Risk Stratification Of Palpitations – When To Worry
Simon James James Cook University Hospital Middlesbrough September 2014
Palpitations ‘Disagreeable sensation of pulsation or movement in the chest and/or adjacent areas’
Brugada P, Gursoy S, Brugada J, Andries E. Investigation of palpitations. Lancet, 1993;341:1254–8.
Palpitations • Common presentation and frequent reason for Cardiology referral • Can cause considerable stress/anxiety for the patient and health care professional • Often benign, less than half of patients with palpitations will have an arrhythmia • Not every identified arrhythmia of clinical significance
Palpitations Sinus rhythm Sinus tachy
Sinus pauses
SVT
Atrial ectopic Atrial Tachy
What is causing the symptoms?
Atrial Flutter
AF
VPBs MMVT
PMVT
First Assessment • Key – Identifying patients with a significant heart rhythm abnormality at risk of adverse outcome who may require treatment • Achieved by taking a careful history and simple investigations
Risk? Sinus bradycardia
Low Risk
Sinus tachycardia
High risk
Atrial ectopics
+
Atrial Tachy Atrial Flutter
AFib SVT Heart Block Ventricular ectopics +
+underlying
cardiomyopathy
TdP VF
*Normal heart VT
History • What do they actually mean by palpitations? – More forceful? – Rate change? – Regular/irregular - Tap it out ?
• Onset and offset • Circumstances in which they occur – Palpitations during exercise cause for concern • Not palpitations at all? – SOB, chest pain
Description of Palpitations • Classical descriptions? • Extra beat / missed beat/pause and a thump • Sudden onset /offset rapid regular • Irregularly irregular (May not be textbook)
Worrying Symptoms • Pre syncope/blackouts • Exercise induced symptoms • Severe Breathlessness – Tachyarrhythmia/decompensation – CCF precipitated by AF with rapid rate resp – (contrast sharp intake of breath – ectopy)
• Chest pain – underlying coronary heart disease – (patients with normal hearts can experience chest discomfort with tachyarrhythmia )
Past Medical History • • • •
Coronary artery disease / angina / MI Heart failure Valve disease Cardiac surgery – Including congenital heart disease
Family History • Heart muscle diseases, IHD, AF • Sudden cardiac death – under the age of 40 – Majority of inherited causes are autosomal dominant – History can focus on 1st degree relatives
• Fatal accidents i.e. RTA/drowning • Epilepsy
Contributing Factors • Anxiety and depression • Alcohol/caffeine • Use of illicit drugs i.e. ecstasy, amphetamines, cocaine • Prescription medications i.e. Beta antagonists, levoythroxine • Class 1 anti arrhythmic – pro arrhythmic • Medication that prolongs QT interval – www.Sads.org.uk/drugs_to_avoid.htm
Examination and Investigations • Physical examination • Pulse check – rate & rhythm • Bloods – FBC, TFT’s, U&E’s – exclude anaemia, thyroid dysfunction, electrolyte disturbance • 12 lead ECG – vitally important • ECG can provide valuable clues about structural heart disease i.e. previous MI, LVH, conduction abnormalities • ECG abnormalities can be subtle
Risk Stratification: the basics • Normal hearts – Good prognosis – May still need treatment on symptomatic grounds
• Structural heart disease – Increases likelihood of life threatening problems – Prior MI – DCM – Cardiac surgery
Normal heart? • Free from cardiac symptoms – Heart failure – Angina – Syncope – Good exercise tolerance – No breathlessness
• No significant history – IHD – Cardiac surgery
Palpitations - High or Low Risk? Case 1 • 17 years old male • No excertional limitation • 5-a-side football 2 x week • Forceful heart beat • No associated symptoms • Normal examination Probable normal heart Low risk
Case 2 • 55 year old male • Breathless walking 50 yds • Palpitations with LOC and chest pain • Mild ankle swelling • Systolic murmur ? Structural heart disease High risk
Stratifying palpitations • • • •
Young patient No other symptoms Normal CVS exam Normal ECG
Pretty much rules out life threatening rhythm disturbances
• Rare conditions where 12 lead ECG findings indicative of high risk
The Exceptions: a recent case • Apparently normal heart with life threatening problems • Pt transferred and clerked in on 1/10/2014 • M.J. 31 yr old male – “fit and well”, no history of note
• Palpitations causing 6 admissions over 12 months – Fast / regular – Mild SOB
12 lead and Provisional diagnosis
• RVOT VT – Benign normal heart arrhythmia – Drug or ablation Rx reasonable options – (Failed to settle on drugs)
The Exceptions: 12 lead in SR
Throw away comments: “All got bad hearts in my family. Father died suddenly ? MI in his 50s” “My Nephew dropped dead during PE age 11. He suddenly collapsed while running about and went blue and died. They think it must have been his heart”
The Exceptions: 12 lead in SR
This man probably does not have benign normal heart VT High probability he has ARVC
Key points from Mr M.J. 1. A 12 lead ECG will pick up the rare but important causes of SCD in what appears to be a healthy young person 2. Taking a proper history / family history would have already raised alarm bells before you even see the ECG
Importance of the 12 Lead ECG • There are rare causes of palpitations in young people that are associated with sudden cardiac death • These can usually be excluded by the 12 lead ECG at rest
High risk – Brugada – Long QT – WPW – ARVC – HCM
Na+ channel dysfunction RSR pattern V1 and V2 “Coved” ST elevation Risk of VF/SCD
High risk – Brugada – Long QT – WPW – ARVC – HCM
Various channel dysfunctions Delayed repolarisation – QTc increased Abnormal T waves Risk of TdP/SCD
High risk – Brugada – Long QT – WPW – ARVC Short PR interval – HCM Delta wave / slurred QRS onset Broad QRS
High risk – Brugada – Long QT – WPW – ARVC – HCM
Epsilon wave
Scarring of RV → VT RBBB / broadened QRS T inversion V1 – V3 Epsilon wave
High risk – Brugada – Long QT – WPW – ARVC – HCM
LV hypertrophy Amplitude of QRS complex increased (ventricular depolarisation) T wave inversion / strain pattern
Palpitations Not Associated With Increased Heart Rate • Occasioanlly bradycardia can present with palpitations – “heart stops” – “missed beats”
• Syncope / pre-syncope
Mobitz type II • Failure of conduction at level of his purkinje system • More likely to be related to structural damage • Intermittent non-conducted P waves without progressive prolongation of the PR interval • Progression to CHB, syncope, sudden cardiac death
Complete Heart Block • Absence of AV conduction /AV dissociation • High risk of ventricular standstill, sudden cardiac death
Summary • Palpitations not always indicative of arrhythmia • Not all arrhythmias clinically significant • Taking a careful history and using simple investigations can predict high risk in patients with palpitations (often before knowing what the culprit rhythm is)
Summary (2) • Low risk patients have normal hearts – No cardiac symptoms / history – Normal ECG and examination
• High risk patients have abnormal hearts – Cardiac symptoms and history – Abnormal ECG and examination
• Remember rare causes of SCD in young otherwise healthy patients
