textbook reading

1. Palpitations
Shirley ooi Summary

2. Caveats
• Symptom characterized by awareness of heartbeat (degdegan)
• Both tachycardia and frequent premature complex arising from both
atrium (PAC) and ventricle (PVC) are felt as palpitations
• Alert of patient occasionally complain of palpitation, when they have
chest discomfort
• Present either with on going palpitation or palpitation which have
resolved
• Patient on going palpitations quickly do 12leads ECG

3. Cause of palpitation
• Cardiac causes
• Metabolic/endocrine causes
• High ouput state
• Medication/drug related
• Respiratory conditions
• Psychiatric disorders
• Physological

4. General approach
• determining haemodinamic stability
• Performing 12 leads ECG
• The 3 aspects of history taking
• Duration
• Rate
• Rhytm
• Termination of episode

5. Cont
• Associated Symptoms
• Conccurrent ischaemic symptoms (diaphoresis, chest pain, dyspnoea,
dizziness)
• A very high ventricular rate will reduce stoke volume and decrease cardiac
output
• Symptomatically this will manifest ranging from postural dizziness if mild to
presyncope, altered mental state and syncope if severe.

6. cont
• History
• Evaluate patient personal family history of heart desease
• Features that suggest hypoglicemia
• Evaluate for features hypothyroidism and pherocromocytoma
• Medication/drugs
• Psyciatric conditions, consider this only as a diagnosis exlusion

7. Cont
• Physical exam
• Vital sign
• Cardiac exam (murmur and regularity of rhythm)
• Respiratory exam evaluate COPD
• Evalution of hyperthyroidism an hypothyroidism
• Investigations
• Other than 12 lead ECG all investigations are to be guided by clinical
evaluation

9. Conditions pre dispose to a tachydysrhytmia
• Some ECG finding to look out for suggest the diagnosis of an earlier
tachydysrhytmia.
1. Abnormal T wave and ST segment point toward possible ischaemia
2. P pulmonale and P mitrale suggest enlarged atrium which associated with
atrial fibrillation
3. Patient with HCM, left atrial enlargement, left ventricular hypertrophy and
deep, narrow Q waves in lateral leads, there are pre dispose to SVT, AF and
VT.

10. WPW syndrome
• Characterized presence of congenital accecory pathway forming
bypass between atriumand ventricle.
• Might develop AVRT a form of SVT.
• Associated with small risk sudden cardiac death
• 10-30% develop AF
• ECG features when in sinus rhytm
• PR interval<120ms
• Delta wave-slurred slow rise affecting the initial portion of the QRS complex
• QRS prolongation >110ms

12. Brugada Syndrome
• Due to a mutation in sodium channel of the heart
• Associated with high incidence of sudden cardiac death in structurally
normal heart
• ECG change often dynamic
• It is diagnosed based on characteristic ECG finding and one below
clinical criteria.
• There are 3 brugada ECG pattern

13. Brugada Diagnosis
• J-point elevation >2mm (0.2mV) in leads V1-V3
• Followed by a coved ST-segment and negative T wave
• Diagnosis of brugada syndrome requires brugada type 1 and one
folloeing criteria:
1. Syncope
2. Nocturnal agonal respiration
3. Family history of sudden cardiac death <45years old
4. Documented VF or VT polimorphyc
5. Coved type ECG family members
6. Inducibility VT with program lectrical stimulation

14. ECG pattern of brugada

15. Long QT syndrome
• Defined as QTc of more than 450ms
• Associated with sudden cardiac death(vf, torsade de pointes, syncope,
especially in presence of severe bradycardia with long pauses
• Cause long Qt
• Congenital
• Acquired :
• electrolytes, hypocalemia, hypocalcemia, hypomagnesemia
• Drug: class 1 or 3 antidysrhytmia ( amiodarone etc), psychotropic drugs, macrolides,
fluroquinolom
• Myocardial Ischaemia

16. ECG

17. Management
• Managed at least in intermediate with ecg monitoring
• O2 if spO2 decreased
• Monitoring ecg 15min, pulse oximetry
• Established peripheral iv line
• Cardioversion if decrease level of consciousness
• Amiodarone drug of choice in managementof stable tachydysrhytmias
except(WPW with Af)

18. TENGKYU