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Course overview


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The way it show and they way you go
by Dr. Ihab Tarawa, Consultant Physician, Soba University Hospital

Published in: Health & Medicine
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Course overview

  1. 1. Ihab B Abdalrahman 1
  2. 2. ARRHYTHMIAS THE WAY IT SHOW &B THE WAY YOU MBBS,Dr. Ihab Abdalrahman, GOMD, ABIM, SSBBSoba University HospitalSAMA- Founder &VP Ihab B Abdalrahman 2
  3. 3. Objectives To recognize the clinical presentations of arrhythmias To determine who need immediate intervention. To know how to capture the rhythm Ihab B Abdalrahman 3
  4. 4. Ihab B Abdalrahman 4
  5. 5. Ihab B Abdalrahman 5
  6. 6. The way it show LOC & No Palpitation SuddenSymptoms & Dizziness Death Ihab B Abdalrahman 6
  7. 7. Ihab B Abdalrahman 7
  8. 8. Message # 1If your patient get palpitationDon’t get yourself palpitation Ihab B Abdalrahman 8
  9. 9. PALPITATIONS COULD BE DUETO Arrhythmias Nonarrhythmic cardiac causes Extracardiac causes Drugs and medications Psychiatric causes Ihab B Abdalrahman 9
  10. 10. ARRHYTHMIC CAUSES Atrial fibrillation/flutter Bradycardia caused by advanced AV block or sinus node dysfunction Bradycardia-tachycardia syndrome(sick sinus syndrome) Multifocal atrial tachycardia Premature supraventricular or ventricular contractions Sinus tachycardia Supraventricular tachycardia Ventricular tachycardia Wolff-Parkinson-White syndrome Ihab B Abdalrahman 10
  11. 11. Palpitations Nonarrhythmic cardiac causes Atrial or ventricular septal defect Cardiomyopathy Congenital heart disease Congestive heart failure Mitral valve prolapse Pacemaker-mediated tachycardia Pericarditis Valvular disease (e.g., aortic insufficiency,stenosis) Ihab B Abdalrahman 11
  12. 12. PALPITATIONS /EXTRACARDIACCAUSES Anemia, Electrolyte imbalance Fever Hyperthyroidism Hypoglycemia Hypovolemia Pheochromocytoma Vasovagal syndrome Ihab B Abdalrahman 12
  13. 13. Drug Ihab B Abdalrahman 13
  14. 14. DRUG-INDUCED ECG ABNORMALITIES Ihab B Abdalrahman 14
  15. 15. PALPITATIONS/PSYCHIATRIC ETIOLOGY Anxiety disorder Panic attacks Ihab B Abdalrahman 15
  16. 16. ANXIETY OR PANIC DISORDER Prevalence of panic disorder in patients with palpitations is 15 to 31 percent. Panic disorder and significant arrhythmias are not mutually exclusive, Cardiac evaluation still may be necessary in patients with suspected panic disorder Ihab B Abdalrahman 16
  17. 17. Differential Diagnosis ofPalpitations/ Drugs andmedications Alcohol, Caffeine beta agonists, phenothiazine, theophylline, isotretinoin, digoxin Cocaine Tobacco Ihab B Abdalrahman 17
  18. 18. DIETARY SUPPLEMENT CAUSINGPALPITATION Chocolate Ephedra/Diet pills Ginseng Bitter Orange Valerian Hawthorn Ihab B Abdalrahman 18
  19. 19. Normal Impulse Conduction Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers Ihab B Abdalrahman 19
  20. 20. Pathophysiology Enhanced or suppressed automaticity  Automaticity is a natural property of all myocytes.  It can be affected +/-vely by:  Ischemia,  scarring,  electrolyte disturbances,  medications,  advancing age. Ihab B Abdalrahman 20
  21. 21. Pathophysiology Triggered activity,  Triggered activity occurs when early afterdepolarizations and delayed afterdepolarizations initiate spontaneous multiple depolarizations, precipitating ventricular arrhythmias. Examples include torsades de pointes and ventricular arrhythmias caused by digitalis toxicity. Ihab B Abdalrahman 21
  22. 22. Pathophysiology Re-entry.  Circuit lead to propagation of the rhythm  The commonest mechanism  Bidirectional or unidirectional block.  Micro level re-entry occurs with VT  Macro level re-entry occurs via conduction through (Wolff-Parkinson-White [WPW] syndrome) concealed accessory pathways. Ihab B Abdalrahman 22
  23. 23. What is arrhythmia Broadly defined as any abnormality in the normal activation sequence of the myocardium. Ihab B Abdalrahman 23
  24. 24.  There are hundreds of different types of cardiac arrhythmias. Ihab B Abdalrahman 24
  25. 25. Ihab B Abdalrahman 25
  26. 26. My dream It would be immensely convenient if every dysrhythmia had a classic ECG appearance and every patient with a given dysrhythmia manifested a similar clinical presentation.
