course overview
DESCRIPTION
Arrhythmias The way it show and they way you go by Dr. Ihab Tarawa, Consultant Physician, Soba University Hospital SAMA VPTRANSCRIPT
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ARRHYTHMIAS THE WAY IT SHOW & THE WAY YOU GO
Dr. Ihab B Abdalrahman, MBBS, MD, ABIM, SSBBSoba University Hospital
SAMA- Founder & VP
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Objectives
To recognize the clinical presentations of arrhythmias
To determine who need immediate intervention.
To know how to capture the rhythm
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The way it show
No Symptom
s
Palpitation &
Dizziness
LOC & Sudden Death
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Message # 1
If your patient get palpitation
Don’t get yourself palpitation
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PALPITATIONS COULD BE DUE TO Arrhythmias
Nonarrhythmic cardiac causesExtracardiac causesDrugs and medicationsPsychiatric causes
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ARRHYTHMIC CAUSES
Atrial fibrillation/flutterBradycardia caused by advanced AV block or sinus node dysfunctionBradycardia-tachycardia syndrome(sick sinus syndrome)Multifocal atrial tachycardiaPremature supraventricular or ventricular contractionsSinus tachycardiaSupraventricular tachycardiaVentricular tachycardiaWolff-Parkinson-White syndrome
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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
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PALPITATIONS /EXTRACARDIAC CAUSES
Anemia, Electrolyte imbalanceFeverHyperthyroidismHypoglycemiaHypovolemiaPheochromocytomaVasovagal syndrome 12Ihab B Abdalrahman
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Drug
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DRUG-INDUCED ECG ABNORMALITIES
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PALPITATIONS/PSYCHIATRIC ETIOLOGY
Anxiety disorderPanic attacks
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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
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Differential Diagnosis of Palpitations/ Drugs and medications Alcohol, Caffeine beta agonists, phenothiazine,
theophylline, isotretinoin, digoxin Cocaine Tobacco
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DIETARY SUPPLEMENT CAUSING PALPITATION
ChocolateEphedra/Diet pillsGinsengBitter OrangeValerianHawthorn
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Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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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.
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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.
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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.
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What is arrhythmia
Broadly defined as any abnormality in the normal activation sequence of the myocardium.
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There are hundreds of different types of cardiac arrhythmias.
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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.
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In arrhythmias one size does not fit all
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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.
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The major determinant
In general, the seriousness of cardiac arrhythmias depends on the presence or absence of structural heart disease.
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Benign In normal heart
Serious in abnormal heart
APC VPC Lone A fib
Non-sustained VT Syncope In patients with CAD Severe LV dysfunction
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Ataa Ataa
Ataa senior (42 years) was an athlete trainer in the army
He won 2 medals He died suddenly in a marathon
race
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Ataa Ataa
Ataa Junior is a 26 year football player.
Ataa junior collapsed during a match in Qatar.
Luckily they have and AED.
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The way it
Show GoCollapse(Near) Sudden cardiac death
DC shockMay be screening
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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.
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The way it
Show GoPalpitationFeatures of a concomitant disease
Diagnose & Treat the disease
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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.
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The way it
Show GoAsymptomaticFeatures of a concomitant disease
Treat the diseaseStratify your patient (CHADS2)
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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%
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The way it
Show GoSymptomaticFeatures of a concomitant disease Hemodynamic ally stable
Treat the diseaseCorrect K, MGAdjust meds
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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
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The way it
Show GoSymptomaticRecurrent Normal Heart
Reassurance No Further testing
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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
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WOLFF-PARKINSON-WHITE SYNDROME
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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.
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The way it
Show GoSymptomaticRecurrent Normal Heart Suspicious RT
EP study Radiofrequency catheter
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The way it shows
In general, severe symptoms are
more likely to occur in the presence of structural heart disease.
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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.
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Occasionally, patients report abrupt syncope without prodromal symptoms, suggesting the possibility of the malignant variety of neurocardiogenic syncope.
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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%
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The way it
Show GoSymptomaticRecurrent & disabling Structural cardiac abnormality
Further testing
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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.
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Way you go Assessment 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.
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Way you go Assessment 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.
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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
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WAY YOU GOWHEN YOU GO FOR STRESS ECG
ECG exercise testing is appropriate in patients who have palpitations with physical exertion and patients with suspected coronary artery disease or myocardial ischemia.
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Capturing the rhythm
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FURTHER DIAGNOSTIC TESTING
CONTINUOUS ECG MONITORS (Holter monitor)- continuously to record data for 24 or 48 hours- diary of any symptoms that occur during the monitoring- most expensive
TRANSTELEPHONIC EVENT MONITORS- save data only for the previous and subsequent few minutes when the patient manually activates the monitor
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HOLTER MONITOR VS EVENT MONITOR
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Choosing an AmbulatoryMonitoring Device Diagnostic yield was
66 to 83% for event monitors 33 to 35% for Holter monitors
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Case study
Rapid heart palpitations with associated dyspnea develop suddenly in a 40-year-old man.
His symptoms are acute and progressive.
In ER
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The way it
Show GoHRBP RR Temp
DC AVN blocker
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Which one of the following signs will determine the way you go?
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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
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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
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This is the way it show
Please determine the way you go
Thank you for going the right way
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