Palpitation, funny turns and syncope

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Palpitation, funny turns and syncope

• Neil Grubb
• Consultant Cardiologist
• Royal Infirmary of Edinburgh

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PALPITATION

• 20 of referrals to Cardiology OPD
• distressing because patients associate irregular
  rhythm with heart attack and sudden death
• symptom can reflect cardiac and non cardiac
  pathology

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CAUSES OF PALPITATION

• Intermittent tachycardias
• SVT
• VT
• atrial flutter and fibrillation
• Intermittent bradycardias
• sinus node disease
• intermittent AV block
• Extrasystoles or ectopic beats

• Augmented stroke volume
• anaemia
• hyperthyroidism
• pyrexia
• aortic incompetence
• Non-cardiac causes
• increased awareness of normal rhythm
• anxiety / panic attacks
• hyperventilation
• diaphragmatic flutter

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INVESTIGATION

• 12 lead ECG may give useful information about
  underlying cardiac disease
• the key is to obtain an ECG during symptoms
• symptoms rarely occur during an ECG recording!

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Ectopic Beats
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ECTOPIC BEATS

• occur in healthy individuals
• relationship with caffeine a myth definitely
  occur with alcohol
• rarely can antiarrhythmic Rx be justified
• frequent atrial ectopy can identify risk of
  atrial fibrillation
• frequent ventricular ectopy only a risk marker in
  patients with IHD or cardiomyopathy

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ECTOPIC BEATS refer ?

• reassurance sufficient for most patients
• if history is classic for ectopy, probably no
  need for ambulatory recording
• increasingly patients will ask for confirmation
  of diagnosis and specialist opinion
• deal with triggers (e.g. alcohol, excess fatigue)
  before considering any other Rx
• beta-blockers occasionally used in highly
  symptomatic patients

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Atrial fibrillation
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MECHANISMS
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MAIN RISK FACTORS FOR ATRIAL FIBRILLATION

• Age
• Mitral valve disease
• Hypertension
• Coronary heart disease
• Heart failure / cardiomyopathy
• Thyrotoxicosis

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CLASSIFICATION OF AF

• Paroxysmal
• Persistent
• Permanent

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ISSUES IN MANAGEMENT OF ATRIAL FIBRILLATION

• Risk of stroke / systemic embolism
• Symptom control
• Rate control strategy versus rhythm control
  strategy

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CARDIOVERSION

• DC electrical OR chemical
• DC more successful for established AF
• Chemical effective for acute (lt48h) AF
• Long-term maintenance of sinus rhythm
  disappointing (lt50 at 1 year)

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Drug treatment of atrial fibrillation 1 Rhythm
Control Approach
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Hierarchy of drugs for rhythm control (normal
heart)

• (Pill-in-pocket flecainide)
• Beta-blocker
• Beta-blocker flecainide
• Amiodarone
• Beta-blocker amiodarone

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Hierarchy of drugs for rhythm control (IHD or CCF)

• Beta-blocker
• Amiodarone
• Beta-blocker amiodarone
• Remember that beta blocker indicated for
  secondary prevention in many patients with IHD
  and heart failure in any case

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Class I drugs

• Flecainide effective in 80 of cases
• Propafenone effective in 80 of cases

(Effectiveness reduction in symptoms) (Proarrhyt
hmia affects patients with structural or
ischaemic heart disease at gt4) (Up to 50 of
patients report side-effects)
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Class III drugs

• Amiodarone effective in up to 85 of cases but
  formidable side-effect profile
• Dronedarone (coming soon)
• Sotalol little more effective than beta-blockers.
  Effective in 60
• (Proarrhythmia risk with sotalol up to 5 in
  female patients)

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Drug treatment of atrial fibrillation 2 Rate
Control Approach
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Hierarchy of treatment for rate control

• Beta-blocker OR rate limiting Ca blocker
• Above plus digoxin
• Amiodarone OR pace and ablate
• Why beta blocker rather than digoxin ?

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SVTs
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• sudden onset
• rapid, regular palpitation
• sometimes dizzy
• hr 140-240bpm

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Management of SVT

• AV node blocking drugs
• (other anti-arrhythmics)
• catheter ablation

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RF Ablation

• Local anaesthetic
• Catheters placed in heart via femoral veins,
  using fluoroscopic guidance
• Tachycardia induced and site of arrhythmia mapped
• Ablating catheter placed over accessory pathway
  and tip heated to 55-65C

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Risk / Benefit

• Drugs
• 70 patients have symptoms reduced
• Treatment is lifelong
• Risk of serious complication 1 with flecainide
  etc

• Ablation
• 90-95 cured
• Treatment is one-off
• Risk of death / MI / CVA lt 1 in 2000
• Risk of pacemaker 1 in 200

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Who should be considered for EP study / ablation ?

• Symptomatic SVTs where
• Patient not keen on long-term medication
• Drugs ineffective / side effects
• Pre-excited atrial fibrillation
• Wolff-Parkinson-White syndrome in
• Pilots
• Competitive athletes
• Patients at risk of atrial fibrillation

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The facts about ablation

• gt90 success rate
• 5 recurrence rate
• 1/100 to 1/600 risk of needing PPM
• 1/3000 risk of death (less than drugs)
• Radiation exposure

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The facts about ablation

• gt90 success rate
• 5 recurrence rate
• 1/100 to 1/600 risk of needing PPM
• 1/3000 risk of death (less than drugs)
• Radiation exposure

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SVT who to refer

• everyone with recurrent SVT, providing they are
  interested in considering treatment

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Syncope
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SCOPE OF THE PROBLEM
Affects around 20 of the population at some
time Accounts for 5 of general medical
admissions Symptoms affect ability to drive,
increase susceptibility to falls and injury, and
reduce independance
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DEFINITION

• Syncope is defined as loss of consciousness
  resulting from interruption of blood supply to
  the brain
• Patients present with blackouts, not syncope
  they cant tell you the mechanism!

