This document discusses palpitations, syncope, and dysrhythmias. It defines palpitations as an awareness of one's heartbeat and notes that a clear history is important for evaluation. Syncope is defined as a transient loss of consciousness due to decreased cerebral blood flow. It has multiple potential causes including neural, cardiac, neurological, and unknown factors. Dysrhythmias refer to abnormalities in cardiac rhythm that range from benign to life-threatening. Evaluation involves obtaining a thorough history, physical exam, and ECG to determine the cause and appropriate treatment. Common dysrhythmias discussed include bradycardias, atrioventricular conduction disturbances, sinus node dysfunction, atrial arrhythmias like atrial fibrill
9. Syncope
Transient loss of consciousness and
postural tone with spontaneous
recovery ( Due to decrease cerebral
blood flow)
Do not confuse with a seizure
disorder
Common 6% hospital admissions and
1-2% emergency admissions
Can occur at any age - Elderly
10. Causes
Any cause of decrease cerebral flow
particularly to the area of brain know
as the *Reticular Activating System*
Classification of causes – Prognosis
(cardiac causes mortality 18 to 33%)
“Those who suffer from recurrent
fainting die suddenly’’
12. Neurally Mediated
Disorders of Autonomic control –
orthostatic intolerance - syncope
Reflex syncope – due to an increased sensitivity of
normal reflex responses or autonomic dysfunction
where abnormal neurovascular control results in
orthostatic hypotension
15. Pathophysiology
Upright position venous pooling
Decrease CO decrease VR
Increase symp A Activation Mechanoreceptors
Withdrawal of symp and activation of
Parasymp
Vasodilatation bradycardia
Decrease cerebral flow
16. Carotid Sinus Hypersensitivity
Abnormal sensitivity of a normal
reflex
Carotid sinus massage result in
sympathetic withdrawal and
parasympathetic activation
Bradycardia prominent feature
17. Situational reflex-mediated syncope
Autonomic dysfunction
Orthostatic hypotension
Upright posture BP decrease
20mmhg systolic or decrease to 90mmhg
More common in the elderly
Do not forget drugs that may ppt syncope
20. How does one evaluate a patient with
syncope ?
History Important++++
Eye witness description if possible
Physical examination
(Neurological Exam)
Logical approach to investigations
21. History
Description of syncopal episode
Provocative factors
Preceding symptoms
Recovery period
Family history
Associated injury
24. Electrocardiography
Mandatory in ALL patients
May offer clues to cause
(Underlying structural heart disease
arrhythmia, Inherited disorders)
ECG recording coupled with certain
maneuvers
31. Dysrhythmias (Cont)
Symptoms – Varied.
Brady episodes may present with
syncope, presyncope and even
sudden death – other –fatigue,
memory impairment and dyspnoea.
Tachy episodes may present with
angina, palpitations , syncope and
sudden death
32. Dysrhythmia (cont)
Role of the following in the
assessment – Important
HISTORY*****
ECG************* Must be of good
quality
35. Pathological causes
Degeneration of the sinus node , AV
node or conduction system.
Extrinsic factors – vagal stimulation
drugs,myocardial infarction
ischaemia,infitration,hypothyroidism,
hypothermia, jaundice and raised
intracranial pressure
36. A-V Conduction Disturbances
First degree – prolongation of the PR
interval.Delayed conduction from A to V.
Second degree – Intermittent of
failure in conduction from the atria to
ventricle.2 types.Type I - Progressive
prolongation of PR interval followed
by a non conducted P wave.Type II –
Normal PR internal with sudden
failure of Conduction.
37. A-V conduction disturbance (cont)
Third degree A-V block – Complete
Complete dissociation of atrial and
ventricular activity(Atria and ventricle
beating at different rates)
There is an escape rhythm(His
bundle 50/min, Purkinje – 20 to
30/min)
Varying degrees of A-v block
43. Atrial Fibrillation
Common
Mechanism – re-entry
Prevalence increases with age(5%)
Multiple causes (“Lone”A F )
Increased risk of stroke
Classification :Paroxysmal,Persistent,
Permanent
Treatment strategies linked to duration and
clinical presentation
44. Atrial Fibrillation
Clinical features (underlying cause
and those related to AF)
ECG – Recent onset AF - Rapid
irregular “f” waves at a rate of 350 to
600. Irregular ventricular response
rate due to variable
conduction.Chronic atrial fibrillation –
Absence of atrial waves with an
irregular R- R interval
46. Atrial Flutter
Re- entry RA
Saw tooth pattern on ECG – Flutter
waves(300/min)
Termination cardioversion ( medical
or Chemical)
Progression to atrial fibrillation
49. Ventricular Tachycardia
Sustained or nonsustained
( Duration)
Monomorphic or polymorphic(Related
to constant or change of the QRS
morphology)
Multiple causes – Myocardial
infarction,CMO,HCM,ARVD,
Treatment Strategies( ECV,Drugs)
LQTS-Torsades*