indian society of electrocardiology long-term monitoring...
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Indian Society of Electrocardiology
Long-term monitoring:
Unraveling mechanism of Syncope
Amit Vora
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Syncope: Etiology
Orthostatic Cardiac
Arrhythmia
Structural
Cardio-
Pulmonary
*
1
• Vasovagal
• Carotid
Sinus
• Situational Cough
Post-
micturition
2
• Drug
Induced
• ANS
Failure Primary
Secondary
3
• Brady Sick sinus
AV block
• Tachy VT
SVT
• Long QT
Syndrome
4
• Aortic
Stenosis
• HOCM
• Pulmonary
Hypertension
5
• Psychogenic
• Metabolic
e.g. hyper-
ventilation
• Neurological
Non-
Cardio-
vascular
Neurally-
Mediated
Unknown Cause = 34%
24% 11% 14% 4% 12%
DG Benditt, UM Cardiac Arrhythmia Center
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History, examination, ECG
Neurally mediated syncope
Orthostatic hypotension
Unexplained syncope
Echo, Exercise test
Abnormal Normal
EP study
Episodes: Single Infrequent Frequent
Evaluation complete Implantable loop Holter, event recorder
recorder ILR
History
Inflow /outflow obstruction Examination
SN dysfunction / AV block
MI, LVH, long QT etc. ECG
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Implantable ECG Monitoring Systems
Activator
Base Station
Monitoring Center
Implanted Device
Physician
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13 yrs-old-boy,
3 episodes of unconsciousness over 1 year,
urinary incontinence.
Examination: Normal
Investigation of choice:
A. EEG /CT / MRI brain
B. ECG
C. Holter / Event recorder
D. All of the above
E. None of the above
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Event recorder:
Your diagnosis:
1.SN dysfunction
2.AV block
3.Vaso-vagal
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Tilt Table Test
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29 yrs-old Nurse
5 episodes of syncope over 3 years
Seen by physician, intensivist, neurologist
Clinical examination – normal
EEG – normal
MRI brain ‘thrice’ – normal
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ECG in pt with syncope:
1. LVH
2. WPW
3. Long QT
4. ARVC / Brugada
5. Chamber enlargement
6. Pulmonary embolism
7. Coronary ischemia
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CV cause of syncope
& normal ECG:
1. Vagally mediated
2. Long QT
3. LVH
4. Pre-excitation
5. Rapid SVT
6. Paroxysmal AV block
7. LA myxoma
8. VBI – steal syndrome
9. Pulmonary embolism
10.Idiopathic VF
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Management plan:
A. Anxiolytics / anti-depressants
B. Anti-epileptics
C. Echo
D. Holter / Long-term ECG monitoring
E. EP study
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72 hr Holter
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Is this artifact
a. Yes
b. No
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4 yr-old girl, presented with seizures
Twice in the morning while getting
ready to go to school
Clinical examination - normal
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How do we proceed?
A. EEG/CT/MRI
B. HUTT
C. ECG/Echo/Holter-Event recorder
D. All of the above
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Holter…
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Best treatment option for LQTS pts:
A. Beta-blockers
B. Beta-blockers & pacemaker
C. Left cervical sympathectomy
D. AICD
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Exertional Syncope
1. Coronary insufficiency
2. Outflow obstruction
3. Fixed output states – PH
4. WPW / Long QT syndrome
5. RVOT - VT
6. Infra-Hisian AV blocks
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82 yrs-old lady
HT on amlodepin
Recent episode of unsteady gait,
Loss of consciousness – few minutes,
Disorientation for a while & then ok
Neurologic Examination / ECG: normal
MRI brain: Thallimic infarct
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How to manage?
A. Anti-platelets & Statins
B. Anti-coagulation
C. CAG
D. Further evaluation
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Event
Monitor..
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Any change of Rx plan?
A. Anti-platelets & Statins
B. Anti-coagulation
C. Β blockers
D. Amiodarone
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One un-fine day.....
