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آریتمی. دکتر محمد رضا تابان متخصص داخلی و فوق تخصص قلب و عروق مرکز قلب شهید مدنی تبریز اسفند 91. Palpitation. definition ? Most probable diagnoses & DDX. Important and serious diagnoses. Common pitfalls. Palpitation definition. A subjective awareness of one’s heartbeat # Bradycardia

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دکتر محمد رضا تابان

متخصص داخلی و فوق تخصص قلب و عروق

مرکز قلب شهید مدنی تبریز

اسفند 91

  • definition ?
    • Most probable diagnoses & DDX.
    • Important and serious diagnoses.
    • Common pitfalls.
palpitation definition
Palpitation definition

A subjective awareness of one’s heartbeat

# Bradycardia

# tachycardia

Spectrum of Patients’ Descriptions

Heart flips or flip-flops

Skipped beats

Strong beats

Irregular beats

Heart thumping

Bubble sensation in heart or chest

Racing or rapid heart beats

Pounding in neck or chest

Heart jumping out of chest

Chest or whole body shaking

most probable diagnoses
Most probable diagnoses
  • Anxiety
  • Premature beats (Ectypes= PAC / PVC)
  • Sinus tachycardia
  • Drugs, e.g. stimulants
  • Psychogenic
  • Arrhythmia: PSVT , AF/afl , VT ,…
common pitfalls
Common Pitfalls
  • Fever / Infection
  • Pregnancy
  • Menopause
  • Drugs, e.g. caffeine, cocaine
  • Mitral valve disease
  • Aortic incompetence
  • Hypoxia / Hypercapnia
masquerade checklist
Masquerade Checklist
  • Depression
  • Diabetes Mellitus
  • Drugs
  • Anemia
  • Thyroid disease
  • Spinal dysfunction
  • Infection (Urinary Tract , …)
important and serious diagnoses
Important and Serious Diagnoses
  • Myocardial infarction / angina
  • Life threatening Arrhythmias

-Wolff-Parkinson-White Syndrome

-LQTs / SQTs

-Burgada sy.

  • Electrolyte disturbances


Characterization of the palpitation

Attendant symptoms

Cardiac history

Arrhythmia history

Family history

Possible systemic & endocrinology disorders

Drug use

1 characterization of the palpitation
1-Characterization of the Palpitation

Circumstances at onset

Duration of the problem

Mode of onset/offset , Trigger factors

Heart rate estimate

Rhythm regularity vs. irregularity

Episode duration

Symptom frequency

2 attendant symptoms
2- Attendant Symptoms

Symptoms arising from rhythm disorder

Symptoms due to CAD or CHF

Neurohormonal responses

Psychological symptoms: Anxiety disorder , Panic attacks

3 cardiac history
3- Cardiac History

Ischemic heart disease

LV dysfunction

Valvular heart disease

Atrial or ventricular arrhythmias

4 arrhythmia history
4-Arrhythmia History

Recurrence vs. new onset

Recent history of radiofrequency ablation

Pacemaker or ICD implantation

5 family history
5- Family History

Long QT syndrome

Brugada’s syndrome

Familial cathecolamine-mediated polymorphic V. tachycardia

Atrial fibrillation

6 possible endocrine and metabolic disorders
6- Possible Endocrine and Metabolic Disorders

Hyper or hypothyroidism



Renal disorders


Electrolyte imbalance


Hx of rheumatic fever

7 drug dietary use
7- Drug & Dietary Use

Bronchodilator therapy, beta agonists,

Caffeine , alcohol , Chocolate

Stimulants / substance abuse: Cocaine

OTC sympathomimetic agents

QT-prolonging drugs

Thyroid replacement medications

phenothiazine, isotretinoin, digoxin


dietary supplement causing palpitation
Dietary Supplement Causing Palpitation

Chocolate , Caffeine , alcohol

Ephedra/Diet pills


Bitter Orange



physical examination
Physical Examination

Often uninformative in young adults

Check for presence of organic heart disease

- LV dysfunction

- Valvular HD

- Congenital HD

Evidence of COPD

Signs of anemia, thyroid and renal disease

Pulse quality, rate, regularity, pauses

Orthostatic hypotension

physical examination1
Physical Examination
  • Best performed while having palpitations
  • Signs especially to consider
    • Palm signs (sweaty, pallor)
    • Radial pulse (character)
    • Blood Pressure
    • Eye signs (pallor, eye signs of thyrotoxicosis)
    • Goitre
    • Jugular vein pulsations
    • Praecordium abnormalities (e.g. cardiac enlargement, murmurs)
diagnostic tests
Diagnostic Tests