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CAUSES OF BLACKOUTS 1 CARDIAC SYNCOPE

• Bradycardia
• Tachycardia
• Mechanical obstruction of circulation
• Aortic stenosis
• HOCM
• Pulmonary embolism

Important because patients with cardiac aetiology
have a far worse prognosis than patients with
blackouts from other causes
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CAUSES OF BLACKOUTS 2 NEUROCARDIOGENIC SYNCOPE

• Simple faint
• Malignant vasovagal syncope
• (and variants e.g. cough and micturition syncope)
• Carotid sinus hypersensitivity

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CAUSES OF BLACKOUTS 3 NEUROGENIC BLACKOUTS

• Epilepsy
• n.b. temporal lobe epilepsy and complex partial
  seizures may not produce classic motor seizure
• Cerebrovascular ischaemia
• TIA / CVA
• Vertebrobasilar insufficiency

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CAUSES OF BLACKOUTS 4 MISCELLANEOUS

• Postural hypotension
• (common in elderly, diabetics and with
  Parkinsons)
• aggravated by diuretics and vasodilator drugs
• Hypoglycaemia

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THE HISTORY
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KEY HISTORY POINTS

• Establish a clear description of the nature and
  temporal pattern of the patients episodes
• Ideally obtain a description from a witness
• Divide your history into prodrome, blackout
  and recovery period

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EXAMINATION
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History and Examination
Do findings suggest a cardiac diagnosis ?

• Yes
• Consider
• Ambulatory ECG
• Loop recorder
• Echo
• (EP study)

No Do findings suggest a neurological diagnosis ?

• Yes
• Consider
• EEG
• Carotid USS
• CT / MRI scan

• No
• Consider
• Tilt test
• ECG with carotid sinus pressure

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INVESTIGATION

• 12 lead ECG may give useful information about
  underlying cardiac disease
• the key is to obtain an ECG during symptoms
• symptoms rarely occur during an ECG recording!

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TILT TEST RESPONSES
CARDIO-INHIBITORY (sinus bradycardia AV
block) VASODEPRESSOR (fall in BP, usually
systolic falls by gt25 mmHg) MIXED A tilt test
in only truly diagnostic if symptoms are
reproduced !
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MANAGEMENT OF BRADYARRHYTHMIAS

• Withdraw drugs that aggravate bradycardia
• Beta-blockers
• Rate limiting calcium channel blockers
• Digoxin
• Other antiarrhythmics
• Check TFTs
• If acute presentation, ensure bradycardia not due
  to ACS
• For many cases a pacemaker is the only option

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INDICATIONS FOR PERMANENT PACING
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• Sino-atrial disease
• Syncope documented due to sinus pause
• Syncope and ambulatory ECG showing daytime pauses
  gt3 s, or night-time pauses gt4.5 s.
• Symptomatic sinus bradycardia
• Where pacing required to prevent drug-induced
  bradycardia
• AV node disease
• Syncope documented due to high grade AV block
• Syncope and Mobitz II or complete AV block on
  ambulatory ECG
• Neurocardiogenic syncope
• Where bradycardia a significant component

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Treatments for ventricular arrhythmias

• Anti-ischaemic
• Anti-anginal drugs
• Percutaneous intervention
• Bypass surgery
• Scar
• Aneurysm resection
• Endocardial resection

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The implantable defibrillator
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ICD Anti-tachycardia Pacing
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ICD Defibrillation
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ICD Implant Rates by Year (Edinburgh)
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Indications for ICD therapy

• SECONDARY PREVENTION
• Resuscitated out-of-hospital VF / VT cardiac
  arrest in absence of MI
• VT with compromise, impaired LV function
  (LVEFlt40) in absence of MI

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Indications for ICD therapy

• PRIMARY PREVENTION
• Post-MI with impaired LV function
• (especially if LBBB or RBBB on ECG)
• Some rarer arrhythmias in young patients

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MANAGEMENT OF NEUROCARDIOGENIC SYNCOPE
Avoid precipitating triggers Withdraw drugs
which aggravate brady / hypotension Ensure good
hydration Salt loading Elasticated stockings
DRUGS Beta-blockers Disopyramide Fludrocortisone
Midodrine PACEMAKER IMPLANTATION Dual chamber,
hysteresis
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SPECIAL CONSIDERATIONS IN THE ELDERLY

• Ambulatory ECG recordings
• Asymptomatic sinus bradycardia, junctional
  bradycardia and AF common
• Establish relationship between arrhythmia and
  symptoms before treating if possible
• Susceptible groups
• Parkinsons disease
• diabetes
• Warfarinisation
• Age is risk factor for embolic stroke in AF. This
  has to be weighed against risk of falls, injury
  etc

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Patients present with symptoms, not diagnoses.
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Referral pathways
SUSPECTED NEW ARRHYTHMIA
YES
SOON / URGENT O/P CLINIC request (vetted)
Any high risk features (see below)

• HIGH RISK FEATURES
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• Known history of ventricular arrhythmias
• Syncope / collapse
• Recent myocardial infarction, bypass surgery,
  pacemaker implant or coronary intervention
  (within past 2 months)

NO
YES
Are symptom episodes frequent, gt2-3 x per week
Is reason for request simply to confirm benign
diagnosis, e.g. ectopic beats, AF, or to rule out
arrhythmic cause ?
NO
ROUTINE O/P CLINIC request
YES
NO
DIRECT ACCESS AMBULATORY MONITORING request
ROUTINE O/P CLINIC request. Consultant may opt
to arrange ambulatory monitor prior to clinic
visit