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”
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Palpitations and Syncope
Symptoms
Cardiovascular origin
May be related to Cardiac rhythm abnormalities
Multiple causes
Assessment priority-those at risk
Treatment –Reassurance to Intervention
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Palpitations
“Awareness of ones heart beat”
History important!!!!
Physical exam
Investigations (Aim)-Correlate symptoms with cardiac rhythm
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HistoryA clear description of the palpitation is helpful
-Onset-Duration of symptom-Heart rate estimate-Regularity of rhythm-Trigger factors
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PalpitationsCommon Causative
Factors
Sinus TachycardiaGradual onsetAnxiety and panic
PrematureEctopic beats
Tachydysrythmias
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Physical Findings and Investigations
Physical FindingsNormal or Abnormal
InvestigationsElectrocardiogramAmbulatory Monitoring
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Treatment
Reassurance-Sinus Tachycardia and ectopic beats
Treatment of specific arrhythmias
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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
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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’’
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Causes
Neurally Mediated
Cardiac
Neurological or psychiatric
Syncope of unknown origin*
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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
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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
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Vasovagal Syncope
Commonest causeAffect all age groupsHypersensitivity of the Autonomic System to any StimuliPostural
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Pathophysiology
Upright position venous pooling
Decrease CO decrease VR
Increase symp A Activation Mechanoreceptors Withdrawal of symp and activation of ParasympVasodilatation bradycardiaDecrease cerebral flow
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Carotid Sinus Hypersensitivity
Abnormal sensitivity of a normal reflex
Carotid sinus massage result in sympathetic withdrawal and parasympathetic activation
Bradycardia prominent feature
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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
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Cardiac syncope
Rhythm DisturbancesBradycardiaAtrioventricular blockSinus node dysfunction
TachycardiaVentricular ArrhythmiaSupraventricular arrhythmia
Structural cardiac disease Aortic stenosisHypertrophic cardiomyopathy
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Neurogenic or Psychiatric
NeurologicalMigraineVertebrobasilar disease Subclavian steal
PsychiatricAnxietyDepressionHyperventilation(Psychogenic syncope)
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How does one evaluate a patient with syncope ?
History Important++++
Eye witness description if possible
Physical examination (Neurological Exam)
Logical approach to investigations
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History
Description of syncopal episode
Provocative factors
Preceding symptoms
Recovery period
Family history
Associated injury
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Clinical Findings
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Investigations
Electrocardiogram*
Ambulatory Monitoring*
Tilt Testing
Electrophysiological Testing (Specialized Tests)
Other – Echocardiography*
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Electrocardiography
Mandatory in ALL patients
May offer clues to cause (Underlying structural heart disease arrhythmia, Inherited disorders)
ECG recording coupled with certain maneuvers
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Ambulatory Monitoring
Holter Monitoring - 24 or 48hr ECG recording- Limitations(Intermittent)
Event recorders – Limitations (Patient Activation)
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Tilt Testing
Very useful in confirming diagnosis in vasovagal syncope
Availability of the necessary hardware
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Electrophysiological Testing
Highly specialized
Restricted to a specific category of patients
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Other
Echocardiography- Clinical clues
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TreatmentDepends on the cause*
Vasovagal syncopeReassurance Avoid provocative factors
Carotid sinus Hypersensitivity(Pacing)
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Dysrhythmia
Abnormality of cardiac rhythm
Range - benign to malignant (Extrasystoles to ventricular fibrillation and asystole)
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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
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Dysrhythmia (cont)
Role of the following in the assessment – Important
HISTORY*****
ECG************* Must be of good quality
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BradycardiasVentricular rate less than 60/min(Physiological and Pathological)
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Bradycardia
Results from : reduction in the rate of normal sinus rhythm : Disturbances of Atrioventrcular conduction
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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
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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.
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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
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A-V Conduction disturbances
Causes
Which ones need treatment
Treatment Strategies
Role of pacing in Prognosis
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Sinus Node Dysfunction(Sino atrial node disease)
InappropriateSinusbradycardia
Sinus pauses
ProneTo Tachy
Treatment : Symptoms
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TACHYCARDIASTACYARRHYTHMIAS
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Tachycardias
Origins :Atria: Ventricle:AV junction
Mechanisms
QRS morphology and duration
Role of antiarrhythmic therapy in Rx
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Atrial Arrhythmias
Atrial FibrillationSinus TachycardiaAtrial FlutterAtrial TachycardiasJunctional tachycardiasother
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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
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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
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Treatment
Onset and duration
Presence of organic disease/ppt factors
Haemodynamic Status
Anticoagulation
Antiarrhythmics
Other
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Atrial Flutter
Re- entry RA
Saw tooth pattern on ECG – Flutter waves(300/min)
Termination cardioversion ( medical or Chemical)
Progression to atrial fibrillation
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Ventricular Tachyarrhythmias
Ventricular tachycardia
Ventricula fibrillation
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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*
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