Palpitaciones y Taquicardia Francisco Jaume, MD FACP, FACC

Definición: Palpitaciones ♥ Estar consiente de los latidos del corazón que pueden ser regulares, irregulares, fuertes o rápidos. ♥ Es percibir los latidos como si el corazón se saliera fuera de ritmo. ♥ Es tener conciencia desagradable de los latidos del corazón que se puede percibir como pausas (“skipped beats”) o la sensación que el corazón se detiene y se acomoda (“vuelco”). ♥ Las palpitaciones pueden sentirse en el pecho, la garganta o en el epigastrio.

QRS Complex

Correlation of the Conduction System with the ECG

Ritmo sinusal normal: 60-100 latidos por minuto

Taquicardia Sinusal: Frecuencia cardiaca de ≥ 101 latidos por minuto

Bradicardia Sinusal: Frecuencia cardiaca ≤ 59 latidos por minuto

Causas de Palpitaciónes ♥ Ejercicio ♥ Ansiedad, estrés o miedo ♥ Fiebre ♥ Cafeína, nicotina, cocaína o pastillas para rebajar de peso ♥ Hiperactividad de la tiroides ♥ Anemia ♥ Hiperventilación ♥ Bajos niveles de oxígeno en la sangre

Otras Causas de Palpitaciónes ♥ Medicamentos: pastillas de hormona tiroidea, agonistas de los receptores beta y los anti-arrítmicos. (Pueden causar un ritmo cardíaco irregular de peor pronóstico). ♥ Prolapso de la válvula mitral ♥ Cardiopatías o enfermedades de corazón de diferentes etiologías.

Tachycardia: Classification 1. Sinus Tachycardia 2. Atrial fibrillation/flutter 3. Narrow-complex tachycardias Paroxysmal supraventricular tachycardia (PSVT) Junctional tachycardia Multifocal atrial or ectopic atrial tachycardia 4. Wide-complex tachycardia of unknown type Wide-complex tachycardia—not specified Aberrant conduction of an SVT 5. Ventricular tachycardia Stable monomorphic VT Stable polymorphic VT (baseline QT interval normal) Stable polymorphic VT (baseline QT interval prolonged: torsades de pointes) The participants should ask to see the rhythm. You can display the rhythm on the screen of the monitor/defibrillator or on the projector screen. Case 8 covers the 4 main types of tachycardias: 1.  Atrial fibrillation/flutter 2.  Narrow-complex tachycardias 3.  Wide-complex tachycardias of unknown type 4.  Stable ventricular tachycardia, either monomorphic or polymorphic, including torsades de pointes The rhythm is torsades de pointes. Review the various tachyarrhythmias and the best way to treat them. A brief arrhythmia medication trial might be attempted while preparing for synchronized cardioversion, but cardioversion should not be delayed. Most patients with a ventricular rate less than 150 bpm do not require (and usually will not benefit from) emergent synchronized cardioversion. Highlight the unstable component of the algorithm. Walk the participants through the initial assessment and management. Highlight the electrical cardioversion algorithm.

Palpitaciónes ♥ La causa más frecuente de palpitaciones es la taquicardia sinusal. ♥ La segunda causa en frecuencia son pausas (“skipped beats o vuelcos”) causados por latidos extra (extra-systoles). ♥ Mensaje importante: La causa más frecuente de palpitaciones son condiciones benignas que no requieren tratamiento.

HOSPITALIZED PATIENTS WITH ARRHYTHMIAS 6% PSVT Atrial fibrillation accounts for 1/3 of patients with arrhythmia as principal diagnosis. 6% PVCs 18% Unspecified 4% Atrial Flutter 9% SSS 34% Atrial Fibrillation 8% Conduction Disease 10% VT 3% SCD 2% VF Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

AND AFLUTTER (> 80%)

Atrial Fibrillation

Atrial Flutter

Atrial Tachycardia

Multifocal Atrial Tachycardia

Atrial Fibrillation: Cardiac Causes Hypertensive heart disease Ischemic heart disease Valvular heart disease Rheumatic: mitral stenosis Non-rheumatic: aortic stenosis, mitral regurgitation Pericarditis Cardiac tumors: atrial myxoma Sick sinus syndrome Cardiomyopathy Hypertrophic Idiopathic dilated (? cause vs. effect) Post cardiac surgery

Atrial Fibrillation: Non-Cardiac Causes Pulmonary COPD Pneumonia Pulmonary embolism Metabolic Thyroid disease: hyperthyroidism Electrolyte disorder Toxic: alcohol (‘holiday heart’ syndrome)

1. Common Mistakes in Managing Patients with Atrial Fibrillation ♥ Failure to recognize the presence of and risks related to asymptomatic Atrial Fibrillation.

Predictors of Thromboembolic Risk in Atrial Fibrillation (CHADS2) ♥ Congestive Heart Failure ♥ Hypertension ♥ Age ≥ 65 years ♥ Diabetes ♥ Stroke or TIA 2 Atrial Fibrillation Investigators. Arch Intern Med. 1994;154:1449-1457.

