Dr Paul Broadhurst

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