15.9 million if the increase in incidence continues. Conclusions—: The age-adjusted incidence of AF increased significantly in Olmsted County during 1980 to 2000. Whether or not this rate of increase continues, the projected number of persons with AF for the United States will exceed 10 million by 2050, underscoring the urgent need for primary prevention strategies against AF development.
There was significant AF-sex interaction demonstrated in the Framingham Heart Study reported in 1998. In these graphs both women and men with AF had significantly higher mortality than age-, sex- and calendar year-matched non-AF subjects. Results are shown for men with AF (n=137), men without AF (n=274+, women with AF (n=192), and women without AF (n=384). AF remained significantly associated with excess mortality, with about doubling of mortality in both sexes. 21 21 Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circ. 1998;98:946-952.
There was significant AF-sex interaction demonstrated in the Framingham Heart Study reported in 1998. In these graphs both women and men with AF had significantly higher mortality than age-, sex- and calendar year-matched non-AF subjects. Results are shown for men with AF (n=137), men without AF (n=274+, women with AF (n=192), and women without AF (n=384). AF remained significantly associated with excess mortality, with about doubling of mortality in both sexes. 21 21 Benjamin EJ, Wolf PA, D’Agostino RB, et al. Impact of Atrial Fibrillation on the Risk of Death: The Framingham Heart Study. Circ. 1998;98:946-952.
Figure 3. TEE in a Patient with Atrial Fibrillation and a Thrombus in the Left Atrial Appendage. The region of the left atrial appendage is shown in horizontal (left-hand panel) and vertical (right-hand panel) planes, with two types of application of color. Inside the appendage, a large thrombus is seen (arrow) that originates at the tip of the appendage. AO denotes aortic valve, LA left atrium, and LV left ventricle.
A 5-mm Thrombus (Arrow) in the Left Atrial Appendage in a Patient with Atrial Fibrillation. Emboli of this size can occlude the middle cerebral artery, resulting in a disabling stroke. Thrombi located in the appendage can be reliably detected by transesophageal echocardiography but not by precordial echocardiography. Reproduced from the Case Records of the Massachusetts General Hospital (N Engl J Med 1969;281:555).
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