Trans Esophageal Echo (TEE)

2. Common Mistakes in Managing Patients with Atrial Fibrillation Inadequate Anticoagulation in Patients with Atrial Fibrillation ♥ Failure to maintain INR greater than 2.0 ♥ Chemical cardioversion without at least 3 weeks of prior anticoagulation ♥ Cardioversion not followed by adequate period of anticoagulation with coumadin

3. Common Mistakes in Managing Patients with Atrial Fibrillation ♥ Assuming rate control is best for all patients with atrial fibrillation

AFFIRM Trial – Is it Worth Struggling to Maintain NSR? (Elderly - >65y/o, Primarily Asymptomatic, 1/3 with First Episode of AFib, Heart disease) Rate Control Vs Rhythm Control 4060 pts with Atrial Fibrillation ♥ No difference in mortality, stroke risk or quality of life. ♥ More frequent hospitalization and adverse drug effects in Rhythm Control arm. “Rate Control for All?!!!!” AFFIRM N Engl J Med 2002;347:1825-33

4. Common Mistakes in Managing Patients with Atrial Fibrillation ♥ Failure to adequately control the heart rate during chronic atrial fibrillation and failure to recognize the potential for tachycardia induced cardiomyopathy

Rate Control During Atrial Fibrillation Guidelines ♥ Identify inadequate rate control – Resting heart rate >80 bpm – Holter monitor - any rate >130 or average rate >90 bpm during daily activity – Exercise test – Bruce protocol > 120 bpm in stage 1 ♥ Use cocktail of digoxin/B blockers/Ca channel blockers ♥ Use His Ablation /Pacemaker if drug therapy ineffective or not tolerated – Remember LBBB with RV pacing ♥ Consider Primary Atrial Fibrillation Ablation especially patients with frequent A Fib paroxysm

5. Common Mistakes in Managing Patients with Atrial Fibrillation ♥ Assuming ablative therapy is ineffective and too risky therapy for control of Atrial Fibrillation. (> 80of triggers initiating Atrial Fibrillation are from the Pulmonary Veins)

Complications of Atrial Fibrilation Ablation Worldwide Survey (8745 pts) • Peri -procedural Death (4 pts) - 0.05% • Pericardial Effusion (107 pts) - 1.22% • Embolic Stroke (67pts) – 0.94% • Pulmonary Vein Stenosis (117 pts) - 1.63% • Esophageal Perforation/ Fistula (0 pts) - 0.1% • Vascular Complications (84 pts) – 0.95% Cappato et al Circulation 111: 1100, 2005

Paroxysmal Supraventricular tachycardia (AV Nodal Reentrant Tachycardia)

Pattern of Atrial and Ventricular Activation: Relationship of P wave and QRS Complex

WPW Syndrome ♥ Reciprocating Tachycardia ♥ Atrial Fibrillation 1. Narrow QRS (Orthodromic): PSVT 2. Wide QRS (antidromic ): Morphology similar to ventricular tachycardia ♥ Atrial Fibrillation

Sinus rhythm: WPW Syndrome Atrial Fibrillation

Atrial fibrillation in a patient with an accessory pathway

Taquicardia Ventricular Monomorfica

Taquicardia ventricular Polimorfica

Palpitaciones Métodos de Diagnóstico ♥ Electrocardiograma (ECG) ♥ Prueba de Ejercicio ♥ ECG Ambulatorio Holter ♥ Estudios Electrofisiológicos

Ambulatory Electrocardiogram (HOLTER) * * Asterisk denotes event recorder

Electrophysiological Studies (EPS): Diagnosis and Treatment AV Nodal Modification or Accesory Pathway Ablation RAO LAO

Conclusions ♥ La causa más frecuente de palpitaciones es la taquicardia sinusal seguido de las extrasistoles: ambas condiciones son benignas y no requieren tratamiento. ♥ El riesgo de trombo embolismo debe ser estimado en pacientes con fibrilación atrial persistente y considerar la indicación de anticoagulación con walfarina. ♥ El ECG ambulatorio (Holter) tiene valor para estimar el significado de palpitaciones. ♥ Estudios electro-fisiológicos tienen valor diagnóstico y terapéutico.

Gracias por su atención

¿¿Preguntas ??

A

Third-degree AV block with ventricular asystole Patient has acute anterior myocardial infarction. He developed right bundle branch block (see wide-QRS complex on left side of strip). Complete heart block abruptly developed: only P waves seen on right side of strip. P waves are not followed by a ventricular escape focus, resulting in ventricular asystole. Comment on lidocaine issue here (escape rhythms are less likely with lidocaine).

Palpitaciones ♥ Las palpitaciones usualmente son benignas. ♥ En ocasiones requieren tratamiento. ♥ Infrecuentemente son arritmias que potencialmente son malignas. ♥ Pueden causar paro cardiorespiratorio y muerte súbita inesperada.

Fibrilación Atrial

Flutter Atrial

Anticoagulación Crónica Fibrilación Atrial Se utiliza Coumadin (warfarina). El nivel terapéutico óptimo se mide con el Prothrombine Time (PT). El PT, se reporta en INR (una relación del PT paciente/PT medido), que debe ser de 2 a 3 veces el nivel normal. INR- International Normalized Ratio

WPW Syndrome (Accessory Pathway)

Tratamiento de Arritmias ♥ Control del ritmo: drogas antiarrítmicas o cardioversión sincronizada ♥ Control de la frecuencia ventricular ♥ Considerar anticoagulación crónica ♥ EPS: ablation of pathways ♥ Defibrilador interno automático