  27. 27. Ihab B Abdalrahman 27
  28. 28. Ihab B Abdalrahman 28
  29. 29. In arrhythmias one size doesnot fit all
  30. 30.  CDC have estimated sudden cardiac death rates at more than 600, 000 per year . Up to 50% of patients have sudden death as the first manifestation of cardiac disease. Ihab B Abdalrahman 30
  31. 31. The major determinant In general, the seriousness of cardiac arrhythmias depends on the presence or absence of structural heart disease. Ihab B Abdalrahman 31
  32. 32. Benign In normal heart Serious in abnormal heart APC  Non-sustained VT VPC  Syncope Lone A fib  In patients with CAD  Severe LV dysfunction Ihab B Abdalrahman 32
  33. 33. Ataa Ataa Ataa senior (42 years) was an athlete trainer in the army He won 2 medals He died suddenly in a marathon race Ihab B Abdalrahman 33
  34. 34. Ataa Ataa Ataa Junior is a 26 year football player. Ataa junior collapsed during a match in Qatar. Luckily they have and AED. Ihab B Abdalrahman 34
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  37. 37. The way itShow GoCollapse DC shock(Near) Sudden May becardiac death screening Ihab B Abdalrahman 37
  38. 38.  Najat is a 36 obese female. She delivered her dream baby 3 days a go. She was brought to ER because of SOB, pleuritic chest pain and palpitation. Ihab B Abdalrahman 38
  39. 39. Ihab B Abdalrahman 39
  40. 40. The way itShow GoPalpitation Diagnose &Features of a Treat the diseaseconcomitantdisease Ihab B Abdalrahman 40
  41. 41.  Haj Adam is a 73 male with vascular dementia Admitted to hospital because of confusion and weakness. No other symptoms. Diagnosed with CAP The resident noticed irregular pulse. Ihab B Abdalrahman 41
  42. 42. Ihab B Abdalrahman 42
  43. 43. The way itShow GoAsymptomatic Treat theFeatures of a diseaseconcomitant Stratify yourdisease patient (CHADS2) Ihab B Abdalrahman 43
  44. 44.  Abdalsatar know to have DM, HTN admitted to CCU with ACS Treated with ASA, BB, ACE, heparin, atrova 12 hour later he had a brief run of He reported some palpitation. He remained conscious with a BP of 110/70, sat 94% Ihab B Abdalrahman 44
  45. 45. Ihab B Abdalrahman 45
  46. 46. The way itShow GoSymptomatic Treat theFeatures of a diseaseconcomitant Correct K, MGdisease Adjust medsHemodynamically stable Ihab B Abdalrahman 46
  47. 47.  Abdalwahid has frequent palpitation. He always feel an extra beat in his pulse No chest pain, DM, HTN, smoking Exam, ECG, Echo all were normal He demanded Holter monitoring which was negative Ihab B Abdalrahman 47
  48. 48. The way itShow GoSymptomatic ReassuranceRecurrent No FurtherNormal Heart testing Ihab B Abdalrahman 48
  49. 49.  22 year male reported recurrent attack of palpitation. He was admitted to CCU twice and diagnosed as VT. One episode required DC shock. Physical exam was normal While searching on his records, you found this tracing Ihab B Abdalrahman 49
  50. 50. WOLFF-PARKINSON-WHITE SYNDROME Ihab B Abdalrahman 50
  51. 51. Clues in the way it shows The presence of sustained regular palpitations or heart racing in young patients without any evidence of structural heart disease suggests the presence of a SVT caused by AV nodal re-entry or SVT caused by an accessory pathway. Ihab B Abdalrahman 51
  52. 52. The way itShow GoSymptomatic EP studyRecurrent RadiofrequencyNormal Heart catheterSuspiciousRT Ihab B Abdalrahman 52
  53. 53. The way it shows In general, severe symptoms are more likely to occur in the presence of structural heart disease. Ihab B Abdalrahman 53
  54. 54.  Syncope in the setting of noxious stimuli such as pain, prolonged standing, or venipuncture, particularly when preceded by vagal-type symptoms (e.g., diaphoresis, nausea, vomiting) suggests neurocardiogenic (vasovagal) syncope. Ihab B Abdalrahman 54
