1. Management of the Patient Presenting with Palpitation Samir Saba, MD Director, Cardiac Electrophysiology University of Pittsburgh

2. Definition Perceptible unpleasant forcible pulsation of the heart, usually with an increase in frequency or force, with or without irregularity in rhythm.

3. Presentation Most common outpatient complaint in patients presenting to PCP and cardiologists 16% in one study of 500 patients Terminology used: –Rapid fluttering in the chest –Flop-flopping in the chest –Pounding in the neck

4. Etiology Cardiac: –Arrhythmias –Cardiac and extracardiac shunts –Valvular heart disease –Pacemaker –Atrial myxoma –Cardiomyopathy Psychiatric: –Panic disorders –Anxiety disorders –Somatization –Depression

5. Etiology Medication: –Sympathomimetic –Vasodilators –Anticholinergic –  -blocker withdrawal Catecholamine Stress: –Exercise –Stress Habits: –Cocaine –Amphetamines –Caffeine –Nicotine

6. Etiology Metabolic disorders: –Hypoglycemia –Thyrotoxicosis –Pheochromocytoma –Mastocytosis –Scombroid Food Poisoning High output states: –Anemia –Pregnancy –Fever –Paget’s disease

7. Arrhythmic Etiologies PAC/PVC Sinus arrhythmias SVT (AF, Aflutter, ORT, AVNRT, AT) Idiopathic ventricular arrhythmias (RVOT, LVOT, fascicular VT) Life-threatening ventricular arrhythmias (MMVT, PMVT, TdP, VFlutter, VF)

8. Approach to the Patient 1.Is the cause of palpitations possibly a life-threatening condition? (Usually cardiac etiology) Majority of outpatients have benign etiologies 2.How can we make the patient feel better?

9. Predictors of Cardiac Etiology Male gender Reporting irregular heart beats History of heart disease Event duration > 5 minutes

10. History Circumstances: –Association with anxiety or panic (20% of palpitations are due to panic attacks and 67% of patients with SVT where diagnosed at some point with panic disorder) –Association with stress (arrhythmias benign and fatal) –Association with position (AVNRT pr PAC/PVC) –Association with syncope or near-syncope (high level of suspicion for VA)

11. Evaluation Detailed History: –Age –Onset –Duration –Circumstances –Symptoms –Termination –Maneuvers (CSM, valsalva) –Regularity (tap out the rhythm) –Medications –Habits –Psychiatric disorders

12. Evaluation Physical Exam: –Rarely during palpitations –Auscultation (MVP, HCM, chronic AF) –Evidence of CMP, valvular disease, congenital abnormalities

13. Evaluation 12-Lead ECG: –PAC/PCV/SVT/VT –WPW –LVH/LAE/RAE –Long QT, Brugada, ARVD –Old MI –Conduction abnormalities predisposing to TdP

14. ECG 1

15. ECG 2

16. ECG 3

17. ECG 4

18. ECG 5

19. ECG 6

20. ECG 7

21. Evaluation: Further Diagnostic Testing The diagnostic yield of history, P/E, and ECG is 1/3. Further diagnostic testing is needed in 3 groups of patients: 1.Those in whom the initial dx suggests arrhythmias 2.Those at high risk of arrhythmias 3.Those who remain anxious about arrhythmias

22. Diagnostic Testing Rule out structural abnormalities of the heart –Echo –Stress test –Cardiac Cath –MRI

23. Diagnostic Testing Document arrhythmia in the setting of symptoms –Ambulatory monitors (HM (yield is 33-35%),, Event recorder, Loop monitor (yield is 66- 88%), continuous ambulatory monitors) –ILR, EP testing

24. Testing

25. Diagnostic Yield of Loop Monitor Yield =100% Yield = 78%

26. ILR 1: Palpitations

27. ILR 2: Palpitations and Syncope

28. EP Study 1

29. EP Study 2

30. EP Study 3

31. Therapy No therapy  -Blockers, CCB Anti-arrhythmic drugs (IC, III) Ablation Devices

32. Inappropriate Sinus Tachycardia Diagnosis of exclusion after ruling out: –Thyrotoxicosis, anemia, fever, dehydration, arrhythmias, etc… Formulas: –HR max = 220 - age –HR max = 205.8 − (0.685 X age) Therapy: –  -blockers or CCB –Sinus node modification (high recurrence rate, need a PM, paralysis of phrenic nerve)

33. Take Home Points 1.Palpitations are very common 2.Differentiating between cardiac and non cardiac causes is essential 3.History, PE, ECG are essential with a yield of 1/3 4.Continuous event monitors are a good adjunct tool with a good diagnostic yield (up to 88%) 5.Therapy can be directed to cause but also empiric (  -blockers)

34. Questions?