1. Palpitations and Common Arrhythmias J. Philip Saul, M.D. West Virginia University Morgantown, WV

2. Outline Definitions Normal cardiac conduction/rhythm Review common arrhythmias –Irregular rhythms –Tachycardias When to worry Initial evaluation and management

3. 59 yo male with palpitations

4. Arrhythmia Features Rate – tachycardia, bradycardia Regularity QRS complex – narrow or wide P waves – axis, rate, synchrony with QRS A:V ratio –>1atrial rhythm –<1ventricular or junctional rhythm –1atrial, junctional or ventricular rhythm

5. 59 yo male with palpitations

6. Palpitations - Definition Sensation of the heartbeat Typically related to either a change in cardiac rhythm or a change in beat intensity

7. Arrhythmia - Definition Abnormality of cardiac rhythm –Premature beat/s –Blocked beat –Tachycardia –Bradycardia –Escape beat/rhythm –Asystole May or may not cause palpitations

8. Specialized Cardiac Conduction System Sinus node AV node

9. 0 - 30 Days1 - 12 Months1 - 16 Years 170 160 70 60 90 80 110 100 130 120 150 140 0 HR vs Age Beats / Min (0 - 200) Age Davignon 1985 98% 95% 75% 50% 5% 25% 2% N189179181119112109138191210226233247 Min885787961141011006868605151 Max168170166188204188176165145139145133

10. Arrhythmias in “Normal” Patients

11. Sinus Bradycardia/Sinus Arrhythmia Does Not Cause Symptoms

12. Skipped Beats

13. Premature Beat or Extrasystole Definition Depolarization of the atria, AV-node, or ventricles More premature than expected Depolarization (or beat) vs systole or contraction May be hard to differentiate by PE from marked sinus arrhythmia

14. Atrial Premature Beat

15. APB Sinus node

16. Atrial Premature Beat Definition Premature P wave Morphology different from sinus P wave QRS usually looks like sinus Can occur with bundle branch block (aberrancy), or AV block Sinus rhythm is reset, usually not fully compensatory

17. Atrial Premature Beat

18. APB with Aberrancy Bundle Branch Block

19. APB with Aberrancy APB Sinus node

20. Blocked Atrial Bigeminy

22. APB with Block APB Sinus node

23. APB’s 220 ms 320 ms 260 ms

24. Junctional Premature Beat

25. JPB Sinus node

26. Junctional Premature Beat Definition Premature QRS Morphology identical to conducted sinus QRS No identifiable conductable P wave Cannot diagnose as JPB in presence of bundle branch block (aberrancy)

27. Junctional Escape Beat vs Junctional Premature Beat

28. Ventricular Premature Beats

29. Ventricular Premature Beat VPB Sinus node

30. Ventricular Premature Beat Definition Premature QRS Morphology different from conducted sinus QRS No identifiable conductable P wave Typically sinus rhythm not reset fully compensatory

31. Ventricular Premature Beats 920 ms900 ms Fully Compensatory Fusion

32. Ventricular Premature Beats

33. Ventricular Trigeminy

34. 1 o Degree AV Block

35. 2 o AV Block, Mobitz Type I (Wenckebach)

36. Second Degree AV Block 2:1

37. 2 o AV Block, Type I (Wenckebach)

38. 2 o AV Block, Type II

39. AV Block - 2 o Degree Type I and Type II Sinus node AV node Type I Wenckebach Type II

40. 3 o AV Block (Complete Heart Block)

41. 1 st degree 2 nd degree Type 1 2 nd degree Type 2 3 rd degree complete

42. The Fast Beat “Rapid heart beat” “Racing heart” “Heart beeping” “Heart beating out of her chest” “Too fast to count” “Pulse was 235 beats/minute” Not!

43. Concerns Supraventricular tachycardia (SVT) Ventricular tachycardia (VT) vs Sinus tachycardia Normal rate with increased beat sensation/intensity

44. Supraventricular Tachycardia (SVT)

45. Valsalva Maneuver

46. Wolff-Parkinson-White (WPW)

47. WPW

48. Ventricular Tachycardia (VT)

49. When to Worry Dizziness, syncope or “seizure” Known heart disease - congenital/acquired Arrhythmia on exam - rapid or irregular Not respiratory related Family hx sudden death, LQTS Abnormal ECG

50. 8 yo with Hx seizures presents to ER with new onset syncope

51. Torsades de Pointes

52. Congenital Long QT Syndrome QTc 590 msec

53. 6 yo with hx of seizure and new onset dizzyness and fatigue

54. 17 yo male with a strong family history of sudden death

55. Brugada Syndrome

56. When to Worry Less Gradual onset/gradual termination No associated symptoms Normal exam or respiratory arrhythmia Normal ECG Associated hyperventilation

57. Asymptomatic 18 year old sports evaluation

58. Evaluation - Initial Careful history of events Physical exam ECG –WPW, long QT, dilated or hypertrophic cardiomyopathy –Premature beats –Rarely see tachycardia –Lots of false positives

59. ECG Documentation > once/day Holter > once/2 wks (non-sust) Event - looping > once/2 wks (sust) Event - nonlooping < once/mo (unclear) Pulse check/ECG < once/mo (clear) Esoph EPS

60. Transtelephonic Event Monitors Memory: non-looping Memory: looping

61. Smart Phone/Watch Based

62. Event Recordings During Palpitations

63. 14 yo s/p surgery for Tetralogy of Fallot with palpitations

64. Malignant Symptoms Admission for telemetry Intracardiac EPS if telemetry unclear

65. Arrhythmias & Palpitations Summary Most are benign - sinus tachycardia, isolated premature beats, … Benign asymptomatic arrhythmias are frequent in children ECG documentation during palpitations is critical Syncope or known heart disease demand more extensive evaluation