Arrhythmias The way it show and they way you go by Dr. Ihab Tarawa, Consultant Physician, Soba University Hospital SAMA VP

1. Ihab B Abdalrahman 1

2. ARRHYTHMIAS THE WAY IT
SHOW &B THE WAY YOU MBBS,
Dr. Ihab Abdalrahman, GO
MD, ABIM, SSBB
Soba University Hospital
SAMA- Founder &
VP
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3. Objectives
 To recognize the clinical presentations of
arrhythmias
 To determine who need immediate
intervention.
 To know how to capture the rhythm
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4. Ihab B Abdalrahman 4

5. Ihab B Abdalrahman 5

6. The way it show
LOC &
No Palpitation
Sudden
Symptoms & Dizziness
Death
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8. Message # 1
If your patient get
palpitation
Don’t get yourself
palpitation
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9. PALPITATIONS COULD BE DUE
TO
Arrhythmias
Nonarrhythmic cardiac causes
Extracardiac causes
Drugs and medications
Psychiatric causes
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10. ARRHYTHMIC CAUSES
Atrial fibrillation/flutter
Bradycardia caused by advanced AV block
or sinus node dysfunction
Bradycardia-tachycardia syndrome(sick
sinus syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular
contractions
Sinus tachycardia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome
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11. Palpitations
Nonarrhythmic cardiac causes
 Atrial or ventricular septal defect
 Cardiomyopathy
 Congenital heart disease
 Congestive heart failure
 Mitral valve prolapse
 Pacemaker-mediated tachycardia
 Pericarditis
 Valvular disease (e.g., aortic
insufficiency,stenosis)
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12. PALPITATIONS /EXTRACARDIAC
CAUSES
Anemia,
Electrolyte imbalance
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Vasovagal syndrome Ihab B Abdalrahman 12

13. Drug
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14. DRUG-INDUCED ECG ABNORMALITIES
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15. PALPITATIONS/
PSYCHIATRIC ETIOLOGY
Anxiety disorder
Panic attacks
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16. ANXIETY OR PANIC DISORDER
 Prevalence of panic disorder in patients
with palpitations is 15 to 31 percent.
 Panic disorder and significant arrhythmias
are not mutually exclusive,
 Cardiac evaluation still may be necessary
in patients with suspected panic disorder
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17. Differential Diagnosis of
Palpitations/ Drugs and
medications
 Alcohol, Caffeine
 beta agonists, phenothiazine, theophylline,
isotretinoin, digoxin
 Cocaine
 Tobacco
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18. DIETARY SUPPLEMENT CAUSING
PALPITATION
Chocolate
Ephedra/Diet pills
Ginseng
Bitter Orange
Valerian
Hawthorn
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19. Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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20. Pathophysiology
 Enhanced or suppressed automaticity
 Automaticity is a natural property of all myocytes.
 It can be affected +/-vely by:
 Ischemia,
 scarring,
 electrolyte disturbances,
 medications,
 advancing age.
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21. Pathophysiology
 Triggered activity,
 Triggered activity occurs when early
afterdepolarizations and delayed
afterdepolarizations initiate
spontaneous multiple depolarizations,
precipitating ventricular arrhythmias.
Examples include torsades de pointes
and ventricular arrhythmias caused by
digitalis toxicity.
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22. Pathophysiology
 Re-entry.
 Circuit lead to propagation of the rhythm
 The commonest mechanism
 Bidirectional or unidirectional block.
 Micro level re-entry occurs with VT
 Macro level re-entry occurs via conduction
through (Wolff-Parkinson-White [WPW]
syndrome) concealed accessory pathways.
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23. What is arrhythmia
 Broadly defined as any
abnormality in the normal
activation sequence of the
myocardium.
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24.  There are hundreds of different
types of cardiac arrhythmias.
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26. My dream
 It would be immensely convenient
 if every dysrhythmia had a classic
ECG appearance
 and every patient with a given
dysrhythmia manifested a similar
clinical presentation.

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29. In arrhythmias one size does
not fit all