  55. 55.  Occasionally, patients report abrupt syncope without prodromal symptoms, suggesting the possibility of the malignant variety of neurocardiogenic syncope. Ihab B Abdalrahman 55
  56. 56.  Suzan is a 54 female, high school English- teacher. Had 3 episodes of syncope in the last 2 month 2 days ago she passed out while watching TV Exam, electrolytes , TNI, ECG and 36 hours monitoring were normal Echo EF 30% Ihab B Abdalrahman 56
  57. 57. The way itShow GoSymptomatic Further testingRecurrent & disablingStructural cardiacabnormality Ihab B Abdalrahman 57
  58. 58. Way you goPrinciples It is important to proceed with a stepwise approach. The goal is to obtain a correlation between symptoms and the underlying arrhythmia . To identify underlying abnormalities To initiate appropriate therapy. Ihab B Abdalrahman 58
  59. 59. Way you goAssessment for Structural Heart Disease History of CAD or MIs, Risk factors for CAD, Family history of sudden cardiac death are extremely important. Cardiac exam may detect an irregular rhythm or premature beats. Ihab B Abdalrahman 59
  60. 60. Way you goAssessment of Structural Heart Disease Examine the ECG for  conduction system delays,  QRS widening,  previous MI,  PVCs. Echo CAD, LV dysfunction, valvular disease Stress testing can demonstrate the presence of CAD. Ihab B Abdalrahman 60
  61. 61. Way you goClues in ECG EVALUATION All patients who complain of palpitations ECG findings warrant further cardiac investigation  evidence of previous myocardial infarction,  left or right ventricular hypertrophy,  atrial enlargement,  AV block,  short PR interval and delta waves (Wolff-Parkinson- White syndrome),  prolonged QT interval Ihab B Abdalrahman 61
  62. 62. WAY YOU GO WHEN YOU GO FOR STRESS ECGECG exercise testing is appropriate inpatients who have palpitations withphysical exertion and patients withsuspected coronary artery disease ormyocardial ischemia. Ihab B Abdalrahman 62
  63. 63.  Capturing the rhythm Ihab B Abdalrahman 63
  64. 64. FURTHER DIAGNOSTIC TESTINGCONTINUOUS ECG MONITORS (Holter monitor)- continuously to record data for 24 or 48 hours- diary of any symptoms that occur during the monitoring- most expensiveTRANSTELEPHONIC EVENT MONITORS- save data only for the previous and subsequent few minutes whenthe patient manually activates the monitor Ihab B Abdalrahman 64
  65. 65. HOLTER MONITOR VS EVENT MONITOR Ihab B Abdalrahman 65
  66. 66. Choosing an AmbulatoryMonitoring Device Diagnostic yield was  66 to 83% for event monitors  33 to 35% for Holter monitors Ihab B Abdalrahman 66
  67. 67. Case study Rapid heart palpitations with associated dyspnea develop suddenly in a 40-year-old man. His symptoms are acute and progressive. In ER Ihab B Abdalrahman 67
  68. 68. The way itShow GoHR DCBP Which one of the following AVN blockerRR signs will determine theTemp way you go? Ihab B Abdalrahman 68
  69. 69.  In a patient with heart palpitations and dyspnea, what piece of clinical history is critical in guiding the initial management? A. Recent cardiac stress test B. Length of time of current symptoms C. Lack of chest pain during symptoms D. History of prior hospitalization for these symptoms Ihab B Abdalrahman 69
  70. 70. Take home Determine if you need immediate action Good H & P Examine the ECG Is it in a good heart or structurally abnormal Think outside the heart Do you need to capture it  Recording devices Ihab B Abdalrahman 70
  71. 71.  This is the way it show Please determine the way you go Thank you for going the right way Ihab B Abdalrahman 71