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• 65 yr-old-lawyer, father of medicine resident
• Pituitary adenoma – 15 yrs
• Anterior wall MI – 12 yrs
• Repeated fainting spells for the past 3 years
(multiple hospitalizations)
• ECG – sinus rhythm, old AWMI with RBBB
• Echo – LVEF 0.35 (steady for the past 10 yrs)
• Holter – no bradycardia, AV blocks, PVCs, NSVT
• CT/MR/EEG – all normal
• CAG – no evidence of reversible ischemia
• Consulted physician, cardiologist, neurologist…
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ECG
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Fainting spells are due to:
A. Pituitary adenoma
B. Epilepsy
C. Bradyarrhythmia
D. Tachyarrhythmia
E. Vagally mediated
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2:1 AV block
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EP study…
A H
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43 yr old lady, sudden
unconsciousness with fall and
convulsions early morning
• CT (brain): small intracranial bleed
• Examination: normal
Next step? A. Anti-convulsants
B. 4 vessel MR Angio
C. Further cardiac evaluation
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Event monitor..
Diagnosis: “Paroxysmal” AV block
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Paroxysmal atrio-ventricular block
Mechanism
Local phase-4 depolarization in the
sub AV nodal conduction system
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94001/1
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Mechanisms initiating paroxysmal AV block
Critical P-P lengthening following:
1. Atrial premature beat conducted/non-conducted
2. Ventricular premature beat with VA conduction
3. HIS bundle extrasystole
4. Critical P-P lengthening after carotid sinus massage
5. After valsalva maneuver
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84338
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96616
96616
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96619/2
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• 64 yrs-old-gentleman
• S/P CABG
• Transient uneasy/dizzy feeling
• NYHA I-II
• LVEF 0.25
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ECG:
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64 yrs, CABG, transient uneasy/dizzy feeling, NYHA I-II, LVEF 0.25
What do you suspect?
A. AV block
B. Postural hypotension
C.TIA
D.Coronary ischemia
E. Ventricular tachycardia
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Investigation of choice:
A. Electrophysiology study
B. Coronary angiography
C. Holter / Event monitor
D. CT scan / MRI brain
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EP study:
AH: 140 ms HV: 60 ms
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1:1 AV @ 450 ms
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In patients with wide QRS & LV dysfunction,
there is a 50% or more chance of syncope
due to ventricular tachyarrhythmia.
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67 yrs-old, HT/DM
Intermittent pre-syncope
(once in 2-3 months; off late increased)
ECG: SR & RBBB
Echo: LVEF 0.60
Investigation of choice:
A. Holter / Event recorder
B. EP study
C. Carotid Doppler / MRI brain
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Diagnosis:
A. AV nodal block
B. Infra-Hisian Block
C. Atrial tachycardia
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Pacemaker indicated
a. Yes
b. No
c. Don’t know
d. Needs CAG
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Elderly man, repeated syncope,
normal Echo
What do you suspect?
A. AV block
B. Postural hypotension
C. Coronary ischemia
D. Ventricular tachycardia
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EPS
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65 yr-old-lady, VVI pacemaker 3 yrs ago for CHB, now c/o syncope
Likely cause of syncope:
1.Pacemaker malfunction
2.Postural hypotension
3.TIA
4.Ventricular tachycardia
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GP started sparfloxacin for respiratory tract infection!
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Conventional Diagnostic Methods/Yield Test/Procedure Yield
(based on mean time to diagnosis of 5.1 months7
History and Physical
(including carotid sinus massage)
49-85% 1, 2
ECG 2-11% 2
Electrophysiology Study without SHD* 11% 3
Electrophysiology Study with SHD 49% 3
Tilt Table Test (without SHD) 11-87% 4, 5
Ambulatory ECG Monitors:
• Holter 2% 7
• External Loop Recorder
(2-3 weeks duration)
20% 7
• Insertable Loop Recorder
(up to 14 months duration)
65-88% 6, 7
Neurological †
(Head CT Scan, Carotid Doppler)
0-4% 4,5,8,9,10
* Structural Heart Disease † MRI not studied
1 Kapoor, et al N Eng J Med, 1983.
2 Kapoor, Am J Med, 1991.
3 Linzer, et al. Ann Int. Med, 1997.
4 Kapoor, Medicine, 1990.
5 Kapoor, JAMA, 1992
6 Krahn, Circulation, 1995
7 Krahn, Cardiology Clinics, 1997.
8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
9 Day S, et al. Am J Med. 1982; 73: 15-23.
10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
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Warning Signs for Malignant Syncope
• Structural heart disease
• During exercise
• Unusual circumstances:
– loud noise, swimming, sleep
• Family history of Sudden Cardiac Death