Resting EKG

Ambulatory EKG monitoring


Exercise testing

Event monitor EKG

Electrophysiologic testing

Implantable loop recorder

  • 1- QT (long QT , short QT)
  • 2- burgada syndrome
  • 3- WPW
  • 4- ARVD ( epsilon wave)
  • 5- HCM
  • 6- MI

Tracing from a young boy with congenital long-QT syndrome. The QTU interval in the sinus beats is at least 600 milliseconds. Note TU wave alternans in the first and second complexes. A late premature complex occurring in the downslope of the TU wave initiates an episode of ventricular tachycardia

wolf parkinson white syndrome
Wolf-Parkinson-White syndrome
  • short PR interval, less than 3 small squares (120 ms)
  • slurred upstroke to the QRS indicating pre-excitation (delta wave)
  • broad QRS
  • secondary ST and T wave changes
      • Localising the accessory pathway
  • An accessory pathway, bundle of Kent, exists between atria and ventricles and causes
  • early depolarisation of the ventricle. The location of the pathway may be deduced as follows:-
  • LOCATION V1 V2 QRS axis
  • left posteroseptal (type A) +ve +ve left
  • right lateral (type B) -ve -ve left
  • left lateral (type C) +ve +ve inferior (90 degrees)
  • right posteroseptal -ve -ve left
  • anteroseptal -ve -ve normal
wide complex tachycardia sinus tach aberrancy svt psvt af flutter aberrancy ventricular tachycardia
Wide Complex Tachycardia--Sinus tach + aberrancy.--SVT (PSVT, AF, flutter) + aberrancy.--Ventricular tachycardia
  • Pretest probability:
    • Majority of wide complex tachycardia is ventricular tachycardia

REMEMBER: VT does not invariably cause hemodynamic collapse; patients may be conscious and stable

clinical clues for regular wide qrs tachycardia
Clinical Clues:for Regular Wide QRS Tachycardia
  • History of heart disease, especially priorMI suggests VT
  • Occurrence in a young patient with no known heart disease  SVT
  • 12-lead EKG (if patient stable) should be obtained
5 questions in tachyarrhythmia
5 Questions in tachyarrhythmia
  • 1- QRS:

Wide or Narrow?



  • 2- Regularity?
    • Regular
    • Regularly irregular
    • Irregularly irregular
  • 3- P-waves?
  • 4- Rate?


  • 5- Rate change sudden or gradual?
1 qrs wide or narrow
1- QRS: Wide or Narrow
  • Narrow
    • Sinus, PSVT, A flutter, A fib
      • (All without aberrancy)
  • Wide
    • SVT + aberrancy
    • Ventricular tachycardia
aberrancy svt with wide complex
Aberrancy - SVT with wide complex
  • Abnormal ventricular conduction
    • Anatomical : RBBB or LBBB
    • Functional : Rate-related BBB
    • Antidromic Reciprocating
      • Goes down through bypass tract
suggest vt
Suggest VT
  • In RBBB pattern > 140 ms
  • In LBBB pattern > 160 ms
1 qrs shape typical or atypical lbbb rbbb
1- QRS: Shape? Typical or atypical LBBB/RBBB
  • true bundle branch block pattern
    • Right or left (sinus or SVT with aberrancy)
  • absence of RS complex in all leads V1-V6(negative Concordance)
1 qrs axis
1-QRS: Axis
  • >45 degree

R in aVR

1 qrs fusion beats capture beats
1- QRS : Fusion beats / capture beats
  • Fusion beats (occasional narrow complex fused with wideone)
  • Capture beats
2 p waves
2- P waves
  • If p waves, and associated with QRS, then sinus (or, rarely, atrial tachycardia)
  • PSVT: generally no p wave visible
    • PR short
    • P wave hidden in QRS, inverted
  • A fib and flutter:
    • No p waves, but flutter may fool you
  • V tach
    • May rarely see P waves, but with no association

