palpitations syncope dysrrhythmias hippocrates “those who suffer from recurrent fainting die...
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Palpitations Syncope Dysrrhythmias
Hippocrates“Those who suffer from recurrentFainting die suddenly”
Palpitations and Syncope
Symptoms
Cardiovascular origin
May be related to Cardiac rhythm abnormalities
Multiple causes
Assessment priority-those at risk
Treatment –Reassurance to Intervention
Palpitations
“Awareness of ones heart beat”
History important!!!!
Physical exam
Investigations (Aim)-Correlate symptoms with cardiac rhythm
HistoryA clear description of the palpitation is helpful
-Onset-Duration of symptom-Heart rate estimate-Regularity of rhythm-Trigger factors
PalpitationsCommon Causative
Factors
Sinus TachycardiaGradual onsetAnxiety and panic
PrematureEctopic beats
Tachydysrythmias
Physical Findings and Investigations
Physical FindingsNormal or Abnormal
InvestigationsElectrocardiogramAmbulatory Monitoring
Treatment
Reassurance-Sinus Tachycardia and ectopic beats
Treatment of specific arrhythmias
Syncope
Transient loss of consciousness and postural tone with spontaneous recovery ( Due to decrease cerebral blood flow)Do not confuse with a seizure disorderCommon 6% hospital admissions and 1-2% emergency admissions Can occur at any age - Elderly
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’’
Causes
Neurally Mediated
Cardiac
Neurological or psychiatric
Syncope of unknown origin*
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
Neurally Mediated
Reflex Mediated
Vasovagal or neurocardiogenic syncopeCarotid sinus hypersensitivitySituational(micturation, defaecation,cough ,swallow)
Autonomic dysfunction
Pure autonomic failure atrophy(Parkinsonism,cerebellarMultiple system)Postural orthostatic tachycardia syndromeSecondary autonomic failure
Vasovagal commonest cause
Vasovagal Syncope
Commonest causeAffect all age groupsHypersensitivity of the Autonomic System to any StimuliPostural
Pathophysiology
Upright position venous pooling
Decrease CO decrease VR
Increase symp A Activation Mechanoreceptors Withdrawal of symp and activation of ParasympVasodilatation bradycardiaDecrease cerebral flow
Carotid Sinus Hypersensitivity
Abnormal sensitivity of a normal reflex
Carotid sinus massage result in sympathetic withdrawal and parasympathetic activation
Bradycardia prominent feature
Situational reflex-mediated syncope
Autonomic dysfunctionOrthostatic hypotensionUpright posture BP decrease20mmhg systolic or decrease to 90mmhgMore common in the elderlyDo not forget drugs that may ppt syncope
Cardiac syncope
Rhythm DisturbancesBradycardiaAtrioventricular blockSinus node dysfunction
TachycardiaVentricular ArrhythmiaSupraventricular arrhythmia
Structural cardiac disease Aortic stenosisHypertrophic cardiomyopathy
Neurogenic or Psychiatric
NeurologicalMigraineVertebrobasilar disease Subclavian steal
PsychiatricAnxietyDepressionHyperventilation(Psychogenic syncope)
How does one evaluate a patient with syncope ?
History Important++++
Eye witness description if possible
Physical examination (Neurological Exam)
Logical approach to investigations
History
Description of syncopal episode
Provocative factors
Preceding symptoms
Recovery period
Family history
Associated injury
Clinical Findings
Investigations
Electrocardiogram*
Ambulatory Monitoring*
Tilt Testing
Electrophysiological Testing (Specialized Tests)
Other – Echocardiography*
Electrocardiography
Mandatory in ALL patients
May offer clues to cause (Underlying structural heart disease arrhythmia, Inherited disorders)
ECG recording coupled with certain maneuvers
Ambulatory Monitoring
Holter Monitoring - 24 or 48hr ECG recording- Limitations(Intermittent)
Event recorders – Limitations (Patient Activation)
Tilt Testing
Very useful in confirming diagnosis in vasovagal syncope
Availability of the necessary hardware
Electrophysiological Testing
Highly specialized
Restricted to a specific category of patients
Other
Echocardiography- Clinical clues
TreatmentDepends on the cause*
Vasovagal syncopeReassurance Avoid provocative factors
Carotid sinus Hypersensitivity(Pacing)
Dysrhythmia
Abnormality of cardiac rhythm
Range - benign to malignant (Extrasystoles to ventricular fibrillation and asystole)
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
Dysrhythmia (cont)
Role of the following in the assessment – Important
HISTORY*****
ECG************* Must be of good quality
BradycardiasVentricular rate less than 60/min(Physiological and Pathological)
Bradycardia
Results from : reduction in the rate of normal sinus rhythm : Disturbances of Atrioventrcular conduction
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
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.
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
A-V Conduction disturbances
Causes
Which ones need treatment
Treatment Strategies
Role of pacing in Prognosis
Sinus Node Dysfunction(Sino atrial node disease)
InappropriateSinusbradycardia
Sinus pauses
ProneTo Tachy
Treatment : Symptoms
TACHYCARDIASTACYARRHYTHMIAS
Tachycardias
Origins :Atria: Ventricle:AV junction
Mechanisms
QRS morphology and duration
Role of antiarrhythmic therapy in Rx
Atrial Arrhythmias
Atrial FibrillationSinus TachycardiaAtrial FlutterAtrial TachycardiasJunctional tachycardiasother
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
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
Treatment
Onset and duration
Presence of organic disease/ppt factors
Haemodynamic Status
Anticoagulation
Antiarrhythmics
Other
Atrial Flutter
Re- entry RA
Saw tooth pattern on ECG – Flutter waves(300/min)
Termination cardioversion ( medical or Chemical)
Progression to atrial fibrillation
Ventricular Tachyarrhythmias
Ventricular tachycardia
Ventricula fibrillation
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*