Palpitaciones y Taquicardia

1. Palpitaciones y Taquicardia Francisco Jaume, MD FACP, FACC

2. 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.

4. QRS Complex

5. Correlation of the Conduction System with the ECG

6. Ritmo sinusal normal: 60-100 latidos por minuto

7. Taquicardia Sinusal: Frecuencia cardiaca de ≥ 101 latidos por minuto

8. Bradicardia Sinusal: Frecuencia cardiaca ≤ 59 latidos por minuto

9. 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

10. OtrasCausas 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.

11. 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)

12. 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.

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

14. AND AFLUTTER (> 80%)

15. Atrial Fibrillation

16. Atrial Flutter

17. Atrial Tachycardia

18. Multifocal Atrial Tachycardia

19. 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: atrialmyxoma • Sick sinus syndrome • Cardiomyopathy • Hypertrophic • Idiopathic dilated (? cause vs. effect) • Post cardiac surgery

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

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

22. 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.

23. Trans Esophageal Echo (TEE)

24. 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

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

26. 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?!!!!” AFFIRMN Engl J Med 2002;347:1825-33

27. 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

28. 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

29. 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)

30. 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

31. Paroxysmal Supraventricular tachycardia (AV Nodal Reentrant Tachycardia)

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

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

34. Sinus rhythm: WPW Syndrome Atrial Fibrillation

35. Atrial fibrillation in a patient with an accessory pathway

36. Taquicardia Ventricular Monomorfica

37. Taquicardia ventricular Polimorfica

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

39. Ambulatory Electrocardiogram (HOLTER) * *Asterisk denotes event recorder

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

41. Conclusions ♥ La causamásfrecuente de palpitacioneses la taquicardiasinusal seguido de las extrasistoles: ambas condiciones son benignas y no requierentratamiento. ♥ 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 estimarel significado de palpitaciones. ♥ Estudios electro-fisiológicos tienen valor diagnóstico y terapéutico.

42. Gracias por su atención

43. ¿¿Preguntas ??

46. A