(AV dissociation) or retrograde


AV Dissociation








Ventricular Tachycardia (VT)


  • Rates range from 100-250 beats/min
  • Non-sustained or sustained
  • P waves often dissociated (as seen here)
3 regularity in tachycardia
3- Regularity in tachycardia
  • Regular
    • VT, Sinus, PSVT, flutter,
  • Regularly irregular
    • Atrial flutter / AT
  • Irregularly irregular
    • AF, MAT
4 rate
4- rate
  • Rate: the faster, the less likely it is sinus

(260 beats/min)

5 sudden vs gradual change re entry vs automaticity
5- Sudden vs. Gradual change(Re-entry vs. automaticity)
  • Sinus: gradual
  • PSVT: sudden
  • Atrial flutter: sudden
  • AF: always changing, but sudden onset
  • Ventricular tachycardia: Sudden
identify ventricular tachycardia
Identify ventricular tachycardia

Regular and wide

  • Step 1: Is there absence of RS complex in all leads V1-V6? (Concordance)
    • If yes, then rhythm is VT
  • Step 2: Is interval from onset of R wave to nadir of the S > 100 msec (0.10 sec) in any precordial leads?
    • If yes, then rhythm is VT.
  • Step 3: Is there AV dissociation?
    • If yes, then rhythm is VT.
  • Step 4: Are morphology criteria for VT present (not typical BBB)?
    • If yes, then VT

> 0.10 sec?

چند تمرین:

Regular Wide QRS Tachycardia:

VT or SVT with Aberrant Conduction?

ventricular tachycardia
Ventricular Tachycardia

Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)

Step 2: RS in V5 > 0.10 ms, therefore v tach

Step 3: No AV dissociation

Step 4: RBBB pattern (tall R in V1). Notching of this monophasic R indicates VT


Artifact Mimicking “Ventricular Tachycardia”

QRS complexes “march through”

the pseudo-tachyarrhythmia





Ventricular tachycardia originating from the right ventricular outflow tract. This tachycardia is characterized by a left bundle branch block contour in lead V1 and an inferior axis.


Left septal ventricular tachycardia. This tachycardia is characterized by a right bundle branch block contour. In this instance, the axis was rightward. The site of the ventricular tachycardia was established to be in the left posterior septum by electrophysiological mapping and ablation.


Ventricular Flutter

  • VT  250 beats/min, without clear isoelectric line
  • Note “sine wave”-like appearance

Ventricular Fibrillation (VF)

  • Totally chaotic rapid ventricular rhythm
  • Often precipitated by VT
  • Fatal unless promptly terminated (DC shock)
is patient stable or unstable
Is patient stable or unstable?
  • Patient has serious signs or symptoms? Look for
    • Chest pain (ischemic? possible ACS?)
    • Shortness of breath (lungs ‘wet’? possible CHF?)
    • Hypotension
    • Decreased level of consciousness
      • (poor cerebral perfusion?)
    • Clinical shock
      • (cool and clammy -- peripheral vaso-constriction?)
  • Are the signs & symptoms due to the rapid heart rate?
  • Or are S/Sx’s & rapid HR due to something else?
    • I.e., is it sinus tach due to sepsis, hemorrhage, PE, tamponade, dehydration, etc.
treatment when in doubt stable or unstable electricity
Treatment when in doubtStable or unstable-Electricity
  • If possible, get 12-lead ECG first
  • If electricity does not work
    • Automatic rhythm
      • Sinus, accelerated junctional, accelerated idioventricular, automatic atrial, MAT—treatment of underlying disorder
    • Chronic atrial fib
      • Be sure it is not physiologic tachycardia
      • Amiodarone for conversion
      • Diltiazem or Digoxin to control rate
    • Refractory ventricular tachycardia
      • Amiodarone
        • 150 mg, may repeat several times
      • Treat underlying ischemia
conclusion when in doubt
Conclusion: When in doubt
  • Shock a fast rhythm
  • Pace a slow rhythm
  • In anterior STEMI
    • Be certain that transcutaneous pacing will capture if there is high grade block
  • But don’t shock sinus tachycardia!!