Caveats • Symptom characterized by awareness of heartbeat (degdegan) • Both tachycardia and frequent premature complex arising from both atrium (PAC) and ventricle (PVC) are felt as palpitations • Alert of patient occasionally complain of palpitation, when they have chest discomfort • Present either with on going palpitation or palpitation which have resolved • Patient on going palpitations quickly do 12leads ECG Cause of palpitation • Cardiac causes • Metabolic/endocrine causes • High ouput state • Medication/drug related • Respiratory conditions • Psychiatric disorders • Physological General approach • determining haemodinamic stability • Performing 12 leads ECG • The 3 aspects of history taking • Duration • Rate • Rhytm • Termination of episode Cont • Associated Symptoms • Conccurrent ischaemic symptoms (diaphoresis, chest pain, dyspnoea, dizziness) • A very high ventricular rate will reduce stoke volume and decrease cardiac output • Symptomatically this will manifest ranging from postural dizziness if mild to presyncope, altered mental state and syncope if severe. cont • History • Evaluate patient personal family history of heart desease • Features that suggest hypoglicemia • Evaluate for features hypothyroidism and pherocromocytoma • Medication/drugs • Psyciatric conditions, consider this only as a diagnosis exlusion Cont • Physical exam • Vital sign • Cardiac exam (murmur and regularity of rhythm) • Respiratory exam evaluate COPD • Evalution of hyperthyroidism an hypothyroidism • Investigations • Other than 12 lead ECG all investigations are to be guided by clinical evaluation Conditions pre dispose to a tachydysrhytmia • Some ECG finding to look out for suggest the diagnosis of an earlier tachydysrhytmia. 1. Abnormal T wave and ST segment point toward possible ischaemia 2. P pulmonale and P mitrale suggest enlarged atrium which associated with atrial fibrillation 3. Patient with HCM, left atrial enlargement, left ventricular hypertrophy and deep, narrow Q waves in lateral leads, there are pre dispose to SVT, AF and VT. WPW syndrome • Characterized presence of congenital accecory pathway forming bypass between atriumand ventricle. • Might develop AVRT a form of SVT. • Associated with small risk sudden cardiac death • 10-30% develop AF • ECG features when in sinus rhytm • PR interval<120ms • Delta wave-slurred slow rise affecting the initial portion of the QRS complex • QRS prolongation >110ms Brugada Syndrome • Due to a mutation in sodium channel of the heart • Associated with high incidence of sudden cardiac death in structurally normal heart • ECG change often dynamic • It is diagnosed based on characteristic ECG finding and one below clinical criteria. • There are 3 brugada ECG pattern Brugada Diagnosis • J-point elevation >2mm (0.2mV) in leads V1-V3 • Followed by a coved ST-segment and negative T wave • Diagnosis of brugada syndrome requires brugada type 1 and one folloeing criteria: 1. Syncope 2. Nocturnal agonal respiration 3. Family history of sudden cardiac death <45years old 4. Documented VF or VT polimorphyc 5. Coved type ECG family members 6. Inducibility VT with program lectrical stimulation ECG pattern of brugada Long QT syndrome • Defined as QTc of more than 450ms • Associated with sudden cardiac death(vf, torsade de pointes, syncope, especially in presence of severe bradycardia with long pauses • Cause long Qt • Congenital • Acquired : • electrolytes, hypocalemia, hypocalcemia, hypomagnesemia • Drug: class 1 or 3 antidysrhytmia ( amiodarone etc), psychotropic drugs, macrolides, fluroquinolom • Myocardial Ischaemia ECG Management • Managed at least in intermediate with ecg monitoring • O2 if spO2 decreased • Monitoring ecg 15min, pulse oximetry • Established peripheral iv line • Cardioversion if decrease level of consciousness • Amiodarone drug of choice in managementof stable tachydysrhytmias except(WPW with Af) TENGKYU