Dr Paul Broadhurst
Aberdeen Royal Infirmary
Palpitations
· Common
· Usually benign
· Underlying diagnosis often made on history
· What is done, depends on symptoms and underlying cardiac condition
History
· What does the patient mean?
· Detailed description: missed beats, strong thumps, rapid tachycardia etc
· Mode of onset and termination
· Associated symptoms
· Check for systemic upset eg thyroid disease, anaemia
· Review past history, drugs, FH, social factors
· Exam often unrewarding
Investigations
Maybe none,
reassure, lifestyle
advice
FBC, TFTs etc as indicated
12 lead ECG
Investigations ?in the community
12 lead ECG recording during palpitations
Holter monitor
Event recorder
Investigations ?in the community
· Echocardiogram
· ETT – if IHD suspected or palpitation relates to exercise
Warning ‘signs’ – may require hospitalisation
Palpitation associated with syncope or presyncope
Investigation - hospital
Loop recorders – implantable and non-implantable
Rarely EP study, SAECG, cardiac imaging (cor angios, MRI scan etc)
Management
· Ectopics, sinus tachycardia
· Treat underlying cause, reassure, lifestyle change, avoid drug therapy if possible
· AF
· Chronic
· Often no palpitations. Rate versus rhythm approach
· Paroxysmal
· Often palpitations. Rhythm control often difficult - refer
Management
PSVT
If infrequent, not troublesome, no occupational issues, no WPW – reassure
Otherwise, refer to electrophysiologist
Medical Px versus curative RFA
Supraventricular Tachycardia (SVT)
· Common
· Usually benign(caution with WPW, AF)
· Responds poorly to prophylactic medication
· RAF widely available from early 1990s
· Cost effective of drugs
· (AV re-entrant tachycardias) > 90% cure rate, - 0.1% mortality
· 5% recurrence
Drug therapy for SVT
Beta-blockers
Verapamil/diltiazem/
digoxin (caution with WPW)
Class 1C drugs (caution with flutter)
Sotalol
Amiodarone
43 year old male
Types of Energy Sources
Direct current
Radiofrequency
Microwave
Ultrasound
Laser
Chemical
Cryogenic
Surgical
RFA activity 2002 to date
Complications
Key points
· Spend time on the history
· If severe symptoms eg syncopy, refer immediately
· 12 lead ECG
· Try & record heart rhythm during an attack
· If appropriate, exclude structural heart disease
· If chronic AF, control rate & thromboembolic risk
Which patients should be referred to an EP for consideration of RFA?
· WPW and history suggestive of SVT (or if high risk occupation)
· Recurrent (documented) ‘SVT’ sufficiently troublesome for prophylactic drugs to be considered – RFA is an appropriate 1st line therapy which is cost effective, safe and usually curative
· Recurrent (?) documented (12 lead ECG) atrial flutter/tachycardia
· Drug refractory atrial fibrillation
· VT associated with structurally normal heart