30.  CDC have estimated sudden cardiac death
rates at more than 600, 000 per year .
 Up to 50% of patients have sudden death as
the first manifestation of cardiac disease.
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31. The major determinant
 In general, the seriousness of cardiac
arrhythmias depends on the presence or
absence of structural heart disease.
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32. Benign In normal heart Serious in abnormal heart
 APC  Non-sustained VT
 VPC  Syncope
 Lone A fib  In patients with CAD
 Severe LV dysfunction
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33. Ataa Ataa
 Ataa senior (42 years) was an athlete trainer
in the army
 He won 2 medals
 He died suddenly in a marathon race
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34. Ataa Ataa
 Ataa Junior is a 26 year football player.
 Ataa junior collapsed during a match in
Qatar.
 Luckily they have and AED.
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37. The way it
Show Go
Collapse DC shock
(Near) Sudden May be
cardiac death screening
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38.  Najat is a 36 obese female.
 She delivered her dream baby 3 days a go.
 She was brought to ER because of SOB,
pleuritic chest pain and palpitation.
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40. The way it
Show Go
Palpitation Diagnose &
Features of a Treat the disease
concomitant
disease
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41.  Haj Adam is a 73 male with vascular dementia
 Admitted to hospital because of confusion
and weakness.
 No other symptoms.
 Diagnosed with CAP
 The resident noticed irregular pulse.
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43. The way it
Show Go
Asymptomatic Treat the
Features of a disease
concomitant Stratify your
disease patient (CHADS2)
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44.  Abdalsatar know to have DM, HTN admitted
to CCU with ACS
 Treated with ASA, BB, ACE, heparin, atrova
 12 hour later he had a brief run of
 He reported some palpitation.
 He remained conscious with a BP of 110/70,
sat 94%
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46. The way it
Show Go
Symptomatic Treat the
Features of a disease
concomitant Correct K, MG
disease Adjust meds
Hemodynamic
ally stable
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47.  Abdalwahid has frequent palpitation.
 He always feel an extra beat in his pulse
 No chest pain, DM, HTN, smoking
 Exam, ECG, Echo all were normal
 He demanded Holter monitoring which was
negative
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48. The way it
Show Go
Symptomatic Reassurance
Recurrent No Further
Normal Heart testing
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49.  22 year male reported recurrent attack of
palpitation.
 He was admitted to CCU twice and diagnosed
as VT. One episode required DC shock.
 Physical exam was normal
 While searching on his records, you found
this tracing
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50. WOLFF-PARKINSON-WHITE SYNDROME
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51. Clues in the way it shows
 The presence of sustained regular
palpitations or heart racing in young patients
without any evidence of structural heart
disease suggests the presence of a SVT
caused by AV nodal re-entry or SVT caused by
an accessory pathway.
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52. The way it
Show Go
Symptomatic EP study
Recurrent Radiofrequency
Normal Heart catheter
Suspicious
RT
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53. The way it shows
 In general, severe symptoms are more likely
to occur in the presence of structural heart
disease.
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54.  Syncope in the setting of noxious stimuli such
as pain, prolonged standing, or venipuncture,
particularly when preceded by vagal-type
symptoms (e.g., diaphoresis, nausea,
vomiting) suggests neurocardiogenic
(vasovagal) syncope.
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55.  Occasionally, patients report abrupt syncope
without prodromal symptoms, suggesting
the possibility of the malignant variety of
neurocardiogenic syncope.
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56.  Suzan is a 54 female, high school English-
teacher.
 Had 3 episodes of syncope in the last 2 month
 2 days ago she passed out while watching TV
 Exam, electrolytes , TNI, ECG and 36 hours
monitoring were normal
 Echo EF 30%
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57. The way it
Show Go
Symptomatic Further testing
Recurrent & disabling
Structural cardiac
abnormality
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58. Way you go
Principles
 It is important to proceed with a stepwise
approach.
 The goal is to obtain a correlation between
symptoms and the underlying arrhythmia .
 To identify underlying abnormalities
 To initiate appropriate therapy.
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59. Way you go
Assessment for Structural Heart Disease
 History of CAD or MIs,
 Risk factors for CAD,
 Family history of sudden cardiac death are
extremely important.
 Cardiac exam may detect an irregular rhythm
or premature beats.
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60. Way you go
Assessment of Structural Heart Disease
 Examine the ECG for
 conduction system delays,
 QRS widening,
 previous MI,
 PVCs.
 Echo CAD, LV dysfunction, valvular disease
 Stress testing can demonstrate the presence
of CAD.
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61. Way you go
Clues in ECG EVALUATION
 All patients who complain of palpitations
 ECG findings warrant further cardiac
investigation
 evidence of previous myocardial infarction,
 left or right ventricular hypertrophy,
 atrial enlargement,
 AV block,
 short PR interval and delta waves (Wolff-Parkinson-
White syndrome),
 prolonged QT interval
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62. WAY YOU GO
WHEN YOU GO FOR STRESS ECG
ECG exercise testing is appropriate in
patients who have palpitations with
physical exertion and patients with
suspected coronary artery disease or
myocardial ischemia.
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63.  Capturing the rhythm
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64. FURTHER DIAGNOSTIC TESTING
CONTINUOUS ECG MONITORS
(Holter monitor)
- continuously to record data for 24 or 48 hours
- diary of any symptoms that occur during the monitoring
- most expensive
TRANSTELEPHONIC EVENT MONITORS
- save data only for the previous and subsequent few minutes when
the patient manually activates the monitor
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65. HOLTER MONITOR VS EVENT MONITOR
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66. Choosing an Ambulatory
Monitoring Device
 Diagnostic yield was
 66 to 83% for event monitors
 33 to 35% for Holter monitors
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67. Case study
 Rapid heart palpitations with associated
dyspnea develop suddenly in a 40-year-old
man.
 His symptoms are acute and progressive.
 In ER
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68. The way it
Show Go
HR DC
BP Which one of the following
AVN blocker
RR signs will determine the
Temp way you go?
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69.  In a patient with heart palpitations and
dyspnea, what piece of clinical history is
critical in guiding the initial management?
 A. Recent cardiac stress test
 B. Length of time of current symptoms
 C. Lack of chest pain during symptoms
 D. History of prior hospitalization for these
symptoms
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70. Take home
 Determine if you need immediate action
 Good H & P
 Examine the ECG
 Is it in a good heart or structurally abnormal
 Think outside the heart
 Do you need to capture it
 Recording devices
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71.  This is the way it show
 Please determine the way you go
 Thank you for going the right way
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